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.

Thalamus L-Sign: A Potential Biomarker of Neonatal Partial, Prolonged Hypoxic-Ischemic Brain Injury or Hypoglycemic Encephalopathy?

BACKGROUND AND PURPOSE: Considerable overlap exists in the MR imaging features of hypoglycemic injury and hypoxic-ischemic brain injury, with similar predilections for the occipital and parietal lobes. In partial, prolonged hypoxia-ischemia, there is cortical destruction at the interarterial watershed zones, and in concomitant hypoglycemia and hypoxia-ischemia, an exaggerated final common pathway injury occurs. We interrogated secondary white matter tract-based thalamic injury as a tool to separate pure injuries in each group. MATERIALS AND METHODS: A retrospective observational study of the MRIs of 320 children with a history of hypoxia-ischemia and/or hypoglycemia was undertaken with 3 major subgroups: 1) watershed-type hypoxic-ischemic injury, 2) neonatal hypoglycemia, and 3) both perinatal hypoxia-ischemia and proved hypoglycemia. Cerebral and thalamic injuries were assessed, particularly hyperintensity of the posterolateral margin of the thalami. A modified Poisson regression model was used to assess factors associated with such thalamic injury. RESULTS: Parieto-occipital injuries occurred commonly in patients with hypoglycemia and/or hypoxia-ischemia. Eighty-five of 99 (86%) patients with partial, prolonged hypoxia-ischemia exhibited the thalamus L-sign. This sign was also observed in patients who had both hypoglycemia and hypoxia-ischemia, predominantly attributable to the latter. Notably, the risk of a thalamus L-sign injury was 2.79 times higher when both the parietal and occipital lobes were injured compared with when they were not involved (95% CI, 1.25-6.23; P = .012). The thalamus L-sign was not depicted in patients with pure hypoglycemia. CONCLUSIONS: We propose the thalamus L-sign as a biomarker of partial, prolonged hypoxia-ischemia, which is exaggerated in combined hypoglycemic/hypoxic-ischemic injury.

Unmet needs of high-risk mothers reduce success of antiretroviral treatment in HIV-infected infants.

In the era of effective prevention of mother-to-child transmission of HIV, the same psychosocioeconomic factors that predispose to mother-to-child transmission also substantially increase the likelihood of antiretroviral therapy failure in infected infants. For HIV-infected infants to benefit from early infant diagnosis and treatment initiation, into which much funding and effort is now invested, it is vital that these unmet needs of high-risk mothers are urgently attended to. From an ongoing study of early infant diagnosis and treatment following in utero transmission in KwaZulu-Natal, South Africa, we describe four cases to highlight these challenges facing transmitting mothers that contribute to treatment failure in their infants.

An isolated outbreak of diphtheria in South Africa, 2015.

An outbreak of respiratory diphtheria occurred in two health districts in the province of KwaZulu-Natal in South Africa in 2015. A multidisciplinary outbreak response team was involved in the investigation and management of the outbreak. Fifteen cases of diphtheria were identified, with ages ranging from 4 to 41 years. Of the 12 cases that were under the age of 18 years, 9 (75%) were not fully immunized for diphtheria. The case fatality was 27%. Ninety-three household contacts, 981 school or work contacts and 595 healthcare worker contacts were identified and given prophylaxis against Corynebacterium diphtheriae infection. A targeted vaccination campaign for children aged 6-15 years was carried out at schools in the two districts. The outbreak highlighted the need to improve diphtheria vaccination coverage in the province and to investigate the feasibility of offering diphtheria vaccines to healthcare workers.

Tuberculosis in HIV-infected South African children with complicated severe acute malnutrition.

SETTING: Academic tertiary referral hospital in Durban, South Africa. OBJECTIVE: To describe the incidence and diagnostic challenges of tuberculosis (TB) in human immunodeficiency virus (HIV) infected children with severe acute malnutrition (SAM). DESIGN: Post-hoc analysis of a randomised controlled trial that enrolled antiretroviral therapy naïve, HIV-infected children with SAM. Trial records and hospital laboratory results were explored for clinical diagnoses and bacteriologically confirmed cases of TB. Negative binomial regression was used to explore associations with confirmed cases of TB, excluding cases where the clinical diagnosis was not supported by microbiological confirmation. RESULTS: Of 82 children enrolled in the study, 21 (25.6%) were diagnosed with TB, with bacteriological confirmation in 8 cases. Sputum sampling (as opposed to gastric washings) was associated with an increased risk of subsequent diagnosis of TB (adjusted relative risk [aRR] 1.134, 95%CI 1.02-1.26). Culture-proven bacterial infection during admission was associated with a reduced risk of TB (aRR 0.856, 95%CI 0.748-0.979), which may reflect false-negative microbiological tests secondary to empiric broad-spectrum antibiotics. CONCLUSION: TB is common in HIV-infected children with SAM. While microbiological confirmation of the diagnosis is feasible, empiric treatment remains common, possibly influenced by suboptimal testing and false-negative TB diagnostics. Rigorous microbiological TB investigation should be integrated into the programmatic management of HIV and SAM.

Adolescent antiretroviral management: Understanding the complexity of non-adherence.

This case-based discussion highlights challenges in adolescent antiretroviral management, focusing on non-disclosure of status and the subsequent impact of suboptimal treatment adherence. Despite the scale-up of antiretroviral therapy (ART) and recommendations made by the World Health Organization (WHO) for ART for all human immunodeficiency virus (HIV)-infected paediatric patients, ART coverage in adolescents lags behind that in adults. Challenges of sustaining lifelong ART in children and adolescents require consideration of specific behavioural, physiological and psychosocial complexities associated with this special group. To preserve future drug options and sustain lifelong access to therapy, addressing non-adherence to treatment is critical to minimising acquisition of ART drug resistance and treatment failure. We review the psychosocial and developmental components that influence the course of the disease in adolescents and consider the complexities arising from perinatal exposure to ART and the growing risk of transmitted ART drug resistance in high-burden resource-limited settings.

HIV-Associated Tuberculosis in the Newborn and Young Infant.

Each year, approximately 250 000 women die during pregnancy, delivery, or postpartum. Maternal mortality rates due to tuberculosis (TB) and HIV in Sub-Saharan Africa now supersede obstetric-related causes of mortality. The majority of cases occur in population-dense regions of Africa and Asia where TB is endemic. The vertical transmission rate of tuberculosis is 15%, the overall vertical transmission rate of HIV in resource-limited settings with mono- or dual-ARV therapy varies from 1.9% to 10.7%. If the millennium development goals are to be achieved, both HIV and TB must be prevented. The essential aspect of TB prevention and detection in the newborn is the maternal history and a positive HIV status in the mother. Perinatal outcomes are guarded even with treatment of both diseases. Exclusive breast feeding is recommended. The community and social impact are crippling. The social issues aggravate the prognosis of these two diseases.