102 AJTCCM VOL. 28 NO. 3 2022
EDITORIAL
South Africa (SA) is a country with limited resources, especially for
medical care in the public sector. Availability of medical services varies
greatly throughout the country. Very specialised care for children is
available in most major centres in SA, although most have limited
beds available.
Away from these major centres, paediatric intensive care beds are
limited and mostly consist of beds in combined adult and paediatric
intensive care units (ICUs), or rather adult ICUs that admit children
when necessary.
is problem is not limited to SA, as many hospitals in low- and
middle-income countries do not have designated paediatric intensive
care units (PICUs) with nursing personnel trained in paediatrics or an
adequate nurse-to-patient ratio to care for critically ill patients. ere is
also a lack of appropriate paediatric equipment and monitoring capacity.
In the issue of AJTCCM, Jingxi et al.[1] report their experience of
children ventilated in a non-PICU setting compared with children
ventilated in a PICU. is was a retrospective analysis with some
limitations, but the authors do demonstrate that critically ill children
ventilated in a non-PICU setting in KwaZulu-Natal Province are more
likely than those in a PICU to be malnourished, to require inotropes,
and to have higher mortality. Mortality was signicantly dierent
between the non-PICU and PICU setting (46.3% v. 19.5%), which
may be due to delayed access to medical services in these cases and
the high rate of malnutrition. On a positive note, duration of stay was
signicantly shorter in the non-PICU setting. Limitations of this study
include dissimilar admission criteria between the dierent units and
unobtainable severity scores to compare the outcomes of the children.
e authors conclude that although increasing access to PICU bed
availability is a long-term goal, the high mortality in the non-PICU
setting highlights the need to optimise availability of resources in non-
PICU wards, to optimise sta availability and training, and to improve
primary healthcare services.
e number of ICU beds has increased during the SARS-CoV-2
pandemic. Furthermore, the pandemic has expanded the experience
of medical personnel working with critically ill patients, but this has
mostly aected the adult population and may not have a signicant
lasting eect on paediatric care.
e old saying that a child is not a small adult is very true in the
critical care setting. ere are many physiological dierences between
adults and children, and the disease spectrum is also very dierent.
As an example, malnutrition in children admitted to an ICU, seen in a
signicant number of cases, increases morbidity and mortality.
e situation cannot easily be improved owing to a number of
factors, which include but are not limited to the following: limited
availability of PICU beds at academic units, significant patient
transportation distances, lack of available air transport, delay in time
from admission to initial contact with referral centres, inadequate
nurse-to-patient ratios to care for critically ill patients, inadequate
training of medical and nursing personnel assigned to critically
ill children, lack of auxiliary services (nutritional, imaging, etc.),
signicantly less care during the evenings and over weekends, due to
the high trauma burden in many hospitals, and lack of appropriate
equipment specic to the paediatric eld.
Burkle et al.[2] have reported that healthcare providers at the onset
of the 21st century share the awareness that, whereas significant
inequities and gaps in health between the ‘haves and have-nots’
continue, there are overall trends towards improvement. is situation
has been helped by the fact that there has been a dramatic drop in the
incidence of infectious disease and trauma in the developed countries.
ere has also been a progressive decrease in under-5 mortality rates
(U5MRs). In parts of the world, especially in developing and least-
developed countries, the U5MR ranges, both in absolute numbers
and in rate of reduction, and availability of resources dier greatly, as
do the economic indicators. Encouragingly, and despite some areas
where U5MRs are increasing, the overall trend is a substantial drop
in U5MRs.[2]
e reality is that there are not enough resources in SA for dedicated
PICUs in every part of the country, although the authorities in each
region should strive to have at least one PICU facility in their region.
Because PICU beds are limited, children are either admitted to
adult ICUs or are managed as critical care cases in paediatric wards.
Two studies in Western Cape and Gauteng provinces showed good
outcomes in patients managed in general wards, but this may not be
applicable to the rest of SA.[3,4]
Dedicated training for both medical and nursing personnel is
needed to improve outcomes in critically ill children. Outreach of
the major units to peripheral areas will improve the transfer of skills
to smaller, more inexperienced units. With the aid of telemedicine,
Zoom or team meetings, ward rounds can be conducted remotely, and
experts can easily be consulted about dicult cases. It is also important
to supply peripheral units with clear management protocols, which are
especially useful when junior doctors are on call. Setting time limits
on the acceptable treatment duration for patients in peripheral units,
before they should be referred to central units for escalated treatment,
should be enforced through quality assurance. Eective and rapid
transport pathways should be created to facilitate the transfer of
critically ill children.
e Jingxi et al.[1] study highlights the need for a large prospective
study to explore outcomes in critically ill children admitted to the
PICU setting v. paediatric patients admitted to a general ward for
critical care management, on a national level. Children managed in
combined adult and paediatric ICUs for medical, surgical and trauma-
related conditions should be included. Resources will remain limited,
but it is important that proper dedicated care is oered to all children
in SA, and PICU access should not be restricted to children living in
cities with academic institutions.
Pierre Goussard, PhD
Department of Paediatrics and Child Health, Faculty of Medicine and Health
Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town,
South Africa
pgouss@sun.ac.za
Do all children in South Africa have access to dedicated paediatric
intensive care?
AJTCCM VOL. 28 NO. 3 2022 103
EDITORIAL
1. Jingxi XL, Tinarwo P, Masekela R, Archary M. Comparison of outcomes between
children ventilated in a non-paediatric intensive care and a paediatric intensive care
unit: A retrospective analysis. Afr J oracic Crit Care Med 2022;28(3):x-x. https://
doi.org/10.7196/AJTCCM.2022.v28i3.215
2. Burkle FM Jr, Argent AC, Kissoon N, Task Force for Pediatric Emergency Mass
Critical Care. e reality of pediatric emergency mass critical care in the developing
world. Pediatr Crit Care Med 2011;12(6 Suppl):S169-S179. https://doi/org/10.1097/
PCC.0b013e318234a906
3. Kruger I, Gie RP, Harvey J, Kruger M. Outcome of children admitted to a general
highcare unit in a regional hospital in the Western Cape, South Africa. S Afr J Child
Health 2016;10(3):156-160. https://doi/org/10.7196/SAJCH.2016.v10i3.981
4. Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign international
guidelines for the management of septic shock and sepsis-associated organ
dysfunction in children. Pediatr Crit Care Med 2020;21(2):e52-e106. https://doi/
org/10.1097/PCC.0000000000002198
Afr J Thoracic Crit Care Med 2022;28(3):102-103. https://doi.
org/10.7196/AJTCCM.2022.v28i3.272
Rib tumours are rare. Approximately 40% are malignant, often
occurring at a young age. Oen the patient presents with mild pain
or just a swelling. e importance of an early diagnosis is that wide
excision is oen curative. Malignant tumours are more likely to present
with pain as compared with benign tumours, which oen present with
swelling only. e important point, however, is that malignant tumours
may be painless and benign tumours may cause pain.
All rib tumours should be considered malignant until proven
otherwise or removed, as wide excision for both benign and malignant
tumours is oen curative.
Douni et al.,[1] in this issue, report on a rare cause of a benign rib
tumour, hydatid disease, which should be considered in areas where
hydatid disease is prevalent. ey highlight the importance of a history,
physical examination, and special investigations, followed by treatment.
Geography matters!
A geographical history is part of good medicine. Medical geography
is an important eld because it aims to provide an understanding of
health problems and improve the health of people worldwide, based on
the various geographic factors inuencing them.[2] e eect of location
on health has been studied since the time of Hippocrates. Snow, in his
important study of cholera in London in 1854, highlighted the eect of
contaminated water.[3] COVID-19, considering its origin and the way it
spreads, is a graphic example of geography and disease. In a study from
the 1960s, areas of industrialisation, exploitation and dense populations
have been shown to be related to high mortality rates. ere are many
factors to be considered such as remoteness from healthcare facilities,
pollution, rainfall, environment, farming facilities and resultant
nutrition.[4]
Hippocrates in 400 BCE said: ‘Whoever wishes to investigate
medicine properly, should proceed thus: in the rst place to consider
the seasons of the year, and what eects each of them produces for they
are not at all alike, but dier much from themselves in regard to their
changes. en the winds, the hot and the cold, especially such as are
common to all countries, and then such as are peculiar to each locality.
We must also consider the qualities of the waters, for as they dier from
one another in taste and weight, so also do they dier much in their
qualities. In the same manner, when one comes into a city to which he
is a stranger, he ought to consider its situation, how it lies as to the winds
and the rising of the sun; for its inuence is not the same whether it lies
to the north or the south, to the rising or to the setting sun.’ On Airs,
Waters, and Places, (English translation by Francis Adams). [5]
To summarise, Hippocrates emphasises that geography makes a
dierence in healthcare.
Even in an endemic area where Echinococcus is common,
involvement of ribs is rare. It is important, however, to consider this
to enable the correct treatment to be offered. During the surgical
procedure, care needs to be taken to avoid spillage of the echinococcal
cyst into the surrounding areas.
I Schewitz, MB ChB, FCS
Department of Cardiothoracic Surgery, University of Pretoria, Midrand,
South Africa
ivan@schewitz.com
1. Douni S, Sabur S, Elmine HT, et al. Hydatid disease of the ribs: An exceptional
location. Afr J Thoracic Crit Care Med 2022;28(3):x-x. https://doi.org/10.7196/
AJTCCM.2022.v28i3.193
2. Briney A. Medical geography: A history and overview of medical geography.
https://www.thoughtco.com/medical-geography-overview-1434508# (accessed
15 August 2022).
3. Rosenberg M. A map stops cholera. https://www.thoughtco.com/map-stops-
cholera-1433538 (accessed 15 August 2022).
4. Subedi R,Greenberg TL,Roshanafshar S.Does geography matter in mortality? An
analysis of potentially avoidable mortality by remoteness index in Canada. Health
Rep2019;30(5):3-15. https://doi.org/10.25318/82-003-x201900500001-eng
5. Burnell AC, Littré E, Cornarius J, van der Linden JA, Adams F. Hippocrates on Airs,
Water, and Places.London: Wyman & Sons, 1881.
Afr J Thoracic Crit Care Med 2022;28(3):103. https://doi.
org/10.7196/AJTCCM.2022.v28i3.216
Rare rib tumours: Where geography matters
