Hepatic Cystic Echinococcosis (Hydatid Cyst) in a Six Year Old.

Presentation To describe a case of cystic echinococcosis (CE) in a previously healthy child and review epidemiology of CE in Ireland. Diagnosis A previously healthy 6 year old girl was found to have a cystic lesion in the right lobe of her liver. Serology for Echinococcus granulosus was positive, and radiological features were suggestive of CE. Treatment The patient was pre-treated with anti-helminthic medications before undergoing a liver segmentectomy to remove the cyst, and received further treatment with albendazole after surgery. Histological findings were consistent with CE due to E. granulosus, likely acquired during travel to continental Europe. Conclusion CE should be considered in the differential of children with asymptomatic cysts in the liver and/or lung, and a travel history elucidated in such cases.

Varicella Related Hospital Admissions in Ireland

Aim The aim of this study was to evaluate trends in admissions for patients with primary varicella infection in Irish hospitals. Methods The Hospital Inpatient Enquiry System was evaluated from Irish hospitals from 2005-2016 for patients with primary varicella infection. Results There were 2717 admissions with primary varicella infection. The average annual number of admissions was 226 for an incidence of 4.87/100,000. Average length of stay (ALOS) was 5-days. Sixty-two (2.5%) patients required intensive-care with an ALOS of 26-days. The most common secondary diagnoses were cellulitis, volume-depletion and streptococcal infection. The number of admissions due to streptococcal infection and cellulitis significantly increased over the period. Conclusion Chickenpox places a consistent burden on Irish healthcare, accounting for in excess of 1100 acute and 160 intensivecare bed days annually. This study adds weight to the argument that universal varicella vaccine should be considered and provides baseline epidemiology to determine vaccine effectiveness in the future.

Kawasaki Disease - A Review of Treatment and Outcomes in an Irish Paediatric Cohort 2010-14.

Diagnosis of Kawasaki Disease (KD) can be challenging due to lack of a diagnostic test, and some children present with 'incomplete' KD when not all diagnostic criteria are met. Treatment with intravenous immunoglobulin (IVIG) and aspirin reduces the risk of coronary artery complications. There is sub-group of patients who are resistant to IVIG/aspirin therapy and are at increased risk of complications. Recent evidence suggests that additional treatment of this high-risk group with corticosteroids is beneficial in reducing this risk. We examine the treatment and coronary artery outcomes, by retrospective review of medical records, of a cohort of 32 paediatric patients with KD admitted to a single Irish tertiary centre from January 2010-December 2014. Twenty-eight percent of patients (9/32) had an incomplete diagnosis of KD; these patients received IVIG later compared to those with a complete KD diagnosis. 15/32 (47%) had abnormal echocardiogram findings in the acute phase, 8/32 (25%) had echocardiogram abnormalities at 6-week follow-up, and 4/32 (12.5%) had persisting abnormalities. This study highlights the potential for adverse outcome in KD, the difficulty in diagnosis in 'incomplete' cases, and the need to identify children at higher risk for adverse outcome where adjunctive therapies would be most beneficial.

Pneumococcal meningitis: clinical outcomes in a pre-vaccine era at a Dublin paediatric hospital, 1999-2007.

AIM: To document the long-term outcomes of pneumococcal meningitis in children presenting to a Dublin paediatric hospital in the pre-pneumococcal conjugate vaccine (PCV7) era (1998-2007). METHODS: Subjects with pneumococcal meningitis were identified at The Children's University Hospital, Dublin through the hospital surveillance system and laboratory archives. RESULTS: 44 children were identified with S. pneumoniae meningitis. Mean age of presentation was 23.45 months (2 days to 13 years) and 28 (65%) cases were less than 12 months old. Eight (18.6%) children died. 55% of cases were left with significant deficits. Of the survivors, 7 (20%) had moderate to severe neurological sequelae. CONCLUSION: Pneumococcal meningitis is a devastating childhood disease with significant mortality and morbidity, especially in those less than 2 years of age. These data provide a baseline against which the impact of PCV7 on pneumococcal meningitis can be measured.

Imported childhood malaria: the Dublin experience, 1999-2006.

AIMS: Imported childhood malaria has never been studied in Ireland. We aimed to document the incidence and species of malaria in children presenting to paediatric hospitals in Dublin and to examine management and outcome measures. METHODS: Subjects were identified through laboratory archives from the three paediatric hospitals in Dublin. Clinical data were extracted retrospectively from clinical and laboratory records. RESULTS: As much as 67 episodes of malaria occurred in 66 children. Episodes occurred among new immigrants (n = 31) and Irish residents (n = 33) who travelled to endemic regions. The majority of those who travelled to endemic regions did not receive appropriate prophylaxis. Plasmodium falciparum was identified in 64 (95%) episodes, 26 with a parasite load above 2%. Eighteen children developed complications. All cases were treated successfully. CONCLUSIONS: Irish health-care practitioners need to encourage malaria prophylaxis among travellers to malaria-endemic regions. Management guidelines should be formulated to assist Irish clinicians treating this potentially fatal illness.

Hepatitis B virus infection in children.

Recent increases in Hepatitis B virus (HBV) infection prompted us to characterize HBV-infected children in Ireland and to audit management, by reviewing prospectively gathered data. Of 46 children (29 [63%] male), median age at presentation was 8.1 years (range 0.6-17.6), monitoring duration was 22.5 months (range 1-101), 23/46 (50%) were European (including 9 [19.6%] Irish), 15 (32.6%) African and 9 (19.6%) Asian. Acquisition was vertical (25/46 [54.3%]), horizontal (5/46 [10.9%]), unknown (16/46 [34.8%]). HBV-DNA was >100,000,000 cpm in 20/32 (62.5%) with chronic infection. Hepatitis B e antigen (HBeAg) was detected in 32/44 (72.7%). We estimate that universal neonatal vaccination (UNV-HBV) could have prevented 22% of cases, and could limit further horizontal HBV spread. This supports the recent introduction of UNV-HBV.

Invasive pneumococcal disease in children in Ireland--the anticipated benefit of conjugate pneumococcal vaccination.

BACKGROUND: Streptococcus pneumoniae is an important cause of childhood illness. Recently a safe and effective 7-valent conjugate pneumococcal vaccine for children has been licensed in the EU. AIMS: To calculate the incidence of invasive pneumococcal disease (IPD) in children in Ireland, to estimate the burden of disease and to anticipate the protective effect of the conjugate vaccine. METHODS: Retrospective review of data from children with IPD. RESULTS: Ninety-six cases of IPD in 95 children including two related deaths were identified. All childhood IPD incidence was estimated at 10.6/100,000. We anticipate that the 7-valent conjugate vaccine could prevent up to 90% of sepsis and up to 82.5% of meningitis cases. CONCLUSIONS: IPD is an important cause of mortality and morbidity in children in Ireland. Routine use of conjugate pneumococcal vaccine would have a significant impact on pneumococcal disease, especially in vaccinated children but also in unvaccinated children and older adults.

A limit on retrieval-induced forgetting.

Retrieving some members of a memory set impairs later recall of semantically related but not unrelated members (M. C. Anderson, R. A. Bjork, & E. L. Bjork, 1994; M. C. Anderson & B. A. Spellman, 1995). The authors investigated whether this retrieval-induced forgetting effect would generalize to testing procedures other than category-cued recall. Although the authors demonstrated a retrieval-induced forgetting effect using a category-cued recall task, they failed to show retrieval-induced forgetting on several different memory tests that used item-specific cues, including a category-plus-stem-cued recall test, a category-plus-fragment-cued recall test, a fragment-cued recall test, and a fragment completion task.

Outcome of infants born to hepatitis C infected women.

BACKGROUND: Hepatitis C virus (HCV) can be transmitted vertically from mother to infant, either late in pregnancy or at delivery. AIMS: To determine the outcome of infants born to HCV infected women, to characterise epidemiology and to design an appropriate infant monitoring schedule. METHODS: Three hundred and fourteen infants, born to 296 HCV positive women between 1994 and 1999 were monitored for a median of 18 months (range 1-52). RESULTS: Forty per cent of infants were small for age and 46% had neonatal abstinence syndrome (NAS). Of 173 infants of defined status, 11 were infected (vertical transmission rate [VTR] 6.4%, 95% CI 2.8-10). Infected infants were diagnosed at a median of three months (range 0.5-10). Liver transaminases elevation was documented in 8% of uninfected infants. A negative HCV PCR test before one month of age did not exclude infection but all infected patients had detectable HCV RNA when next tested (range 2-10 months). CONCLUSIONS: 94% of infants born to HCV antibody positive women are not HIV infected. Liver transaminase elevation in exposed infants is not always indicative of infection. A minimum monitoring schedule of testing (PCR and antibody) at six to eight weeks, six and 18 months allows early diagnosis while detecting late seroconversions.

Antenatal hepatitis B screening - is there a need for a national policy?

Routine antenatal testing for hepatitis B carriage with maternal consent was introduced at the Rotunda in January 1998. The uptake of testing has been excellent; 99.98% of women presenting for antenatal care accepted hepatitis B (HBV) screening in the 30-months from January 1998 through June 2000. The prevalence of HBV carriage was 0.35% (58 pregnancies of 16,222 tested) increasing from 0.25% in 1998 (16 of 6227) to 0.45% in the first six months of 2000 (16 of 3484). Fifty-five women had 58 pregnancies (three women had two pregnancies). Two of these were e-antigen positive. HBV carrier status was previously unknown in 48 (87%). Two additional women had acute HBV infection in pregnancy. Forty-five infants have been born to mothers included in this screening programme. Audit of infant outcome reveals excellent compliance with immunisation and follow-up: 29 (64%) have completed the 3 dose HBV vaccination schedule to date. Thirteen infants (31%) are still attending; three are lost to follow-up including one whose family has emigrated. Routine antenatal screening for hepatitis B carriage is cost-effective and should be considered a standard of care in maternity practice.

Planning and execution of a successful hepatitis B immunization program.

Today's college students occupy a "window" between older adults, whose need for hepatitis B vaccination is minimal, and younger people who receive the vaccine as part of their childhood immunization series. However, because of the high-risk activities that are often part of student behavior, college students are among the individuals who are at the highest risk for this disease; 75% of all reported hepatitis B cases occur in persons between the ages of 15 and 39 years. It is therefore imperative that college health professionals take seriously their responsibility to educate students about issues related to hepatitis B and make available programs that enable the students to receive immunizations. This article briefly describes a successful hepatitis B education and immunization program at an institution that has no mandatory prematriculation immunization requirements.

The efficacy and tolerability of combination antiretroviral therapy in pregnancy: infant and maternal outcome.

Antiretroviral therapy (ART) and Caesarean section (CS) delivery significantly reduce the risk of vertically transmitted HIV infection. Attention must focus on determining the optimal management strategy for HIV-positive pregnancies. Guidelines must reflect not only the activity and tolerability of combination ART in pregnancy for mother and infant and the potential short and long-term infant toxicity, but also whether surgical delivery can confer an added benefit if combination ART had reduced plasma viraemia to undetectable levels. To aid the development of management strategies for the Republic of Ireland, a retrospective detailed review of all HIV-positive pregnancies since the introduction of combination ART was undertaken. Since 1997 there have been 25 deliveries to 24 women. Combination ART reduced plasma viraemia to undetectable levels in 76% mothers at delivery. The CS rate was 28% and no unanticipated infant toxicity was encountered. To date no infant has proven infected. Three infants have seroreverted and 24 of 26 infants have had at least 2 negative HIV ribonucleic acid (RNA) and polymerase chain reaction (PCR) tests. Two infants are less than one month old. In this study, the CS rate of 28% is below that reported from many centres yet no vertical transmission was found. Given the efficacy of ART in reducing plasma viraemia, the additional benefit of CS for these women is questionable.

Hepatitis C infection in an Irish antenatal population.

BACKGROUND: Hepatitis C infection (HCV) has an estimated seroprevalence of 1-2% in women of child-bearing age and vertical transmission rate of 5-15%. AIMS: To characterise the current trends of HCV in an Irish antenatal population. METHODS: Infants of HCV seropositive women, born 1994 to 1999, were referred to the Paediatric Infectious Diseases service. Maternal details were collected retrospectively. RESULTS: 296 HCV seropositive women were studied. 244 (82%) were infected through intravenous drug use (IVDU), 25 (8%) through heterosexual contact and 13 (7%) via blood products. Nine women had no identifiable risk factors. Coinfection with other blood borne viruses was uncommon (4.7% HIV, 3.4% hepatitis B). Of 84 women tested for HCV-RNA, 46 (55%) were positive. Eighty three (26%) delivered prematurely; the caesarean section rate was 11%. CONCLUSIONS: HCV is increasingly detected in antenatal clinics. Heterosexual contact is a mode of spread. Maternal HCV viraemia can be variable in pregnancy. Further study of HCV in pregnancy is needed to define the impact of pregnancy on HCV, accurately predict infant outcome and selectively target interventions to women at greatest risk of transmission.

Suppression of reflexive saccades in younger and older adults: age comparisons on an antisaccade task.

Inhibitory control of prepotent responses has been examined by using the antisaccade task, during which a reflexive saccade toward a peripheral onset must be suppressed before an eye movement in the opposite direction from the onset can be executed. In the present experiments, we sought to determine whether older and younger adults would perform similarly on this task. Older adults had a harder time suppressing their reflexive responses, as measured by an increase in the proportion of saccade direction errors. Despite an age-related decline in saccade direction accuracy, the increase in saccade latency associated with the antisaccade condition was the same for both younger and older adults. These results support the view that the effectiveness of inhibitory control declines with age (Hasher & Zacks, 1988; Hasher, Zacks, & May, 1999).

Accidental exposures to blood and other body fluids in a large academic medical center.

Healthcare workers' and students' exposures to blood-borne pathogens during a 1-year period (1997) at a large university academic medical center were analyzed. The university health manages the Blood-Borne Pathogen Post-Exposure Control Program at the university and treats all reported exposures of students, faculty, and staff. Comparative exposure rates for all categories of healthcare workers, the work site where injuries occurred, and the circumstances involved in 298 exposure incidents are outlined. A standardized postexposure prophylaxis protocol provides for definition of the health status of all known source patients and assessment of the potential need for treatment of the exposed clinician. Implications of the study for focusing on improvements in training healthcare workers in proper procedures and the use of personal protective equipment in dealing with blood-borne pathogens are discussed.

Paediatric HIV infection in the Republic of Ireland and the need for antenatal screening.

Thirty-seven HIV-infected children have been identified in the Republic of Ireland since 1985. Only 12 (32%) of 37 were followed prospectively from birth. Median age at diagnosis was 18 months (4 weeks to 8 years). In 32 (86%) of 37 cases, HIV infection was acquired as a result of transmission from mother to infant with intravenous drug use (IVDU) the most frequent risk factor for maternal acquisition of HIV. Of these 32 children, median maternal age at delivery was 24 (interquartile range (IQR) 23-26) years with median gestation at delivery 40 (IQR 38-40) weeks. Mode of delivery was by vaginal delivery in all 29 (91%) cases where mode of delivery is known. Only 2 infants were breastfed. Seven children have died at a median age of 9 (0.8-9.6) years. As of July 1997, 12 children have AIDS, 14 have symptomatic disease without AIDS and 3 are asymptomatic. Median age at AIDS diagnosis was 2.6 (0.1-6.5) years. Median survival time post-AIDS diagnosis was 6.5 (1.8-8.3) years. Of 29 living children, 24 mothers and 14 fathers are HIV infected and only 14 children live with both parents. Childhood HIV infection has had a significant personal, social and financial impact on both Irish families and society in general. More effective measures to control HIV infection among intravenous drug users are needed. Antenatal detection of HIV-infected mothers is paramount as vertical transmission can be successfully prevented and morbidity and death can be prevented in the infected infant.

Mother-to-child transmission of human immunodeficiency virus (HIV) in Ireland: a prospective study.

Symptomatic HIV infection was first diagnosed in an Irish child in 1985. A prospective study was initiated to determine the vertical transmission rate (VTR) of HIV and the average age of infant seroreversion and to monitor clinical, immunologic and virologic evidence for HIV infection in seroreverters. Ninety three HIV positive infants have been prospectively identified since 1985. The predominant underlying maternal risk factor for HIV infection is intravenous drug use (IVDU) (96 per cent). Of 93 infants, median gestational age was 40 weeks and median birth weight 3125 grams. Ninety-four per cent of infants were bottle fed. Currently 72 (77 per cent) infants are uninfected, 12 (13 per cent) are infected, 4 (4.5 per cent) are indeterminate and 5 (5.5 per cent) have been lost to follow up. The intermediate estimate of vertical transmission rate (VTR) is 14.3 per cent. The median age at documented seroreversion was 12 months. There are no significant differences between infected and non-infected children in male/female ratio, gestational age, mode of delivery or birth weight. Strategies to reduce the transmission of HIV among drug users in combination with routine antenatal screening and antiretroviral prophylaxis of vertical transmission are all measures which can reduce HIV infection in our children.

Perinatal transmission of HIV and diagnosis of HIV infection in infants: a review.

Paediatric HIV infection has become a major burden on families, communities and health services worldwide. The vast majority of children now acquire HIV as a result of mother to infant (vertical) transmission. Recent major advances have occurred following the greater understanding of the risk factors for perinatal transmission and the role of antiretroviral therapy in preventing transmission. Now that interruption of vertical transmission is possible, early identification of HIV-infected pregnant women is critical. As of June 1997, HIV infection has been diagnosed in 37 children under 15 yrs of age in the Republic of Ireland; 32 as a result of maternal to infant transmission. The exact timing of HIV transmission during pregnancy is unclear but it is estimated that 60-70 per cent of infants may be infected at the time of delivery with approximately 30 per cent infected earlier in gestation. Vertical transmission rates vary from 15-40 per cent in different global areas. Antenatal and perinatal zidovudine treatment can reduce this rate by 60-70 per cent. Risk factors for the vertical transmission of HIV-1 are multifactorial. These factors include maternal disease status, in particular maternal viral load, route of delivery, duration of membrane rupture, presence of obstetric complications and infant feeding practices. Definitive diagnosis of HIV infection in infancy has been difficult in the past. Direct viral detection methods now allow the reliable diagnosis of HIV infection in the first few months of life. The most effective intervention to reduce perinatal HIV infection will be the better identification of HIV positive pregnant women with the subsequent introduction of measures to interrupt vertical transmission of HIV.

Childhood needlestick injuries in the Dublin metropolitan area.

Childhood needlestick injuries and other risk exposures outside of hospital are becoming increasingly common. A retrospective review of casenotes to ascertain the incidence, epidemiology and adequacy of management and follow-up of exposures in the Dublin metropolitan area revealed 52 cases between July 1995 and October 1996. Median age of children was 7.4 years. Most occurred in inner city areas with a recognised high prevalence of i.v. drug use. Only 2 high-risk exposures were identified. On presentation all cases received Hepatitis B vaccination and 56% received Hepatitis B immunoglobulin. Following Hepatitis B virus, Hepatitis C virus and Human immunodeficiency virus testing, no seroconversions have been identified to date in 9 children with completed tests. General follow-up and Hepatitis B immunisation when initiated were not always complete. Standardised management protocols and wider availability of counselling are recommended.

Cryptosporidiosis in children who visited an open farm.

In the summer of 1995, cryptosporidiosis was diagnosed in a child in hospital. This child had taken part in a summer activity project involving 161 children and nine adults. Reports of a similar illness among a number of other participants prompted an outbreak investigation. A cohort study was conducted in two phases. Thirteen children (aged 6 to 15 years) out of 161 respondents to the first questionnaire met the case definition for illness and cryptosporidium was detected in stools from seven of the 13. Illness was significantly associated with child participants who had visited an open farm (p < .000005). Nine of the cases sought medical attention, and two were admitted to hospital. The second phase of the cohort study was conducted among 52 of the 55 people who had visited the open farm. Illness was significantly associated with playing in sand to which animals had access, at the edge of a stream beside a picnic area (p < .005). Contact with various animals was not associated with illness. This outbreak emphasises the risk for children of visiting open farms. Managers of open farms need to be aware of the potential for transmission of infectious diseases to visiting children. Strict implementation of hygiene measures is essential to minimise risk.