Gastrointestinal bleeding following NSAID ingestion in children

Gastrointestinal (GI) bleeding could result from various conditions in a child, and could be life threatening. Severe GI bleeds are, however, rare and their incidence is relatively unknown. Here, we report on two children who presented with GI bleeding following ingestion of NSAID. Two female children presented to our unit with GI bleeding. One was 6 years old and the other was 2 years old. Both presented with a history of fever and passage of bloody stools. There was a positive history of NSAID ingestion in both patients that was prescribed in the referring hospitals. The older child had a packed cell volume of 19% on presentation, and digital rectal examination indicated melaena. There was no history of vomiting. She received one unit of blood transfusion and was managed nonoperatively with antacids. Her recovery was uneventful. The younger patient presented with an abdominal distension and peritonitis, packed cell volume was 17% on presentation, and was malnourished. Exploratory laparatomy showed two kissing perforations, one measuring about 2 cm in the second part of the duodenum and the other measuring 1 cm in the gallbladder. There were no demonstrable gallstones. She underwent a cholecystectomy and closure of the duodenal perforation. The patient, however, developed a superficial surgical site infection that responded to local wound care. Recovery was otherwise uneventful. A thorough assessment of drug history should be performed to rule out NSAID ingestion in a child with a GI bleed. Keywords: enteropathy, gastrointestinal-bleeding, NSAI

Fracture neck of femur: Epidemiology and surgical treatment at Nohd Kano

OBJECTIVE: To access the epidemology, pattern and surgical treatment of fracture neck of femur (FNF). PATIENTS AND METHOD: A 5-year retrospective study of FNF at NOH Kano, which considered; Epidemology, Radiological pattern and surgical treatment and outcome between January 1998 and December 2002. RESULTS: 54 patients were surgically treated for FNF. Male – female ratio is 3.5:1. The active age group of 20 – 60 years (68.5%) were those mainly affected. The aetiological factors implicated are road traffic accident (50%) of which motorcycle related is highest amongst other vehicles, wheelbarrows, and bicycles. Falls (44%), Pathological fractures (5.6%). The surgical treatment showed more of the arthroplastic procedure (64.8%) than fixation (35.2%). Severely displaced fractures with irreversible complications, make for this treatment option. CONCLUSION: Education of our population on early presentation to hospital is needful. Efforts at curtailing the motorcycle menace must be adopted. Nigerian Journal of Orthopaedics and Trauma Vol.3(1) 2004: 1-

Single-layer closure of typhoid enteric perforation: Our experience

Background: Typhoid enteritis is rare in developed countries. The  increasing prevalence of typhoid fever with enteric perforation in our  environment is alarming. Peritonitis follows enteric perforation due to typhoid enteritis. Surgical treatments and repair of the perforated areas due to typhoid enteritis varies between institutions with high mortality and morbidity.Materials and Methods: We retrospectively studied the effects of single versus double layer intestinal closure after typhoid enteric perforation with peritonitis in 902 pediatric patients from September 2007 to April 2012. All the patients underwent laparotomy after resuscitation and antibiotic cover. The patients were divided into two groups: group A (n = 454) double layerclosure and group B (n = 448) single layer closure.Results: There were 554 males and 348 females with male to female ratio 1.6:1. Ages of the patients were three years to 14 years with mean age at eight years and mode at nine years. The following clinical outcomes were recorded: burst abdomen 38 (8.3%) vs 3 (0.6%), enterocutaneous fistula  formation 52 (11.4%) vs 8 (1.7%), superfi cial wound infection 215(47.3%) vs 91 (20.3%), ligature fistula 13 (2.8%) vs 7 (1.5%), mean length of 29.4 ± 7.8 vs 45.3 ± 11.6.Conclusion: Our results showed that single layer closure of the perforated ileum due to typhoid enteric perforation with peritonitis in children was effective by reducing complication rates.Key Words: Children, single layer closure, typhoid enteric perforatio

Evaluation of cosmetic appearance of herniotomy wound scars in African children: Comparison of tissue glue and subcuticular suturing

Aim: To evaluate the cosmetic appearance of herniotomy wound scars closed using either the tissue glue or subcuticular suturing technique. Materials and Methods: Prospective randomised control study; randomisation into tissue glue and suturing groups. Ethical clearance obtained. Cosmetic outcome were based on visual analogue scale by parents and Hollander wound evaluation scale by a Plastic Surgeon blinded to the wound closure method. Results: Fifty one wounds were evaluated, 26 in the tissue glue group and 25 in the suturing group. Parents′ evaluation using Visual Analogue scale (VAS) showed that in the suturing group, 17 parents (68%) gave a VAS of 8cm while six parents (24%) gave a score of 7cm. Two parents (8%) gave a score of 9cm. In the tissue glue group, 22 parents (84.6%) scored the scar of their children as 8 or 9cm on the VAS while four parents (15.4%) gave a score of 7cm. The median VAS was 8cm for both groups with a range of 7 to 9cm. The Chi- square test showed that the parents preferred tissue glue compared with subcuticular suturing (X2 = 7.90, P < 0.05). The Hollander Wound Evaluation Scale (HWES) used by Plastic Surgeon showed 21 herniotomy wounds (84%) had a score of 6 in the suturing group while four wounds (16%) had a score of 5. In the tissue glue group, 19 wounds (73%) had a score of 6, six wounds (23.1%) had a score of 5 and a patient (3.8%) had a score of 4. The median score is 6 for both groups. There was no statistically significant difference between both groups (X 2 = 1.481, P = 0.393). Conclusion: This study has shown that the cosmetic outcome of wound closure using the tissue glue technique and subcuticular suturing technique are similar

Adaptation of the Wound Healing Questionnaire universal-reporter outcome measure for use in global surgery trials (TALON-1 study): mixed-methods study and Rasch analysis

BackgroundThe Bluebelle Wound Healing Questionnaire (WHQ) is a universal-reporter outcome measure developed in the UK for remote detection of surgical-site infection after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries, and to make recommendations for its adaptation.MethodsThis was a mixed-methods study within a trial (SWAT) embedded in an international randomized trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). Structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale, and conduct a translatability assessment. Translation was completed into five languages in accordance with Mapi recommendations. Next, data from a prospective cohort (SWAT) were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model.ResultsIn the qualitative phase, 10 structured interviews and six focus groups took place with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval, and judgement were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Owing to the number of extreme (floor) values, the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality, indicating validity of the ordinal total WHQ score. There was significant overall model misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach's α was high at 0.86. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ items 1 (redness), 3 (clear fluid), 7 (deep wound opening), 10 (pain), 11 (fever), 15 (antibiotics), 16 (debridement), 18 (drainage), and 19 (reoperation). Changes to three item response categories (1, not at all; 2, a little; 3, a lot) were adopted for symptom items 1 to 10, and two categories (0, no; 1, yes) for item 11 (fever).ConclusionThis study made recommendations for cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed-methods data from three continents. Translations are now available for implementation into remote wound assessment pathways

Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

BACKGROUND: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. METHODS: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. FINDINGS: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2-2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3-0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2-18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46-13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99-17·34]) or anaesthesia complications (11·47 (1·20-109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7-5·0). INTERPRETATION: Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. FUNDING: Medical Research Council of South Africa.Medical Research Council of South Africa