Electronic Integrated Management of Childhood Illness (eIMCI): a randomized controlled trial to evaluate an electronic clinical decision-making support system for management of sick children in primary health care facilities in South Africa.

BACKGROUND: Electronic clinical decision-making support systems (eCDSS) aim to assist clinicians making complex patient management decisions and improve adherence to evidence-based guidelines. Integrated management of Childhood Illness (IMCI) provides guidelines for management of sick children attending primary health care clinics and is widely implemented globally. An electronic version of IMCI (eIMCI) was developed in South Africa. METHODS: We conducted a cluster randomized controlled trial comparing management of sick children with eIMCI to the management when using paper-based IMCI (pIMCI) in one district in KwaZulu-Natal. From 31 clinics in the district, 15 were randomly assigned to intervention (eIMCI) or control (pIMCI) groups. Computers were deployed in eIMCI clinics, and one IMCI trained nurse was randomly selected to participate from each clinic. eIMCI participants received a one-day computer training, and all participants received a similar three-day IMCI update and two mentoring visits. A quantitative survey was conducted among mothers and sick children attending participating clinics to assess the quality of care provided by IMCI practitioners. Sick child assessments by participants in eIMCI and pIMCI groups were compared to assessment by an IMCI expert. RESULTS: Self-reported computer skills were poor among all nurse participants. IMCI knowledge was similar in both groups. Among 291 enrolled children: 152 were in the eIMCI group; 139 in the pIMCI group. The mean number of enrolled children was 9.7 per clinic (range 7-12). IMCI implementation was sub-optimal in both eIMCI and pIMCI groups. eIMCI consultations took longer than pIMCI consultations (median duration 28 minutes vs 25 minutes; p = 0.02). eIMCI participants were less likely than pIMCI participants to correctly classify children for presenting symptoms, but were more likely to correctly classify for screening conditions, particularly malnutrition. eIMCI participants were less likely to provide all required medications (124/152; 81.6% vs 126/139; 91.6%, p= 0.026), and more likely to prescribe unnecessary medication (48/152; 31.6% vs 20/139; 14.4%, p = 0.004) compared to pIMCI participants. CONCLUSIONS: Implementation of eIMCI failed to improve management of sick children, with poor IMCI implementation in both groups. Further research is needed to understand barriers to comprehensive implementation of both pIMCI and eIMCI. (349) CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov ID: BFC157/19, August 2019.

Patterns of disease on admission to children's wards and changes during a COVID-19 outbreak in KwaZulu-Natal Province, South Africa.

BACKGROUND: Major causes of under-5 child deaths in South Africa (SA) are well recognised, and child mortality rates are falling. The focus of child health is therefore shifting from survival to disease prevention and thriving, but local data on the non-fatal disease burden are limited. Furthermore, COVID-19 has affected children's health and wellbeing, both directly and indirectly. OBJECTIVES: To describe the pattern of disease on admission of children at different levels of care, and assess whether this has been affected by COVID-19. METHODS: Retrospective reviews of children's admission and discharge registers were conducted for all general hospitals in iLembe and uMgungundlovu districts in KwaZulu-Natal Province, SA, from January 2018 to September 2020. The Global Burden of Disease framework was adapted to create a data capture sheet with four broad diagnostic categories and 37 specific cause categories. Monthly admission numbers were recorded per cause category, and basic descriptive analysis was completed in Microsoft Excel. RESULTS: Overall, 36 288 admissions were recorded across 18 hospital wards, 32.0% at district, 49.8% at regional and 18.2% at tertiary level. Communicable diseases, perinatal conditions and nutritional deficiencies (CPNs) accounted for 37.4% of admissions, non-communicable diseases (NCDs) for 43.5% and injuries for 17.1%. The distribution of broad diagnostic categories varied across levels of care, with CPNs being more common at district level and NCDs more common at regional and tertiary levels. Unintentional injuries represented the most common cause category (16.6%), ahead of lower respiratory tract infections (16.1%), neurological conditions (13.6%) and diarrhoeal disease (8.4%). The start of the local COVID-19 outbreak coincided with a 43.1% decline in the mean number of monthly admissions. Admissions due to neonatal conditions and intentional injuries remained constant during the COVID-19 outbreak, while those due to other disease groups (particularly respiratory infections) declined. CONCLUSIONS: Our study confirms previous concerns around a high burden of childhood injuries in our context. Continued efforts are needed to prevent and treat traditional neonatal and childhood illnesses. Concurrently, the management of NCDs should be prioritised, and evidence-based strategies are sorely needed to address the high injury burden in SA.

Strongyloides stercoralis infestation masquerading as steroid resistant asthma.

A 42 year old man presented with steroid resistant asthma of 6 months duration. Serial chest radiographs showed migrating interstitial shadowing. Electrocardiographs showed decreasing R-wave progression in the precordial leads, and endomyocardial biopsy showed eosinophil infiltration with fibrosis. Bronchoscopy revealed inflammatory changes and lavage showed filariform larvae of Strongyloides stercoralis in the washings. This confirms the diagnosis of parasitic infection with eosinophilic cardiomyopathy.

Acute resistant asthma caused by excessive beta-2-adrenoceptor agonist inhalation and reversed by inhalation of beclomethasone.

With the aim of devising an improved beta 2-agonist treatment regimen for patients presenting with acute severe resistant asthma, a double-blind, placebo-controlled randomised study of the effect of fenoterol and beclomethasone inhalations was done in 40 patients. Fenoterol inhalations had minimal effect in acute resistant asthma, but significant improvement was obtained when beclomethasone inhalations were given before fenoterol inhalations. Sequential beclomethasone and fenoterol inhalations can therefore be used as a preliminary emergency treatment for these patients.

Diabetes mellitus, pulmonary tuberculosis and chronic calcific pancreatitis revisited.

The prevalence of chronic calcific pancreatitis (CCP) was determined in 25 successive patients with both diabetes mellitus and newly diagnosed pulmonary tuberculosis. Twenty patients (80%) were alcoholics and all were black. Of these, 9 (45%) had CCP. In only 3 of these 9 patients was the history compatible with the condition diagnosed. Clinical steatorrhoea was absent in the patients with CCP. Pulmonary tuberculosis was extensive with major involvement of three or more lung zones in 36% of patients. Mainly basal involvement of the lungs was present in 8% of patients.

A correlative study of serum digoxin levels and electrocardiographic measurements.

The ST-segment appearance, PR interval, corrected QU time and T-wave amplitude from standard electrocardiograms of 70 patients were correlated with serum digoxin levels done on the same day. The absence of a digtalis effect on ST segments, upright T waves and PTQ scores (a combination function of PR, QT and T) of one or less, correlated well with the absence of "toxic" serum digoxin levels (greater than 1,8 ng/ml). PTQ scores showed a significant linear correlation with serum digoxin levels, and PTQ scores of more than 3,0 were in all instances associated with "toxic" serum digoxin levels. These observations merit futher investigation and could be useful in clinical situations.

The inhibition of c-AMP-phosphodiesterase by phenobarbitone.

The early effects of phenobarbitone, theophylline, thyroxine and of combinations of these drugs, on rat liver microsomal aniline hydroxylase activity, were studied, and the results were compared with the effect of phenobarbitone on purified c-AMP-phosphodiesterase in vitro. The stimulatory effect of phenobarbitone on hepatic microsomal aniline hydroxylase activity was found to be simulated by theophylline, and also by thyroxine. When phenobarbitone and thyroxine were used, the effect was approximately equal to the sum of the individual effects, but no summation was seen when phenobarbitone and theophylline were used. Phenobarbitone caused an inhibition of c-AMP-phosphodiesterase activity in vitro. The magnitude of this inhibitory effect was found to be dependent on the dose of phenobarbitone. The significance of c-AMP-phosphodiesterase inhibition by phenobarbitone is discussed.