Arise tube- A novel double-lumen suction tube for oesophageal atresia

Background: Airway compromise is a major criterion that determines the outcome of care in oesophageal atresia (OA). The maintenance of dry throat through suction of the airway and throat is a vital step to the survival of neonates with OA. This prevents aspiration of saliva and mucus plugging of the airway which can compromise pulmonary function. Pre-operative aspiration pneumonitis increases the morbidity and possible mortality of neonatal OA. The Replogle® tube is usually not readily available and costly for caregivers in most centres in the low-income countries. Objective: To introduce a local adaptation of suction tubing for clearance of the airway in OA. Method and Case Series: The Abdur-Rahman Ilorin Suction oEsophageal (ARISE) suction tube is constructed with a size 6 Fr feeding tube which was tunnelled from a side opening into the lumen of a 10 Fr feeding tube. The distance of the pouch from the incisor is first measured and multiple fenestrations (1 cm apart) are made on the wall of the outer tubes sparing about 2 cm from the measured length near the incisor. Three side fenestrations are made 1.5 cm apart from the tip on the side of the inner tube. The ARISE tube is placed in the upper OA pouch to suck saliva and prevent aspiration in the neonate. The tip of tube is positioned about 0.5 cm above the blind end of the oesophageal pouch. The inner (small lumen) tube is connected to a low-pressure suction machine at 0.2KPa (−15 to −35 cm H2O) for continuous drainage of saliva and the outer (big lumen) tube functions as air vent and irrigation channel. This protects the mucosal from being sucked into the inner tube lumen. Irrigation of tube is done with 2–3 ml of 0.9% saline every 4 h and as necessary. Result: This ARISE suction tube allowed adequate and continuous suction of the pouch and throat with the baby being calm, and caregivers also stress free. The patient maintained good arterial oxygen saturation and there was no aspiration into the airway. Conclusion: The ARISE double-lumen suction tube can easily be constructed in many resource-poor health institutions where OA is managed. This will improve the pre-operative management of neonatal OA in such environment making the baby's condition optimal for surgical intervention

First successfully separated set of thoraco-omphalopagus twins in Ilorin, Nigeria: A case report

The birth of babies sharing body part(s) and surviving independently is indeed a scientific marvel. Conjoined twinning is a rare phenomenon with various presentations, having an estimated incidence of 1 per 200,000 live births. The successes recorded by experts in developed countries in the separation of conjoined twins in recent times, especially among those with complex unions are indeed fascinating. The management of conjoined twins presents a great challenge to medical and surgical teams in tropical African countries such as ours where we are faced with challenges of limited resources and facilities, even amidst the presence of well-trained experts. The incidence of conjoined twins is difficult to report in our practice because of failures that accompanied previous cases that were managed and not reported. This is the first successful separation after two previous failed attempts at our center. We report a case of successful surgical separation of thoraco-omphalopagus conjoined twins who were undiagnosed prenatally and delivered by emergency cesarean section following prolonged labor by a primiparous woman. Babies were joined from the lower chest and the upper abdomen and they shared a single umbilicus and omphalocele sac. No internal viscus was shared apart from the torso wall. They were cared for from 12 h of live until 127 days of live when they were successfully separated by a team of medical and surgical experts. This is a report of a successful separation of conjoined twins at the University of Ilorin Teaching Hospital in North Central Nigeria. Careful interdisciplinary conduct of expert activities will ensure the survival of rare congenital malformations such as conjoined twinning even in underdeveloped climes

Impact of the COVID-19 pandemic on patients with paediatric cancer in low-income, middle-income and high-income countries: a multicentre, international, observational cohort study

OBJECTIVES: Paediatric cancer is a leading cause of death for children. Children in low-income and middle-income countries (LMICs) were four times more likely to die than children in high-income countries (HICs). This study aimed to test the hypothesis that the COVID-19 pandemic had affected the delivery of healthcare services worldwide, and exacerbated the disparity in paediatric cancer outcomes between LMICs and HICs. DESIGN: A multicentre, international, collaborative cohort study. SETTING: 91 hospitals and cancer centres in 39 countries providing cancer treatment to paediatric patients between March and December 2020. PARTICIPANTS: Patients were included if they were under the age of 18 years, and newly diagnosed with or undergoing active cancer treatment for Acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, Wilms' tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas or neuroblastomas, in keeping with the WHO Global Initiative for Childhood Cancer. MAIN OUTCOME MEASURE: All-cause mortality at 30 days and 90 days. RESULTS: 1660 patients were recruited. 219 children had changes to their treatment due to the pandemic. Patients in LMICs were primarily affected (n=182/219, 83.1%). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 (95% CI 2.93 to 50.3) and 7.9 (95% CI 3.2 to 19.7) times the odds of death at 30 days and 90 days, respectively, after presentation during the COVID-19 pandemic (p<0.001). After adjusting for confounders, patients with paediatric cancer in LMICs had 15.6 (95% CI 3.7 to 65.8) times the odds of death at 30 days (p<0.001). CONCLUSIONS: The COVID-19 pandemic has affected paediatric oncology service provision. It has disproportionately affected patients in LMICs, highlighting and compounding existing disparities in healthcare systems globally that need addressing urgently. However, many patients with paediatric cancer continued to receive their normal standard of care. This speaks to the adaptability and resilience of healthcare systems and healthcare workers globally

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.The aim of this study was to inform vaccination prioritization by modelling the impact of vaccination on elective inpatient surgery. The study found that patients aged at least 70 years needing elective surgery should be prioritized alongside other high-risk groups during early vaccination programmes. Once vaccines are rolled out to younger populations, prioritizing surgical patients is advantageous

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