Browsing by Author "Rode, H"
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- ItemOpen AccessCervical lymph node biopsy - watch the nerves!(2006) Numanoglu, A; Rode, HExperience with the delayed diagnosis and severe consequences of accessory nerve injury following cervical gland lymph node biopsy prompted us to survey the practice of South African paediatric surgeons and to ascertain the incidence of accessory nerve injury. Cervical lymph gland biopsies are often performed for diagnostic and therapeutic purposes and although spinal accessory nerve (SAN) injury seldom occurs, it remains a significant injury. The operation is relatively minor and cervical glands are commonly biopsied/removed in South Africa by junior doctors, registrars and general practitioners. The operation is often performed as a day case under suboptimal circumstances, despite the fact that it is common knowledge that posterior triangle nodular biopsy carries the risk of iatrogenic damage to the accessory nerve.
- ItemOpen AccessFour decades of conjoined twins at Red Cross Children's Hospital - lessons learned(Health and Medical Publishing Group, 2006) Rode, H; Cywes, S; Lawrenson, J; Numanoglu, A; Fieggen, A G; Brown, R A; Davies, M R Q; Hewitson, J P; Hoffman, E B; Jee, L D; Mann, M D; Matthews, L S; Millar, A J W; Peter, J C; Thomas, J; Wainwright, HConjoined twins represent a rare but fascinating congenital condition, the aetiology of which remains obscure. Over the past four decades, the paediatric surgeons at Red Cross Children's Hospital have been involved in the management of 46 pairs of conjoined twins, of which 33 have been symmetrical and 12 asymmetrical. Seventeen symmetrical twins have undergone separation with 22 children (65%) surviving; all of the live asymmetrical twins survived separation. We describe the important features of this unique cohort, outline our approach to management and present the results of this approach. We consider some of the ethical and moral dilemmas we have confronted, and discuss the prenatal diagnosis, obstetric implications and postnatal care of these children, including the relevant investigations and anaesthetic and surgical management. Specific aspects related to the cardiovascular system, hepatobiliary and gastrointestinal tracts, urogenital tract, central nervous system and musculoskeletal system are highlighted.
- ItemOpen AccessIatrogenic pneumatosis intestinalis and pneumatosis hepatis(2007) Bickler. W S; Alexander, A; Pitcher, R D; Wieselthaler, N; Rode, HA term male fetus with meconium-stained liquor was delivered at a peripheral hospital. He developed abdominal distension and bile-stained vomiting shortly after birth. Meconium ingestion was suspected. Gastric lavage was attempted using inappropriately high volumes and concentrations of sodium bicarbonate in this newborn with undiagnosed jejunal atresia. Subsequent abdominal radiographs documented the presence of the jejunal atresia and pneumatosis intestinalis (PI), together with air in both the porta hepatis and liver parenchyma (Figs 1 - 3). The latter features were interpreted as representing necrotising enterocolitis. The child was transferred to Red Cross Children’s Hospital, Cape Town, for corrective surgery.
- ItemOpen AccessLiver transplantation at Red Cross War Memorial Children's Hospital(2006) Spearman, C W N; McCulloch, M; Millar, A J W; Burger, H; Numanoglu, A; Goddard, E; Gajjar, P; Davies, C; Muller, E; McCurdie, FJ; Kemm, D; Cywes, S; Rode, H; Kahn, DThe liver transplant programme for infants and children at Red Cross War Memorial Children’s Hospital is the only established paediatric service in sub-Saharan Africa. Referrals for liver transplant assessment come from most provinces within South Africa as well as neighbouring countries. Patients and methods. Since 1987, 81 children (range 6 months - 14 years) have had 84 liver transplants with biliary atresia being the most frequent diagnosis. The indications for transplantation include biliary atresia (48), metabolic (7), fulminant hepatic failure (10), redo transplants (3) and other (16). Four combined liver/kidney transplants have been performed. Fifty-three were reduced-size transplants with donor/recipient weight ratios ranging from 2:1 to 11:1 and 32 children weighed less than 10 kg. Results. Sixty patients (74%) survived 3 months - 14 years post transplant. Overall cumulative 1- and 5-year patient survival figures are 79% and 70% respectively. However, with the introduction of prophylactic intravenous ganciclovir and the exclusion of hepatitis B virus (HBV) IgG core Ab-positive donors, the 1-year patient survival is 90% and the projected 5-year paediatric survival is > 80%. Early (< 1 month) postliver-transplant mortality was low. Causes include primary malfunction (1), inferior vena cava thrombosis (1), bleeding oesophageal ulcer (1), sepsis (1) and cerebral oedema (1). Late morbidity and mortality was mainly due to infections: de novo hepatitis B (5 patients, 2 deaths), Epstein-Barr virus (EBV)- related post-transplantation lymphoproliferative disease (12 patients, 7 deaths) and cytomegalovirus (CMV) disease (10 patients, 5 deaths). Tuberculosis (TB) treatment in 3 patients was complicated by chronic rejection (1) and TB-drug-induced subfulminant liver failure (1). Conclusion. Despite limited resources, a successful paediatric programme has been established with good patient and graft survival figures and excellent quality of life. Shortage of donors because of infection with HBV and human immunodeficiency virus (HIV) leads to significant waiting-list mortality and infrequent transplantation.
- ItemOpen AccessMedical consent for a minor - an alternative proposal(Health and Medical Publishing Group, 2006) Rode, H; Karpelowsky, J SUnder current South African law, in terms of Child Care Act 74 of 1983,1 consent for elective surgery, HIV testing and therapy can only be given by the biological mother, married father or legal guardian of a minor. Where the consent of a parent or legal guardian cannot be obtained, permission for a medical procedure must be sought from the Minister of Social Development if in the opinion of a medical practitioner the procedure is necessary, i.e. consent by proxy. While we can accept that the intention of the law is to protect the welfare of the child, we find that this prejudices those patients requiring consent via the social service department. This procedure has in the past often led to delays and/or cancellations of the intended surgery or institution of appropriate therapy. It is a protracted pathway and at times a frustrating endeavour.
- ItemOpen AccessMeningococcal septicaemia complications involving skin and underlying deeper tissues - management considerations and outcome(Health and Medical Publishing Group, 2007) Bickler, SW; Bosenberg, A T; Numanoglu, A; Rode, HObjective: To describe surgical experience with purpura fulminans related to meningococcaemia in a single institution, and to suggest a management protocol. Methods: A retrospective review was done of patients admitted to the intensive care unit at Red Cross War Memorial Children's Hospital in Cape Town with the clinical diagnosis of purpura fulminans. Results: During a 28-year period (1977 - 2005) 112 children (average age 3.4 years) were treated for meningococcaemia with purpura fulminans. Overall mortality was 10.7%. Local treatment consisted of measures to improve circulation, infection control and healing of necrotic tissue. Demarcation of necrotic areas was evident at 5.5 days and the average area of skin necrosis was 14% total body surface area (range 2 - 85%). The lower limbs were predominantly affected. Purpura fulminans resolved in 35 children (31.2%) without skin necrosis. Skin grafting was required in 77 children (68.8%). Factors associated with a poor outcome for peripheral extremity salvage were progressive irreversible skin changes, early disappearance of distal pulses, tense cold swollen extremities and intense pain on passive movement of the affected extremity. Amputations were performed proximal to the area of necrosis, on average 27 days after injury. Conclusions: Meningococcaemia is a disease with potentially devastating consequences. Early surgical consultation is essential. Skin- and soft-tissue-releasing incisions should be considered early to reduce the incidence of extremity necrosis. Small necrotic areas usually separate spontaneously with secondary healing or can be excised and sutured. Larger necrotic areas should be excised only after demarcation has been established, and can be covered with delayed skin grafting. Amputation should be conservative but may require revision.
- ItemOpen AccessOverview of a paediatric renal transplant programme(2006) McCulloch, M; Gajjar, P; Spearman, W; Burger, H; Sinclair, P; Savage, L; Morrison, C; Davies, C; Ruysch van Dugteren, GPA; Maytham, D; Wiggelinkhuizen, J; Pascoe, M D; McCurdie, F J; Pontin, A; Muller, E; Numanoglu, A; Millar, A J W; Rode, H; Khan, DINTRODUCTION: Renal transplantation is the therapy of choice for children with end-stage renal failure. There are many challenges associated with a paediatric programme in a developing country where organs are limited. METHODS: A retrospective review was undertaken of 149 paediatric renal transplants performed between 1968 and 2006 with specific emphasis on transplants performed in the last 10 years. Survival of patients and grafts was analysed and specific problems related to drugs and infections were reviewed. RESULTS: On review of the total programme, 60% of the transplants have been performed in the last 10 years, with satisfactory overall patient and graft survival for the first 8 years post transplant. At this point, transfer to adult units with non-compliance becomes a significant problem. Rejection is less of a problem than previously but infection is now a bigger issue--specifically tuberculosis (TB), cytomegalovirus (CMV) and Epstein-Barr virus (EBV) infections with related complications. A wide variety of drugs are available for tailoring immunosuppression to minimise side-effects. CONCLUSION: It is possible to have a successful paediatric transplant programme in a developing country. However, to improve long-term outcomes certain issues need to be addressed, including reduction of nephrotoxic drugs and cardiovascular risk factors and providing successful adolescent to adult unit transition.
- ItemOpen AccessPrimary keratinocyte cell culture on EpiGen membranes for autologous skin grafts in paediatric burn patients(2005) McCabe, K; De Wet, P M; Rode, HCultured epithelial autografts have been shown to be an effective permanent skin replacement for major burn injuries and have proved life-saving when insufficient donor skin has been available. Several membrane systems have been developed that facilitate the transfer of cultured cells on to the recipient. The aim of the study reported here was to test the effectiveness of EpiGen, a synthetic polymer membrane, as a cell culture support matrix for the transplantation of cultured autografts. Skin biopsies were obtained from 22 paediatric burn patients with an affected total body surface area of between 7% and 80%. Basal keratinocytes were harvested from the dermal/epidermal junction and cultured in a collagen 1-coated flask in modified Green’s medium. After two passages, isolated keratinocytes were grown on EpiGen membranes until semiconfluent. Wound beds were excised and covered with widely (1:3) meshed split skin grafts. Membranes were grafted with the basal cell layer directed against the wound bed. Unseeded membranes were applied and served as controls. Wounds were dressed and closed appropriately. Grafts were regularly inspected for ‘take’ and the membranes were removed 10 days after application. Seven patients had to be excluded from the study. Cell culture results of the remaining 15 patients showed excellent cell growth and expansion on EpiGen membranes within a mean culture time of 2.6 days post membrane seeding. The membranes facilitated easy transfer of cultures onto the recipient. A mean keratinocyte graft ‘take’ of 95% and a mean control graft ‘take’ of 90% were recorded at the time of membrane removal. The mean level of clinically evident re-epithelialization on keratinocyte grafted areas in recipients was 87% as opposed to 60% in the unseeded control areas.
- ItemOpen AccessResuscitation in major burns: The problem of fluid creep(2009) Rogers, A D; Karpelowsky, J S; Argent, A; Millar, A J; Rode, HWe have noticed an alarming tendency for burn patients to be over-resuscitated, and we believe that protocols should be reviewed in light of our own and international experience. We recently managed an 8-year-old boy with 52% fullthickness burns, who developed abdominal and limb compartment syndromes during the period of resuscitation. The fluid volumes infused above those calculated were 1.6 and 4.7 litres on days 1 and 2 respectively to maintain haemodynamic stability and urine output above 2 ml/kg/h. Within 48 hours of the injury, he developed poor peripheral perfusion and a distended abdomen; the intravesical pressure was 32 mmHg and the abdominal perfusion pressure 23 mmHg. Abdominal decompression and three limb fasciotomies were performed, but small-bowel and lower limb muscle necrosis had developed. The patient deteriorated rapidly despite inotropic support and died.
- ItemOpen AccessRisk factors affecting software projects in South Africa(APM, 2006) Smith, D; Eastcroft, M F; Mahmood, N; Rode, HThis paper reports on an analysis of risk factors relevant to South African software projects. Seven of the most widely cited studies in the research literature regarding software project risk were evaluated along with a detailed examination of the 53 risk factors developed by Schmidt, Lyytinen, Keil & Cule (2001). Forty completed questionnaires, submitted by software project managers, were analysed. The main findings of this research were: • Project managers of varying experience perceived different software risks to be important • Risks relating to quality, cost, time, requirements or methodology were not perceived to be more important than risks relating to people, relationships or change) by project managers The top ten most important risks as perceived by project managers were: • Lack of top management commitment to the project • Unclear/ misunderstood scope/ objectives • Schedule Flaw • Lack of client responsibility, ownership and buy-in of the project and it’s delivered systems • No planning or inadequate planning • Project not based on sound business case • Lack of available skilled personnel • Not managing change properly • Lack of adequate user involvement • Poor risk management From this list it was noted that risks number 5, 6, 7 and 8 were unique to this study and were not found in prior studies in the research literature. It was concluded that the importance of these risks may be unique to South African software projects.
- ItemOpen AccessSurgical complications of bacille Calmette-Guérin (BCG) infection in HIV-infected children: Time for a change in policy?(Health and Medical Publishing Group, 2008) Karpelowsky, J S; Alexander, A G; Dix Peek, S; Millar, A J W; Rode, HAIM: Bacille Calmette-Guérin (BCG) immunisation is well established as part of the South African national expanded programme for immunisation (EPI). The World Health Organization (WHO) currently recommends that BCG be given to all asymptomatic infants irrespective of HIV exposure at birth but does not recommend BCG vaccination for children with symptomatic HIV infection. This approach, however, has led to HIV-infected neonates who are asymptomatic at birth, developing severe vaccine-related complications. We present a surgical case series, representative of a minority of the cases in circulation, in support of a change to the timing of BCG administration to HIV-exposed neonates. METHODS: A case series of 17 HIV-infected patients with surgical complications of BCG vaccination. RESULTS: Seventeen patients are presented. The first two illustrate disseminated systemic BCG infection, resulting in BCG infection of the lymph nodes, liver, spleen and tibia, and the second with gastrointestinal involvement causing bowel obstruction. The other 15 patients represent a series of severe ulcerating lymphadenitis secondary to BCG. CONCLUSION: The risks of BCG in HIV-infected infants are significant. Current recommendations are not satisfactory, and a change in policy is required to prevent the harmful effects of this vaccine in a high-risk group of patients. We believe that there is sufficient need to adequately stratify patients and vaccinate them according to a protocol that takes impaired immunity into consideration.
- ItemOpen AccessThe child rape epidemic: Assessing the incidence at Red Cross Hospital, Cape Town, and establishing the need for a new national protocol(2007) Cox, S; Andrade, G; Lungelow, D; Schloetelburg, W; Rode, HIntroduction. There were 52 733 reported rapes in South Africa in 2003/2004, almost half of them involving children. South Africa is faced with the challenge of developing an appropriate management strategy to foster effective treatment and curtail the incidence of sexual assault. A child sexual assault protocol for the Western Cape exists, but does not address the specialised needs of the child. Objective. We aimed to ascertain the incidence of child rape seen at Red Cross War Memorial Children's Hospital, Cape Town, with emphasis on the circumstances that surround the victimisation of children. We also aimed to demonstrate the need for a new national standard protocol of specialised care for child victims' injuries. Method. A retrospective review of medical records of sexual assault victims from 2003 to 2005. Results. There were 294 patients, 254 females and 40 males. Victims ranged from 10 months to 13 years in age (mean 5.8 years). The number of cases and severity of injuries increased annually. There were 14 third-degree, 22 second-degree and 91 first-degree injuries. Seventy-nine per cent of assaults were by a perpetrator known to the victim. All but 5 perpetrators were male. Fifty-eight per cent of rapes occurred in the patient's own home or that of a friend or relative. Conclusion. The number and severity of injuries have increased yearly. This shift is consistent with the overall increase in reported sexual assaults. Policy makers must respond to this call. Finalising sexual assault policy, clinical management and evidence collection guidelines and ensuring that they are disseminated and implemented nationally must be prioritised. Educational drives targeting parents and patients with the demonstrated demographics must be established.
- ItemOpen AccessThe impact of subspecialty services on healthcare delivery - a community health centre based study(2006) Cox, S; Mpofu ,F; Berg, A; Rode, HObjectives. The objective was to evaluate the role of a paediatric surgical consultant at a primary health care facility. Design. Descriptive and prospective. Setting. In the process of planning and implementation of the 2010 health plan of the Provincial Government of the Western Cape, a shift occurred in the delivery of health care to children from a provincially based hospital system to a municipally based primary health care system. To contribute towards enabling this process, the Department of Paediatric Surgery at Red Cross War Memorial Children’s Hospital established a paediatric surgical day clinic at a local community health centre during 2001. Subjects. Information was obtained from patient data sheets containing details of consultations at the sub-specialist surgical clinic at Michael Mapongwana Community Health Centre. Results. Over a 58-month period 1 171 children were seen, of whom 655 were male and 427 female. Their ages ranged from 0 to 19 years, the largest group being under 1 year. Eighty per cent of patients were accompanied by their mothers. The correct diagnosis was established by the nurse practitioners in 71%. General paediatric surgical conditions predominated, followed by medical, dermatological, orthopaedic, trauma, otolaryngo-pharyngology, infectious diseases, ophthalmology, urology, neurosurgery, malignancy and maxillofacial conditions. The details are set out in the report. In total 597 patients were referred directly to an appropriate care facility and 574 patients could be managed entirely at the clinic level. Conclusions. This study demonstrated the significant public health problem of paediatric surgical disease. It emphasised the preventative and cost-effective role of a surgical clinic at primary health care level. The clinic allowed for timely surgical intervention in 65% of surgical cases, thereby decreasing inappropriate tertiary referrals. We believe that bringing specialists into the community can only strengthen the 2010 health care plan.
- ItemOpen AccessTreatment of paediatric burns with a nanocrystalline silver dressing compared with standard wound care in a burns unit: A cost analysis(2011) Cox, S; Cullingworth, L; Rode, HBurns are a leading cause of non-natural death in South African infants and children. Conventional care of partial-thickness burns often requires painful, time consuming and costly twice-daily dressing changes to clean the wound and apply antimicrobial topical agents. A new topical nanocrystalline silver-coated (NS) dressing (Acticoat; Smith & Nephew) has been developed and is the first-line treatment of choice in many burn centres. However, because of its cost the Department of Health has been reluctant to introduce it as a standard of care. We retrospectively studied 4 randomly selected paediatric burn patients, calculating the cost associated with the use of NS dressings and comparing this with the projected costs of three previously standard burn wound treatment regimens. NS dressings were changed every 3 days based on their sustained and slow release of silver ions over 72 hours. Using NS clearly saved costs compared with the three other regimens. The demonstrated cost savings resulted primarily from the decreased number of dressings, and the presumed shorter hospital stay.