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IntroductionWilms tumor therapy in low- and middle-income countries (LMICs) relies on treatment protocols adapted to resource limitations, but these protocols have rarely been evaluated in real-world settings. Such evaluations are necessary to identify high-impact research priorities for clinical and implementation trials in LMICs. The purpose of this study was to identify highest priority targets for future clinical and implementation trials in sub-Saharan Africa by assessing outcomes of a resource-adapted treatment protocol in Malawi. MethodsWe conducted a retrospective cohort study of children treated for Wilms tumor with an adapted SIOP-backbone protocol in Lilongwe, Malawi between 2016 and 2021. Survival analysis assessed variables associated with poor outcome with high potential for future research and intervention. ResultsWe identified 136 patients, most commonly with stage III (n = 35; 25.7%) or IV disease (n = 35; 25.7%). Two-year event-free survival (EFS) was 54% for stage I/II, 51% for stage III, and 13% for stage IV. A single patient with stage V disease survived to 1 year. Treatment abandonment occurred in 36 (26.5%) patients. Radiotherapy was indicated for 55 (40.4%), among whom three received it. Of these 55 patients, 2-year EFS was 31%. Of 14 patients with persistent metastatic pulmonary disease at the time of nephrectomy, none survived to 2 years. Notable variables independently associated with survival were severe acute malnutrition (hazard ratio [HR]: 1.9), increasing tumor stage (HR: 1.5), and vena cava involvement (HR: 3.1). ConclusionHigh-impact targets for clinical and implementation trials in low-resource settings include treatment abandonment, late presentation, and approaches optimized for healthcare systems with persistently unavailable radiotherapy.

PurposeWilms tumor is a common renal cancer of childhood with long-term survival rates exceeding 80% in high-resource countries, yet survival remains below 50% in the low-resource settings of Africa. We assessed outcomes of a resource-adapted treatment protocol at a Malawian hospital to identify actionable factors affecting survival.MethodsWe assessed clinical outcomes with a single-center retrospective cohort study of children diagnosed between 2016 and 2021 in Lilongwe, Malawi.FindingsWe identified 136 patients with Wilms tumor, most commonly with stage III (25.7%) or IV disease (25.7%). Two-year overall survival (OS) was: Stage I, 78%; Stage II, 27%; Stage III, 62%; Stage IV, 23%, Stage V, 0%. Event-free survival (EFS) was: Stage I, 60%; Stage II, 0%; Stage III, 51%; Stage IV, 13%; Stage V, 0%. After death, treatment abandonment was the most common event comprising EFS, occurring in 26.5% of patients. Among 43% of patients who completed therapy, 2-year OS was 80% and EFS was 69%. Relapse was documented in 9.6% of patients. Radiotherapy was indicated for 40.4% patients, among whom only three received it due to regional unavailability. Factors associated with OS were severe acute malnutrition (Hazard ratio, HR, 1.9), increasing tumor stage (HR, 1.5), and inferior vena cava involvement (HR, 2.7). On multivariable analysis, only tumor stage remained associated with outcome.InterpretationImplementing a curative resource-adapted treatment protocol in an extremely resourced-constrained environment was feasible in Malawi and resulted in relatively favorable outcomes in low-stage disease, particularly among those who completed therapy. However, factors such as late-stage disease, frequent abandonment, and absent radiotherapy represent ongoing implementation barriers that should be the focus of continued research funding and intervention in Africa.

Purpose: COVID-19 led to significant reduction in surgery worldwide. Studies, however, of the effect on surgical volume for pediatric patients in low- and middle-income countries (LMICs) are limited.Methods: A survey was developed to estimate waitlists in LMICs for priority surgical conditions in children. The survey was piloted and revised before it was deployed over email to 19 surgeons. Pediatric surgeons at 15 different sites in 8 countries in Sub-Saharan Africa and Ecuador completed the survey from February 2021 to June 2021. The survey included the total number of children awaiting surgery and estimates for specific conditions. Respondents were also able to add additional procedures. Results: Public hospitals had longer wait times than private facilities. The median waitlist was 90 patients and the median wait time was 2 months for elective surgeries.Conclusion: Lengthy surgical wait times affect surgical access in LMICs. COVID-19 had been associated with surgical delays around the world, exacerbating existing surgical backlogs. Our results revealed significant delays for elective, urgent and emergent cases across Sub-Saharan Africa. Stakeholders should consider approaches to scale the limited surgical and perioperative resources in LMICs, create mitigation strategies for future pandemics, and establish ways to monitor waitlists on an ongoing basis.

Background Untreated surgical conditions may lead to lifelong disability in children. Treating children with surgical conditions may reduce long-term effects of morbidity and disability. Unfortunately, low- and middle-income countries have limited resources for paediatric surgical care. Malawi, for example, has very few paediatric surgeons. There are also significantly inadequate infrastructures and personnel to treat these children. In order to strengthen resources that could provide such services, we need to begin by quantifying the need. Aim To estimate the approximate prevalence of surgical conditions among children in Malawi, to describe the anatomical locations and diagnoses of the conditions and the presence of injuries. Methods A cross-sectional, nationwide survey of surgical needs was performed in 28 of 29 districts of Malawi. Villages, households and household members were randomly selected. A total of 1487 households were visited and 2960 persons were interviewed. This paper is a sub analysis of the children in the dataset. Information was obtained from 255 living children and inquiry from household respondents for the 255 children who had died in the past year. The interviews were conducted by medical students over a 60-day period, and the validated SOSAS tool was used for data collection. Results There were 67 out of 255 (26.3%) total children living with a surgical condition at the time of the study, with most of the conditions located in the extremities. Half of the children lived with problems due to injuries. Traffic accidents were the most common cause. Two-thirds of the children living with a surgical condition had some kind of disability, and one-third of them were grossly disabled. There were 255 total deceased children, with 34 who died from a surgical condition. The most prevalent causes of death were congenital anomalies of the abdomen, groin and genital region. Conclusion An extrapolation of the 26% of children found to be living with a surgical condition indicates that there could be 2 million children living with a condition that needs surgical consultation or treatment in Malawi. Congenital anomalies cause significant numbers of deaths among Malawian children. Children living with surgical conditions had disorders in their extremities, causing severe disability. Many of these disorders could have been corrected by surgical care. publishedVersion

Upper airway obstruction in children is a serious and a potentially life-threatening problem. As such the most important aspect is to establish the level of obstruction to instigated appropriate treatment without worrying too much about the diagnosis in the first instance.

Endoscopic visualisation of the airway and digestive tract has made huge progress in the past decades. The early designs followed Nitze’s method of providing illumination with an incandescent bulb. These have now been replaced with flexible fibre-optic light systems and Hopkins rod-lens telescopes. At the same time, manufacturers have miniaturised many of these endoscopic instruments for use in infants and children. Much of this equipment remains expensive and, especially in children, fragile. Therefore such facilities may not be available in sub-Saharan Africa (SSA), and children still die because of something as simple as an inhaled peanut.

Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, service delivery and implementation outcomes for 2-years at each site. The primary clinical outcome will be all-cause, in-hospital mortality. Secondary outcomes include the occurrence of a major complication, length of hospital stay and time to full enteral feeds. Service delivery outcomes include time to hospital and primary intervention, and adherence to the pre-hospital and in-hospital protocols. Implementation outcomes are acceptability, adoption, appropriateness, feasibility, fidelity, coverage, cost and sustainability. Pre- and post-intervention clinical outcomes will be compared using Chi-squared analysis, unpaired t-test and/or Mann-Whitney U test. Time-series analysis will be undertaken using Statistical Process Control to identify significant trends and shifts in outcome overtime. Multivariate logistic regression analysis will be used to identify clinical and implementation factors affecting outcome with adjustment for confounders. Outcome: This will be the first multi-centre interventional study to our knowledge aimed at reducing mortality from gastroschisis in low-resource settings. If successful, detailed evaluation of both the clinical and implementation components of the study will allow sustainability in the study sites and further scale-up. Registration: ClinicalTrials.gov Identifier NCT03724214.