The use of hospital medical records for child injury surveillance in northern Malawi.

Our study evaluates the usefulness and the limitations of using the medical records of a central referral hospital to develop a child injury surveillance system in northern Malawi. The most prevalent types of injury were falls (29.6%), road traffic injuries (22.0%), burns (21.4%) and poisoning (15.1%). Older children (aged 5-14 years), in the cool-dry season (May to August) and the hot-dry season (September to October), were significant predictors for total injury admissions. Our study indicated that hospital medical records are a valuable component of a child injury surveillance system and can illustrate the trends and patterns of moderate to severe injuries as well as suggest potential prevention strategies for local settings. Combined with a specially designed trauma registry form, it is possible for developing countries at local level to combat the emerging public health issues.

Increased mortality of male adults with AIDS related to poor compliance to antiretroviral therapy in Malawi.

OBJECTIVE: To investigate the effect of gender on mortality of HIV-infected adults receiving antiretroviral therapy (ART) and its possible reasons. METHODS: A retrospective study to review the records for outcomes of adult cases receiving ART at Mzuzu Central Hospital, Malawi, between July 2004 and December 2006. RESULTS: Over the study period, 2838 adult AIDS patients received ART. Of these, 2029 (71.5%) were alive and still on ART, 376 (13.2%) were dead and 433 (15.3%) were lost to follow-up. Survival analysis with Kaplan-Meier estimator showed significantly higher survival rates among females than males in WHO stage 1, 2 and 3 (both P < 0.0001) and borderline in stage 4 (P = 0.076). The Cox model revealed a death hazard ratio (males vs. females) of 1.70 (95% confidence interval 1.35-2.15) after controlling for WHO clinical stages, body mass index and age. More men than women were lost to follow-up in all occupations except health workers. CONCLUSIONS: The most important reasons for a higher mortality in male patients starting ART may relate to their seeking medical care at a more advanced stage of immunodeficiency and poorer compliance with therapy. The issue needs to be addressed in scaling up ART programmes in Africa.

Risk factors for early mortality in children on adult fixed-dose combination antiretroviral treatment in a central hospital in Malawi.

OBJECTIVES: In children aged less than 15 years, to determine the cumulative proportion of deaths occurring within 3 and 6 months of starting split-tablet adult fixed-dose combination antiretroviral therapy (ART) and to identify risk factors associated with early deaths. DESIGN: A retrospective cohort analysis. METHODS: Data were collected and analysed from ART patient master cards and the ART register of all children registered for treatment between July 2004 and September 2006 in the ART clinic at Mzuzu Central Hospital, northern Malawi. RESULTS: A total of 439 children started on ART, of whom 220 (50%) were male; 37 (8%) were aged less than 18 months, 172 (39%) 18 months to 5 years, and 230 (52%) were 6-14 years. By September 2006, 49 children (11%) had died, of whom 35 (71%) died by 3 months and 44 (89%) by 6 months. The cumulative incidence of death at 3, 6, 12 and 24 months after ART was 8, 12, 13 and 15%, respectively. After multivariate analysis, being in World Health Organization clinical stage 4, having severe wasting and severe immunodeficiency were factors significantly associated with 3-month mortality and 6-month mortality, respectively. CONCLUSION: Although children do well on ART, there is high early mortality. Scaling up HIV testing and simple diagnostic tests for infants and children, expanding routine provision of cotrimoxazole prophylaxis, and investigating the role of nutritional interventions are three measures that, if implemented and expanded countrywide, may improve ART outcomes.

Methylprednisolone pulse therapy for massive lymphadenopathy in a child with intravenous immunoglobulin-resistant Kawasaki disease.

Kawasaki disease (KD) is an acute febrile multi-system vasculitis of unknown etiology. The diagnosis is based on clinical features. We describe a case of intravenous immunoglobulins (IVIG)-resistant KD presenting with persistent fever and massive cervical lymphadenopathy associated with mild respiratory distress. The symptoms resolved after methylprednisolone pulse therapy. High-dose pulse steroid may be an alternative therapeutic option in KD which presents with possible life-threatening complications or failure to respond to high-dose IVIG infusion.

Cyclosporin A therapy in a case with hyperimmunoglobulin E and nephrotic syndrome.

We describe the beneficial effects of treatment with cyclosporin A in a 10-year-old boy with hyperimmunoglobulin E and refractory nephrotic syndrome. The patient was initially resistant to steroid therapy with prednisolone alone. Additional therapy with cyclosporin A was then prescribed, effectively reducing levels of serum immunoglobulin E and preventing flare up of nephrotic syndrome.

Henoch-Schonlein purpura with hemorrhagic bullae in children: report of two cases.

Henoch-Schonlein purpura (HSP) is the most common form of acute vasculitis primarily affecting children. Clinical features include skin rashes, arthritis, abdominal pain and nephritis. Skin biopsy on immunofluorescence often reveals granular depositions of immunoglobulin A (IgA) and C3 within the walls of the dermal vessels as well as in the connective tissue of the upper dermis. The diversity of skin rashes produces confusion in diagnosis of HSP, especially in the presence of bullous lesions. Bullous lesions are very rare in children with HSP, whereas they often appear in adults with HSP. We report 2 cases of HSP in whom hemorrhagic bullae manifested predominantly. In our report, the skin biopsies of both patients revealed typical leukocytoclastic vasculitis without IgA and complement depositions on direct immunofluorescence studies. Dramatic improvement of clinical symptoms and signs was observed within a few days after corticosteroids were administered. There was neither recurrence nor nephritis in these 2 patients.

The relationship of eosinophilia to intravenous immunoglobulin treatment failure in Kawasaki disease.

To investigate the role of eosinophils in Kawasaki disease (KD) and the relationship to initial intravenous immunoglobulin (IVIG) treatment failure. A retrospective analysis of all children who were admitted and met the criteria of KD between 1999 and 2005. The patients were divided into IVIG-responsive and IVIG-resistant groups. A total of 185 patients were enrolled during the study period. A series of blood eosinophils and biochemistry studies were correlated to the effectiveness of IVIG. The neutrophils percentage before IVIG treatment (pre-IVIG), leukocyte counts within 3 days after IVIG treatment (post-IVIG), liver enzyme, albumin levels, and post-IVIG eosinophils percentage were all significantly different between the two groups in univariate analysis. Under multivariate analysis with logistic regression, post-IVIG eosinophilia [peripheral blood (PB) eosinophils >or=4%] had an inverse correlation to KD patients with IVIG-resistance (p = 0.003). Also, pre-IVIG hypoalbuminemia (albumin

IL-12-independent Th1 polarization in human mononuclear cells infected with varicella-zoster virus.

T helper type 1 (Th1) cells perform a critical role in fighting intracellular organisms, and interleukin-12 (IL-12) is known to promote a Thl response. This study was conducted to identify whether an IL-12-independent Th1 reaction is induced by the varicella-zoster virus (VZV) in human beings. It was found that different intracellular microorganisms could induce IFNgamma but not IL-12 production. Induction of IFNgamma production by VZV was associated with IFNalpha production and phosphorylation of both the signal transducer and activator of transcription-1 (STAT-1) and STAT-4 in lymphocytes. In contrast, Bacillus Calmette-Guerin (BCG) induced IL-12 production in association with STAT-4 but not STAT-1 activation. Anti-IFNalpha but not anti-IL-12 antibodies blocked the VZV-induced Th1 polarization. A patient with an IL-12 receptor beta1 chain deficiency showed a normal VZV- but not a normal BCG-induced Th1 reaction, further supporting the concept of an IFNalpha-mediated, IL-12-independent Th1 reaction in response to certain intracellular infections. Identification of the early Th1 polarization induced by IFNalpha versus IL-12 in response to specific viruses may enable the development of better therapeutic strategies tailored to different infections.