Causes of delayed presentation in patients with diabetic septic foot: a short prospective case series study at Nonga General Hospital

@#Surgical services in Papua New Guinea (PNG) have seen an increase in admissions of patients with diabetic septic foot (DSF). Perception and beliefs about the causes of foot ulcer in PNG differ from medical evidence and may play a role in foot-related behaviours among DSF patients. This hospital-based prospective case series study examined the reasons for late presentation among 30 DSF patients in Nonga General Hospital from October 2013 to October 2014. Belief in sorcery was the most common cause of late presentation. Those who chose more than one home treatment were the most likely to present late, and those who presented late had a higher chance of getting a lower extremity amputation than those who presented early.

The role of surgery and oral methotrexate treatment on lower lip squamous cell carcinoma in Milne Bay Province and National Capital District, Papua New Guinea

@#This cohort study was undertaken over 54 months to observe the effectiveness of primary surgery and long-term oral methotrexate (MXT) treatment on lower lip squamous cell carcinoma (SCC) in Milne Bay Province and National Capital District, Papua New Guinea (PNG). The current standard treatment for lower lip SCC depends on the stage of the disease: stage 1 is treated with either surgery or radiotherapy only, while stages 2 and 3 are treated with surgery followed by chemotherapy and radiotherapy; stage 4 is metastatic disease and is treated with palliative chemotherapy and radiotherapy. Due to limited treatment options available in Papua New Guinea for cancer patients, this study was conducted with the primary aim of finding an alternative, affordable and effective treatment option for lower lip SCC in our setting. There were 20 patients recruited in the study with histologically confirmed SCC of the lower lip. They had primary surgeries which included selective neck dissection (SND) for positive neck involvement (stages 2, 3 and 4) (8; 40%) and tumour resection and reconstruction (20; 100%), and, once the wounds had healed well, they were commenced on long-term oral MXT treatment for 24 months. The follow-up period was approximately 54 months and the results of the primary outcomes measured were: no local recurrence, no neck metastasis, no distant metastasis and no mortality. In conclusion, even though we acknowledge the small number of subjects recruited, this cohort study does give some hope to health care practitioners, including surgeons, in PNG that lower lip SCC can be alternatively treated with surgery and methotrexate when there are no other treatment modalities available in their health facility.

Factors associated with lower extremity amputation in patients presenting with diabetic septic foot: a prospective case series

@#The rapid demographic changes occurring in the Pacific island countries, including Papua New Guinea, have led to a rapid increase in the prevalence of non-communicable diseases. Surgical services in Papua New Guinea are seeing a marked increase in admissions for diabetic septic foot (DSF). Lower extremity amputation is common, although specific criteria for this procedure are lacking. We report a prospective case series of 20 patients admitted to the Surgical Ward of Nonga General Hospital with DSF from October 2013 to July 2014. Patients who had lower extremity amputation were younger, had a higher level of HbA1c and a higher Wagner ulcer score than those managed conservatively.

Gastroschisis management without a neonatal intensive care unit and total parenteral nutritional support

@#In the absence of a neonatal intensive care unit (NICU) and total parenteral nutrition (TPN) gastroschisis management is challenging (1). If surgical closure is not done within the first 6 hours post partum, impending complications intervene, which then prevent a good outcome in such infants. The defect near the right side of the umbilicus provides the avenue for the intra-abdominal contents to protrude into the amniotic cavity in intra-uterine life and visceral exposure to the external environment increases the morbidity after delivery. The tight 2.5-5 cm bottleneck diameter provides further complications if not surgically corrected immediately. The prognosis has improved over the years and in well-set-up hospitals more than 95% have survived. Appropriate antenatal diagnosis (2) and early neonatal surgical intervention have improved the survival of these neonates. Blood investigation to assist with the antenatal diagnosis, such as amniotic fluid beta-endorphin analysis (3) and alpha-fetoprotein, assists in anticipating severe complications. Prevention of complications such as mesenteric infarct, fluid and electrolyte imbalance, necrotizing enterocolitis (NEC) and raised intra-abdominal compartment syndrome (RIACS) (2) and providing nutritional support have resulted in the good outcome of these cases. In the absence of accurate radiological diagnosis and back-up support services such as NICU and TPN, it is challenging to manage such infants. In a country where subspecialties are lacking it is very difficult to reassure the parents of a gastroschisis patient. Most of them do not make it. The following two case reports highlight some of these limitations and the alternative measures that can be taken to address the issues.

Randomized clinical trial to compare a single dose with 3 doses of prophylactic antibiotic in open reduction and internal fixation of the fractures of long bones

@#To reduce the incidence of surgical site infection (SSI), perioperative antimicrobial prophylaxis has long been advocated for joint replacement and open reduction with internal fixation of long bones. Increasing health care costs have focused hospital interest on more cost-effective procedures. Although current literature indicates that single-dose antibiotic prophylaxis is comparable to a 3-dose regimen, there are no reports from lowincome countries. The primary aim of this study was to compare the infection rate following open reduction and internal fixation of long-bone fractures in groups with a single dose and 3 doses of prophylactic antibiotic. The secondary aim was to compare the costeffectiveness of both antibiotic regimens. This is a prospective randomized clinical trial (RCT) to compare the incidence of surgical site infection between the patients allocated randomly into two groups with different antibiotic prophylactic regimens: single dose or 3 doses 8 hourly of 1g ceftriaxone administered intravenously. 200 consecutive patients who underwent open reduction and internal fixation (ORIF) for closed long-bone fractures were enrolled in this study. The rate of postoperative SSI was 4.1% in the single-dose group and 2.2% in the 3-dose group; the overall SSI rate was 3.2%. The primary endpoint of this study, which is the incidence of SSI, showed no significant difference between the single-dose and 3-dose prophylactic antibiotic groups. Furthermore, there was no difference between groups regarding the length of hospital stay. Our randomized clinical trial affirmed that single-dose antibiotic prophylaxis in orthopaedic clean operations is not only a cost-saving practice but also is effective for SSI prevention, and should be incorporated in the development of clinical practice guidelines in tropical hospitals.

The management of spine pathology in Papua New Guinea

This paper outlines the principles of the management of different spinal diseases. In Port Moresby General Hospital between 2004 and 2006 there were 41 spinal injuries, 36 cases of spinal tuberculosis (8 of whom were operated on), 3 non-tuberculous infections and 11 degenerative conditions. The incidence of spinal dysraphism is low in Papua New Guinea with only 5 cases recorded in Port Moresby over the 3-year period. Identification and assessment of spinal pathology were sometimes limited by a lack of radiological investigation and often the resources were not available for optimal treatment. 8 cases with myelopathy had no definitive diagnosis made.