Consensus statement on measures to promote equitable authorship in the publication of research from international partnerships.

Despite the acknowledged injustice and widespread existence of parachute research studies conducted in low- or middle-income countries by researchers from institutions in high-income countries, there is currently no pragmatic guidance for how academic journals should evaluate manuscript submissions and challenge this practice. We assembled a multidisciplinary group of editors and researchers with expertise in international health research to develop this consensus statement. We reviewed relevant existing literature and held three workshops to present research data and holistically discuss the concept of equitable authorship and the role of academic journals in the context of international health research partnerships. We subsequently developed statements to guide prospective authors and journal editors as to how they should address this issue. We recommend that for manuscripts that report research conducted in low- or middle-income countries by collaborations including partners from one or more high-income countries, authors should submit accompanying structured reflexivity statements. We provide specific questions that these statements should address and suggest that journals should transparently publish reflexivity statements with accepted manuscripts. We also provide guidance to journal editors about how they should assess the structured statements when making decisions on whether to accept or reject submitted manuscripts. We urge journals across disciplines to adopt these recommendations to accelerate the changes needed to halt the practice of parachute research.

The role of macrolides in childhood non-cystic fibrosis-related bronchiectasis.

Non-cystic fibrosis-related bronchiectasis is a chronic inflammatory lung disease, which is regarded as an "orphan" lung disease, with little research devoted to the study of this condition. Bronchiectasis results in impaired quality of life and mortality if left untreated. The tools available in the armamentarium for the management of bronchiectasis entail antibiotic therapy traditionally used to treat exacerbations, stratagems to improve mucociliary clearance, and avoidance of toxins. Macrolides have been known for the last two decades to have not only anti-bacterial effects but immunomodulatory properties as well. In cystic fibrosis, the use of macrolides is well documented in subjects colonized with Pseudomonas aeruginosa, to improve quality of life and lung function. There is currently emerging evidence to suggest the benefit of macrolides in subjects not colonized with Pseudomonas aeruginosa. This beneficial effect has been less explored in the context of bronchiectasis from other causes. The purpose of this paper is to review the current literature on the use of macrolides in non-cystic fibrosis related bronchiectasis in paediatrics.

Comparison of outcomes between children ventilated in a non­paediatric intensive care and a paediatric intensive care unit: A retrospective analysis.

Background: Lack of paediatric intensive care infrastructure, human resources and expertise in low- and middle-income countries (LMICs) often results in critically ill children being managed in non-intensive-care unit (ICU) settings. Objectives: To compare the mortality between critically ill patients who required ventilation for more than 24 hours in a non-paediatric ICU (PICU) setting v. those admitted directly to a PICU. Methods: Participants were enrolled if they were between one month and 13 years of age and were ventilated in a non-PICU ward in a regional hospital and a PICU ward in a tertiary/quaternary hospital during the study period of January 2015 - December 2017 in KwaZulu-Natal, South Africa. Descriptive statistics, chi-square test, Wilcoxon test and binary logistic regression were used for data analysis. Ethics approval was obtained (approval number BE568/18 BREC) from the Biostatistics Research Council of the University of KwaZulu-Natal. Results: Of the 904 admissions, 25.1% (n=227) were admitted to non-PICU and 74.9% (n=677) to a PICU. A significantly higher proportion of non-PICU patients were malnourished than PICU patients (26.4% v. 13.3%, p<0.001). Patients ventilated in a PICU were 76% less likely to die (p<0.001), while patients who required inotropes were 15.08 (9.68 - 24.34) times more likely to die (p<0.001). There was a statistically significant association between admission setting and survival outcome, with higher mortality in the non-PICU setting than in the PICU setting (46.3% v. 19.5%, p<0.001). Conclusion: Critically ill children ventilated in a non-PICU setting in KwaZulu-Natal are more likely to be malnourished, require inotropes and have higher mortality. Although increasing access to PICU bed availability is a long-term goal, the high mortality in the non-PICU setting highlights the need to optimise the availability of resources in these non-PICU wards, optimise and train the staff, and improve primary healthcare services.

Invasive fungal infections in a paediatric intensive care unit in a low-to middle-income country.

Background: Paediatric intensive care units (PICUs) are high-risk settings for healthcare-associated infections. Invasive fungal infection (IFI) is one of the common causes of healthcare-associated infections. Objectives: To describe the prevalence and short-term outcomes of children with IFI, and to offer a basis for the efficient prevention and treatment of IFI. Methods: A retrospective study was conducted in children under the age of 12 years over a two-year period. Participants were categorised according to pre-defined microbiology criteria into IFI if they had a positive culture from blood or other sterile sites. Data collected included demographics, invasive procedures, length of stay and mortality. Results: One thousand and forty-two children were admitted during the study period. Of the total, 56.8% (n=592) were male. Median length of stay was 18 days (mean±SE 18.6±8.9). IFI was identified in 35 cases per 1 000 admissions, with 77.7% of these infants under the age of one year. The mean length of stay was 18.6 days compared with 7.5 days for children with bacterial infections. The in-hospital mortality for invasive fungal infection was 36% compared with 16% for all admissions. Findings confirmed that colonisation was more prevalent than IFI. Conclusion: IFIs are common among infants, and these patients have a higher mortality rate and prolonged hospital stay. Therefore we recommend early diagnosis and timely treatment with high-performance antifungal drugs to improve the prognosis in children with IFI.

Position statement for adult and paediatric spirometry in South Africa: 2022 update.

Spirometry is required as part of the comprehensive evaluation of both adult and paediatric individuals with suspected or confirmed respiratory diseases and occupational assessments. It is used in the categorisation of impairment, grading of severity, assessment of potential progression and response to interventions. Guidelines for spirometry in South Africa are required to improve the quality, standardisation and usefulness in local respiratory practice. The broad principles of spirometry have remained largely unchanged from previous versions of the South African Spirometry Guidelines; however, minor adjustments have been incorporated from more comprehensive international guidelines, including adoption of the Global Lung Function Initiative 2012 (GLI 2012) spirometry reference equations for the South African population. All equipment should have proof of validation regarding resolution and consistency of the system. Daily calibration must be performed, and equipment quality control processes adhered to. It is important to have standard operating procedures to ensure consistency and quality and, additionally, strict infection control as highlighted during the COVID-19 pandemic. Adequate spirometry relies on a competent, trained operator, accurate equipment, standardised operating procedures, quality control and patient co-operation. All manoeuvres must be performed strictly according to guidelines, and strict quality assurance methods should be in place, including acceptability criteria (for any given effort) and repeatability (between efforts). Results must be categorised and graded according to current guidelines, taking into consideration the indication for the test.

Improving access to affordable quality-assured inhaled medicines in low- and middle-income countries.

BACKGROUND: Access to affordable inhaled medicines for chronic respiratory diseases (CRDs) is severely limited in low- and middle-income countries (LMICs), causing avoidable morbidity and mortality. The International Union Against Tuberculosis and Lung Disease convened a stakeholder meeting on this topic in February 2022.METHODS: Focused group discussions were informed by literature and presentations summarising experiences of obtaining inhaled medicines in LMICs. The virtual meeting was moderated using a topic guide around barriers and solutions to improve access. The thematic framework approach was used for analysis.RESULTS: A total of 58 key stakeholders, including patients, healthcare practitioners, members of national and international organisations, industry and WHO representatives attended the meeting. There were 20 pre-meeting material submissions. The main barriers identified were 1) low awareness of CRDs; 2) limited data on CRD burden and treatments in LMICs; 3) ineffective procurement and distribution networks; and 4) poor communication of the needs of people with CRDs. Solutions discussed were 1) generation of data to inform policy and practice; 2) capacity building; 3) improved procurement mechanisms; 4) strengthened advocacy practices; and 5) a World Health Assembly Resolution.CONCLUSION: There are opportunities to achieve improved access to affordable, quality-assured inhaled medicines in LMICs through coordinated, multi-stakeholder, collaborative efforts.

Pulmonary arteriovenous malformation in a child with multiple brain abscesses: A case report.

Pulmonary arteriovenous malformations (PAVMs) are caused by abnormal connections between arteries and veins, which lead to right-to-left shunting of deoxygenated blood. Here, we report an 11-year-old male who presented with signs suggestive of intracranial pathology. The patient displayed signs of a chronic illness, possibly congenital malformation that was complicated by PAVM and multiple brain abscesses. This case illustrates the importance of doing a detailed examination and investigations, especially if the history alone is not helpful in making a diagnosis.

Barriers and determinants of asthma control in children and adolescents in Africa: a systematic review.

OBJECTIVE: To identify reasons for poor asthma control in African children and adolescents. DESIGN: Systematic review DATA SOURCES: PubMed, Scopus, CINHAL, PsycINFO, MEDLINE and Web of Science databases were systematically searched up to 31 May 2020. Hand searching was done on Sabinet, African Journal online and Google Scholar. ELIGIBILITY CRITERIA: Studies identifying barriers to asthma control, where asthma control was assessed by the validated Asthma Control Test/Child Asthma Control Test and/or Asthma Control Questionnaire were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently selected studies for inclusion with disagreements resolved by a research team discussion, including a third reviewer. Data were extracted using the Cochrane Effective Practice and Organization of Care data collection form. The quality of the included studies was assessed using the modified Newcastle-Ottawa quality assessment scale. Identified barriers were reported in a thematic narrative synthesis. PRIMARY OUTCOMES: Poorly controlled asthma and associated factors. RESULTS: From 914 records, three studies conducted between 2014 and 2019 in Nigeria, Uganda and South Africa met the inclusion criteria. A total of 883 children aged 4-19 years were analysed. Older age, concurrent allergy and city-dwelling significantly impacted asthma control. Few children with asthma symptoms in the community had ever used inhaled corticosteroids (6.7%) and identified reasons included lack of asthma diagnosis (38.8%) and no prescribed treatment (47.6%). CONCLUSION: Asthma control in African children is impacted by age, allergy, urbanisation and lack of access to asthma diagnosis and treatment. More studies focusing on identifying barriers to asthma control in Africa are needed. PROSPERO: Registration no: CRD42020196755).

A historical overview of childhood asthma in southern Africa: Are we there yet?

Background: The prevalence of asthma, the most common respiratory disease in children, has increased in many low- and middle-income countries (LMICs), particularly in Africa. Despite poor infrastructure and limited resources, researchers in southern Africa have sought to determine the prevalence of childhood asthma, with variable results reflecting actual differences as much as methodological limitations and biases. Objectives: To collate and report findings from studies on the epidemiology of childhood asthma in southern Africa. Methods: A review of the literature was undertaken. Results: The prevalence of childhood asthma in southern Africa is variable but has increased over the last four decades, particularly in South Africa (3.17% to 21.29%). Methods used to assess the burden of asthma have been in the form of questionnaires, bronchial hypersensitivity provocation tests, lung function measurement and fractional exhaled nitric oxide (FENO). Conclusion: The prevalence of childhood asthma is increasing in rural and urban areas in southern Africa. Research collaboration driven by a better understanding of the heterogeneous nature of asthma can improve challenges faced in evaluating the burden of asthma in African countries.

Maternal use of a combination of recreational and antiretroviral drugs (nyaope/whoonga): Case reports of their effects on the respiratory system in infants.

Nyaope/whoonga is an indigenous street drug in South Africa (SA). It is made from a combination of neuro-stimulatory illicit drugs such as antiretroviral drugs, heroin, cannabis, opioids, cocaine as well as common household powders such as flat-screen television glass powder. It is a very addictive substance and is used even during pregnancy. Its effects on the developing fetus have been described as causing neonatal abstinence syndrome (NAS), intrauterine growth restriction (IUGR) and neurological complications. There are no data in the literature that report its effect on the respiratory system (RS) of the fetus or neonates. We describe two children who were prenatally exposed to nyaope and presented with upper and lower respiratory tract obstructions associated with recurrent pneumonias. Further studies are required to describe the adverse effects of whoonga on the developing RS of prenatally exposed fetuses.

Surgical management of pulmonary hydatid cysts in children in KwaZulu-Natal Province, South Africa.

BACKGROUND: Pulmonary hydatid cyst disease is still a major problem in countries like South Africa (SA), where livestock farming is common. Hydatidosis has a variable clinical course depending on the size, location and complications of the cyst. For pulmonary cysts of any size, surgery remains the gold standard for treatment, with lung conservation surgery being the ideal. OBJECTIVES: To describe the epidemiology, clinical presentation, surgical management, and surgical outcomes of paediatric pulmonary hydatid disease in children referred to the Department of Cardiothoracic Surgery at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal Province, SA. METHODS: We retrospectively reviewed and analysed the medical records of 38 children between the ages of 0 and 18 years with pulmonary hydatid cysts, who were referred to the Department of Cardiothoracic Surgery at IALCH and underwent surgical management between 1 January 2008 and 31 December 2018. The medical records were evaluated for patients' demographics, clinical evaluation, surgical management strategies and surgical outcomes. RESULTS: Of the 38 patients, 60.5% were male, with a mean age of 6.5 years. More than two-thirds of the patients (68.4%) were from the Eastern Cape and 31.6% were from KwaZulu-Natal. The majority of the cysts (84.2%; n=32) were classified as large (5 - 9 cm in diameter) and giant (≥10 cm in diameter). Forty-eight surgical procedures were performed and lung preservation surgery by enucleation and capitonnage was preferred. Some patients developed postoperative complications such as prolonged air leaks from bronchopleural fistula (18.8%; n=9) and 88.9% (n=8) of these patients healed with chest tube drainage and physiotherapy. Lung resection was only required in 4% (n=2) of the patients. The mean (standard deviation) number of days spent in hospital was 7 (4) days. All children survived with no recurrences. CONCLUSION: Conservative surgical procedures such as enucleation of the cysts of any size are possible, safe, reliable and reproducible.

Determinants of lung health across the life course in sub-Saharan Africa.

LUNG HEALTH ACROSS THE life course is influenced by factors affecting airway and alveolar development and growth during antenatal and perinatal periods, throughout childhood and adolescence, and into adulthood. Lung function trajectories are set in early life and childhood deficits may predispose to non-communicable respiratory diseases, such as asthma and chronic obstructive pulmonary disease, in later years. Potential risk factors are common in many sub-Saharan African (sSA) countries; adverse antenatal environments cause in utero growth restriction and prematurity; HIV and respiratory infections, including TB are common; exposure to air pollution is widespread, including household air pollution from biomass fuel use, traffic-related pollution in rapidly expanding cities, and tobacco smoke exposure. Multiple disadvantages experienced in early life require an integrated approach that addresses reproductive, maternal and child health. Public health strategies need to tackle multiple risk factors, emphasising Universal Health Coverage, to maximise lung health in the world´s poorest, most vulnerable populations. This review explores potential determinants of lung health across the life course. Due to the extensive topic and wide range of related literature, we prioritised more recent citations, especially those from sSA, focusing on risk factors for which there is most information, and which are most prevalent in the region.

Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines.

BACKGROUND: Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis. OBJECTIVES: To produce revised guidelines for pneumonia in South African children under 5 years of age. METHODS: The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision. RECOMMENDATIONS: Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided. VALIDATION: The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.

Life after paediatric intensive care unit.

Advances in critical care medicine have led to reduced mortality but increased morbidity. Post-intensive care unit syndrome (PICS) develops after critical illness and presents as cognitive, physical and/or psychosocial impairments. PICS is prevalent in 10 - 36% of patients after discharge from paediatric intensive care unit. Multiple risk factors are associated with PICS, but there is no single causal factor. Factors range from clinical illnesses to intensive care intervention. The care plan should be aimed at prevention, early identification and post-ICU management of PICS by a multidisciplinary team.

Disseminated nocardiosis in an immunocompetent patient.

Nocardiosis is a rare opportunistic bacterial infection. We describe an 8-year-old immunocompetent patient who presented with constitutional symptoms suggestive of probable tuberculosis (TB) in whom we confirmed a diagnosis of nocardiosis. Nocardia is a Gram-positive bacterium that is ubiquitous in soil and decaying vegetable matter. N. asteroides is the most common species. Despite the traditional description of nocardiosis as an opportunistic infection, case reports and case series of pulmonary nocardiosis have recently been reported in immunocompetent patients. Three clinical presentations of nocardiosis have been described; acute, subacute and chronic suppurative infections with episodes of exacerbations and remissions. We describe the presentation, diagnosis, management and prognosis of a rare case of disseminated nocardiosis managed initially as disseminated TB with no improvement.

An urgent need for African spirometry reference equations: the Paediatric and Adult African Spirometry study.

BACKGROUND: The GLI2012 (Global Lung Initiative 2012) has provided the largest data set to date for multi-ethnic spirometry reference equations; however, data on African populations are limited. In pulmonary function testing, diagnosis of lung disorder is based on comparing the individual's lung function to a reference appropriate for sex and ethnicity.METHODS: We conducted a systematic review of studies reporting spirometry results in healthy children and adults in Africa. Data from these studies were collated for Z-scores of forced expiratory volume in 1 sec (zFEV1), forced vital capacity (zFVC) and zFEV1/FVC compared to GLI reference equations.RESULTS: Nine studies, covering a total of 4750 individuals from North, South, East, West and Central Africa (52% were female), were reviewed. Marked differences were noted between individuals from North Africa and sub-Saharan Africa. The Southern zFEV1 (-0.12 ± 0.98), zFVC (-0.15 ± 0.98) and zFEV1/FVC (0.05 ± 0.89), Central zFEV1 (-0.16 ± 0.79), zFVC (-0.09 ± 0.83) and zFEV1/FVC (-0.17 ± 0.71) and East African zFEV1 (0.10 ± 0.88), zFVC (0.16 ± 0.85) and zFEV1/FVC (-0.10 ± 0.95) cohorts had an excellent fit with the GLI-African American. The West African showed a poor fit to all reference equations. The North African group showed the best fit for the GLI Caucasian zFEV1 (-0.12 ± 1.37), zFVC (-0.26 ± 1.36) and zFEV1/FVC (0.25 ± 1.11). The zFEV1/FVC ratios were stable across all the populations.CONCLUSION: Current evidence seems to support the use of GLI2012 reference values in North African and sub-Saharan African populations after taking into account ethnic correction factors.

Two cases of unusual airway pathology, in which a careful history contributed to a successful diagnosis.

Lower airway obstruction commonly presents with wheezing but is not always caused by asthma. Considering the case history and course of illness is of utmost importance in determining the cause of wheezing. We present two cases admitted to the paediatric intensive care unit, in which a double aortic arch was found to be the cause of wheezing. The cases illustrate the importance of a systematic approach when investigating a patient with persistent wheeze, especially when there is a poor response to conventional therapy.

Invasive fungal infections among critically ill children: Epidemiology, risk factors and outcomes.

Critically ill children are at high risk of developing invasive fungal infection in a paediatric intensive care unit. This is due to the vulnerability of these children and invasive nature of the care provided.

Genetic relatedness of Staphylococcus aureus isolates obtained from cystic fibrosis patients at a tertiary academic hospital in Pretoria, South Africa.

Cystic fibrosis (CF) is an inherited recessive disease that affects mucocillary clearance in the lung, allowing it to be colonised with bacteria such as Staphylococcus aureus. To survive in the CF lung S. aureus adapts both phenotypically and genotypically, through various mechanisms. In this study, multiple specimens were collected from the participants and were processed routinely and were additionally cultured in chromogenic media. Multiplex PCR assays were employed to detect methicillin resistance and selected virulence and quaternary ammonium compound (qac) genes. Genetic relatedness of the S. aureus was determined using agr, SCCmec and spa typing as well as pulsed field gel electrophoresis (PFGE) and multi-locus sequence typing (MLST). Thirty-three S. aureus isolates were isolated, of which 51% (17/33) were methicillin resistant S. aureus (MRSA). The virulence and qac genes were more prevalent in MRSA than the methicillin sensitive S. aureus (MSSA) isolates. The PFGE analysis showed nine distinct pulsotypes while MLST showed eight sequence types. All the STs detected in this study, except for ST508 have been previously isolated from CF patients according to the literature. This study showed a genetically diverse S. aureus population with a high prevalence of virulence genes among the MRSA isolates from the CF clinic.

Factors impacting asthma control in children in a low-to-middle income country setting: a retrospective study.

OBJECTIVES: 1) To assess asthma control and its evolution over time among children in a low-to-middle-income country, and 2) to explore whether demographics, type of asthma medication, comorbidities or exacerbations impact asthma control. METHODS: In a retrospective study in children with asthma aged 6-18 years conducted between 2005 and 2010, we collected clinical and demographic data and used Global Initiative for Asthma (GINA) criteria to assess asthma control. Proportions of children with well-controlled, partially controlled and uncontrolled asthma were calculated. Associations between different time points for lung function were investigated using Pearson correlation coefficients. Mixed effect regression analysis was used to investigate the effect of demographics, medication, comorbidity and exacerbations on lung function. RESULTS: According to GINA criteria, asthma was well controlled in 44.9% of 189 enrolled children. Choice of add-on treatment and doubling the dose of inhaled corticosteroids, long-acting ß-agonist or leukotriene receptor antagonists did not affect lung function tests (all P > 0.05). On mixed-model analysis, there was a correlation between duration of asthma treatment and forced expiratory volume in 1 s (FEV1) % predicted (P < 0.05). Exacerbations and uncontrolled asthma had a negative impact on FEV1 % predicted (P < 0.05). Therapeutic decisions were guided by spirometry results in only 21% of cases. CONCLUSION: Asthma control was not achieved in the majority of the children. Choice of step-up therapy did not impact asthma control or lung function.