Multi-criteria analysis of strategies towards sustainable recycling of phosphorus from sewage sludge in Austria.

To promote optimal phosphorus (P) recovery from municipal wastewater and sewage sludge with viable legal instruments, it is imperative to understand the regional and national consequences of different legal requirements for recycling. In this study we develop a scenario-based analysis to assess the environmental and economic impact of different national P recovery strategies in the context of a detailed representation of the existing Austrian wastewater infrastructure. This assessment combines material flow analysis, life cycle assessment and life cycle costing and includes the indicators P recycling rate, P utilization degree, heavy metal removal rate, share of heavy metals' content in wastewater redirected to agricultural soils, global warming potential, cumulated energy demand, terrestrial acidification potential, volume of freight transport and annual costs. The following main conclusions can be drawn. P recovery from ash shows the highest potential regarding the utilization of P from wastewater. A high P utilization from wastewater should rely on recovery technologies that decontaminate products, otherwise pollutant loads to agricultural soils might increase. P recovery to the extent of 60-85 % of P in WWTPs influent can be achieved by savings/costs of -0.8 to +4.7 EUR inhabitant-1 yr-1 in addition to current cost of the wastewater treatment/sludge disposal system. Key factors to be considered for costs are the choice of recovery process, revenues from products, and the use of existing incineration infrastructure. P recovery can lead to the reduction of greenhouse gas emissions in Austria if nitrous oxide emissions from sludge incineration are limited and efficient heat utilization strategies are implemented. There is a trade-off in terms of environmental and economic costs in choosing a more centralized or decentralized mono-incineration strategy.

[Muscular injuries of athletes : Importance of ultrasound]. / Muskelverletzungen des Sportlers : Stellenwert des Ultraschalls.

CLINICAL/METHODICAL ISSUE: Muscular injuries represent the most common musculoskeletal lesions. Especially in professional athletes an imaging clarification is essential in order to define the exact location of the lesion, the affected muscles, the extent and degree of the injury as well as to define possible concomitant complications. The best possible therapy can be initiated and a necessary rest period for a low risk resumption of sporting activity can be individually specified. STANDARD RADIOLOGICAL METHODS/METHODICAL INNOVATIONS: Due to technical improvements, for example mobile devices and thus increased rapid availability as well as relative cost-effectiveness compared to other modalities, the imaging evaluation of muscle injury would nowadays be unthinkable without ultrasound. PERFORMANCE: The article discusses general prerequisites for the performance of muscle ultrasound as well as a standardized examination algorithm of muscle injuries beginning with general and leading to special tips and tricks. ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS: Despite the known investigator dependence, ultrasound enables a reliable and unerring imaging clarification of muscle injuries. For this reason, ultrasound should be considered as the first-line diagnostic imaging modality when dealing with muscle trauma.

[Ultrasound-guided interventions on the peripheral nervous system]. / Ultraschallgesteuerte Interventionen am peripheren Nervensystem.

CLINICAL/METHODICAL ISSUE: Up to the advent of high-resolution ultrasound, interventions on the peripheral nervous system, including local anesthesia and pain treatment were performed without visual guidance, which in some cases led to treatment failure or local tissue and nerve damage. METHODICAL INNOVATIONS: Progress in the field of ultrasound has enabled the functional visualization, anesthesia and anti-inflammatory or neurolytic treatment of many peripheral nerves, such as the brachial plexus, nerves of the upper and lower extremities and various nerves of the trunk. Contrast medium-guided biopsies have also become feasible. ACHIEVEMENTS: This article discusses the general prerequisites for such interventions and details the visualization and the interventional algorithms for interventions on the brachial plexus, on large nerves often affected by compression neuropathies, such as the median, ulnar, sciatic and femoral nerves and small nerves, such as the lateral cutaneous nerves of the thigh. Furthermore, contrast medium-aided biopsies of intraneural and perineural masses are discussed. Finally, the treatment of stump neuromas via phenol instillation is described. PRACTICAL RECOMMENDATIONS: Innovations in high-resolution ultrasound allow the reliable and safe diagnosis and treatment of various pathologies of the peripheral nervous system with few side effects. Compared to older methods, which did not use visual guidance ultrasound provides higher success rates and lower adverse event rates in many instances.

Doppler-guided haemorrhoidal artery ligation with suture mucopexy compared with suture mucopexy alone for the treatment of Grade III haemorrhoids: a prospective randomized controlled trial.

AIM: Novel minimally invasive techniques aimed to reposition the haemorrhoidal zone have been established for prolapsing haemorrhoids. We present a prospective randomized controlled trial to evaluate the efficacy of additional Doppler-guided ligation of submucosal haemorrhoidal arteries (DG-HAL) in patients with symptomatic Grade III haemorrhoids. The trial was registered as ClinicalTrials.gov identifier NCT02372981. METHOD: All consecutive patients with symptomatic Grade III haemorrhoids were randomly allocated to one of the two study arms: (i) Group A, DG-HAL with mucopexy or (ii) Group B, mucopexy alone. End-points were postoperative pain, faecal incontinence, bleeding, residual prolapse and alterations of the vascularization of the anorectal vascular plexus. Vascularization of the anorectal vascular plexus was assessed by transperineal contrast enhanced ultrasound. Patients recorded their symptoms in a diary maintained for a month. RESULTS: Forty patients were recruited and randomized to the two study groups. Patients in Group A had less pain in the first two postoperative weeks. At the 12-month follow-up, two patients in Group A (10%) and one in Group B (5%) showed recurrent Grade III haemorrhoids (P = 0.274). No significant morphological changes were observed in the transperineal ultrasound findings between the preoperative assessment and the assessment at 1 and 6 months in either group (P > 0.05). CONCLUSION: Mucopexy techniques for treating prolapsing haemorrhoids are effective, but DG-HAL does not add significantly to the results achieved by mucopexy. Repositioning the haemorrhoidal zone is the key to success, and mucopexy should be placed at the sites of the largest visible prolapse.

Ultrasound imaging of the axillary nerve and its role in the diagnosis of traumatic impairment.

PURPOSE: The axillary nerve (AN) is frequently injured during shoulder trauma and imaging is required to define the site and extent of nerve injury. However, the AN has a rather complex course through several soft tissue compartments of the shoulder and axilla. Therefore, imaging of the nerve with MRI and sonography is troublesome. Thus detection and sonographic assessment bases on thorough knowledge of local topography. MATERIALS AND METHODS: This investigation aimed at defining reliable anatomical landmarks for AN-sonography in 5 volunteers and later validating the proposed sonographic examination protocol in 10 unselected patients. RESULTS: With strict adherence to the proposed examination algorithm, sonography of the AN was feasible in all volunteers and patients. Furthermore, sonographic findings correlated nicely with the golden standard "surgical exploration" concerning severity and topography of neural impairment. CONCLUSION: Based on our study results we propose our algorithm for AN-sonography as the first-line imaging tool for the assessment of axillary nerve trauma.

Transperineal ultrasonography as a complementary diagnostic tool in identifying acute perianal sepsis.

BACKGROUND: Successful anal fistula care in complex cases can be assisted by specialized imaging which accurately defines the site of the internal fistula opening and the fistula type. There are currently limited data concerning the clinical indications for and accuracy of transperineal ultrasound (TP-US) in acute perianal sepsis. The aims of this study were to compare the anatomical interpretation of TP-US images with magnetic resonance imaging (MRI) and surgical findings in an unselected patient cohort presenting with acute perianal sepsis. METHODS: Sixty-seven consecutive patients with acute anorectal sepsis referred from the surgical department were examined using TP-US and Gadolinium-enhanced MRI with both examiners blinded to the surgical results. Fistulae were categorized by the Parks' classification of fistula type. RESULTS: Thirty-six abscesses were detected by MRI, 38 by TP-US and 30 by surgical examination. Operatively discordant cases showed only ischiorectal panniculitis. TP-US was more accurate in the diagnosis of superficial sepsis and MRI in the diagnosis of deep-seated perirectal infection. TP-US and MRI show concordance with operative findings in fistula diagnosis with a tendency for TP-US to overdiagnose trans-sphincteric fistulae and MRI to over diagnose extra-sphincteric fistulae. Comparison of TP-US with MRI showed good agreement for perianal abscess diagnosis (τ = 0.82) and for fistula diagnosis (τ = 0.68). For fistulae, TP-US showed moderate agreement with surgery (τ = 0.43) with only fair agreement between MRI and surgery (τ = 0.29). CONCLUSIONS: Transperineal ultrasound complements other imaging modalities in the anatomical diagnosis of acute perianal abscesses and fistulae. It has specific advantages over other techniques and is accurate in the detection of superficially located perirectal sepsis showing concordance with MRI and surgical findings.

Negative pressure wound therapy for sternal wound infections following congenital heart surgery.

OBJECTIVE: This study examines the efficacy of a comprehensive, multidisciplinary wound management team and negative pressure wound therapy (NPWT) for the treatment of sternal wound infections in congenital heart surgery patients. METHOD: A single-institution retrospective review of all congenital heart surgery patients with post-operative sternal wound infections who were treated with NPWT was performed. Patients were evaluated based on (a) whether NPWT occurred before or after the establishment of a multidisciplinary wound management team, and (b) whether NPWT was initiated early (within 2 days) or late (greater than 2 days) after diagnosis of a sternal wound infection. RESULTS: The median duration of NPWT was 12 days (range 2-50 days). NPWT was successfully initiated in patients as young as 15 days of age. There was a trend toward shorter duration of both NPWT and antibiotic use following (a) the implementation of the multidisciplinary wound management team, and (b) in patients with early use of NPWT; however, these results did not achieve statistical significance. CONCLUSION: NPWT can be successfully utilised in congenital heart surgery patients, including young neonates, for the treatment of sternal wound infections. The trends observed in the reduction of wound therapy duration and antibiotic duration with early implementation of negative pressure therapy and multidisciplinary wound management require further investigation to verify their clinical efficacy in patient care.

Thickened hyperechoic outer epineurium, a sonographic sign suggesting snapping ulnar nerve syndrome?

PURPOSE: Snapping ulnar nerve syndrome (dislocation of the ulnar nerve over the medial epicondyle) is one of many causes of ulnar neuropathy at the elbow. This preliminary study was performed to search for sonographic signs suggesting the presence of this condition. METHODS AND MATERIALS: We retrospectively investigated 11 patients with snapping ulnar nerve syndrome (SNAP) in comparison with an age-matched group of 20 patients with idiopathic cubital tunnel syndrome (SNU). Patients were grouped according to the presence of paretic or merely sensory deficits. Nerve cross section area (CSA) and thickness of outer epineurium (ET) was measured and correlated with neurological findings. Statistical differences were evaluated with the Mann-Whitney U-Test. RESULTS: 5 SNAP (10 SNU) patients had sensory symptoms only, 6 SNAP (10 SNU) patients had paretic deficits. CSA in sensory SNU was 0.14 cm(2), in paretic SNU 0.19 cm(2), in sensory SNAP 0.15 cm(2) and in paretic SNAP 0.14 cm(2). ET in sensory SNU was 0.85 mm, 0.8 mm in paretic SNU, 1.05 mm in sensory SNAP and 1.1 in paretic SNAP. Differences in CSA were not significant depending on symptoms or group, differences in ET were not significant depending on symptoms but on group (SNAP versus SNU) at α = 0.05. CONCLUSION: A thickened, hyperechoic outer epineurium in a patient with ulnar neuropathy at the elbow might be a statistically significant differential feature of snapping ulnar nerve syndrome and should be involved in a further functional sonographic evaluation during flexion/extension of the elbow.

Human papillomavirus vaccination in Africa: An airway perspective.

INTRODUCTION: Recurrent respiratory papillomatosis (RRP) is a chronic condition caused by Human papillomavirus six (HPV-6) and HPV-11 that involves the respiratory tract. Disease severity ranges from mild (hoarseness), through to severe (stridor, respiratory distress and airway emergencies). Africa has the fastest growing and youngest population of all the continents. It also has the greatest burden of cervical cancer. There is an association with infection of the oncogenic HPV strains and the strains responsible for RRP. It is reasonable to conclude that although RRP may be underestimated in low-to-middle-income countries, it poses a considerable health risk to Africa. The primary aim of this project was to assess the suitability of HPV vaccination coverage on the African continent. METHODS: A prospective study was designed to consist of an online survey. It was distributed to 135 African otolaryngologists. Questions focussed on HPV vaccination programmes; whether they were government directed; and their rollout. Information from countries that had multiple otolaryngologists respond to the survey were compared. Additionally, data review and corroboration were performed. RESULTS: There were 58 (43%) participants from 19 countries. Nine countries reported a national vaccination programme (NVP), five used Cervarix; four used quadrivalent Gardasil. Collateral data revealed 18 of 54 countries had NVP in Africa and 26 countries had completed HPV vaccine pilot or demonstration projects. CONCLUSIONS: HPV vaccination in Africa should be urgently re-evaluated to include the HPV-6 and HPV-11 strains that cause JORRP, which have not been recognised during national vaccination programme planning.

Punched nerve syndrome: ultrasonographic appearance of functional vascular nerve impairment.

PURPOSE: The mechanical impact of a neighboring vessel on a "punched" nerve segment is thought to be one possible cause of compression neuropathy but has not been proven definitively. We report on 9 subjects with unclear clinical mononeuropathies in whom we could clearly define peripheral nerve impairment by such vessels on real-time high-resolution ultrasound (HRUS). MATERIALS AND METHODS: Nine subjects with unclear mononeuropathy based on clinical neurological examination were referred to our department for HRUS assessment. The shape, inner and outer echotexture, size and diameter, and overall integrity of these nerves were assessed including an exact analysis of the surrounding soft tissues to search for potentially extraneural pathology. This included duplex imaging to identify even tiny atypical vascular structures. RESULTS: In all patients duplex HRUS showed the pulsatile and "punching" character of the relevant vessels and the direct mechanical impact of these vessel. The involved nerve segments appeared enlarged with a hypoechoic change of echotexture including at least partial masking of their inner fascicular texture. CONCLUSION: Although rare, a "punching" vessel can be the cause of a compression neuropathy. Therefore, duplex HRUS must be included in every HRUS examination of patients with otherwise unclear mononeuropathy.

Profile of paediatric tuberculosis mastoiditis - a case series.

BACKGROUND: Tuberculosis (TB) otitis media is an uncommon site of extrapulmonary TB and can primarily present as a complicated TB mastoiditis (TBM). This complication is rare in children, even in TB endemic areas but necessitates early identification as delays can lead to severe morbidities. We describe the clinical characteristics as a case series to raise awareness of the condition, and highlight fundamentals related to diagnosis and management. METHODS: A retrospective chart review of clinical and radiological information of five children with TBM seen at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa, over the last 5 years. Variables collected included symptomatology, duration of disease, investigations and management. RESULTS: All were under 5 years of age and presented with typical features of acute bacterial mastoiditis. Mean duration of symptoms was 12 days (range 3-30 days). Two children had known TB contacts. Two children had pulmonary involvement, one with miliary TB. CT of the temporal bone demonstrated extensive bony destruction of the petromastoid and demineralised ossicles in all cases. Three children had intracranial extension. Four children demonstrated hearing loss between 30 dB and 83 dB. Necrotising granulomatous inflammation was present in the mastoid specimens in all cases. Confirmatory diagnosis was made via GeneXpert polymerase chain reaction (PCR) (2), Ziehl-Nielson (ZN) stain (1) or a positive TB culture (2). Postoperatively, one patient had normal hearing, two patients had mild conductive hearing loss (CHL), one had mild-moderate CHL and one had profound hearing loss. CONCLUSION: Delays in identification and management result in marked bony destruction and hearing loss. Radiological and surgical findings typical of TBM, therefore, require tissue sampling from the ear for urgent microscopic, PCR and histologic testing, allowing the avoidance of a mastoidectom. In a TB endemic setting, children with typical findings and necrotising granulomatous inflammation on histology should be considered for prompt commencement of anti-TB therapy while awaiting a definitive diagnosis.

Medicine and the Law.

Congenital high airway obstruction syndrome (CHAOS) is a rare condition that can be diagnosed antenatally by ultrasound. It is usually lethal without immediate intervention at delivery. A 24-year-old woman was diagnosed with fetal CHAOS at 27 weeks' gestation. The couple declined termination of pregnancy. A multidisciplinary team including obstetricians, geneticists, paediatric surgeons, neonatologists and anaesthetists was constituted to plan an ex utero intrapartum treatment (EXIT) procedure. After several simulations, a caesarean section was performed at 38 weeks' gestation under deep inhalational anaesthesia. The fetus was fully delivered with placenta remaining in utero to maintain perfusion. A surgical airway was established via tracheostomy in approximately 5 minutes. The operation was then completed with no maternal complications. The child remains well at 3 years of age. To our knowledge, this is the first EXIT procedure performed for CHAOS in the public sector. This procedure can be lifesaving and is possible with proper planning.

Optimizing ultrasound-guided biopsy of musculoskeletal masses by application of an ultrasound contrast agent.

PURPOSE: We report on a novel approach to the work-up of musculoskeletal lesions with addition of an ultrasound contrast agent followed by focal ultrasound-guided biopsy. MATERIALS AND METHODS: In this pilot study 25 patients (age: 12-75) with unclear musculoskeletal tumors underwent grayscale ultrasound, color Doppler, contrast-enhanced ultrasound and subsequent ultrasound-guided biopsy. Grayscale and color Doppler ultrasound were performed with a 12-5 MHz broadband linear transducer and contrast-enhanced ultrasound with a 9-3 MHz broadband linear transducer (iU22®, Philips, USA) using a second-generation contrast agent (SonoVue®, Bracco, Italy). After the definition of the target area by contrast-enhanced ultrasound, guided biopsies were performed with a spring-loaded tru-cut™ biopsy needle using the coaxial technique. RESULTS: The definition of enhancing and viable tumor regions resulted in a diagnostic yield of the subsequent biopsy of 100%. Seventeen tumors were classified as malignant and eight as benign, which was finally confirmed by histological work-up or the further clinical follow-up. CONCLUSION: This pilot study with a limited series of patients improved the diagnostic yield of ultrasound-guided biopsy to 100%, which is at least rather promising. Our easy-to-use algorithm should reduce the rate of inconclusive histology results mainly caused by sampling errors to an unrivaled minimum.

Notable features in composite tissue allografts: value of high-resolution ultrasonography as a first-line imaging modality.

PURPOSE: Hand transplantation is challenging, especially with respect to postoperative care. Serious complications including rejection of the transplant are possible. To date, imaging has relied mainly on plain radiography, CT and MRI. High-resolution ultrasound (HRUS) has the potential to be a quick, cost-effective and dynamic alternative at least for the initial assessment of most of these complications. We report on our experience with HRUS in three patients after bilateral hand/forearm transplantation. MATERIALS AND METHODS: Three male patients with bilateral hand/forearm transplantation after traumatic amputation underwent periodic HRUS and color Doppler assessment. These exams focused especially on the detection of changes at the coaptation sites (nerve/muscle/tendon coaptation) and expected changes in vessels and healing bones in the compound allograft. The HRUS data were compared to available data of other radiological imaging modalities. RESULTS: Relevant post-transplant changes such as neuromas, arteriovenous fistulas, heterotopic ossifications and scars were specified by HRUS. In addition information on muscle and tendon function was gained by dynamic ultrasound. In most cases no relevant information gain by other modalities was stated. CONCLUSION: Based on our experience, we recommend sonography as a first-line modality for the follow-up of patients who underwent composite tissue allografting. HRUS allows the reliable and timely diagnosis of relevant complications and the monitoring of postoperative changes and sets the course for therapy or further more invasive imaging.

Vascular considerations for stapled haemorrhoidopexy.

OBJECTIVE: Modern haemorrhoidectomy techniques aim to interrupt arterial blood supply to the hypertrophied piles. The aim of this study was to investigate morphological and physiological alterations in the terminal branches of the superior rectal artery (SRA) in patients with haemorrhoidal disease treated by stapled haemorrhoidopexy (SH) using noninvasive transperineal ultrasound. METHOD: Thirty-seven consecutive patients (14 women, 23 men; median age 52, range 30-77 years) who underwent SH for treatment of grade III haemorrhoids were scanned by transperineal colour Doppler ultrasound at baseline, 4 weeks and 3 months postoperatively. Seventeen healthy volunteers served as the control group (nine women, eight men; median age 24, range 18-72 years). Calibre and arterial flow velocity (AFV) of the terminal branches of the SRA were measured. RESULTS: Baseline measurements significantly differed between patients and the control group (median calibre 2, range 0.9-3.6 mm, vs 1, range 0.6-1.2 mm, and median AFV 24, range 10-65 cm/s, vs 12, range 5-21 cm/s, P < 0.0001). Postoperative follow-up showed no significant alterations in the physiological parameters. Patients with a higher recurrence rate of haemorrhoidal disease had higher baseline AFV values. CONCLUSION: Stapled haemorrhoidopexy does not reduce arterial inflow in the feeding vessels of the anorectal vascular plexus. Preoperative ultrasound may serve as a tool for assessing vascularization status in haemorrhoidal disease and is useful in deciding whether patients should undergo SH or, for individuals with high AFV, whether conventional haemorrhoidectomy might be the better choice.

Reintroduction of elective paediatric otolaryngology procedures in South Africa during the COVID-19 pandemic.

Cancelling elective clinical consultations and surgical procedures was instrumental in assisting hospitals prepare for the COVID-19 crisis. Essential bed space was made available, and it allowed mobilisation of health workers and enforced social distancing. A shift in patient-centred ethics to public health ethics was required to provide a utilitarian approach to the crisis. However, at some point, clinicians need to start becoming patient centred again, and this needs to happen within the utilitarian framework. Children only account for 1 - 5% of confirmed COVID-19 cases, and they present with a much milder disease spectrum than adults. Consequently, paediatric units may be at the forefront of implementing reintroduction of patient-centred elective clinical and surgical procedures. The following recommendations provide a framework to do this in a way that minimises risk to patients and clinicians. They are the first paediatric guidelines in the literature to propose a strategy to reintroduce elective surgical procedures.

'Smart' grommets.

OBJECTIVE: A novel, smartphone-based technique for endoscopic grommet insertion is presented.Results and conclusionThis method is both cost-effective and time-saving, offering a valuable alternative to the traditional microscope-based method in a resource-constrained setting.

Tympanostomy tube insertion practice in under-18-year-olds in the South African private healthcare sector insured by Discovery Health.

BACKGROUND: The reported rates of tympanostomy tube insertion (TTI) in children vary significantly internationally. Lack of adherence to evidence-based clinical guidelines may contribute to these differences. OBJECTIVES: To study the rates of TTI in South Africa (SA) in children ≤18 years old in the private healthcare sector, both nationally and regionally, to compare these with international TTI rates, and to determine the use of preoperative audiometry and tympanometry. METHODS: A retrospective analysis was done of data obtained from the Discovery Health database. Rates of TTI were analysed nationally and regionally and in different age groups, as was the use of tympanometry and audiograms. RESULTS: The SA TTI rates were much higher than published international rates except for the 0 - 1-year age group in Canada and Denmark and the 0 - 15-year age group in Denmark. There was a statistically significant regional variation in TTI rates as well as in the use of preoperative audiometry and tympanometry. CONCLUSIONS: SA private sector TTI rates are high by international standards. Significant regional variations may indicate over- or underservicing in certain regions. Further investigation of causes for the high TTI rate and regional variations is recommended. Education of healthcare professionals on recognised indications for TTI may improve patient selection.

Hearing outcomes in children with meningitis at Red Cross War Memorial Children's Hospital, Cape Town, South Africa: A silent crisis.

BACKGROUND: Bacterial meningitis is one of the most common causes of hearing loss. Hearing loss develops within the first few days following the onset of meningitis, highlighting the importance of early audiology referrals. Post-meningitis hearing loss may lead to cochlear ossification, making traditional cochlear implantation impossible. OBJECTIVES: To determine the duration of time from meningitis diagnosis to audiology referral. A second objective was to determine the prevalence and severity of meningitis-related sensorineural hearing loss (SNHL) at Red Cross War Memorial Children's Hospital (RCWMCH), a paediatric tertiary hospital in Cape Town, South Africa (SA). METHODS: A retrospective folder review of all children diagnosed with meningitis and referred for audiological evaluation was conducted over an 18-month period between 1 January 2015 and 30 June 2016. Descriptive statistical methods were used for data analysis. RESULTS: The total number of inpatients diagnosed with unspecified meningitis at RCWMCH between January 2015 and June 2016 was 345. The total number diagnosed with bacterial meningitis was 68. Only 16 children with meningitis (23.5%) were referred to the Department of Audiology at RCWMCH over the 18-month period. Twelve children had confirmed bacterial meningitis. All the children had up-to-date immunisations. The mean (standard deviation) time from diagnosis to audiology referral was 17 weeks (16.9; range 1 - 60). The overall prevalence of hearing loss was 42.8%. Four children (28.5%) were diagnosed with severe to profound SNHL. CONCLUSIONS: Less than a quarter of all children diagnosed with bacterial meningitis at RCWMCH over the 18-month study period were referred to audiology. Frequent delays in referrals for audiological assessment following meningitis were noted. This may indicate a lack of awareness on the part of doctors. Healthcare practitioners need to be made aware of the need for prompt audiological testing for children with meningitis. In SA, local guidelines for early diagnosis and monitoring of hearing in children who have had meningitis should be developed in order to improve hearing outcomes.

What is the availability of services for paediatric ENT surgery and paediatric surgery in Africa?

BACKGROUND: Children constitute 50% of Africa's population. Sub-Saharan Africa has the highest under-five mortality rates in the world. This study is the first to document the availability of paediatric ENT and paediatric surgery services in Africa. OBJECTIVE: To determine the availability of paediatric ENT services in Africa, as well as that of paediatric surgery that would complement paediatric ENT. METHOD: A descriptive observational study in the form of an online questionnaire was distributed by email to known ENT and paediatric surgeons based in Africa. RESULTS: Surgeons from twelve of 23 African countries responded to the survey. Seven countries had both ENT and paediatric surgery responses. In 8 of the 11 countries, the number of ENT surgeons per country was<6% of that of the UK, with 1 ENT surgeon per 414,000 people and 1 paediatric surgeon per 1,181,151 people. Ten of 11 countries reported hearing assessments in schools were poor/unavailable. Seventy-three percent responded positively for access to rigid laryngoscopes, bronchoscopes, cameras and fibre optic cables, tracheostomy, anaesthesia and nurse practitioners. Access was reported as poor/unavailable for balloon dilators 73% (8/11 countries); CPAP machines 73% (8/11) and sleep studies 82% (9/11 countries). Flexible endoscopes were available in 50% (4/8 countries), 75% (6/8 countries) had access to a camera, monitor and stack. Thirty-eight percent (3/9 countries) reported no ENT specialists with paediatric training. CONCLUSIONS: There is a great shortage of paediatric ENT and paediatric surgery services in Africa. More regional training opportunities and health infrastructure for these surgical specialties are needed. Collaborative development of paediatric ENT, surgery and anaesthesia should be considered to improve ENT-related child health in Africa.