A perspective in the management of myelomeningocoele in the KwaZulu-Natal Province of South Africa

Meningomyelocele Perioperative Management in Neonatal: Case Series

BACKGROUND

Myelomeningocele (MMC) is a congenital malformation affecting the central nervous system, categorized as a neural tube defect (NTDs). In untreated cases, the mortality rate within the first six months of life ranges from 35% to 70%. Globally, its incidence is estimated 0.8 to 1 per 1000 live births, and rates are higher in Asia and lower socioeconomic groups. This disease imposes a significant treatment cost and burden due to life-long disabilities. In less developed or developing countries, delays in diagnosis can lead to complications such as infection and rupture. Although rupture is a rare complication in MMC, there are limited studies that have reported it. This study aims to discuss the perioperative management and potential complications of ruptured MMC.

METHOD

This study presents four cases of ruptured MMC that were referred from private hospitals and managed by Hasan Sadikin General Hospital in West Java, Indonesia. Each patiens underwent a clinical assessment and diagnostic evaluation upon arrival, followed by perioperative theraphy and management of any complications that emerged during treatment.

RESULT

In three of the four cases, the children were over 24 h old when they were admitted to the hospital. Three cases were located in the lumbosacral region while one case was located in the thoracic region. Upon arrival, the clinical presentations we observed included microcephaly, small for gestational age (SGA) and congenital talipes equionavrus (CTEV). And we found several complications included wound dehisence, respiratiory failure, hydrocephalus, leg weakness, menigitis and sepsis after surgery.

CONCLUSIONS

Perioperative management is highlighted as vital, necessitating a multidisciplinary approach and precise surgical techniques to mitigate severe complications.

The Importance of Neurosurgical Intervention and Surgical Timing for Management of Pediatric Patients with Myelomeningoceles in Bangladesh

OBJECTIVE

Reports on the management and survival of children with myelomeningocele defects in Bangladesh are limited. This study describes the characteristics and outcomes of these children, focusing on the timing of surgical repair and factors affecting survival.

METHODS

We enrolled patients with myelomeningoceles in a case-control study on arsenic exposure and spina bifida in Bangladesh. Cases were subsequently followed at regular intervals to assess survival. Demographic, clinical, and surgical characteristics were reviewed. Univariate tests identified factors affecting survival.

RESULTS

Between 2016 and 2022, we enrolled 272 patients with myelomeningocele. Postnatal surgical repair was performed in 63% of cases. However, surgery within 5 days after birth was infrequent (<10%) due to delayed presentation, and there was a high rate (29%) of preoperative deaths. Surgical repair significantly improved patient survival (P < 0.0001). Older age at time of surgery was also associated with improved survival rates, which most likely represents that those who survived to older ages prior to surgery accommodated better with their lesions. Patients who presented with ruptured lesions had lower survival rates.

CONCLUSIONS

Timely neurosurgical repair of myelomeningoceles in Bangladesh is hindered by late patient presentation, resulting in a high preoperative patient death rate. Neurosurgical intervention remains a significant predictor of survival. Increased access to neurosurgical care and education of families and non-neurosurgical providers on the need for timely surgical intervention are important for improving the survival of infants with myelomeningoceles.

Single surgeon case series of myelomeningocele repairs in a developing world setting: Challenges and lessons

Purpose

Neural Tube Defects are the second most common group of birth malformations following congenital heart anomalies, with myelomeningoceles being the most severe manifestation (MMC). They require expedited surgical repair, preferably within 72 ​h of birth. In low- and middle-income countries (LMIC) where resources are limited, timing to MMC repair is not optimal and leads to undesirable outcomes. The purpose of this study was to determine whether a proactive approach in a setting from a LMIC could achieve repair within 72 ​h.

Methods

A concerted effort to expedite repair of all neonates referred with a MMC was undertaken from 01 January 2014 to 1 August 2015. A consensus was reached between neonatologists and neurosurgeons that neonates born or admitted with a MMC are referred immediately to surgeons and that repair will be performed within 72 ​h of birth. Hospital records of neonates who had MMC repaired during this period were reviewed for infant characteristics and hospital outcomes.

Results

24 patients with a MMC were operated upon by the senior author (CP) during the study period. Only 13 of these patients were born at the treating institution and 11 were referred from outside hospitals. Most MMCs were in the lumbosacral region and mean MMC surface area was 19.4 ​cm². Mean time to repair for the entire series was 13.6 days. Patients born at the treating institution has a mean time to repair of 10.5 days and patients referred from outside had a mean time to repair of 17.3 days. Series wide, only 21% of neonates were operated upon in less than 72 ​h.

Conclusion

Despite a pro-active commitment to repairing MMCs within 72 ​h for the duration of this series, satisfactory time to repair was not achieved. Late referral, referral from outside hospitals and operating theatre availability were the predominant factors leading to delay in MMC repair. Nevertheless, time to repair in our series was significantly shorter than that reported in MMC repair series based in similar environments. This suggests that even if the gold-standard of a 72-h window cannot be achieved, neonates benefit from much quicker repair when a concerted effort to minimise repair time is employed. This study also highlights the urgent need to address health care constraints in LMIC to improve outcomes for this vulnerable group.

Management and outcomes of myelomeningocele-associated hydrocephalus in low-income and middle-income countries: a systematic review and meta-analysis protocol

INTRODUCTION

Hydrocephalus and myelomeningocele (MMC) place disproportionate burdens of disease on low-income and middle-income countries (LMICs). MMC-associated hydrocephalus and its sequelae result in a spectrum of severely devastating clinical manifestations, for which LMICs are disproportionately unprepared in terms of human, capital and technological resources. This study aims to review and compare the management and outcomes of infant MMC-associated hydrocephalus in LMICs and high-income countries.

METHODS AND ANALYSIS

This systematic review and meta-analysis will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. The following databases will be searched without restrictions on language, publication date or country of origin: EMBASE, MEDLINE, The Cochrane Library, Global Index Medicus, African Journals Online and SciELO. All peer-reviewed studies of primary data reporting management and outcomes of infant MMC-associated hydrocephalus will be included. Where high-quality homogeneous studies exist, meta-analyses will be conducted to compare the management and outcomes of MMC-associated hydrocephalus across socioeconomic and geographical regions of the world. The primary outcome will be treatment failure of the first-line hydrocephalus treatment, which we defined operationally as the performance of a second intervention for the same reason as the first. Secondary outcomes include time to failure, rates of mortality and postoperative complications.

ETHICS AND DISSEMINATION

Ethical approval was not applicable because this study does not involve human participants. Dissemination strategies will include publication in a peer-reviewed journal, oral and poster presentations at conferences and an interactive web application to facilitate interaction with the findings and promote the discussion and sharing of findings on social media.

PROSPERO REGISTRATION NUMBER

CRD42021285850.

Escalation of antimicrobial resistance among MRSA part 2: focus on infections and treatment

INTRODUCTION

MRSA is associated with causing a variety of infections including skin and skin structure infections, catheter and device-related (e.g. central venous catheter, prosthetic heart valve) infections, infectious endocarditis, blood stream infections, bone, and joint infections (e.g. osteomyelitis, prosthetic joint, surgical site), central nervous system infections (e.g. meningitis, brain/spinal cord abscess, ventriculitis, hydrocephalus), respiratory tract infections (e.g. hospital-acquired pneumonia, ventilator-associated pneumonia), urinary tract infections, and gastrointestinal infections. The emergence and spread of multidrug resistant (MDR) MRSA clones has limited therapeutic options. Older agents such as vancomycin, linezolid and daptomycin and a variety of newer MRSA antimicrobials and combination therapy are available to treat serious MRSA infections.

AREAS COVERED

The authors discuss infections caused by MRSA as well as common older and newer antimicrobials and combination therapy for MRSA infections. A literature search of MRSA was performed via PubMed (up to September 2022), using the keywords: antimicrobial resistance; β-lactams; multidrug resistance, Staphylococcus aureus, vancomycin; glycolipopeptides.

EXPERT OPINION

Innovation, discovery, and development of new and novel classes of antimicrobial agents are critical to expand effective therapeutic options. The authors encourage the judicious use of antimicrobials in accordance with antimicrobial stewardship programs along with infection-control measures to minimize the spread of MRSA.

Seeking tirelessly for better health and life conditions for the child with myelomeningocele

OBJECTIVE

to understand the experience of families in the care of children with myelomeningocele.

METHOD

a qualitative research study, which adopted Symbolic Interactionism and Grounded Theory as its theoretical and methodological framework, and the semi-structured interview as a data collection instrument. Twenty-eight participants from thirteen families living in a municipality in the inland of São Paulo took part in the study.

RESULTS

the family tirelessly seeks better health and life conditions for the child with myelomeningocele; aiming at the child's autonomy, it is mobilized to the necessary treatments, to learn the care, to adapt the routine, as well as to supply for all the child's needs so that it reaches potential development, looking for a less dependent future with inclusion and social ascension.

CONCLUSION

family nursing shows potential support in the face of myelomeningocele, due to its ability to apprehend the family system, evaluate it and enable intervention proposals in the care process. In this study, rehabilitation nursing was also emphasized, since it goes together with the child and the family who experience myelomeningocele.