Short Reports :;.; • ;. : ; >.." ; •• , ; ••.. , -; •..• , , •.,., •• - : •.• -•• : .; •. , • ... ... ..,. diagnosis of Kaposi's sarcoma, chronic enteropathy, cryptococcal meningitis, Pneumocystis carinii pneumonia, or oesophageal candidiasis: AIDS was mentioned in 24 (43%) and VCT requested in 20 (36%) of these patients. Three hundred and seven patients had a principal working diagnosis of TB: AIDS was mentioned in 43 (14%) and VCT requested in 26 (9%). AIDS was mentioned in the case files more frequently in mission (21%) and central (17%) hospitals compared with district (II %) hospitals (P<0.05). Referrals for VCT were low in each type of hospital (mission II %; central II %; and district 8%). Discussion This cross-sectional study highlights the enormous burden imposed on hospitals by the TB epidemic. Many patients are considered for possible TB, and in over one-third sputum specimens are being requested for laboratory AFB examination. Seventy-seven rer cent of TB patients in Malawi are HIV-seropositive . In Queen Elizabeth Central Hospital, over 70% of all medical inpatients are HIV-seropositive (Zijlstra, personal communication], in keeping with find- ings from other African countries. Despite this, AIDS is infrequently written in case files, even when diseases which are almost always associated with HIV, such as Kaposi's sarcoma or cryptococcal meningitis, are diagnosed. There are few referrals for VCT, even in patients with suspected TB or a classical HIV-related disease. Stigma and the absence of anything to offer a patient labelled with a diagnosis of AIDS are the likely explanations for not mentioning the diagnosis of AIDS in case notes or referring patients for VCT. However, changes have to take place if Malawi is to start winning the battle against HIV/AIDS. Modelling studies in East Africa have demonstrated the cost-effectiveness ofVCT in averting further HIV infections'', Co-trimoxazole prophylaxis, recommended by UNAIDS as part of a minimum package of care for people living with AIDS in Africa>, should be considered for HIV-seropositive patients, and this may provide individual benefit. Anti- retroviral therapy may become accessible to the population in the future. Health workers must take a lead in this difficult area, and can begin by 'breaking the silence'. Acknowledgements We thank the Department for International Development (DFID), UK, the Norwegian Agency for Development Cooperation (NORAD) and the Royal Dutch Tubercu- losis Association (KNCV) for financial support as part of their aid contribution to Operational Research of the Malawi National Tuberculosis Control Programme. The study received the approval of the National Health Science Research Committee. References UNAIDS. Malawi - Epidemiological Fact Sheet on HIV/ AIDS and Sexually Transmitted Infections. 2000 Update. Geneva: UNAIDS/World Health Organization, 2000 2 Kwanjana JH, Harries AD, Gausi F, Nyangulu DS, Salaniponi FM. TB-HIV seroprevalence in patients with tuberculosis in Malawi. Malawi Med J 2001;13:7-10 3 Grant AD, Sidibe K, Domoua K, et al. Spectrum of disease among HIV -infected adults hospitalised in a respiratory 168 medicine unit in Abidjan, Cote d'Ivoire. Int J Tuberc Lung Dis 1998;2:926-34 4 Sweat M, Greogorich S, Sangiwa G, et al. Cost-effectiveness of voluntary HIV-I counselling and testing in reducing sexual transmission of HIV-I in Kenya and Tanzania. Lancet 2000;356: 113-21 5 UNAIDS. Provisional WHO/UNAIDS Secretariat Recom- mendations on the Use of Co-trimoxazole Prophylaxis in Adults and Children Living with HIV/AIDS in Africa. Geneva: UNAIDS/WHO, 2000 Gastrointestinal perforation in children due to blunt abdominal trauma in Hazara, Northern Pakistan Arshad Zafar MBBS FCPS Nasir Orakzai MBBS FRCS Aamir Ghafoor MBBS MRCP Sajjad Ahmad MBBS FCPS Ayub Medical College, Abbottabad, Pakistan Correspondence to: Dr Arshad Zafar, House No. 207,Street No.2, ]innahabad, Abbottabad, Pakistan E-mail: azafar@brain.net.pk TROPICAL DOCTOR, 2003, 33,168-170 SUMMARY A retrospective study of 25 children with gastrointestinal perforation due to blunt abdominal trauma in a single region of Pakistan is presented.The age, sex,aetiology, site of perforation, abdominal and X-ray findings, associated injuries, surgical procedures and out- come were analysed. There were 20 boys and 5 girls: mean age was 10years.The injuries were the result of road traffic accidents 12 (4B%), falls 11 (44%) and 'struck by animals' two (8%). Associated injuries occurred in 19 (76%). On admission 20 (80%) patients had peritonitis while 18 (72%) had pneumoperitoneum. Mean time from trauma to admission was 10 hours and admission to operation was 5 hours. Ileum was the most common site of perforation. Simple closure was the most common surgical procedure. Complications occurred in nine (36%) patients - six (24%) died. Delay in presentation and operation was associated with increased morbidity and mortality. Frequent evalua- tion of the child and abdominal X-rays are still the important tools for early diagnosis of gastrointestinal perforation following blunt abdominal trauma. Introduction Trauma is a leading cause of morbidity and mortality in children and adolescents with more than 200000 deaths occurring annually in the USA 1. Blunt abdominal trauma in children is usually managed conservatively/. Gastrointestinal tract perforation due to blunt abdom- inal trauma is relatively uncommon. However, in some cases perforation may occur and delay in diagnosis increases the morbidity and mortality. Early diagnosis is difficult because clinical, laboratory and radiological Tropical Doctor July20m, 33