Transfusion of blood components in pediatric age groups: an evidence-based clinical practice guideline adapted for the use in Egypt using 'Adapted ADAPTE'.

Pediatric transfusion is a complex area of medicine covering a wide age range, from neonates to young adults. Compared to adult practice, there is a relative lack of high-quality research to inform evidence-based guidelines. We aimed to adapt the pre-existing high-quality practice guidelines for the transfusion of blood components in different pediatric age groups to be available for national use by general practitioners, pediatricians, and other health care professionals. The guideline panel included 17 key leaders from different Egyptian institutions. The panel used the Adapted ADAPTE methodology. The panel prioritized the health questions and recommendations according to their importance for clinicians and patients. The procedure included searching for existing guidelines, quality appraisal, and adaptation of the recommendations to the target context of use. The guideline covered all important aspects of the indications, dosing, and administration of packed red cells, platelets, and fresh frozen plasma. It also included transfusion in special situations, e.g., chronic hemolytic anemia and aplastic anemia, management of massive blood loss, malignancies, surgery, recommendations for safe transfusion practices, and recommendations for modifications of cellular blood components. The final version of the adapted clinical practice guideline (CPG) has been made after a thorough review by an external review panel and was guided by their official recommendations and modifications. A set of implementation tools included algorithms, tables, and flow charts to aid decision-making in practice. This adapted guideline serves as a tool for safe transfusion practices in different pediatric age groups.

Mycoplasma genitalium's Antibiotic Resistance in Sexually Transmitted Infections Clinics in Israel.

OBJECTIVES: To determine the prevalence of antibiotic resistance rate in Mycoplasma genitalium, and distribution of mutations associated with this resistance, among patients that attended sexually transmitted infections (STI) investigation clinics. MATERIALS AND METHODS: This cross-sectional study included M. genitalium-positive samples (urine, vaginal, rectal, and pharyngeal swabs) collected from 170 patients attending two STI investigation clinics, which were subjected to macrolide and quinolone resistance mutations analyses. Data regarding patient age, sex, and material/anatomical site of testing were collected. RESULTS: Macrolide-resistance mutations were identified in 48.8% of samples and were more common among males (p < .0001) and in rectal samples (p < .05). A2059C was the most prevalent macrolide-resistance mutation (18.2%). Quinolone resistance was detected in 23% of the samples, with S83I being the most common (17.1%) mutation. Rate of co-resistance to macrolides and quinolones was 21.2%. CONCLUSIONS: The high rate of antibiotic resistance found in the current study, especially to macrolides, underscores the importance of antibiotic resistance monitoring in M. genitalium isolates in cases of persistent or recurrent urethritis/cervicitis, in cases of treatment failure and among specific populations. Such surveillance will improve treatment regimens and cure rates.

Sexually Transmitted Diseases in Northern Israel: Insights From a Large Referral Laboratory.

OBJECTIVES: The aims of the study are to investigate the distribution and frequency of different sexually transmitted diseases (STDs) among a large study population of individuals undergoing STD investigation both in inpatient and STD clinic settings and to evaluate influence of test anonymity on the positivity rate of pathogens. MATERIAL AND METHODS: A retrospective study retrieved epidemiologic data from the following 3 sources: a secondary referral hospital and 2 STD clinics in Northern Israel. Positivity rate of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma genitalium , and Trichomonas vaginalis (TV) was assessed and stratified based on age, sex, site of sampling, and anonymity of test. Adjusted odds ratios (ORs) were calculated by multivariable logistic regression. RESULTS: Overall, 3,753 assays were performed on 2,407 patients who were screened for STD. Chlamydia trachomatis (4.8%) was the most frequently detected STD, followed by NG (2.1%), MG (1.9%), and TV (0.6%). Mycoplasma genitalium (OR, 4.32; 95% CI, 1.70-10.97; p = .001) and NG (OR, 6.08; 95% CI, 2.18-16.96; p < .001) were significantly associated with male sex, while TV was more frequently encountered among female individuals (OR, 4.34; 95% CI, 1.49-12.50; p = .003). Mycoplasma genitalium infection was detected most commonly by urine samples, while rectal swabs were the leading source of positive tests for CT. Compared with fully identified patients, those tested anonymously were 6-fold more likely to be tested positive for TV (adjusted OR, 6.49; 95% CI, 2.06-20.42; p = .001). CONCLUSIONS: Chlamydia trachomatis and NG are the leading non-HIV STDs in Northern Israel. Anonymous tests predict higher positivity of TV. Rectal sampling should be increasingly used because of its efficacy in detecting CT infections.

Epidemiologic Surveillance in Israel of Cryptosporidium, a Unique Waterborne Notifiable Pathogen, and Public Health Policy.

BACKGROUND: Cryptosporidium is a major threat to water supplies worldwide. Various biases and obstacles in case identification are recognized. In Israel, Cryptosporidiosis was included among notifiable diseases in 2001 in order to determine the burden of parasite-inflicted morbidity and to justify budgeting a central drinking water filtration plant. OBJECTIVES: To summarize the epidemiologic features of 14 years of Cryptosporidium surveillance and to assess the effects of advanced water purification treatment on the burden of disease. METHODS: From 2001 to 2014, a passive surveillance system was used. Cases were identified based on microscopic detection in stool samples. Confirmed cases were reported electronically to the Israeli Ministry of Health. Overall rates as well as age, gender, ethnicity and specific annual incidence were calculated per 100,000 population in five age groups: 0-4, 5-14, 15-44, 45-64, > 65 years. RESULTS: A total of 522 Cryptosporidium cases were reported in all six public health districts. More cases were detected among Jews and among males, and mainly in young children, with a seasonal peak during summer. The Haifa sub-district reported 69% of the cases. Most were linked to an outbreak from the summer of 2008, which was attributed to recreational swimming pool activity. Cases decreased after installation of a central filtration plant in 2007. CONCLUSIONS: As drinking water in Israel is treated to maximal international standards, the rationale for further inclusion of Cryptosporidium among mandatory notifiable diseases should be reconsidered. Future surveillance efforts should focus on timely detection of outbreaks using molecular high-throughput testing.

[INFLUENZA VACCINATION AMONG HEALTHCARE WORKERS - THE DATA AND THE DUTY].

INTRODUCTION: Seasonal influenza is a significant disease affecting public health due to substantial morbidity and mortality and a high economic burden. in view of its high propensity for genetic mutations, the virus can easily evade preexisting immunity acquired from prior exposure to it, thereby causing severe seasonal epidemics. Influenza vaccination has been shown to be safe and effective. In many countries, including Israel, it is recommended to all members of the population aged 6 months and older, especially those with a higher risk of developing severe complications. Its adverse effects are mostly minimal, local and systemic. No evidence-based relationship between the vaccination and neurological syndromes was found. Infected health care workers (HCWs) may transmit influenza to patients, many of whom have serious underlying conditions that increase their risk of complications. Therefore, influenza vaccination among HCWs is recommended in the United States and in >40 other countries including Israel. In spite of that, the vaccination coverage rates remain low in Israel and in many countries. The reasons include low levels of awareness to the disease severity, to the safety and effectiveness of the vaccine and low levels of trust in authorities. The effectiveness and safety of the vaccine in preventing influenza among the recipients is well documented. High quality evidence on the effectiveness of the vaccine in preventing the disease among patients and family members of HCWs who receive the vaccine is limited. However, combining the existing evidence and the clear biological plausibility lead to the conclusion that the recommendation for vaccinating health care workers against influenza to protect patients is a well-based policy. This is the policy of the WHO, CDC and health authorities in most developed countries. The Ministry of Health in Israel will continue to promote programs to increase vaccine compliance rates among HCWs and to define the uptake of vaccination as a moral duty.

Feasibility and validity of early screening for identifying infants with poor social-communication development in a well-baby clinic system.

UNLABELLED: This study examined the feasibility and validity of implementing an autism spectrum disorders (ASD) screening for 12-month-old infants. METHOD: Parents of 583 infants, 12months of age attending well baby clinics (WBCs), completed the First Year Inventory-Lite (FYI-L). Ten infants who failed the FYI-L and a subset of 12 infants who passed the identified FYI-L were evaluated using the Autism Observation Scale for Infants (AOSI) and the Mullen Scales of Early Learning. Information regarding social-communication development ≥24months of age was extracted from medical records of 153 of the 583 infants. RESULTS: Mean response rate across clinics was 26.63%. Infants at risk compared to controls showed significantly higher scores on the AOSI, lower composite scores on the MSEL, and a higher rate of referral for a developmental evaluation. At 24months, 95% of infants who were negatively screened had no social-communication problems on their medical records; 60% of those who were screened positive had documented problems on medical records. CONCLUSION: ASD screening using the FYI-L at 12months in a healthcare setting identifies infants with poor social-communication development, yet parents had low compliance with screening.

Genomic alterations in the F8 gene correlating with severe hemophilia A in Egyptian patients.

BACKGROUND: Hemophilia A (HA) is an inherited X-linked recessive coagulation disorder caused by factor VIII (F8) deficiency. F8 rearrangements involving intron 22 (int22) and intron 1 (int1) account for almost half of severe HA phenotype also a hotspot exon 14 provides numerous mutational patterns. This study aims to identify F8 gene mutations among Egyptian HA patients. METHODS: DNA samples from 60 HA patients were screened for int22 and int1 rearrangements using simplified inverse shifting PCR (IS-PCR) followed by exon 14 sequencing. Also, four uncharacterized patients were studied by targeted exome sequencing. RESULTS: In 33.3% of the studied patients, we identified three int22 rearrangements, three exon 14 mutations (two frameshift; one novel (NM_000132.3:c.2734_2735delAA, p.(N912Ffs*6)), a second reported mutation (NM_000132.3:c.3091_3094delAGAA, p.(K1031Lfs*9)), and one nonsense mutation (NM_000132.3:c.2440C>T, p.(R814*)). All identified mutations were detected in patients with severe HA phenotype. Targeted exome sequencing could not detect any known pathogenic variants. CONCLUSION: Intron 22 rearrangement and exon 14 mutations correlate with most severe hemophilia A Egyptian patients.

The Relation between Serum Hepcidin, Ferritin, Hepcidin: Ferritin Ratio, Hydroxyurea and Splenectomy in Children with ß-Thalassemia.

BACKGROUND: Hepcidin, a small peptide hormone, is established as the main regulator of iron homeostasis. AIM: To estimate serum hepcidin, ferritin, and hepcidin: ferritin ratio in ß-thalassemia patients and to determine the effect of splenectomy and hydroxyurea on serum hepcidin. METHODS: A study was conducted on 30 thalassemia major (ßTM), 29 thalassemia intermedia (ßTI) and 29 healthy children's controls. Data were collected by patient interviewing where detailed history-taking and thorough clinical examinations were carried out. Serum ferritin and hepcidin were measured by ELISA assay (Bioneovan Co. Ltd Beijing, China). RESULTS: Βeta-thalassemia patients had higher serum ferritin, serum hepcidin and lower Hb and hepcidin: ferritin ratio compared to the controls (p < 0.001, 0.010, 0.001, 0.001) respectively. Β-TM patients had higher mean serum hepcidin and serum ferritin compared to ß-TI, with statistically significant difference (P = 0.042, P < 0.001, respectively). Twenty-one patients out of 29 ßTI was on hydroxyurea therapy; these patients had significantly lower levels of serum ferritin (P < 0.004) and significantly higher levels of Hb (P < 0.004). Serum ferritin was statistically significantly higher in splenectomized patients P < 0.009. Serum hepcidin level was insignificantly higher in splenectomized patients than non-splenectomized patients (21.6 ± 14.75, 17.76 ± 10.01 ng/mL). Hepcidin showed a significantly positive correlation with hepcidin: ferritin ratio in all studied groups. CONCLUSION: Serum hepcidin was elevated in ß-thalassemia children with more evident elevation in ßTM patients. Splenectomy played no major role in hepcidin regulation. Knowing that hepcidin in serum has a dynamic and multi-factorial regulation, individual evaluation of serum hepcidin and follow up, e.g. every 6 months could be valuable, and future therapeutic hepcidin agonists could be helpful in management of iron burden in such patient.

Prevalence and Anti-Microbial Susceptibility of Hospital Acquired Infections in Two Pediatric Intensive Care Units in Egypt.

BACKGROUND: Hospital-acquired (nosocomial) infection is a common serious health problem worldwide, especially in pediatric intensive care units and is associated with high mortality and morbidity, prolonged hospital stays and high cost. AIM: To determine the types of organisms involved in hospital-acquired an infection in two pediatric intensive care units during the one-year study and its anti-microbial susceptibility. MATERIAL AND METHODS: This study was carried out in the pediatric intensive care units (PICU) of Ain Shams & Cairo Universities, where 86 pediatric patients were recruited. Their age ranged from 1 month to 156 months with mean 20.7 ± 25.8 months. Male to female ratio was 37:29. Four samples were collected from each child for culture and sensitivity: blood, endotracheal aspirate, urine and skin swab. RESULTS: The most common microorganism was staphylococcus while Gram-negative bacteria were the commonest group. Amikacin and imipenem are the most sensitive antibiotics. Risk estimate for different risk factors among studied patients revealed no significance. CONCLUSION: Staphylococcus was the commonest micro-organism while Gram-negative infections were the commonest group among PICU with a predominance of Acinetobacter and Klebsiella. Respiratory infections were the most common, followed by blood-borne infection. Risk factors for mortality were not significant.

[Mother's education and ethnicity effect on health measures for children in the Haifa subdistrict].

OBJECTIVE: This study aimed to assess the association between the health markers of vaccination coverage, birth weight, hemoglobin levels and nutritional status with the ethnic origin and the mother's educational status among all infants born in 1995 and toddlers born in 1994 in the Haifa subdistrict. METHODS: The data on vaccination coverage rates and other different measures was collected from the Mother and Child Health (MCH) centers in the Haifa subdistrict. MCH centers were categorized into 4 levels of mother educational status (MES) using the distribution of the average number of years of schooling of the registered children's mothers. RESULTS: (1) More than half of the Arab sector in this study were classified in the lowest level of MES, while only 3% of the Jewish sector in this study were classified in this level. (2) No significant association between vaccine coverage rate and MES or ethnicity was found. (3) The percentage of low birth weight was higher among Jews. (4) No consistent association between birth weight and MES. (5) The rate of children with anemia was higher in Arabs (18%) than in Jews (10%). (6) No significant association between anemia and MES in both sectors. CONCLUSIONS: Differences in health measures were found to be associated with ethnicity but not with mother educational status. Arabs were found to be at higher risk for anemia and probable improper nutrition habits than Jews. Thus appropriate health promotion programs should be targeted towards this group, especially programs to improve the hemoglobin levels.

Variables correlated with elderly referral from nursing homes to general hospitals.

BACKGROUND: Referring patients from nursing homes to general hospitals exposes them to nosocomial diseases, and may result in the development of a broad spectrum of physical, mental and social damages. Therefore, minimizing the referring of nursing home patients to hospitals is an important factor for keeping the elderly healthy and minimizing health expenditures. In this study we examined the variables related to the referral rates from nursing homes to general hospitals and the relationship between the referral and the mortality rates among the elderly who live in nursing homes in the Haifa Sub-district. METHODS: Thirty-two nursing homes were included in a cross-sectional study. All medical directors and head nurses were interviewed using a structured questionnaire between November 2006 and October 2007. Statistical analysis, including the ANOVA and the nonparametric Spearman tests, were employed to determine the factors that influence referral rates and the correlation between referral rates and mortality rates. RESULTS: The referral rate ranged between 18 and 222 per 100 financed elderly in a single year. In the multivariate analysis, the absence of a physician from the nursing home at the time of the referral to general hospitals was the only significant variable related to referral rates. No significant relationships were found between referral rates and mortality rates. CONCLUSIONS: Absence of a significant relationship between referral rates and mortality rates may indicate that high referral rates do not necessarily protect the elderly from death. Therefore, any recommendations issued by the Ministry of Health (MOH) should emphasize in-house treatment rather than hospitalization. Clear instructions on referral from nursing homes to general hospitals need to be constructed by the MOH. The MOH should increase the presence of physicians in the nursing homes, especially, when the need to refer a patient arises. Further quantitative and epidemiologic studies should be conducted in order to, more fully and reliably, create guidelines for policy recommendations.

Decreased head circumference velocity as related to developmental deficit in infancy.

We evaluated the significance of head circumference growth velocity as related to developmental deficits during infancy. Head circumferences, lengths, and developmental diagnoses were retrieved in a standard manner at ≥ 2 time points from 437 infants with developmental deficits, and 3909 normally developing infants. Infants' ages ranged from 1-24 months, with final diagnoses ascertained at age 24 months. Increased velocity during the first 2 months in typical infants was evident in the study group during the period 2-4 months. A differential head circumference growth velocity was observed, and infants diagnosed with motor delay presented decreased velocity between ages 2-4 months, compared with infants receiving other nonmotor developmental diagnoses. These differences remained after controlling for birth weight and length. No significant sex effect was evident. Infants with developmental deficits demonstrate delayed acceleration of head circumference velocity, compared with typical infants in the first 2 months. Infants with motor delay manifest decreased velocity, compared with infants presenting other developmental deficits. These differences may be related to delayed white matter maturation.

Plasma neutrophil gelatinase-associated lipocalin as an early biomarker for prediction of acute kidney injury after cardio-pulmonary bypass in pediatric cardiac surgery.

INTRODUCTION: Cardiopulmonary bypass (CPB) surgery is considered one of the most frequent surgical procedures in which acute kidney injury (AKI) represents a frequent and serious complication. The aim of the present study was to evaluate the efficiency of neutrophil gelatinase-associated lipocalin (NGAL) as an early AKI biomarker after CPB in pediatric cardiac surgery. MATERIAL AND METHODS: The study included forty children aged 2 to 78 months undergoing CPB. They were divided into group I: patients who suffered AKI grades II and III; and group II: patients who did not develop AKI or at risk. Peripheral venous blood was withdrawn pre- and post-operatively for serial measurements of NGAL and creatinine. Statistical analysis was performed using Statistical Package for Social Sciences version 14. RESULTS: Mean plasma NGAL levels showed highly significant elevations in group I patients at 2, 12, and 24 h after surgery (p < 0.0001) compared to group II. Significant correlations were found between NGAL and creatinine at different time intervals. Highly significant correlations (p < 0.0001) were found between plasma NGAL and AKI at 2, 12 and 24 h after surgery. A cut-off level of 100 ng/ml at 2 h, and 125 ng/ml at 12 h post-operatively both recorded the highest accuracy, being 95% accurate, with sensitivity of 100% and 89.5% respectively, and specificity of 90.5% and 100% respectively. CONCLUSIONS: This study showed that plasma NGAL could be used as an early biomarker for detection of AKI following CPB. We recommend further studies on a wider scale to validate the current study results.

Red cell alloimmunization and autoantibodies in Egyptian transfusion-dependent thalassaemia patients.

INTRODUCTION: The objective of this study was to explore the frequency of red cell alloantibodies and autoantibodies among ß-thalassaemia patients who received regular transfusions. MATERIAL AND METHODS: This study included 501 patients with ß-thalassaemia. This work planned to study the presence of alloantibodies and autoantibodies to different red cell antigens in multitransfused thalassaemia patients using the ID. Card micro typing system. RESULTS: Of a total of 501 ß-thalassaemia patients included in the study, 11.3% of patients developed alloantibodies; 9.7% of these alloantibodies were clinically significant. The most common alloantibodies were anti-K, anti-E and anti-C. The rate of incidence of these alloantibodies was 3.9%, 3.3% and 1.7% respectively. Autoantibodies occurred in 28.8% of the patients and 22.1% of these antibodies were typed IgG. There was a significant association between splenectomy with alloimmunization and autoantibody formation (p = 0.03, p = 0.001 respectively). There was no significant association between alloantibody, autoantibody formation and number of transfused packed red cells. CONCLUSIONS: Alloimmunization to minor erythrocyte antigens and erythrocyte autoantibodies of variable clinical significance are frequent findings in transfused ß-thalassaemia patients. There is an association between absence of the spleen and the presence of alloimmunization and autoantibody formation.