By Midhun Mohan

This case report outlines an extremely important treatable global health issue: childhood blindness.

Access to essential paediatric eye surgery in the developing world: a case of congenital cataracts left untreated
Untreated childhood cataracts remain prevalent especially in developing countries. They are a major health burden, not only affecting the individual’s quality of life but also predisposing the individual to becoming a financial burden for the country. This report is of a case of congenital cataracts in a young boy from the Philippines who was left blind since birth.
The mother observed the boy’s vision problems when she noted him bumping into things at the age of 1. When the boy was 2, the health care worker noted opacities on both lenses. The boy was seen at the rural health clinic at the age of 5 and diagnosed with bilateral congenital cataracts and referred to an opthamologist.
Note above the three year delay in getting the boy seen at the rural health clinic. This delay is likely due to:
The poor education of the parents affecting their health seeking behaviours and thus not fully appreciating the seriousness of their child’s condition
Inadequate competency levels of the health care workers. This is could be due to a lack of proper training, which is likely to stem from a lack of funding

Despite being diagnosed, the patient remained untreated for the next 7 years!
What was the reasoning behind such a long gap between diagnosis and treatment? There were two reasons:
The family were not able to afford the treatment
There was a lack of funding from the national health provider

The patient was not able to attend follow up, and three months after surgery, the patient’s visual acuity started to decrease.
There are 3 main factors that that can result in good visual outcomes after cataract surgery:

• Early recognition
• Surgical intervention
• Good follow up after surgery

The report states that:
“Early diagnosis is essential for appropriate and timely intervention and good visual function. Visual outcome is largely dependent on the timing of surgery when dense cataracts are present. Good results have been reported in children undergoing surgery before 6 weeks of age for unilateral cataract and before 10 weeks of age in bilateral cases”

What are the ways in which early diagnosis and intervention can be increased?
It is important to note that any proposed method of increasing early diagnosis has to be economically viable for this developing country. A novel tool that has been recently introduced is the “Portable Eye Examination Kit (PEEK).”

Portable Eye Examination Kit (PEEK)
PEEK is a multifunctional, smartphone based tool which aims to empower eye health workers to diagnose eye diseases and provide a low-cost device for managing and monitoring the treatment of patients.
The modified smartphone contains a series of eye tests in the form of apps that can be used by individuals with little training. Furthermore, because the eyes tests are on a smartphone, it is extremely portable being able to reach the most remotest areas.
One of the app’s it contains is the “Acuity App” which uses a shrinking letter that appears on screen and is used as a basic vision test. It uses the camera’s flash to illuminate the back of the eye to check for disease.
The smartphone is relatively cheap, costing around £300 rather than using bulky eye examination equipment costing in excess of £100,000. The low cost of this device makes it very appealing for developing countries.

Below are useful links to learn more about the Portable Eye Examination Kit (PEEK)
http://www.peekvision.org
http://www.bbc.co.uk/news/health-32914227
http://cehc.lshtm.ac.uk/peek/

Technology has the potential to greatly enhance patient care especially in developing countries. If PEEK was available in this boy’s village, could his blindness have been prevented?

By Manasi Jiwrajka 

Background

I recently completed a surgical placement with a Burns Unit, and was drawn to a recent case report on Global Health describing the appalling effects of severe paediatric burns. The Devastating Effects of a Fire Burn in a Child (1) is about a 2-year old boy with 40% burns to his head and arms. He was not seen immediately after the burn, instead, he presented 1 month later to an eye clinic in Hakkari, Turkey. By then he was blind.

This case raises two main issues:

1. “Accidental house fires cause nearly half (49%) of the injuries resulting in death” (1). How could these be prevented?
2. Delayed presentation without adequate first aid led to a poor outcome for the child. Would the outcome have been different if the patient had better access to healthcare?

Epidemiology

“Burn injuries represent a significant public health concern in both developing and developed countries” (1). Specifically, the WHO estimates that 265 000 deaths occur each year from fires alone, with more than 96% of deaths occurring in low and middle-income countries. Mortality due to burns is over 10 times higher in low and middle income than in high income countries (2). Many studies have found a correlation between socioeconomic deprivation and the incidence and severity of burn injury (3-5). The socioeconomic factors including crowding, poverty and poor maternal education pose as significant risk factors for paediatric burns (6).

Causes of burns

The relevance of this case in Hakkari, in Turkey is that “the incidence of childhood fire burns in Turkey is unknown because of inadequate records.” (1). “In Turkey, tea is made using two narrowly based containers that are stacked on top of each other”; these may easily topple (7). Globally, most burns occur at home, especially in the kitchen. Paediatric burns often occur when parents leave their children alone (even for a moment). His mother “left [her] baby at home sleeping near the electric heater” (1, 8, 9).

Worldwide, open flame burns are the most common, followed closely by scalds. Ignition of clothing is a common cause of burns in low and middle income countries including Ethiopia, India and Papua New Guinea. In Ethiopia, it was found that 93% of burn injuries in rural areas were due to open fires inside homes causing the ignition of clothing. In India, saris catching fire whilst cooking on kerosene stoves are a cause of deaths due to burns amongst adults. Similarly, 50% of hospitalizations due to burn injuries in Papua New Guinea are due to ignition of grass skirts (10-13). In Mexico, Ghana and Taiwan, boiling liquids and hot baths were found to cause scalds among children (2, 14-16).

Global Health Issues

There are several socio-economic factors that play a role. The authors write:

“Socio-demographic factors linked to an increase incidence of burns include low household income, living in a deprived are, living in rented accommodation, young mothers, single-parent families and children from ethnic minorities. The parental educational level, parent occupation and the type and size of accommodation are also important.”

The issue of access to healthcare is two-fold: (i) access to treatment and (ii) access to prevention. This patient’s mother quotes, “because we are poor and have no health insurance, I could not take the child to the hospital right away. It was only one month later that I was able to take the child to an ophthalmologist” (1). Access to a reliable electrical supply precludes the use of open fires.

Burn care costs comprise preventative measures, emergency response, and treatment and follow-up. In Turkey, Sahin et al. showed that the mean cost associated with per percent of burn area was $368 (compared to $927 per percent burn in New Zealand), and each percent burn corresponded to 2 days in the hospital. In the case of the 2 year old patient with 40% burns, the total cost would be about $15000 with 80 days in the hospital. This overall cost of burn management is higher than other medical problems such as stroke and HIV/AIDS (17, 18). In comparison, cost analysis of burns management in Australia showed that management of burns patient was not significantly higher than other patients in ICU receiving a similar level of care. The only difference, however, was in physiotherapy, dressing and medication costs (19). This lack of discrepancy in Australia could be attributed to overall increased healthcare costs rather than specifically for burns, similar to the high cost in New Zealand. In low and middle-income countries, including Turkey, the costs associated with HIV/AIDS and cardiovascular issues is lower than burns due to the availability of knowledge, resources and medical specialists compared to burns management that requires highly specialised care. A lack of specialist burn services is, therefore, an important factor not only in burn care, but also in healthcare funding.

Interventions to prevent burn injuries can be divided into education programs, engineering programs and enforcement, and include “improvement in socioeconomic status, improved housing, provision of basic amenities (eg, water), proper regulation and design of industrial products (eg, kerosene stove), proper storage of flammable substances, and supervision of children” (20).

Education is also fundamental to long-term awareness of burn injuries. The authors suggest “the establishment of a national programme would help ensure sufficient funds are available and allow coordination of the efforts of district, regional and tertiary care centres.” Others suggest the need for public education, broadcasting programmes, and the implementation of stringent government regulation (7).

References

1. Istek Ş. The devastating effects a fire burn in a child. BMJ Case Reports. 2015;2015.
2. Agbenorku P, Agbenorku M, Fiifi-Yankson PK. Pediatric burns mortality risk factors in a developing country’s tertiary burns intensive care unit. International Journal of Burns and Trauma. 2013;3(3):151-8.
3. Edelman LS. Social and economic factors associated with the risk of burn injury. Burns : journal of the International Society for Burn Injuries.33(8):958-65.
4. Cubbin C, Smith GS. Socioeconomic Inequalities in Injury: Critical Issues in Design and Analysis. Annual Review of Public Health. 2002;23(1):349-75.
5. Park JO, Shin SD, Kim J, Song KJ, Peck MD. Association between socioeconomic status and burn injury severity. Burns : journal of the International Society for Burn Injuries. 2009;35(4):482-90.
6. Delgado J, Ramírez-Cardich ME, Gilman RH, Lavarello R, Dahodwala N, Bazán A, et al. Risk factors for burns in children: crowding, poverty, and poor maternal education. Injury Prevention. 2002;8(1):38-41.
7. Nursal TZ, Nursal TZ, Yildirim S, Tarim A, Caliskan K. Burns in Southern Turkey: Electrical Burns Remain a Major Problem. Journal of burn care & rehabilitation. 2003;24(5):309-14.
8. Forjuoh SN. Burns in low- and middle-income countries: A review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns : journal of the International Society for Burn Injuries. 2006;32(5):529-37.
9. Rossi LA, Braga ECF, Barruffini RdCdP, Carvalho EC. Childhood burn injuries: circumstances of occurrences and their prevention in Ribeirão Preto, Brazil. Burns : journal of the International Society for Burn Injuries. 1998;24(5):416-9.
10. Sawhney CP. Flame burns involving kerosene pressure stoves in India. Burns : journal of the International Society for Burn Injuries. 1989;15(6):362-4.
11. Kalayi GD. Burns in children under 3 years of age: the Zaria experience. Annals of tropical paediatrics. 1996;16(3):243-8.
12. Barss P, Wallace K. Grass-skirt burns in Papua New Guinea. Lancet. 1983;1(8327):733-4.
13. Peck MD. Epidemiology of burn injuries globally. 2015. In: UpToDate [Internet]. Waltham, MA: UpToDate.
14. Hijar-Medina MC, Tapia-Yanez JR, Lozano-Ascencio R, Lopez-Lopez MV. [Home accidents in children less than 10 years of age: causes and consequences]. Salud publica de Mexico. 1992;34(6):615-25.
15. Tung KY. A seven-year epidemiology study of 12,381 admitted burn patients in Taiwan–using the Internet registration system of the Childhood Burn Foundation. Burns : journal of the International Society for Burn Injuries. 2005;31 Suppl 1(1):S12-7.
16. Forjuoh SN. Childhood burns in Ghana: epidemiological characteristics and home-based treatment. Burns : journal of the International Society for Burn Injuries. 1995;21(1):24-8.
17. Sahin I, Ozturk S, Alhan D, Açikel C, Isik S. Cost analysis of acute burn patients treated in a burn centre: the Gulhane experience. Annals of Burns and Fire Disasters. 2011;24(1):9-13.
18. Lofts JA. Cost analysis of a major burn. The New Zealand medical journal. 1991;104(924):488-90.
19. Patil V, Dulhunty JM, Udy A, Thomas P, Kucharski G, Lipman J. Do burn patients cost more? The intensive care unit costs of burn patients compared with controls matched for length of stay and acuity. Journal of burn care & research : official publication of the American Burn Association. 2010;31(4):598-602.
20. Peck MD. Prevention of fire and burn injuries. 2015. In: UpToDate [Internet]. Waltham, MA: UpToDate.

By Kristian Dye

For this post, I have chosen to write about a Case Report that comes from the United Kingdom. It’s about a patient with a complex set of management challenges, however none of them are rare – and the United Kingdom is almost certainly one of the best places in the world to be with such a complex constellation of conditions.

So far, this does not sound like compelling global health territory, however it addresses a problem that is universal within health care systems globally – polypharmacy. This is an issue which affects certain populations more than others (for example, in elderly populations (1), an average of 2-9 medications are taken daily, with one in six (2) over 65s taking 10 or more daily).

The issue, in this case, is further complicated by the prescriptions not all originating from a single physician. In an older person, they maybe taking antihypertensives, a statin and drugs to reduce cardiovascular risk – however, they will likely all originate with the primary care physician.

‘The patient… is supported regularly by general practice, the school nurse, ear nose and throat specialists, general and community paediatrics, dietetics, specialist dentistry and ophthalmology’

From this list of involved specialties, the potential formulary that prescriptions will come from is probably as wide as in any case imaginable. This opens up an enormous range of potential drug interactions.

This is a real day-to-day patient safety issue faced in all healthcare settings, whether the system is well integrated or highly fragmented.

‘An example where the lack of an up-to-date medication list led to a potential medication-related problem was the prescription of azithromycin for an ear infection by an ENT surgeon. There is a documented drug interaction between azithromycin and domperidone, a medicine used regularly to treat the patient’s gasto-oesophageal reflux’

The solution suggested in the case is to centralise the patient’s records, but not in the way we usually imagine.

Integrated health care records are usually conceived of as a centralised database that healthcare workers are able to tap into and pull down records for their patient. These systems are highly resource intensive and logistically difficult to deliver over large geographical areas. The alternative is wonderfully elegant.

We trust our patients. If we ensure that when we prescribe something, we add it to a patient-held record, then we know that our colleagues will know what we have done, and are able to factor this in to their own treatment decisions. The solution in the case is a smartphone app (3), which is highly convenient for the more than 1.75 billion smartphone users (4) worldwide – however there’s no reason why a similar approach couldn’t be undertaken on old-fashioned paper for those who don’t have access to the technology – in the UK we’ve been doing this for child health (5) for years.

Surely, then, this seems like an easy decision. We can improve the safety of our patients, by trusting our patients. If we can trust patients with the risk of possessing the medicines, why not trust them with the records too?

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295469/
2. http://www.bmj.com/content/347/bmj.f7033
3. https://itunes.apple.com/gb/app/medication-passport/id595970381?mt=8
4. http://www.emarketer.com/Article/Smartphone-Users-Worldwide-Will-Total-175-Billion-2014/1010536
5. http://www.rcpch.ac.uk/improving-child-health/public-health/personal-child-health-record/personal-child-health-record