Right-sided Weakness in a Rwandan Patient with Unrepaired Tetralogy of Fallot

Background

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease encountered in pediatrics. Long-term survival after surgical repair has improved; however, reported mortality rates in unrepaired TOF are significant. Associated complications include neurological sequelae, most frequently brain abscess and stroke. In countries without early intervention for congenital heart disease including TOF, delayed presentations and complications require recognition by healthcare workers.

Case presentation

A 22 year old male with a history of unrepaired TOF presented to Rwanda’s tertiary university hospital, University Teaching Hospital of Kigali (CHUK) with acute right-sided hemiparesis. Diagnostic imaging identified a left-sided brain lesion consistent with brain abscess and cardiac mass concerning for an endocardial vegetation. He was managed with intravenous antibiotics, but subsequently died due to complications of septicemia.

Conclusion

In countries where surgical repair of TOF is not available, early recognition and medical management are key in temporizing the development of devastating sequelae. Describing the prevalence of CHD in Rwanda is urgent, requiring further research by which effective prevention and treatment strategies can be developed.

Patterns of injuries among Children visiting Gondar town public health institutes, Northwest Ethiopia, 2019

Background: Injuries have been recognized as the leading cause of death in children for nearly 40 years. However, most epidemiological studies of injuries have not been community-based and are limited either to a single type of injury, such as head injuries or burnsor to a specific cause of injury, such as consumer products.

Objective: To determine patterns of injuries among children visiting Gondar town public health institutes, Northwest Ethiopia,2019.

Methods: An institutional-based prospective cross-sectional study was conductedamong children visiting Gondar town public health institutes of Amhara region, Northwest Ethiopia from June 25 to September 25, 2019. A total of 385 participants were included in the study. Data were entered into Epi-info version 7.2.1 and exported to SPSS version 21.0 for analysis and descriptive statistics were presented in text, tables, charts, and graphs.

Result: The majority of the pediatric trauma cases were seen in males 61.8%, (n = 238) and females comprised only 38.2% (n = 147). Stone or stick injury (29.1%) was the most common mode of trauma followed by road traffic injuries (21.0%), falls (19.0%), and burns (14.0%). The majority of injuries happened during playing (53%) and around the home (37.9%). In this study the three top most frequent sites of injuries were: lower extremity injury 167 (43.4%), upper extremity127 (33.0%), and head injury 50 (13.0%).

Conclusion and recommendation: The high rate of pediatric trauma from sticks or stones, roadways, and falls highlights the need for increased supervision and identification of specific dangers when playing. In our scenario, a comprehensive trauma registry appears to be critical for developing policies to lessen the burden of pediatric trauma. Further research with large sample size and associated factors for pediatric injuries is recommended.

Children with Conductive Hearing Loss Fitted with Hearing Aids: Outcomes and Caregiver Experiences in South Africa

Introduction Hearing aids are a frequent management option for children with conductive hearing loss (CHL) and it is necessary to determine the efficacy of outcomes. Limited information regarding caregivers’ perceptions and experiences are available to examine outcomes in this population.

Objectives To describe hearing aid outcomes and caregivers’ experiences for children with CHL who wear behind-the-ear (BTE) hearing aids.

Methods Retrospective review of clinical data from 19 children between 0 and 13 years of age with CHL, who were fitted with BTE hearing aids between January 2017 and March 2020. Hearing aid outcomes were documented at one month post-hearing aid fitting, via average daily use and caregiver and teacher reports obtained through the Parents’ Evaluation of Aural/oral performance of Children (PEACH) and the Teachers’ Evaluation of Aural/oral performance of Children (TEACH). Telephonic surveys were conducted with 13 caregivers to explore their experiences. Qualitative data from open-ended questions were analyzed thematically.

Results The average hearing aid use was 6.5 hours/day (2.0 standard deviation, SD; range 4.1–10.3) for bilateral hearing aid users. Questionnaire results indicated that most children (PEACH – 83.3% and TEACH – 92.3%) used their hearing aids more than 75% of the time. Participants performed better in quiet environments with limited sensitivity to loud sounds at home and at school. Reported challenges included stigma and device compliance.

Conclusions Children with CHL used their hearing aids for comparable hours (5–8 hours/day), as reported for children with sensorineural hearing loss, but less than the recommended 10 hours/day required for adequate language development. Caregivers reported benefits equivalent to expectations, with challenges similar to those reported in high-income countries.

Wilms’ tumor in low- and middle-income countries: survey of current practices, challenges, and priorities

Purpose
To identify the current practices and priorities in Wilms’ tumor management for surgeons in low- and middle-income countries (LMICs).

Methods
One hundred thirty-seven pediatric surgeons from 44 countries completed surveys on Wilms’ tumor surgical strategy in LMIC. This survey was distributed through the Global Initiative for Children’s Surgery, Pan-African Pediatric Surgical Association, and Latin American Pediatric Surgical Oncology Group.

Results
Ninety-two respondents (67.2%) participated from 19 lower middle-income countries (43.2%). Twenty-one respondents (15.3%) participated from nine lower income countries (20.5%). Nineteen respondents (13.9%) participated from 13 upper middle-income countries (29.5%). Most providers do not obtain biopsy for suspected Wilms’ tumor (79%). Delayed resection after preoperative chemotherapy is the preferred approach (70%), which providers chose due to protocol (45%), to decrease tumor rupture (22%), and to decrease complications (8%). The providers’ goal was to prevent tumor spillage and upstaging (46%) or to prevent bleeding, complication, or other organ resections (21%). Most surgeons believed that upfront resection increased the risk of tumor spillage (72%).

Conclusion
Providers in LMICs prefer delayed resection after preoperative chemotherapy to reduce the incidence of tumor spillage and upstaging of Wilms’ tumor. An evidence-based guideline tailored to the LMIC context can be developed from these findings.

Firearm injuries among children due to the Kivu conflict from 2017 to 2020: A hospital-based retrospective descriptive cohort study

Introduction
Firearm-related injuries are deadly but avoidable. The case of Kivu, a region in the Eastern Democratic Republic of Congo (DRC), is alarming. Decades of unresolved regional conflicts birthed armed groups that have massacred inhabitants and injured several children. This regional instability has also created barriers to seeking and obtaining timely care, decreasing the survival rate. This region’s lack of data on paediatric fatal and nonfatal firearm injuries (F&NFFIs) needs studying. Thus, we aim to determine the prevalence and evaluate the outcomes of paediatric F&NFFIs in Kivu.

Methods
We included all F&NFFI paediatric patients (≤18 years), admitted at our institution between 2017 and 2020. We extracted data from patient records. Next, we assessed the relationship between determinants of paediatric outcomes using the Chi-square test and the student’s t-test. Confounders were identified using cox regression.

Results
This study included 101 paediatric patients, mostly male (63.4%), with an average age of 15.9 years residing 164.4 km on average from the hospital. On average, they were admitted 2.9 days post-injury, with the most affected anatomical regions being lower limbs (53.5%) and upper limbs (18.8%). The mean length of stay was 52.9 days, and the mortality rate was 4.0%. Also, injury complications increased the mean length of stay and mortality rate. In addition, mortality was correlated with circulatory failure and anaemia.

Discussion
Paediatric F&NFFIs in Eastern DRC is a preventable tragedy. Mortality is increased by injury complications and correlates with some biological factors. Prevention strategies should be developed to protect children and appropriate measures should be established to improve rates of prehospital care and early hospital presentation to lower mortality and improve paediatric outcomes.

Knowledge, attitudes, and perceptions of Kenyan healthcare workers regarding pediatric discharge from hospital

Objective
To assess attitudes, perceptions, and practices of healthcare workers regarding hospital discharge and follow-up care for children under age five in Migori and Homa Bay, Kenya.

Methods
This mixed-methods study included surveys and semi-structured telephone interviews with healthcare workers delivering inpatient pediatric care at eight hospitals between November 2017 and December 2018.

Results
The survey was completed by 111 (85%) eligible HCWs. Ninety-seven of the surveyed HCWs were invited for interviews and 39 (40%) participated. Discharge tasks were reported to be “very important” to patient outcomes by over 80% of respondents, but only 37 (33%) perceived their hospital to deliver this care “very well” and 23 (21%) believed their facility provides sufficient resources for its provision. The vast majority (97%) of participants underestimated the risk of pediatric post-discharge mortality. Inadequate training, understaffing, stock-outs of take-home therapeutics, and user fees were commonly reported health systems barriers to adequate discharge care while poverty was seen as limiting caregiver adherence to discharge and follow-up care. Respondents endorsed the importance of follow-up care, but reported supportive mechanisms to be lacking. They requested enhanced guidelines on discharge and follow-up care.

Conclusion
Kenyan healthcare workers substantially underestimated the risk of pediatric post-discharge mortality. Pre- and in-service training should incorporate instruction on discharge and follow-up care. Improved post-discharge deaths tracking–e.g., through vital registry systems, child mortality surveillance studies, and community health worker feedback loops–is needed, alongside dissemination which could leverage platforms such as routine hospital-based mortality reports. Finally, further interventional trials are needed to assess the efficacy and cost-effectiveness of novel packages to improve discharge and follow-up care.

Perspectives on perioperative management of children’s surgical conditions during the COVID-19 pandemic in low-income and middle-income countries: a global survey

Background
Many organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019 (COVID-19) pandemic. We surveyed providers of children’s surgical care working in low-income and middle-income countries (LMICs) to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices.

Methods
A survey of children’s surgery providers in LMICs was performed. Respondents reported how their perioperative practice had changed in response to COVID-19. They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform. Changes in surgical practice reported by respondents were analyzed thematically.

Results
A total of 132 responses were obtained from 120 unique institutions across 30 LMICs. 117/120 institutions (97.5%) had issued formal guidance on delaying or limiting elective children’s surgical procedures. Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities (82% in LICs vs 99% in lower middle-income countries and 100% in upper middle-income countries, p=0.036). Although 122 (97%) providers believed cases should be limited during a global pandemic, there was no procedure where more than 61% of providers agreed cases should be delayed or canceled.

Conclusions
There is little consensus on which procedures should be limited or delayed among LMIC providers. Expansion of testing capacity and local, context-specific guidelines may be a better strategy than international consensus, given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.

Blood Transfusion and Lung Surgeries in Pediatric Age Group: A Single Center Retrospective Study

Background
Blood transfusion is not without harm, and recent studies suggest association between transfusion and poor outcome in critically ill patients. Although it is prescribed for many reasons based on the firm belief that blood transfusion improves oxygen carrying capacity, it carries notable adverse hazards. Importantly, lung surgeries are counted as moderate to high-risk operations and take a significant risk of blood loss.
Aim
This study aims to reveal the association between blood transfusion and poor clinical outcomes and characterize the epidemiology of blood transfusion after pediatric chest surgery.
Settings and design
Retrospective cohort study, done throughout 3 years.
Materials and methods
A total of 248 patients who underwent open thoracotomy and lung surgery and aged ≤18 years were classified according to the need of intraoperative or postoperative blood transfusion into two groups: Group I (non-transfused = 130) and Group II (transfused = 118).
Statistical analysis
SPSS v25 was used for analysis.
Results
Transfusion probability ranged between 42.8% and 50% according to type of surgery. As regard to postoperative variables, there was no significant difference between both groups regarding the duration of analgesia, allergic reactions, need of re-operation and in-hospital mortality. However, transfused group showed significant increase in duration of antibiotic, persistent postoperative fever, time to remove chest drains, ICU stays, hospital stay and pneumonia. Incidence of pneumonia had a relative risk 1.82 with transfused compared to non-transfused group.
Conclusion
Transfusion group in pediatrics undergoing lung surgeries in our study was more prone to adverse outcomes such as pneumonia, delayed time to remove chest drains, prolonged ICU stay, and hospital stay.

Pediatric Appendicitis Severity in KwaZulu-Natal, South Africa: A Retrospective Cohort Analysis

Acute appendicitis is a common pediatric surgical emergency; however, there are few grading systems to assign disease severity. The American Association for the Surgery of Trauma (AAST) recently developed a grading system for a variety of emergency surgical conditions, including appendicitis. The severity of acute appendicitis in younger patients in KwaZulu-Natal (South Africa) is unknown. We aimed to describe the disease severity in this patient population using the AAST grading system hypothesizing that the AAST grade would correlate with morbidity, management type, and duration of stay.
Single institutional review of patients <18 years old with a final diagnosis of acute appendicitis during 2010-2016 in KwaZulu-Natal, South Africa, was performed. Demographics, physiologic and symptom data, procedural details, postoperative complications, and Clavien-Dindo classification were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and nominal logistic regression analyses were performed to compare AAST grade and outcomes.
A total of 401 patients were identified with median [IQR] age of 11 [5-13], 65% male. Appendectomy was performed in all patients; 2.4% laparoscopic, 37.6% limited incision, and 60% midline laparotomy. Complications occurred in 41.6%, most commonly unplanned relaparotomy (22.4%), surgical site infection (8.9%), pneumonia (7.2%), and acute renal failure (2.9%). Complication rate and median length of stay increased with greater AAST grade (all p < 0.001). AAST grade was independently associated with increased risk of complications.
Pediatric appendicitis is a morbid disease in a developing middle-income country. The AAST grading system is generalizable and accurately corresponds with management strategies as well as key clinical outcomes.