Mortality and associated factors among children admitted to an intensive care unit in muhimbili national hospital, from the time of admission to three months after discharge: a prospective cohort study.

BACKGROUND: Mortality of children admitted to Intensive Care Units (ICU) is higher in low-to-middle-income countries (LMICs) as compared to high-income countries (HICs). There is paucity of information on outcomes following discharge from ICU, especially from sub-Saharan Africa region. This study was conducted to determine mortality and its associated factors among children admitted to Pediatric ICU (PICU) at Muhimbili National Hospital, from admission to three months after discharge. METHODOLOGY: This was a hospital-based prospective cohort study conducted between July 2021 and May 2022, among children admitted to PICU who were followed up for 3-month after discharge. Structured questionnaires were used to collect data from their medical charts. Telephone interviews were made after discharge. Medical records and verbal autopsy were used to determine the cause of death after discharge. Cox regression analysis was performed to assess the association between variables. A p-value of < 0.05 was considered statistically significant. Survival after PICU discharge was estimated by Kaplan - Meier curve. RESULTS: Of 323 children recruited, 177(54.8%) were male, with a median age of 17 months (1-168). The leading cause of PICU admission was severe sepsis 90/323(27.9%). A total of 161/323 children died, yielding an overall mortality of 49.8%. Of 173 children discharged from PICU, 33(19.1%) died. The leading cause of death among children who died in the general ward or as readmission into PICU was sepsis 4/17(23.5%). Respiratory diseases 4/16(25.0%) were the commonest cause of death among those who died after hospital discharge. Independent predictors of overall mortality included single organ dysfunction with hazard ratio(HR):5.97, 95% confidence interval (CI)(3.05-12.26)] and multiple organ dysfunction [HR:2.77,95%CI(1.03-2.21)]. Chronic illness[HR:8.13,95%CI(2.45-27.02)], thrombocytosis [HR:3.39,95%CI(1.32-8.73)], single[HR:3.57,95%CI(1.42-9.03)] and multiple organ dysfunction[HR:3.11,95%CI(1.01-9.61)] independently predicted post-PICU discharge mortality. CONCLUSION: Overall mortality and post- PICU discharge mortality were high and more likely to affect children with organ dysfunction, chronic illness, and thrombocytosis. The leading causes of mortality post- PICU discharge were sepsis and respiratory diseases. There is a need for a focused follow up plan of children post- PICU discharge, further research on the long term survival and strategies to improve it.

Prevalence of iron deficiency and iron deficiency anaemia among children with congenital heart defects at tertiary hospitals in Dar es Salaam, Tanzania: a cross-sectional study.

Introduction: iron deficiency (ID) is the most prevalent nutritional problem worldwide with children being the most vulnerable. In children with congenital heart defect (CHD), ID may lead to iron deficiency anaemia (IDA) which carries a poor prognosis due to exacerbation of left ventricular dysfunction and heart failure. This study assessed the prevalence and factors associated with ID and IDA among children with CHD at Muhimbili National Hospital (MNH) and Jakaya Kikwete Cardiac Institute (JKCI) in Tanzania. Methods: a descriptive hospital-based cross-sectional study was conducted among 238 participants with echocardiography confirmed CHD presenting at MNH and JKCI. A structured questionnaire was used to collect demographic data and medical history. Anthropometric measurements were done and blood samples for evaluation of complete blood count, serum ferritin and C-reactive protein were collected. Descriptive statistics such as frequencies, percentages, median with interquartile range, were used to describe study participants. Comparison of continuous variables was performed using Student's t-test or Mann-Whitney U-test as appropriate and Chi-square (x2) test or Fisher's exact test for categorical variables to determine associations. Odds ratio (OR) with 95% confidence intervals (CI) were estimated to determine risk factors for iron deficiency and iron deficiency anaemia. All analyses were conducted using SPSS version 20 and p-value ≤0.05 was considered statistically significant. Results: characteristic of study participant majority 66.4% (n 158) were less than 60 month of age with nearly equal number of male 51.3%(122) to female 48.7% (n 116). The overall prevalence of anaemia among study participants was 47.5% (n 238) with mild, moderate and severe anaemia being 21.4%, 21.4% and 4.6% respectively. The prevalence of iron deficiency was 26.9% (n 64) and that of iron deficiency anaemia was 20.2% (n 48). Age below 5 years, cyanotic CHD, history of recent illness and less consumption of red meat were significantly associated with iron deficiency (ID) and iron deficiency anaemia (IDA). After controlling for independent variables, history of recent illness aOR 0.46, 95% CI 0.22-0.98 P 0.045 less frequent consumption of red meat aOR 0.11 95% CI 0.04-0.32 P <0.001 and cyanotic CHD aOR: 0.40, 95% CI 0.18-0.87; p 0.021, were associated with of iron deficiency similarly age below 5 years aOR 0.33 0, 95% CI 14-0.89 P 0.02 early weaning practices aOR 0.50 95% CI 0.23-0.97 P 0.050 less frequent consumption of red meat aOR 0.07 CI (0.02-0.24 p <0.01 were significantly associated with iron deficiency anaemia. Conclusion: nearly half of the children with CHD in this study had anaemia, more than a quarter had ID and one-fifth had IDA. Routine screening and management of both ID and IDA in children with CHD should be practised during weaning and throughout the childhood to prevent ventricular dysfunction further heart failure.

Assessment of coronary ischaemia by myocardial perfusion dipyridamole stress technetium-99 m tetrofosmin, single-photon emission computed tomography, and coronary angiography in children with Kawasaki disease: pre- and post-coronary bypass grafting.

BACKGROUND: Coronary artery lesions in Kawasaki disease invasively assessed by coronary angiography. Evaluation of myocardial perfusion by single-photon emission computed tomography may identify the haemodynamic significance of coronary lesions. OBJECTIVE: To evaluate diagnostic accuracy of dipyridamole stress technetium-99 m tetrofosmin, single-photon emission computed tomography as a possible alternative to invasive coronary angiography for detection and follow-up of myocardial ischaemia in patients with Kawasaki disease, and pre- and post-coronary bypass grafting. PATIENTS AND METHODS: Coronary angiography and single-photon emission computed tomography were performed on 21 patients who were classified into three groups - group I (stenosis), group II (giant aneurysms), and group III (small aneurysms). Of the 21 patients, 16 (groups I and II) patients with myocardial perfusion defects, who underwent coronary bypass grafting, were followed up with single-photon emission computed tomography. RESULT: In group I, all patients had significant coronary stenosis and 100% of them had perfusion defects in the anterior and septal walls. In group II, all patients had giant aneurysms and 83% of them had inferior and inferolateral perfusion defects. In group III, all patients had small aneurysms and 100% of them had normal perfusion. Pre-coronary bypass grafting myocardial ischaemic defects disappeared in all patients after surgery. Sensitivity, specificity, and accuracy of single-photon emission computed tomography were 94, 100, and 95%, respectively. CONCLUSION: Technetium-99 m tetrofosmin single-photon emission computed tomography can be applied as an accurate non-invasive diagnostic technique for detecting myocardial perfusion defects with coronary artery lesions, and to show improved or even normalised perfusion of the myocardium in patients after surgical revascularisation.

A framework for practical and rigorous impact monitoring by field managers of marine protected areas.

Monitoring is a crucial component of conservation in marine protected areas (MPAs) as it allows managers to detect changes to biodiversity and to infer cause of change. However, the complexities of sampling designs and associated statistical analyses can impede implementation of monitoring by managers. Two monitoring frameworks commonly used in marine environments are statistical testing and parameter estimation. For many managers these two approaches fail to help them detect change and infer causation for one or more reasons: the complexity of the statistical test, no decision-making structure and a sampling design that is suboptimal. In collaboration with marine park rangers in Egypt, we instigated a monitoring framework to detect impacts by snorkelers in a pragmatic but scientifically rigorous way. First, we used a literature review to define causal criteria to facilitate inference. This was essential because our sampling design was suboptimal due to a lack of baseline data and there was only one impact site. Second, we established a threshold level of coral damage that if exceeded would trigger management to reduce the impact of snorkelers. This provided a clear decision-making structure. Third, we estimated effect sizes with confidence intervals to detect change. For the field managers, this approach to detection was easier to understand than assessing a null hypothesis and provided critical information for decision making. At no stage during the short study period did snorkelers cause damage that exceeded the threshold and thus mitigation was not required. In situations of technical and financial constraints this framework will increase the implementation of effective impact monitoring for many activities in MPAs and enhance management of marine biodiversity.