A Neonatal Early Warning System (NEWS) in Port Moresby General Hospital, Special Care

@#The neonatal mortality rate in Papua New Guinea is high, estimated at 24 per 1000 live births. The neonatal case fatality rate in newborns in provincial and referral hospitals was 5.9% in 2021. Deteriorating newborns can be difficult to identify. This observational study investigated the feasibility of using a neonatal colour coded observation and response chart to identify neonates at risk of deterioration and to promptly escalate care in the Special Care Nursery of Port Moresby General Hospital. The chart was adapted from the Plymouth Hospital Neonatal Early Warning System chart, and was used to collect data over 8 weeks between 1st May and 30th June 2022. One hundred and fifty seven (157) neonates were observed over the 72 hours following admission to the Special Care Nursery. Neonates were grouped into those that had triggers (vital signs that fell in the red zone) and a stable group (who had no observations in the red zone). Of the 157 patients recruited 72 (45.9%) were stable, and 85 (54.1%) had triggers that should prompt a response. Forty seven (55.3%) of the neonates in the trigger group had appropriate interventions. Neonates with observations in the red zone (triggers) were more likely to die in the first 72 hours compared with those with no triggers. Most of the nurse responded positively to the introduction of the chart. Whilst the Neonatal Early warning System is a tool that can be used to identify neonates at risk of clinical deterioration, proper training of its use and knowledge of and appropriate escalation of care are necessary to ensure its benefit

The Brixia Chest X Ray Severity Score in adult patients with symptomatic Covid-19 Infection : A useful guide to management

@#COVID-19 is a highly contagious viral illness with a wide spectrum of clinical manifestations ranging from asymptomatic or mild cold like symptoms to a devastating and often fatal respiratory illness. The elderly and those with underlying morbidity are the groups most often, but certainly not exclusively, associated with death from respiratory pathology. COVID-19 respiratory illness usually manifests clinically as pneumonia with predominant imaging findings of an atypical or organized pneumonia. Chest radiography (CXR) helps to assess the progress of the disease. The BRIXIA score based on radiological appearance may be used to determine the severity and clinical outcome of a patient with COVID-19. The aim of this study was to assess the relationship between the BRIXIA score and the clinical outcome of positive COVID-19 patients at Port Moresby General Hospital (PMGH) in Papua New Guinea (PNG). In this descriptive retrospective study conducted at the Radiology Department of the PMGH the records of 129 Polymerise Chain Reaction (PCR) confirmed patients admitted to PMGH between September and December 2021 were examined. The patients were grouped into mild, moderate or severe categories depending on clinical features at the time of diagnosis. There were 89 (69%) males and 40 (31%) females. The mean (SD) age was 52 (12) years, and the median (IQR) was 53 (44-60). Their admission CXRs were given a Brixia score. Mean (SD) Brixia scores for mild (n=24), moderate (n=67) and severe (n=38) were 4.5 (2.5), 8.9 (2.7) and 12.5 (3.5) respectively. The Brixia score was significantly related to the clinical severity, F 55.49, p <0.001. Twenty seven (77%) of the 35 patients who died had comorbidities of whom 21 (78%) were in the clinically severe group. A Brixia score of 9 or more was closely associated with death, p = 0.001, Odds Ratio with 95% Confidence interval (0R) of 3.9 (1.7-9.6). The Brixia CXR severity score is a useful tool in assessing clinical severity and prognosis in patients with COVID 19.

Thiamine levels in malnourished children in Port Moresby General Hospital

@#Thiamine deficiency may be associated with severe acute malnutrition (SAM) and contribute to its clinical signs and complications. This hospital-based prospective study aimed to determine if thiamine deficiency is present in children with SAM in Port Moresby General Hospital (PMGH). Convenient sampling was used to select 208 children aged between 2 months and 13 years (median age 15 and IQR 11-32 months) presenting to the Children’s Emergency Department requiring venipuncture for routine testing who had additional blood taken for assay of thiamine levels. Nutritional status was determined using the WHO weight for height (WFH) z-scores. Details of socioeconomic background and diet were recorded. Thiamine levels were determined using enzyme-linked immunosorbent assay (ELISA) test kits. A total of 158 (76%) of the 208 samples were satisfactory for analysis; 86 (54%) from children with normal WFH, 26 (17%) from those with moderate malnutrition and 46 (29%) from those with severe malnutrition. Thiamine levels were normally distributed overall. The mean was 34.18  5.8 ng/ml. This was within the reference level of 16-48ng/ml. There was no statistically significant difference in levels between the normal, moderately and severely malnourished children (33.6  5.6, 35.3  5.7 and 34.4  5.7 ng/ml). The assay of thiamine levels in serum using ELISA is not the best method for determining thiamine deficiency and further studies using whole blood and high-performance liquid chromatography are needed

Assessing Preventative Maintenance and Sustainability of Oxygen Concentrators in Health Facilities in Papua New Guinea

@#The lifespan of medical equipment depends on preventative maintenance. Properly functioning oxygen concentrators are the only practical sources of oxygen in many Low & Middle Income Countries and their use reduces mortality in hospitalised children. We provided 82 concentrators with pulse oximeters, split flow meters, oxygen tubing, and an oxygen analyser to 38 health facilities. Training and instructions on how to perform preventative maintenance were provided. The concentrators were monitored for three years after they were installed, by assessing the proportion of concentrators still producing optimal oxygen at greater than 85% purity, the proportion that underwent weekly maintenance checks, and the proportion that were faulty and repaired. A logbook for weekly documentation of performance, maintenance, faults and repairs, was employed. Faults were additionally identified by a biomedical engineer during the visits. Twenty nine oxygen concentrators underwent regular maintenance checks, 25 (86.2%) of which had a median of 30 (IQR: 9 - 65) checks. Twenty-four were functioning well throughout the three years. One concentrator was used for 23,807 hours before requiring repair. Fourteen (24%) of the 58 concentrators used at the start of the programme had problems, two were repaired, and 12 were replaced. Concentrator failure was mostly caused by excessive movement, dust, and leaking in the internal tubing. Routine preventative maintenance, thorough documentation of performance and reporting of problems, and having access to clinicians and a knowledgeable biomedical engineer are essential for oxygen concentrator longevity in health care facilities in low-resource settings.

Computed-Tomography staging of Breast Cancer and its role in Patient Management in a resource-limited setting: A retrospective study from Fiji

@#Breast cancer is now the leading cause of mortality from cancer in Women in Fiji. State of the art diagnostic measures such as MRI, PET scanning and advanced tumour markers are unavailable in many LMIC countries including Fiji, but CT is becoming more widely available. The aim of the study was to determine the association between CT/anatomical staging and prognosis in a resource-limited setting, and its role in planning appropriate treatment strategies. This was a retrospective, analytical study of the data from the Colonial War Memorial Hospital Oncology department tumour register recorded between 2013 and 2018. The mean age of the breast cancer patients with confirmed diagnosis was 54.93 years with SD of 12.4 years. There was a 40% 3 year mortality rate. CT reports were available for 196 patients. Poor prognosis was very closely associated with Tumour size (p=0.002, OR 0.26 (0.10-0.63)), Nodes (p<0.001, OR 0.25 (0.13-0.48.)) and Metastases (p<0.001, OR 0.13 (0.07- 0.25)).The lungs were the most frequent site of metastases. CT staging enables accurate TNM classification, which is closely associated with prognosis. In the absence of advanced cytopathological and imaging modalities CT staging has an important part to play in planning appropriate treatment.

Neonatal admissions to the Eastern Highlands Provincial Hospital Special Care Nursery 2011-2015

@#Background: According to the Papua New Guinea (PNG) 2015 Annual Report on Child Morbidity and Mortality, neonatal conditions remained the second leading cause of hospital admission. We aimed to identify the common causes of neonatal admissions and deaths in the Eastern Highlands Provincial Hospital (EHPH) Special Care Nursery, and to identify interventions to improve neonatal outcomes in EHPH. Method: This was a retrospective descriptive study of neonatal admissions over a 5-year period: 2011 to 2015. Data collected from the ward admission register included demographic information, admission diagnoses, outcomes and causes of death where applicable. Results: From 2011 to 2015 there were 5177 neonatal admissions and 504 deaths with an overall case fatality rate of 9.7%. More than one admission diagnosis was recorded for some babies. The leading diagnoses were prolonged rupture of membranes (PROM) (25%), low birthweight (LBW) (20%), neonatal sepsis (NNS) (18%), meconium aspiration syndrome (MAS) (16%) and birth asphyxia (BA) (14%). The leading causes of death by admission diagnosis were LBW (259/1013, 26%), BA (141/746, 19%), MAS (80/852, 9%), NNS (79/915, 9%) and babies born before arrival (BBA) (61/306, 20%). 76% of the admissions were hospital-born babies, but 46% of deaths were in the 24% of babies born outside the hospital. The independent predictors of neonatal death were LBW (odds ratio [OR] 7.31), BA (OR 5.94), health centre birth (OR 3.07) and village birth (OR 2.18). Conclusion: LBW, BA and being born outside of a hospital were the strongest risk factors for neonatal death in the Eastern Highlands during this 5-year period. For PNG to achieve the Sustainable Development Goal of a neonatal mortality rate of 12 per 1000 live births, these 3 areas need to be addressed by multifaceted approaches within and outside the health sector.

Forty years of postgraduate medical training at the University of Papua New Guinea

@#SUMMARY BACKGROUND: Forty years after the first postgraduate diplomates (in child health and obstetrics & gynaecology) graduated in 1976 it is appropriate to track the development of postgraduate training and to assess training outcomes. METHODOLOGY: Data were extracted from graduation documents from 1976 and were checked with senior academic staff and with the current postgraduate lists. RESULTS: Postgraduate diploma programs in anaesthesiology, ophthalmology and otorhinolaryngology followed those in child health and obstetrics & gynaecology. The first home-grown specialists in surgery and child health graduated in 1979 and the MMed program is now offered across the spectrum of medical disciplines with the exception of cancer medicine. Of the 344 postgraduate diplomates, a third have been females and 41 (12%) have been Pacific islanders. 166 (48%) have completed MMed and 56 (16%) are currently in the MMed programs. Since 1979, 378 specialists have graduated with the MMed and 3 with the MDS, of whom 21 (6%) have died and 2 have retired on medical grounds. 74 (19%) of the specialists are female and 40 (10%) are Pacific islanders. Of the 322 living Papua New Guinean (PNG) national specialists currently working 70 (22%) are female, 23 (7%) are currently based overseas, 30 (9%) are working in the private sector and 9 (3%) are no longer working in the medical arena. 260 (81%) are in the public sector, 240 (75%) in the clinical area and 20 (6%) in the administrative area. 22 surgical specialists and 1 anaesthesiologist have completed subspecialty training through the Higher Postgraduate Diploma programs. Other disciplines will follow suit. 12 PNG doctors have obtained overseas Fellowships or Membership of their specialty Royal College. Only 3 are currently based in Papua New Guinea. Master’s programs in community health and public health (27 graduates) were introduced in 1987, medical science (16 graduates) in 2006 and pharmacy (3 graduates) in 2012. CONCLUSION: The postgraduate programs at the School of Medicine and Health Sciences of the University of Papua New Guinea have been highly successful in training clinical specialists for Papua New Guinea and Pacific island countries, and in producing a core of the health workforce with Master’s degrees in public health, medical sciences and pharmacy. Loss of the specialist workforce overseas has been relatively small.

Zinc status of children aged 12 to 59 months resident in the National Capital District, Papua New Guinea

@#Zinc deficiency is a major public health problem in some resource-limited countries. This study assesses the zinc status of 90 pre-school-age children, aged 12 to 59 months, resident in the National Capital District (NCD), Papua New Guinea. Children attending the Children's Outpatient Clinic at Port Moresby General Hospital participated in this cross-sectional study. Informed consent was obtained from parents before using blood samples from their children. Flame atomic absorption spectrometry was used to measure the serum zinc concentration. C-reactive protein (CRP) in serum was measured by enzyme immunoassay and used to interpret the serum zinc data. The median serum zinc concentration for all the children was 83.6 μg/dl and the interquartile range was 64.6-103.7 μg/dl. The prevalence of serum zinc deficiency (Zn <65.0 μg/dl) among all the children was 26%; and 42% had elevated serum CRP level. Serum zinc deficiency was present among 31% and 20% of the children in the 12 to 24 months and over 24 months age groups respectively. The prevalence of serum zinc deficiency among the male and female children was 28% and 25% respectively. The high prevalence of zinc deficiency among the children may be caused by the high rate of subclinical infection and low bioavailability of absorbable zinc in the popular foodstuffs that they are consuming. The prevalence of zinc deficiency among the children with and without elevated serum CRP strongly suggests the need for continuous monitoring of the zinc status of pre-school-age children in the NCD

The use of blood and blood products in the Paediatric Unit of Port Moresby General Hospital

@#This prospective descriptive study aimed to document the use and the quality of delivery of blood products in paediatric patients at the Port Moresby General Hospital. Paediatric patients transfused in the Paediatric Ward, the Special Care Nursery, the general Intensive Care Unit, the full Nursing Care Ward and the Children's Outpatient Department were included. 555 transfusion requests were dispensed from the blood bank to paediatric patients during the six months from the end of February to August 2012. Detailed information about age, sex, diagnosis, indication for transfusion and whether or not this followed standard indications, timeliness of transfusion and the quality of the transfusion procedure was recorded for a convenience sample of 64 patients, 37 males and 27 females, with a median age of 33 months and an interquartile range of 9-72 months. The most common indication for transfusion was infection-related anaemia. 50% of patients transfused did not meet standard indications for this intervention. In 86% of cases there was a delay in blood transfusion, blood shortage being an important contributing factor. Adequate monitoring of transfusion occurred in only 20% of the patients. No major adverse reactions were reported. It is highly recommended that a blood transfusion checklist be designed to improve the quality of blood transfusion practices and monitoring. Clinicians need to improve their prescribing of blood in accordance with established guidelines.

The prevalence of chronic suppurative otitis media in children in Port Moresby public clinics

@#This prospective descriptive study aimed to determine the prevalence of chronic suppurative otitis media (CSOM) in children presenting to 5 urban clinics and the Children's Outpatient Department of the Port Moresby General Hospital. 395 children between the ages of 6 months and 12 years were included. 70 (18%) had some form of ear disease. Of the 28 children with CSOM (7%), 18 had unilateral and 10 had bilateral ear pathology. Only 8 of these children presented because of discharging ears. An additional 4 children had dry perforation, 1 had cholesteatoma and 2 had mastoiditis. The high prevalence of CSOM indicates that it is an issue of major public health importance. Risk factors for the development of CSOM were common in the children assessed. Prompt recognition of the problem and management by way of thorough and regular ear wicking should be stressed. Consideration should be given to making ciprofloxacin ear drops available. All clinics should have a functioning auriscope and front-line health workers should be trained to be able to diagnose and treat CSOM. Communities need education about the importance of early diagnosis and management of CSOM.

Paediatric cancer in Papua New Guinea: moving to the next stage

@#We reviewed the cases of paediatric malignancy at Port Moresby General Hospital (PMGH) over the 18 months between June 2014 and December 2015 and compared diagnoses and outcomes with previously reported data. Children with paediatric cancer account for 0.5- 1% of admissions to the PMGH Paediatric Unit and around 0.4% of admissions to provincial hospitals. Efforts to improve outcome have included establishment of linkages with and practical experience at the Children’s Cancer Centre of the Royal Children’s Hospital in practical supportive care measures established. Potentially curative chemotherapy was started on 26 of the 47 patients in the series, of whom 13 are known to have died. Better outcomes are possible within our setting. We have a paediatrician with considerable and appropriate expertise in paediatric oncology, linked to a centre of excellence in Australia, but we will need a dedicated Paediatric Cancer Unit, separate from the highly infectious paediatric wards and with its own staff. Local community support for such a unit will be required.

Child sexual abuse at Eastern Highlands Provincial Hospital: a prospective descriptive study

@#Child sexual abuse (CSA) is common throughout the world and has been recognized as a common presentation at the Eastern Highlands Provincial Hospital. The aim of this prospective study was to describe the presentations and outcomes of CSA in the hospital. A structured questionnaire was used to collect data from the guardians of 38 children aged between birth and 15 years presenting with a history of sexual abuse between February and August 2013. Children were followed up at three months to ascertain the presence of sexually transmitted infection and to determine how the issue of abuse was resolved by the family. There were 35 females and 3 males aged between 3 and 15 years with a median age of 5.5 years and interquartile range of 4-9 years. 28 (80%) of the 35 girls had been raped and one of the boys had been anally raped. Over half of the children’s mothers were illiterate and lived a subsistence lifestyle. The perpetrator was known to the subjectin 36 (95%) of the cases. Coercion was used by the perpetrators in 22 cases (58%). Gram stains of vaginal swabs from 28 children showed gonococci in 15 (54%). Compensation payments were used to resolve the issue of abuse in 13 (72%) of 18 cases at 3-month follow up. There has been an increase in the number of children diagnosed with sexual abuse at the Eastern Highlands Provincial Hospital. There is an urgent need for existing child protection laws such as the Lukautim Pikinini Act to be robustly implemented and for the development of Family Welfare Centres to provide a holistic approach to the management and support of victims of CSA and their families.

The Paediatric Society of Papua New Guinea: 40 years on and child health is at a turning point

@#The Paediatric Society of Papua New Guinea (PNG) has been in existence for 40 years, and in that time has been involved in The Society has grown from a small base to over 80 members and trainees. The Society has had a major role in developing guidelines and standards for paediatrics and child health. It has provided guidance to the Department of Health and the community on child health matters. The Society has worked closely with educational institutions to design and implement paediatric training for all cadres of health workers, and is a collegiate and friendly group supporting child health workers. This paper outlines a brief history of the Society, on its 40th anniversary.

Thirty years of the Paediatric Standard Treatment Book

The publication of the 8th edition of the Paediatric Standard Treatment Book 30 years after the first edition was introduced in 1975 provided an opportunity to examine the changes in the book's content and composition that have occurred over time. A detailed analysis of all editions of the book was made. The 8th edition is bigger, contains more clinical and guidance topics, and is undoubtedly more complex than the first. Health workers of different levels of training undoubtedly value the book, but there is evidence that it is frequently not used appropriately. The books form an important historical record of the changes in treatment of various clinical conditions that have been driven by alterations in antimicrobial susceptibility and by the emergence of evidence for efficacy. The current book is intricately linked with the Integrated Management of Childhood Illness and the treatments it contains are based on best evidence and practicality. Whilst there are challenges in ensuring that the information in the standard treatment book is accessible, practical and up to date, the book will continue to provide the basis for treatment of the common conditions presenting in children in the future.

Mortality in children admitted to Port Moresby General Hospital: how can we improve our hospital outcomes?

A detailed audit, part retrospective and part prospective, of deaths occurring in children admitted to the children's wards of the Port Moresby General Hospital over a 12-month period was made. 238 children died out of the 4898 admitted, an overall case fatality rate of 4.9%, with a monthly range of 3.7%-9.6%. The proportion of deaths approximated the proportion of admissions in each age group. 92% of the children had a weight of less than 80% of the standard weight for age and 30% weighed less than 60% of the standard weight for age. 24 (11%) of the deaths occurred within the first 6 hours of admission, 39 (17%) within the first 12 hours and 58 (26%) within the first 24 hours. 89 children (40%) died more than one week after admission. Pneumonia, meningitis, measles and septicaemia were the four leading certified causes of death and paediatric AIDS was the fifth. Less than half of the deceased children were appropriately immunized for their age. 27 deaths (12%) were assessed as preventable. 150 (67%) were classified as from treatable causes but unavoidable, 18 (8%) from untreatable causes, 22 (10%) of undetermined cause and 34 (15%) avoidable. The factors associated with avoidable deaths were delayed treatment (20 children), inadequate treatment (8 children), incorrect treatment (1 child) and others (5 children). Infant and child mortality could be reduced by general measures such as improving community nutrition and immunization status and improving care-seeking behaviour. Hospital-related measures to reduce mortality include improving the accuracy and effectiveness of triage and provision of adequate staffing levels and bed space. Periodic in-depth audit is necessary to assess quality of patient care, to identify problems and to point towards their solution. Accurate recordkeeping is essential for appropriate audit and planning.

Neonatal outcome at Modilon Hospital, Madang: a 5-year review

An audit of neonatal care at Modilon Hospital, Madang was performed using obstetric and neonatal data for the five years 1995-1999. The overall perinatal mortality rate (PNMR) was 51.1 per 1000 total births with an early neonatal mortality rate (ENNMR) of 12.7 and a stillbirth rate (SBR) of 38.5. 839 neonates aged 0-28 days were admitted to the Special Care Nursery. The male to female ratio was 1.3:1. 186 babies (22%) died. The case fatality rate was higher in males than females (p<0.001). Babies born at health centres or born before arrival had a significantly higher fatality rate than hospital-born babies (p<0.001). The case fatality rate was highest in babies born preterm and declined with increasing birthweight from less than 1000 to 3999 g. The major recorded causes of admission were neonatal sepsis, prematurity, neonatal jaundice, birth asphyxia, respiratory distress and meconium aspiration syndrome. 60% of deaths occurred within 48 hours of admission, 32% between 48 hours and 7 days and 8% at 7 days or older. The proportion of deaths occurring during the afternoon and night shifts was significantly higher than that during the morning shift (p<0.001). This was most likely to be related to staffing levels. The major causes of death were prematurity or low birthweight (27%), sepsis (23%) and birth asphyxia (17%). Other causes of death included congenital abnormalities, meconium aspiration and meningitis. Antenatal care is still not universally available for Papua New Guinean women. Home delivery of high-risk mothers is commonplace, and women delivering in hospital often present in established labour. Perinatal and neonatal problems are therefore frequent. Newborn babies have the right to the best available care. This can only be provided if hospitals and health facilities understand the basic requirements of neonatal care and provide designated space, adequate staffing and proper equipment.