Browsing by Subject "Pediatrics"

Now showing 1 - 12 of 12
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    Amoebic liver abscess in Natal African children
    (1961) Scragg, Joan Noelle
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    An Examination of Lumbar and Ventricular Cerebrospinal Fluid Findings in Children with Tuberculous Meningitis and Hydrocephalus
    (2019) Mwenda, Lona Albertha; Figaji, Anthony; Rohlwink, Ursula; Diedericks, Ralph
    Background: Childhood tuberculous meningitis (TBM) has poor outcomes. These are often associated with delayed diagnosis because early diagnosis and treatment is challenging. Existing diagnostic criteria use CSF characteristics to suspect TBM. However, lumbar and ventricular CSF may differ. These differences have not been well characterised Sometimes only ventricular CSF is available and decisions about surgical treatment may be influenced by CSF characteristics. This study examined CSF parameters from lumbar and ventricular compartments in patients with TBM and hydrocephalus who required neurosurgical procedures, their CSF temporal profiles, differentials between compartments, and factors that may influence these results. Methodology: A descriptive cross-sectional study was conducted including data from two prospective TBM studies. Children treated for TBM and hydrocephalus at Red Cross War Memorial Children’s Hospital with lumbar and/ or ventricular samples were selected. Pooled lumbar verses ventricular samples and paired time-linked samples in individual patients were analysed. Differences in CSF cell counts and biochemistry parameters across compartments were analyzed using Wilcoxon signed rank test, and temporal profiles graphically presented. Associations between laboratory, clinical and radiological data were analyzed using Mann-Whitney’s U test. To test for associated factors, results of the nature of hydrocephalus (level of CSF obstruction) and spinal imaging were analyzed where available. Association between CSF parameters and morbidity was analyzed. Results: Eighty-one patients were studied, 29 had time-linked paired CSF. The mean patient age was 36 months (2- 156 months), 93% were HIV-uninfected, and the mortality rate was 13.6%. Seventy-two percent had communicating hydrocephalus, 16% non-communicating, and 12% uncertain (unable to demonstrate level of block). Medians of admission lumbar CSF showed low glucose (2.2 mmol/L), low chloride (112 mmol/L), raised protein (2g/L) and elevated white cell count (165 x 106 /L). Corresponding values for admission ventricular CSF were minimally affected glucose (3mmol/L), mildly low to normal chloride (114.5mmol/L), normal to mildly raised protein (0.5g/L) and less elevated white cell count (22 x 106 /L). In paired samples, all parameters were significantly different between lumbar and ventricular CSF. Ventricular CSF showed milder aberrations than lumbar CSF: lower protein and total white cell count, higher glucose and chloride. All paired samples showed higher lumbar CSF protein; lower lumbar CSF chloride in almost 80%; lower lumbar CSF glucose in 96%. Analysis of possible factors was limited by the small patient numbers who had full brain and spine imaging, and also paired CSF samples (n=17). However, maximum lumbar CSF protein was associated with severity of spinal disease on imaging. The lymphocyte ratio between lumbar and ventricular CSF was higher in patients with non-communicating and uncertain hydrocephalus. CSF parameters normalized slowly. White cell count and lymphocyte CSF differential were associated with favorable outcome in survivors. Conclusion: Lumbar CSF depicted a typical TBM pattern. Ventricular CSF differed: CSF parameters were less abnormal in both pooled analysis and across individual paired samples. Spinal disease severity and nature of hydrocephalus may affect this differential. The CSF compartment sampled is therefore clinically relevant when interpreting CSF characteristics for diagnostic and treatment decisions. Studies of TBM diagnosis, pathophysiology, biomarkers and drug concentrations should consider these differences.
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    Caregivers' experiences of pathways to care for seriously ill children in Cape Town, South Africa: A qualitative investigation
    (Public Library of Science, 2016) Jones, Caroline H D; Ward, Alison; Hodkinson, Peter W; Reid, Stephen J; Wallis, Lee A; Harrison, Sian; Argent, Andrew C
    Purpose Understanding caregivers' experiences of care can identify barriers to timely and good quality care, and support the improvement of services. We aimed to explore caregivers' experiences and perceptions of pathways to care, from first access through various levels of health service, for seriously ill and injured children in Cape Town, South Africa, in order to identify areas for improvement. METHODS: Semi-structured, qualitative interviews were conducted with primary caregivers of children who were admitted to paediatric intensive care or died in the health system prior to intensive care admission. Interviews explored caregivers' experiences from when their child first became ill, through each level of health care to paediatric intensive care or death. A maximum variation sample of transcripts was purposively sampled from a larger cohort study based on demographic characteristics, child diagnosis, and outcome at 30 days; and analysed using the method of constant comparison. RESULTS: Of the 282 caregivers who were interviewed in the larger cohort study, 45 interviews were included in this qualitative analysis. Some caregivers employed 'tactics' to gain quicker access to care, including bypassing lower levels of care, and negotiating or demanding to see a healthcare professional ahead of other patients. It was sometimes unclear how to access emergency care within facilities; and non-medical personnel informally judged illness severity and helped or hindered quicker access. Caregivers commonly misconceived ambulances to be slow to arrive, and were concerned when ambulance transfers were seemingly not prioritised by illness severity. Communication was often good, but some caregivers experienced language difficulties and/or criticism. CONCLUSIONS: Interventions to improve child health care could be based on: reorganising the reception of seriously ill children and making the emergency route within healthcare facilities clear; promoting caregivers' use of ambulances and prioritising transfers according to illness severity; addressing language barriers, and emphasising the importance of effective communication to healthcare providers.
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    Epidemiology of histologically proven Glomerulonephritis in Africa: A systematic review and meta-analysis
    (Public Library of Science, 2016) Okpechi, Ikechi G; Ameh, Oluwatoyin I; Bello, Aminu K; Ronco, Pierre; Swanepoel, Charles R; Kengne, Andre P
    Background and aim: Glomerulonephritis (GN) is a leading cause of end-stage renal disease (ESRD) in Africa. Data on epidemiology and outcomes of glomerular diseases from Africa is still limited. We conducted a systematic review on the epidemiology of histologically proven glomerular diseases in Africa between 1980 and 2014. Materials and methods We searched literature using PubMed, AfricaWide, the Cumulative Index to Nursing and Allied Health Literature on EBSCO Host, Scopus, African Journals online databases, and the African Index Medicus, for relevant studies. The review was conducted using standard methods and frameworks using only biopsy-confirmed data. RESULTS: Twenty four (24) studies comprising 12,093 reported biopsies from 13 countries were included in this analysis. The median number of biopsies per study was 127.0 (50-4436), most of the studies (70.0%) originated from North Africa and the number of performed kidney biopsies varied from 5.2 to 617 biopsies/year. Nephrotic syndrome was the commonest indication of renal biopsy. The frequency of reported primary pathologic patterns included, minimal change disease (MCD); 16.5% (95%CI: 11.2-22.6), focal segmental glomerulosclerosis (FSGS); 15.9% (11.3-21.1), mesangiocapillary GN (MCGN); 11.8% (9.2-14.6), crescentic GN; 2.0% (0.9-3.5) and IgA nephropathy 2.8% (1.3-4.9). Glomerular diseases related to hepatitis B and systemic lupus erythematosus had the highest prevalence among assessed secondary diseases: 8.4% (2.0-18.4) and 7.7% (4.5-11.7) respectively. There was no evidence of publication bias and regional differences were seen mostly for secondary GNs. CONCLUSIONS: Glomerular diseases remain poorly characterized in sub-Saharan Africa due to declining renal biopsy rates and consequent paucity of data on pathologic patterns of key renal diseases. Development of renal biopsy registries in Africa is likely to enable adequate characterization of the prevalence and patterns of glomerular diseases; this could have a positive impact on chronic kidney disease evaluation and treatment in the African continent since most glomerulopathies are amenable to treatment.
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    A multifaceted intervention to improve the quality of care of children in district hospitals in Kenya: a cost-effectiveness analysis
    (Public Library of Science, 2012) Barasa, Edwine W; Ayieko, Philip; Cleary, Susan; English, Mike
    A cost-effective analysis conducted by Edwine Barasa and colleagues estimates that a complex intervention aimed at improving quality of pediatric care would be affordable and cost-effective in Kenya.
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    Packages of care for attention-deficit hyperactivity disorder in low-and middle-income countries
    (Public Library of Science, 2010) Flisher, Alan J; Sorsdahl, Katherine; Hatherill, Sean; Chehil, Sonia
    In the sixth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Alan Flisher and colleagues discuss the treatment of attention-deficit hyperactivity disorder.
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    Pathways to care for critically ill or injured children: A cohort study from first presentation to healthcare services through to admission to intensive care or death
    (Public Library of Science, 2016) Hodkinson, Peter; Argent, Andrew; Wallis, Lee; Reid, Steve; Perera, Rafael; Harrison, Sian; Thompson, Matthew; English, Mike; Maconochie, Ian; Ward, Alison
    Purpose Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided. METHODS: A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors. RESULTS: The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children. CONCLUSIONS: The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.
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    Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression
    (Public Library of Science, 2013) Lowe, David M; Rangaka, Molebogeng X; Gordon, Fabiana; James, Chris D; Miller, Robert F
    Objective: Pneumocystis jirovecii pneumonia (PCP), the commonest opportunistic infection in HIV-infected patients in the developed world, is less commonly described in tropical and low and middle income countries (LMIC). We sought to investigate predictors of PCP in these settings. Design Systematic review and meta-regression. METHODS: Meta-regression of predictors of PCP diagnosis (33 studies). Qualitative and quantitative assessment of recorded CD4 counts, receipt of prophylaxis and antiretrovirals, sensitivity and specificity of clinical signs and symptoms for PCP, co-infection with other pathogens, and case fatality (117 studies). RESULTS: The most significant predictor of PCP was per capita Gross Domestic Product, which showed strong linear association with odds of PCP diagnosis (p<0.0001). This was not explained by study design or diagnostic quality. Geographical area, population age, study setting and year of study also contributed to risk of PCP. Co-infection was common (444 episodes/1425 PCP cases), frequently with virulent organisms. The predictive value of symptoms, signs or simple tests in LMIC settings for diagnosis of PCP was poor. Case fatality was >30%; treatment was largely appropriate. Prophylaxis appeared to reduce the risk for development of PCP, however 24% of children with PCP were receiving prophylaxis. CD4 counts at presentation with PCP were usually <200×10 3/ ml. CONCLUSIONS: There is a positive relationship between GDP and risk of PCP diagnosis. Although failure to diagnose infection in poorer countries may contribute to this, we also hypothesise that poverty exposes at-risk patients to a wide range of infections and that the relatively non-pathogenic P. jirovecii is therefore under-represented. As LMIC develop economically they eliminate the conditions underlying transmission of virulent infection: P. jirovecii , ubiquitous in all settings, then becomes a greater relative threat.
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    Point-of-care CD4 testing to inform selection of antiretroviral medications in South African antenatal clinics: a cost-effectiveness analysis
    (Public Library of Science, 2015) Ciaranello, Andrea L; Myer, Landon; Kelly, Kathleen; Christensen, Sarah; Daskilewicz, Kristen; Doherty, Katie; Bekker, Linda-Gail; Hou, Taige; Wood, Robin; Francke, Jordan A
    BACKGROUND: Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays. METHODS: We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO " Option A "): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/life-year saved). RESULTS: In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory , POC improved clinical outcomes and reduced healthcare costs. CONCLUSIONS: In antenatal clinics implementing Option A , the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.
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    Progressive muscular dystrophy in childhood
    (1960) Dubowitz, Victor; Lawson, David; Daniel, P M
    The words of Gowers are as true today as they were nearly a century ago. My interest in muscular dystrophy started in 1957 when, as Senior House Officer at Queen Mary's Hospital for Children, Carshalton, Surrey, I first observed a large number of children suffering from this tragic disease. The frustration of helplessly, watching its inevitable course stimulated the present study.After obtaining an initial impression or' the collection from my clinical observations and a review of the hospital records between 1920 and 1950, I started a more systematic enquiry. The present investigation compromises my personal observations on 65 cases ranging in age from 3 to 16 years. Of these, 57 were seen and followed up at Queen Mary's Hospital for Children, and 8 at the Southern Hospital, Dartford, Kent.
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    A rare mutation causing autosomal dominant STAT1 deficiency in a South African multiplex kindred with disseminated BCG infection
    (2023-07-29) Greybe, Leonore; Leung, Daniel; Wieselthaler, Nicole; le Roux, David M.; Chan, Koon W.; Lau, Yu L.; Eley, Brian
    Abstract Background Autosomal dominant signal transducer and activator of transcription 1 (STAT1) deficiency, part of the Mendelian susceptibility to mycobacterial disease (MSMD) group, frequently causes disseminated Bacillus Calmette-Guérin (BCG) infections, but has not been reported from Sub-Saharan Africa (SSA) where routine birth BCG vaccination is practiced. Case presentation Two half-siblings presented five years apart, with multifocal osteomyelitis as the dominant feature of disseminated BCG, which was successfully treated with antimycobacterial therapy. Whole exome sequencing demonstrated a novel heterozygous substitution in the splice site between intron 13 and exon 14 of the STAT1 gene, NM_007315: c.1128-1G>A, in the proband and his mother and was later confirmed in his half-brother. Conclusions Children with BCG vaccine complications in SSA should be referred for further investigation and particular consideration of MSMD.
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    Retention in care of HIV-infected children from HIV test to start of antiretroviral therapy: systematic review
    (Public Library of Science, 2013) Mugglin, Catrina; Wandeler, Gilles; Estill, Janne; Egger, Matthias; Bender, Nicole; Davies, Mary-Ann; Keiser, Olivia
    BACKGROUND: In adults it is well documented that there are substantial losses to the programme between HIV testing and start of antiretroviral therapy (ART). The magnitude and reasons for loss to follow-up and death between HIV diagnosis and start of ART in children are not well defined. METHODS: We searched the PubMed and EMBASE databases for studies on children followed between HIV diagnosis and start of ART in low-income settings. We examined the proportion of children with a CD4 cell count/percentage after after being diagnosed with HIV infection, the number of treatment-eligible children starting ART and predictors of loss to programme. Data were extracted in duplicate. RESULTS: Eight studies from sub-Saharan Africa and two studies from Asia with a total of 10,741 children were included. Median age ranged from 2.2 to 6.5 years. Between 78.0 and 97.0% of HIV-infected children subsequently had a CD4 cell count/percentage measured, 63.2 to 90.7% of children with an eligibility assessment met the eligibility criteria for the particular setting and time and 39.5 to 99.4% of the eligible children started ART. Three studies reported an association between low CD4 count/percentage and ART initiation while no association was reported for gender. Only two studies reported on pre-ART mortality and found rates of 13 and 6 per 100 person-years. CONCLUSION: Most children who presented for HIV care met eligibility criteria for ART. There is an urgent need for strategies to improve the access to and retention to care of HIV-infected children in resource-limited settings.