Responding to the need: An evaluation of the subspecialty units in a pediatric surgical department in a limited resource setting using selected optimal resources for children's surgery strategies.

BACKGROUND: The Global Initiative for Children's Surgery group published the Optimal Resources for Children's Surgery (OReCS) document outlining the essential criteria and strategies for children's surgical care in low-resource settings. Limited data exist on subspecialties in pediatric surgery and their contribution to global surgery efforts. The study aimed to evaluate the development of subspecialty units within Chris Hani Baragwanath Academic Hospital (CHBAH) Department of Pediatric Surgery (DPS) from January 1, 2018 to December 31, 2021 using selected OReCS strategies for the improvement of pediatric surgery. METHODS: A retrospective descriptive research design was followed. The study population consisted of CHBAH PSD records. The following data were collected: number of patients managed in PSD subspecialty unit (the units) clinics and surgeries performed, number of trainees, available structures, processes and outcome data, and research output. RESULTS: Of the 17,249 patients seen in the units' outpatient clinics, 8275 (47.9%) burns, 6443 (37.3%) colorectal, and 2531 (14.6%) urology. The number of surgeries performed were 3205, of which 1306 (40.7%) were burns, 644 (20.1%) colorectal, 483 (15.1%) urology, 341 (10.6%) hepatobiliary, and 431 (12.8%) oncology. Of the 16 selected strategies evaluated across the 5 units, 94% were available, of which 16.4% was partly provided by Surgeons for Little Lives. Outcome data in the form of morbidity and mortality reviews for all the units is available, but there is no data for timeliness of care with waiting lists. There were 77 publications and 41 congress presentations. CONCLUSION: The subspecialty units respond to the global surgical need by meeting most selected OReCS resources in the clinical service provided.

The epidemiology of traumatic brain injuries sustained by children under 10 years of age presenting to a tertiary hospital in Soweto, South Africa.

BACKGROUND: Traumatic brain injury (TBI) in the paediatric population is a significant contributor to death and disability worldwide. In sub-Saharan Africa, death and disability from TBI are still superseded by infectious disease. Mechanisms of injury differ by region and socioeconomics, but in general, falls, road traffic collisions (RTCs), being 'struck by/against objects' and non-accidental injuries (NAIs) are responsible for most cases. OBJECTIVES: To: (i) quantify the burden of TBI in terms of demographics, causes and severity; (ii) explore resource utilisation regarding length of stay, computed tomography (CT) brain scan use and multidisciplinary participation; (iii) interrogate possible temporal patterns of injury; and (iv) thus identify potential targets for community-based prevention strategies. METHODS: In a 5-year retrospective review of all children aged <10 years admitted with TBI between September 2013 and August 2018, demographics, date of injury, mechanism of injury, severity of TBI based on the Glasgow Coma Scale, and requirement for a CT brain scan were collected for each patient. Outcomes were reported as discharge, transfer or death. Outcomes for children sustaining isolated TBI were compared with those for children sustaining TBI with polytrauma. RESULTS: A total of 2 153 patients were included, with a mean (standard deviation) age of 4.6 (2.7) years and a male/female ratio of 1.7:1. RTCs were the most frequent cause of injury at 59% (80% of these were pedestrian-vehicle collisions), followed by falls at 24%. Mild TBIs accounted for 87% of admissions, moderate injuries for 6%, and severe injuries for 7%. Polytrauma was associated with increased severity of TBI. The cohort had a 2.3% mortality. NAIs accounted for 6% of injuries and carried a 4% mortality. The median (interquartile range) duration of hospitalisation was 1 (1 - 3) days, ranging from <24 hours to 132 days. CT scans were performed on 43% of admitted patients, and 48% of patients had consultations with another medical or allied medical discipline. Injuries were more frequent during the summer months and over weekends. Infants aged <1 year were identified as a group particularly vulnerable to injury, specifically NAI. CONCLUSIONS: Paediatric TBI was demonstrated to be a resource-intensive public health concern. From the results, we identified potential primary prevention targets that could perhaps be incorporated into broader community-based intervention programmes. We also identified a need to study long-term consequences of mild TBI further in our paediatric population.

Correlation of white cell count and CRP in acute appendicitis in paediatric patients.

BACKGROUND: Ten per cent of children who present with abdominal pain at an emergency department are diagnosed with acute appendicitis. The diagnosis of which relies on clinical acumen, but addition of tests such as measurement of the white cell count (WCC) and C-reactive protein (CRP) are needed to decrease the morbidity associated with inappropriate surgical management. This study evaluates the sensitivity, specificity and accuracy of the WCC and CRP separately and when used in combination and evaluates whether an increased WCC and CRP are associated with complicated appendicitis. METHOD: A retrospective record review of all paediatric patients who underwent appendicectomy between June 2010 and December 2016 was conducted. Demographic data, the WCC, CRP and histology results were reviewed. RESULTS: 763 records were reviewed. The sensitivity and specificity of the WCC were 69.6% and 43.1% respectively and of the CRP were 95.4% and 24.5% respectively. The sensitivity was higher when both the CRP and WCC were elevated (97.47%). A normal WCC and CRP had a specificity of 98%, with an odds ratio of 8.69 of a patient not having appendicitis. There was a borderline significance between the WCC and the presence of acute appendicitis (p = 0.0494). The CRP was significant in patient with acute appendicitis (p < 0.0001). The WCC and CRP between uninflamed appendix specimens, uncomplicated appendicitis and complicated appendicitis was significant. CONCLUSION: Both increasing CRP and WCC correlates with an increased likelihood of the presence of complicated appendicitis. The chance of a patient having appendicitis with both normal WCC and CRP is low.

Management of undifferentiated embryonal sarcoma of the liver in children: a case series and management review.

BACKGROUND: Undifferentiated embryonal sarcoma of the liver (UESL) is a rare neoplasm, and the third-most common paediatric hepatic malignancy. However, no treatment guidelines exist. No randomised, controlled trials support specific combinations of therapy. OBJECTIVE: To compare presentation and management of UESL with other series, review the literature, and formulate treatment guidelines. METHODS: A retrospective chart review of all hepatic malignancies was conducted from 1996 to 2007 and 5 children with UESL were identified. Management and outcomes were documented. The literature regarding treatment modalities up to September 2012 was reviewed. RESULTS: Over a period of 11 years, 5 patients presented. All underwent surgery and 4 received chemotherapy. One received radiotherapy at relapse. Three are disease-free with follow-up of 58 - 184 months. One died after relapse, as did the patient whose family declined chemotherapy. CONCLUSION: The improved outcomes are consistent with the international experience and are probably related to combined treatment modalities and advances in supportive care. Pre-operative percutaneous biopsy provides no benefit if the lesion is resectable because it may not prove to be diagnostic, and may cause recurrence in the biopsy tract. If resectable, the recommended treatment is primary excision and adjuvant chemotherapy, with radiotherapy in selected cases. If unresectable, open biopsy is necessary to document histology, and neo- adjuvant chemotherapy is given prior to resection. If deemed unresectable, liver transplantation is considered.

Paediatric liver transplantation in Johannesburg: initial 29 cases and prospects for the future.

BACKGROUND: The Wits Donald Gordon Medical Centre paediatric liver transplant programme is the second such unit in sub-Saharan Africa. Initiated in November 2005, it forms part of the centre's solid organ transplant unit, comprising kidney, liver and simultaneous kidney-pancreas arms. Initially established in the private sector, we recently received government approval to expand our programme into the provincial sector and have performed transplants on several provincial-sector patients. Current challenges relate to the lack of appropriately trained paediatric sub-specialists, specifically critical care practitioners and hepatologists. METHODS: Subsequent to institutional approval, a retrospective chart analysis of all paediatric liver transplants performed at our facility to date was conducted. RESULTS: Defining children as those under 18 years of age, 29 patients have received a cadaveric liver transplant since 2005, using 16 whole livers, 10 reduced-size grafts, and 3 split segments; 13 were transplanted with biliary atresia, 3 hyperoxalurea, 3 autosomal recessive polycystic disease, 2 alpha-1 antitrypsin deficiency, and 2 idiopathic, with the remainder for a wide spectrum of other pathologies. Seven patients received combined liver-kidney transplants. There were 3 in-hospital mortalities. The remaining 26 patients are all long-term survivors. We describe 7 acute surgical morbidities in 6 patients, and 8 long-term surgical morbidities. One patient was subsequently re-transplanted in Cape Town. CONCLUSIONS: Despite a shortage of organs, we have overcome a steep learning curve, with results comparable with other early series. The current threat to the continued viability of our unit is the lack of appropriately trained paediatric hepatologists and intensivists.

Damage control in the abdomen and beyond.

BACKGROUND: Damage control is not a modern concept, but the application of this approach represents a new paradigm in surgery, borne out of a need to care for patients sustaining multiple high-energy injuries. METHODS: A Medline search was performed to locate English language articles relating to damage control procedures in trauma patients. The retrieved articles were manually cross-referenced, and additional academic and historical articles were identified. RESULTS AND CONCLUSION: Damage control surgery, sometimes known as 'damage limitation surgery' or 'abbreviated laparotomy', is best defined as creating a stable anatomical environment to prevent the patient from progressing to an unsalvageable metabolic state. Patients are more likely to die from metabolic failure than from failure to complete organ repairs. It is with this awareness that damage control surgery is performed, enabling the patient to maintain a sustainable physiological envelope.

Mobile mammography: the first six-months experience at Mount Sinai Hospital.

Mount Sinai Hospital's Mobile Mammography Program, BreastCheck, is designed to screen large numbers of women for breast cancer in the greater Hartford area. Despite the American Cancer Society recommendations for screening mammography, many physicians still are not complying with these guidelines. This report details our first six-months experience. Two thousand two hundred thirty women were screened, 38 women had biopsies, and 14 cancers were detected. The overall rate of breast cancer detection is 6.3/1,000 which compares favorably with the rates from the National Breast Cancer Demonstration Detection Project (BCDDP) of 4.6/1,000.