INTRODUCTION: Improving the quality of care is a fundamental issue in medicine. The analysis of routine practice and its adequacy to the available evidence can detect areas for improvement. We have decided to apply these principles to the surgical treatment of phimosis in pediatric age. The aim of this study is to analyze the situation of phimosis surgery for children up to 18 years of age in our environment and its compliance with current recommendations. MATERIAL AND METHODS: Retrospective descriptive observational study including surgeries performed for phimosis in children and adolescents up to 18 years of age in 2022 and 2023. Data were compared with the recommendations of the European and British Pediatric Urology Associations. RESULTS: A total of 222 medical records were included. All surgeries were performed on an outpatient basis and with loco-regional anesthesia. The percentage of pathological phimosis was 11%. Among physiological phimosis, 47% were asymptomatic (70% between 3 and 7 years of age). DISCUSSION: According to current European recommendations, phimosis surgery is reserved for cases of symptomatic pathological or physiological phimosis or with increased risk of urinary tract infection. In pediatric patients in our environment, all aspects of phimosis surgery are performed according to current recommendations, but the percentage of asymptomatic phimosis operated on in young children is high. Based on the possibility of spontaneous resolution, the indication and optimal age of intervention in this group of patients should be reviewed.
S Fuentes, N Vicente-Sánchez, M E Martín-Castillo et al.
BACKGROUND: Infant male circumcision reduces urinary tract infections during infancy and sexually transmitted infections during adulthood. However, people in varous communities challenge male infant circumsizion in Ethiopia. Data regrading male infant circumsion is crucial component of designing preventive strategy, resource allocation and planning mainly in rural communities. Despite its importance, no study is conducted on male infant circumsion practice and associated factors in the study setting so far. OBJECTIVE: To assess prevalence and factors associated with male infant circumcision in Konso Zone, South Nation Nationality People Regional State of Ethiopia, in 2022. METHODS AND MATERIALS: Community-based cross-sectional survey was conducted among randomly selected districts in Konso Zone, Southern Nation Nationality and Peoples Regional States, Ethiopia, from 30 June to 30 July 2022. A multi-stage sampling technique was applied to enrol study subjects. Data was collected through face-to-face interviews using a structured questionnaire. Then, it was entered into epi-data 4.6 and exported to STATA version 14 for analysis. Descriptive statistics were presented using tables,charts and texts. Bivariate and multivariable logistic regression analysis were used to evaluate association between each independent variable and dependent variable. All explanatory variables with P-value less than 0.25 in bivariate regression were fitted into multi-variable regression. Variables whose P-value less than 0.05 with 95% confidence intervals (CI) was used to declare statically significance. RESULTS: Prevalence of male infant circumcision was 24.9% in this study. Factors such as women with good knowledge of male circumcision (AOR = 7.3; 95% CI: 4.3, 12.5), women age more than 36 years (AOR = 2.2; 95% CI: 1.1, 4.3) and women with a favourable attitude to male circumcision (AOR = 9.2; 95% CI: 4.5, 18.8) were significantly associated with male infant circumcision practice in this study. CONCLUSION: Prevalence of male infant circumcision was lower in this study compared to national threshold. Women knowledge towards male infant circumcision, aged more than 36 years, and women with favourable attitude to male circumcision are factors positively associated with male infant circumcision. Hence, stakeholders should empower women using health education about male infant circumcision and mobilise the community.
Voluntary medical male circumcision (VMMC) to protect against sexual transmission of HIV is a key part of HIV prevention interventions in 15 priority countries in Southern and Eastern Africa. Ensuring that VMMC programs reach adolescent males is important in countries with large young populations. We designed a methodology to explore the joint decision-making dynamics among caregivers and adolescents aged 10-19, and the drivers and barriers for circumcision, in order to identify levers which can drive uptake of VMMC. Our approach was grounded in behavioral science to address some of the limitations of survey-based research (e.g., the "say-do gap," social desirability bias, respondent fatigue). Our methods included 1) interviews with adolescent boys and their caregivers to understand how adolescents interact with their families, other key stakeholders, and the healthcare system; 2) journey mapping to understand how boys and caregivers move through the stages of progress toward the decision for VMMC, and the influence of context, family, and community members; and 3) Ethnolab, a decision-making game that tests behavioral hypotheses in hypothetical situations mimicking the real-life context of decision-making about VMMC, enabling an understanding of boys' and caregiver's motivators, barriers, and mental models via observation as well as questioning. Factors influencing the decision for VMMC included anticipated pain of the surgical procedure, mistrust about safety, the boy's uncertainty about his caregiver's consent, and caregiver's uncertainty about the adolescent's assent, and caregiver's concern about their adolescent boy's maturity level and ability to deal with VMMC, among others. Conversely, in-group seeking, the belief that being circumcised is appreciated by women, and improved hygiene were among the positive factors motivating decisions for VMMC. Demand generation should involve the whole family unit, encouraging discussion and trust within and among households, and recognizing and addressing the ways decision dynamics change as the boy ages through adolescence.
Glanzmann thrombasthenia (GT) is a rare inherited bleeding disorder caused by quantitative or qualitative defects of platelet integrin GPIIb/IIIa (CD41 and CD61). This study intended to describe the demographics, clinical features, and treatment response of GT patients in several hematology centers in Egypt. A cross-sectional multi-center study involved 87 children (<18 years old) diagnosed with GT. Clinical data were recorded as bleeding manifestations, response to treatment modalities, and laboratory results. The study included eighty-seven children (61 females and 26 males) with a median age of 8 years. Sixty-one children (55.2%) were born to parents who were consanguineous. The median age at presentation was 3 years (birth-14 years). The most frequent initial presenting symptom was epistaxis (39.1%), followed by cutaneous bleeding (29.9%), gastrointestinal bleeding (23%), heavy menstrual bleeding (19.5%), bleeding per gum (10.3%), and post-circumcision bleeding (5.7%), while one patient initially presented with intracranial hemorrhage (1.1%). These also constituted common bleeding sites. Eighty children (92%) received treatment. Platelet transfusions were given to 65 patients, with a response rate of 73.8%, and recombinant factor VII concentrates were given to 71 patients, with a response rate of 90.1%. Type I GT represented most of our patients (79.3%), followed by type III (11.5%) and type II (9.2%). No significant correlation was found between CD41/CD61 expression and other parameters as the patient's age, bleeding frequency, and treatment response. There was no evident difference between the three forms of GT regarding clinical characteristics such as bleeding severity or response to treatment. What is known: • Glanzmann thrombasthenia is the most common inherited platelet function abnormality. • Treatment is based on general supportive measures, platelet transfusion and recombinant factor VIIa. What is new: • Glanzmann thrombasthenia is an underestimated disorder, with a significant delay in diagnosis. • Although it has three types, there is no significant variation in bleeding phenotype between them.
Laila M Sherief, Magdy El Ekiaby, Mahmoud El-Hawy et al.
BACKGROUND: Long wait times for new patient visits can delay necessary care and lead to patient dissatisfaction. Minimizing nonessential scheduled follow-up visits may increase surgeons' availability to see new patients. Postoperative clinic visits are typically scheduled to detect complications. However, there is limited data on how often postoperative complications are diagnosed during scheduled follow-up visits versus during other encounters. We examined whether complications were routinely detected during scheduled follow-up visits after low-risk procedures in healthy children. METHODS: A single-center observational study was performed using Current Procedural Terminology/International Classification of Diseases codes and a chart review. Our cohort included patients who underwent appendectomy, inguinal hernia repair, pyloromyotomy, or circumcision between 2016 and 2023. A scheduled follow-up visit was defined as a postoperative clinic visit with a surgeon that was made ≥3 days before the clinic visit date and within 8 weeks of surgery. A complication that was diagnosed at an encounter other than the scheduled follow-up visit was defined as an "uncaptured complication." The primary exposure was provider scheduled follow-up visit rate, and the primary outcome was rate of uncaptured complications. RESULTS: In total, 2,676 patients were included. Surgeon scheduled follow-up visit rate was categorized as low versus high based on the mean scheduled follow-up visit rate of 63%. The median rate of uncaptured complications for physicians with both a low scheduled follow-up visit rate and a high scheduled follow-up visit was 1.4% (P = .99). Even on adjusted analysis, high scheduled follow-up visit rate was not protective against uncaptured complications. Only procedure type and younger age were predictive of incidence of uncaptured complications. CONCLUSION: Routine scheduled follow-up visits after low-risk operations in healthy children do not effectively capture postoperative complications. Implementing a culture of follow-up as needed could increase surgeon availability to see new patients in ambulatory clinics.
INTRODUCTION: Sexually transmitted infections (STIs) are a major global public health problem, associated with infertility, adverse pregnancy outcomes, and significant social and economic burdens. These challenges are particularly severe in underprivileged communities. A 2024 World Health Organisation report highlighted a global surge in STIs, requiring intensified efforts to improve their control and management. In order to appropriately respond and reverse the status quo, it is important to understand the extent to which the current interventions have reached the beneficiaries. This study aimed to assess the coverage of sexually transmitted infection (STI) services using the Lot Quality Assurance Sampling (LQAS) approach in eight districts of Central Uganda. METHODOLOGY: A household survey was conducted in eight districts, targeting four population groups: mothers of children aged 0-11 months, women aged 15-49 years, men aged 15 + years, and youth aged 15-25 years. LQAS was used, with each district stratified into five supervision areas (SAs). In each SA, 19 respondents were randomly sampled from each target group. The survey assessed key indicators related to STIs, including knowledge of STI symptoms, knowledge of actions to take when infected with an STI, and engagement in risky sexual behavior. The study also examined condom use during risky sex, circumcision acceptance and non-acceptance among men, including reasons for its acceptance or non-acceptance. Overall and district-specific coverage was calculated with 95% confidence intervals. Indicator coverage in the SAs was classified using LQAS decision rules (DRs) for each indicator, using the overall coverage as benchmark for setting the DR. RESULTS: The findings revealed that mothers of children aged 0-11 months demonstrated superior knowledge of STIs and appropriate actions to take if one has an STI. Men (15 + years) and youth (15-24 years) reported engaging more in risky sexual behavior compared to women 15-49 years and mothers of children aged 0-11 months. Relatedly, men 15 + years reported higher condom use during risky intercourse. Youth were more likely to be circumcised than older men. Coverage for most indicators varied across SAs and districts. However, one in forty of the SAs fell short of average coverage in all the indicators. Personal hygiene was the leading motivator for circumcision acceptance while fear of pain was the leading driver for refusal to accept being circumcised. CONCLUSIONS: The findings highlight vital disparities in STI knowledge and risky sexual behavior among different demographic groups. These findings inform public health strategies to address STI disparities and improve reproductive health outcomes. District and SA-specific bottleneck analysis is recommended in order to provide actionable solutions to improve low-indicator coverage in low-coverage districts and SAs.
Simon Peter Katongole, Semei Christopher Mukama, Jane Nakawesi et al.
BACKGROUND: Youth in southern Africa continue to be at high risk of HIV infection. We investigated the awareness of, access to, and uptake of HIV prevention interventions (pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), voluntary medical male circumcision and condoms) among youth in Zimbabwe. METHODS: A population-based survey of youth aged 18–24 years in 24 communities across three provinces was conducted between October 2021 and June 2022. An interviewer-administered questionnaire collected sociodemographic and sexual behaviour data including awareness of, access to, and use of HIV preventative interventions. Data were analysed using descriptive statistics and mixed-effects logistic regression weighted for clustering. RESULTS: We recruited 17,682 youth (60.8% female, median age 20 years (Interquartile range 19–22)). Altogether 46.8% (n = 3634) of unmarried youth and 5.6% (n = 3538) of married youth reported consistent condom use and 49.8% (n = 3369) of men reported being circumcised. Awareness of PrEP and PEP was 11.2% and 11.9% respectively. 6900 participants (38.4%) reported at least one eligibility criterion for PrEP. Eligibiltiy criteria included having multiple partners or receiving money or goods for sex in the last year, HIV-negative individuals in serodiscordant relationships, those who had ever been treated for an STI, ever injected drugs, been pregnant or taken PEP. In comparison to the non-eligible population (n = 10782), the eligible population were more likely to have heard of PrEP (13.5% vs. 9.9%, p < 0.001), been offered PrEP if they had heard of it (17.0% vs. 6.3%, p < 0.001) and to have ever taken PrEP if offered it (60.7% vs. 27.0%, p < 0.001). Those in the richest wealth quintiles and with higher education level were more likely to have heard of PrEP and report regular condom use. Forty-two of 199 (20.2%) who reported having experienced forced sex in the last year sought healthcare afterwards, of these 17 of 42 (36.0%) had been offered PEP and 12 of 17 (63.7%) had ever taken it. CONCLUSIONS: Use of HIV preventive interventions remains limited among youth despite longstanding HIV programmes. Lack of awareness limits use of PrEP and PEP. There are underlying socioeconomic barriers limiting awareness of and demand for condoms, circumcision and pharmacological prophylaxis. These must be urgently addressed. TRIAL REGISTRATION NUMBER: NCT03719521.
Sophie H Kelly, Steven Azizi, Chido Dziva Chikwari et al.
When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.
BACKGROUND: Female genital cutting (FGC) causes permanent harm to women and the girl child. It is a threat to women's bodily integrity and a violation of their fundamental human rights. Nigerians still engage in this high-risk behaviour even though it is on the decline. AIMS: The objective of the study was to determine the prevalence of mother-to-daughter FGC and associated factors. MATERIALS AND METHODS: A sample of 10,568 women who reported mother-to-daughter FGC from the 2018 Nigeria demographic and health survey were analysed. The prevalence of this outcome variable was estimated using percentages. The multivariable binary logit model was used to examine its associated factors. RESULTS: The weighted prevalence of mother-to-daughter FGC was 15.0%. Women having secondary or tertiary education had 27% reduction in the odds of mother-to-daughter FGC when compared with those with no formal education or primary. Non-poor women had 28% reduction in the odds of mother-to-daughter FGC when compared with poor women. Older women had higher odds of mother-to-daughter FGC when compared with mothers aged 15-19 years. Islamic women had 2.80 times higher odds of mother-to-daughter FGC when compared with Christian women. Those who are covered by health insurance had 51% reduction in the odds of mother-to-daughter FGC when compared with uninsured women. Ever-married women and those employed had higher odds of mother-to-daughter FGC when compared with single and unemployed women. Respondents who watch television or use the internet had 27% and 61% reduction in the odds of mother-to-daughter FGC when compared with those who do not watch television or use the internet, respectively. CONCLUSION: The practice of mother-to-daughter FGC still persists in Nigeria. There is a need to implement multifaceted interventions such as educational programmes targeting women of low socio-economic status. Mother-to-daughter FGC can be addressed through empowerment.
INTRODUCTION: The transition of voluntary medical male circumcision (VMMC), an HIV prevention service, in Zimbabwe from a donor-funded to a government-owned programme involves the collective efforts and alignment of national and subnational government leaders, managers, healthcare providers, village health workers, community members, donors and implementing partners. We sought to understand stakeholders' perspectives on barriers, facilitators and recommendations as a vertical HIV prevention programme transitioned to an integrated, government-led model. METHODS: We conducted 54 semistructured stakeholder interviews at the national and subnational levels. Interviews were audio recorded, transcribed and thematically analysed. RESULTS: Participants highlighted a range of psychological and structural barriers and facilitators to integrating and sustaining the VMMC programme. Respondents mentioned financing and staffing barriers to integration, particularly a lack of domestic resources, the transition from a fee-for-service to a facility-based performance model and staff attrition. Notably, resistance to changing the VMMC programme's operations was a significant barrier that may be tied to individual psychological barriers such as loss of power and job security. Donors and partners continued to control the funding for VMMC. Ideally, the Ministry of Health and Child Care should have more autonomy over these decisions. At the subnational level, there is an opportunity for increased responsibility and a greater sense of ownership through the decentralisation of governance. CONCLUSIONS: To ensure successful integration and local ownership of VMMC as an HIV prevention programme, stakeholders must address both psychological and structural barriers while aligning their perspectives on the transition. Individual providers have valid concerns about their financial security and the burden of additional responsibilities without adequate compensation. It is crucial for donors and partners to reduce their involvement and oversight. Additionally, resolving the financial barriers that prevent the government from having complete control of the programme will require empowering local government stakeholders to fully take ownership.
Amanda Marr Chung, Joseph Murungu, Peter Case et al.
