The spectrum of orofacial clefts and treatment logistics at Universitas Academic Hospital, Bloemfontein, South Africa.

BACKGROUND: Cleft lips and/or palates should be identified early and be operated on at specific ages according to international recommendations. In African countries, however, cleft lip and palate surgeries are often delayed. METHODS: A retrospective, descriptive study was done to determine the distribution, specific time delays, demographics and loss to follow-up of patients with cleft lip and/or palates treated at Universitas Academic Hospital over a 10-year period. Data was obtained from outpatient files from the Plastic and Reconstructive Surgery Department at Universitas Academic Hospital. Two hundred and three of 318 records (63.8%) had the defined variables documented. RESULTS: The median time from first presentation to specialist consultation was 1.9 months. The median ages for first presentation was 2.2 months and for specialist consultation 5.2 months. Patients mainly had isolated cleft palates (42.4%), followed by both cleft lip and palate (31%) and isolated cleft lips (24.6%). A quarter of patients (25.6%) were lost to follow-up. More than a third (36.5%) of patients were referred from the local Motheo district and 12.8% were referred from Lesotho. CONCLUSION: In our setting, patients with cleft lip and/or palate are generally diagnosed and referred late. These patients also have delayed access to specialist consultation. Often patients are only evaluated by specialists at ages whereby they should have already undergone their first surgeries. Too many patients are lost to follow-up.

Devolution and the regional health divide: a longitudinal ecological study of 14 countries in Europe.

BACKGROUND: Greater regional devolution can reduce economic inequalities between regions; however, the impact on health inequalities is not clear. We investigated the association between changes over time in the level of devolution in European countries and regional economic and health inequalities. METHODS: We used the proportion of government expenditure controlled by subnational levels of government as our measure of devolution in 14 European countries between 1995 and 2011. Fixed effects linear regression models were used to analyse trends in the level of devolution, trends in regional economic inequalities (Gini-coefficient) and trends in regional health inequalities (slope index) in life expectancy. RESULTS: Each additional percentage of government expenditure managed at subnational level reduced the Gini-coefficient of regional GDP by -0.17 points (95% CI: -0.33 to -0.01; P = 0.04). However, it increased the slope index of regional life expectancy by 23 days (95% CI: -2 to 48; P = 0.07). When trends in regional economic inequalities were controlled for, as a potential mediator-increased devolution-was significantly associated with an increase in health inequalities between regions (P = 0.01). CONCLUSIONS: Increased devolution does not appear to reduce regional health inequalities-even when it reduces regional economic inequalities-and it could be associated with increased health inequalities.

Socioeconomic deprivation and the burden of head and neck cancer-Regional variations of incidence and mortality in Merseyside and Cheshire, North West, England.

OBJECTIVES: The aim of this longitudinal study was to examine the distribution of head and neck cancer (HANC) disease burden across the region comparing it to national trends. DESIGN: We undertook a retrospective study of routine data combining it with indicators of deprivation and lifestyle at small geographical areas within the 9 Local Authorities (LAs) of Merseyside and Cheshire Network (MCCN) for head and neck cancers. Data from the North West of England and England were used as comparator regions. SETTING: This research was undertaken by the Cheshire and Merseyside Public Health Collaborative, UK. PARTICIPANTS: The Merseyside and Cheshire region serves a population of 2.2 million. Routine data allowed us to identify HANC patients diagnosed with cancers coded ICD C00-C14 and C30-C32 within 3 cohorts 1998-2000, 2008-2010 and 2009-2011 for our analysis. MAIN OUTCOME MEASURES: Directly age-standardised incidence rates and directly age-standardised mortality rates in the LAs and comparator regions were measured. Lifestyle and deprivation indicators were plotted against them and measured by Pearson's correlation coefficients. RESULTS: The incidence of head and neck cancer has increased across the region from 1998-2000 to 2008-2010 with a peak incidence for Liverpool males at 35/100 000 population. Certain Middle Super Output Areas contribute disproportionately to the significant effect of incidence and mortality within LAs. Income deprivation had the strongest correlation with incidence (r = .59) and mortality (r = .53) of head and neck cancer. CONCLUSION: Our study emphasises notable geographical variations within the region which need to be addressed through public health measures.

Cervical squamous intraepithelial lesions and associated cervical infections in an HIV-positive population in Rural Mpumalanga, South Africa.

BACKGROUND: The incidences of genital human papillomavirus (HPV) infection, associated squamous intraepithelial lesions and cervical squamous cell carcinoma are significantly increased in HIV-positive women. The role of other cervicovaginal infections in the acquisition of the HPV infection, cervical carcinogenesis and genital HIV infection remains largely speculative. METHODS: A retrospective study was conducted including 1087 HIV-positive women in rural Mpumalanga province, South Africa, for the period 1 May 2009 to 31 August 2010. For each patient, the age at first presentation, cervical cytological diagnosis, subsequent follow-up cytology and histology, and microscopically visible infections (including endemic Bilharzia) were tabulated and statistically analysed. RESULTS: The prevalence of low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), squamous cell carcinoma, atypical squamous cells of undetermined significance (ASC-US) and atypical squamous cells, cannot exclude HSIL (ASC-H) in the study population were 22.1%, 30.9%, 0.6%, 13.5% and 4.0%, respectively. LSIL, HSIL and squamous cell carcinoma were diagnosed, respectively, at the average ages of 35.7, 37.9 and 37.2 years. Four patients with cervical intraepithelial neoplasia grade 1 (CIN1), 32 with CIN2/CIN3 and two with cervical squamous cell carcinoma were also diagnosed with Bilharzia. Of the other infections only bacterial vaginosis had a positive statistical correlation with HPV-induced cervical abnormalities (LSIL, HSIL or squamous cell carcinoma). CONCLUSION: This study confirms the high prevalence of progressive HPV-associated cervical disease in a rural Southern African HIV-positive population, which is at least equal to or worse than in other African HIV-positive studies. The high incidence of Bilharzia infection in those cases that underwent cervical cone excision suggests a possible relationship with progressive HPV disease and cervical carcinogenesis. Bacterial vaginosis (perhaps in combination with Bilharzia) may compromise the normal barriers against HPV and HIV infection.

Detection of peritoneal adhesions using ultrasound examination for the evaluation of an innovative intraperitoneal mesh.

BACKGROUND: In this multicenter study, we evaluated the efficiency of a specific ultrasound examination in detecting postoperative bowel adhesions and assessed the adhesion rate associated with the intraperitoneal use of Parietex composite mesh (polyester mesh covered on the visceral side by a hydrophilic resorbable film). METHODS: Eighty patients (36 male, 44 female; average age, 58.2 years [ranges 30-80]) were included in a study carried out at eight centers. The main inclusion criterion was the surgical treatment of incisional and umbilical hernias using an intraperitoneal mesh. The results of a preoperative ultrasound examination were compared to a macroscopic perioperative exploration. In addition, in 76 of the 80 patients, a postoperative ultrasound examination was repeated at 2 and 12 months. RESULTS: The ultrasound findings for peritoneal adhesion detection were as follows: sensitivity, 77%; specificity, 74%; positive predictive value, 65%; negative predictive value, 84%; accuracy, 75%. Postoperative adhesions after 1 year were detected in 14% of patients. CONCLUSIONS: Although these patients had undergone repeated surgery and treated to be (obese) body mass index (mean, 28), the ultrasound exam had a high accuracy rate; when it was negative, there were no adhesions in 84% of cases. The use of a hydrophilic composite mesh is associated with a low rate of adhesions (14%).

[Strangulated obturator hernia: a report of 17 cases]. / Hernie obturatrice étranglée: à propos de 17 cas.

PURPOSE OF THE STUDY: To assess clinical, therapeutic and diagnostic findings of strangulated obturator hernias. PATIENTS AND METHOD: Retrospective study of 17 patients (16 women, 1 man; average age: 81.7 years), all treated in the same service, for strangulated obturator hernia. The studied criteria were: clinical characteristics (general status, obstruction, sign of Romberg-Howship), morphologic exams, mean delay for surgical treatment, and occurrence of postoperative complications. RESULTS: The clinical examination revealed small bowel obstruction in 94% of the patients (n = 16) and incomplete obstruction in 1 patient; 23.5% of the patients presented a sign of Romberg-Howship. A major slimming was observed in 82% of the cases. A computed tomography, performed in 3 patients, showed the presence of air in the under-pubic channel. Preoperative diagnosis of obturator hernia was suspected in 23.5% of the cases. Surgical treatment was performed after a mean delay of 5.3 d. The mortality and morbidity rates were respectively 35 and 18%. CONCLUSION: Due to the low specificity of clinical examination, preoperative diagnosis of obturator hernia remains difficult. Computed tomography can be of great help for the diagnosis. Any therapeutic delay increasing mortality rate, surgery is mandatory in case of small bowel obstruction in order to make the diagnosis and the treatment of such rare pathology.

[Abdominoperineal resection for locally recurrent rectal cancers following anterior resection]. / Amputation abdominopérinéale pour récidives locales des cancers du rectum après résection antérieure.

STUDY AIM: The aim of this retrospective study was to evaluate the short and long term results of abdominoperineal resection for local recurrence following low anterior resection of a rectal adenocarcinoma and to determine the prognostic factors. PATIENTS AND METHODS: From January 1978 to December 1996, 35 patients (17 women, 18 men) with a mean age of 59.4 years, underwent an abdominoperineal resection for local recurrence after low anterior resection of a rectal adenocarcinoma. The primary tumor was below the peritoneum in 29 cases, and the mean security margin was 3 cm under the tumor. Tumor staging at the time of primary surgery included 23 Dukes B, 11 Dukes C, and 1 Dukes D. The mean time elapsed between low anterior resection and local recurrence was 16.4 months. The histological diagnosis of recurrence was obtained preoperatively in 29 cases (82.8%). RESULTS: Resection was curative in 12 patients and palliative only in 23 patients. The recurrence was intramural in 3 cases, extramural in 10 cases, and mixed in 22 cases. Ten patients had an extended "en bloc" resection including one or several adjacent organs, and a synchronous metastasis was resected in 2 cases. The mortality rate was 2.8% (n = 1) and the morbidity rate was 23% (n = 8). The 1-year and 5-year survival rates were respectively 77 and 30.2% with the univariate analysis of prognosis factors of survival, there were four pretherapeutic factors (age, staging of the primary tumor, delay of the recurrence, CEA rate) and four therapeutic factors (curative resection, extramural recurrence, staging of the recurrence, postoperative radiotherapy). The curative or not curative type of resection was the only independent predictor of survival with multivariate analysis. CONCLUSION: The results of this study seem to justify an abdominoperineal resection for local recurrence after low anterior resection whenever possible. Long-term results may possibly be improved by using adjuvant treatment.

[Internal hernia: a rare cause of intestinal obstruction. Apropos of 14 cases]. / Hernie interne: une cause rare d'occlusion intestinale. A propos de 14 cas.

AIM OF THE STUDY: Internal hernia is an uncommon cause of acute intestinal obstruction. The aim of this study was to retrospectively evaluate the diagnosis, the management, and the follow-up of the internal hernias operated over a 10-year period in our department of visceral surgery. METHODS: 14 spontaneous internal hernias were observed. The patients were evaluated with respect to symptoms, radiological findings, time elapsed between the onset of symptoms and surgery, type of operation performed, postoperative morbidity and mortality, postoperative stay, and follow-up. RESULTS: There were 8 men and 6 women. The preoperative diagnosis was evoked in only one case. The mean time elapsed between the onset of the symptoms and surgery was 31.1 hours (range 6 to 72 hours). Two intestinal resection were performed. Mean postoperative hospital stay was 11.3 days (range 6 to 22 days). The morbidity was 21.4% with no mortality. Mean follow-up was 7 months (range 3 to 15 months); one patient developed an incisional hernia. CONCLUSION: Since preoperative diagnosis of an internal hernia is difficult because of the lack of specific signs, morbidity and mortality can be decreased with early surgical intervention. Operative risks include vascular accidents, especially to hernia neck vessels.

Bloodborne viruses in forensic medical practice in South Africa.

Health care workers are at risk of exposure to bloodborne viruses including human immunodeficiency virus types 1 and 2 (HIV-1 and -2), hepatitis B virus (HBV) and hepatitis C virus (HCV). However, limited data is available regarding these risks to forensic medical personnel who are exposed daily to large numbers of severely traumatized bodies in South Africa, a country that has an existing and growing HIV epidemic and a high HBV seroprevalence. Because no specific prescriptions ensuring occupational safety in this regard exist for forensic medical personnel in South Africa, the prevalence of bloodborne viruses within this setting must be determined. Blood was taken randomly from 263 bodies examined at the Medicolegal Laboratory in Pretoria. Serologic tests to detect antibodies to HIV, HCV, and human T-cell lymphotropic virus types I and II (HTLV-I and -II) and to detect the presence of HBV surface antigen (HBsAg) were performed and positive results confirmed using conventional serologic assays. Serologic tests detected at least one of the four bloodborne viruses in 21% of cases. The overall seroprevalence for HIV-1/2 was 11%, rising to 19% in the sexually active reproductive age group (15 - 49 years). The HBsAg prevalence overall was 8%, rising to 9% in sexually active reproductive individuals. There was a low overall HCV seroprevalence of 1% and an even lower HTLV-I/II seroprevalence of 0.01%. Forensic medical personnel in South Africa are therefore at risk of exposure to bloodborne viral pathogens in, on average, 1 of 5 bodies autopsied. This risk is compounded by the high daily workload, traumatized state of many of the bodies, and adverse working conditions. It is imperative that occupational health safety guidelines be created for the forensic medicine discipline and crime scene attendants in South Africa.