Practice patterns in pediatric infectious encephalopathy in four centers in Africa.

Introduction: Infectious encephalopathy (IE), including meningitis, infectious encephalitis, and cerebral abscess, remains prevalent and carries high mortality and morbidity in children, especially in low and middle income countries (LMIC). This study aims to describe the usual care and outcomes of pediatric IE in four LMIC hospitals in sub-Saharan Africa to support evidence-based care guideline development. Methods: This is a secondary analysis of the Prevalence of Acute Critical Neurological disease in children: A Global Epidemiological Assessment-Developing Countries study, a 4-week, prospective, observational study in children (1 week to 17 years) with IE presenting to referral hospitals in Ethiopia, Kenya, Rwanda, and Ghana. Data collection included diagnostic testing, interventions, and patient outcomes [e.g., mortality, Pediatric Cerebral and Overall Performance Category Scores (PCPC and POPC)]. Results: Seventy-two children with IE were enrolled. Most patients were diagnosed with undifferentiated IE (78%, n = 56). Specific etiologies included cerebral malaria (10%, n = 7), viral encephalitis (4%, n = 3), tuberculosis (4%, n = 3), bacterial meningitis (3%, n = 2), and cerebral abscess (1%, n = 1). Fourteen patients (20%) had a head computed tomography performed. Thirty two (44%) children had a lumbar puncture but only 9 samples (28%) were sent for culture. Median time from diagnosis to antimicrobial therapy was 3 h (IQR 1-12 h). Half (51%, n = 33) of inpatients received intracranial pressure (ICP)-directed treatment but none underwent ICP monitoring. Mortality was 13% (n = 9). The percentage of children with a favorable cognitive score decreased from 95% (n = 62) prior to admission to 80% (n = 52) and 77% (n = 50) at discharge for PCPC and POPC respectively. Discussion: IE led to considerable morbidity and mortality in this cohort, and evaluation and management varied across the care continuum. Resource limitations and diagnostic constraints may have affected diagnosis-directed therapy and other aspects of management. Further studies are needed to describe the epidemiology and management of IE in LMICs to inform future treatment protocols, the role of technological and human capacity building to support both basic monitoring and interventions, as well as creative new solutions to emergency and critical care in these settings.

Intrabiliary Ascariasis: A Case Report of an Uncommon Cause of Acute Abdomen and Obstructive Jaundice in Children.

Background: Intrabiliary ascariasis is an uncommon cause of biliary colic and obstructive jaundice among children due to the small size of the ampullary orifice. A high index of suspicion for patients living in an endemic area and radiologic examination are crucial for diagnosis and treatment. Case Presentation: A 12-year-old male Ethiopian child presented with colicky right upper quadrant pain, nausea, and vomiting for 3 days. Physical examination showed slightly icteric sclera and slightly tender hepatomegaly. Laboratory and ultrasound examinations were suggestive of obstructive jaundice secondary to intra-biliary ascariasis. The child was admitted and followed by conservative management including maintenance fluid, nil per mouth, and analgesics. The abdominal pain and icterus resolved on his second and third day of admission, respectively. A follow-up ultrasound showed that the worm had migrated from the common bile duct. The patient was dewormed with a single dose of oral albendazole 400mg and discharged home. Currently, the patient is well and attending school. Conclusion: Although biliary ascariasis is an uncommon cause of acute abdomen and obstructive jaundice, it should be suspected among patients from endemic areas presenting with suggestive clinical and laboratory features. Conservative treatment is the treatment of choice for uncomplicated biliary ascariasis patients.

An exploratory assessment of the management of pediatric traumatic brain injury in three centers in Africa.

Purpose: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs. Methods: We completed a secondary analysis of a prospective observational study in children (<18 years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and Wilcoxon rank sum tests. Results: Fifty-six children presented with TBI (age 0-17 y), most commonly due to falls (43%, n = 24). Emergency department Glasgow Coma Scale scores were ≤ 8 in 21% (n = 12). Head computed tomography was performed in 79% (n = 44) of patients. Forty (71%) children were admitted to the hospital, 25 (63%) of whom were treated for suspected intracranial hypertension. Intracranial pressure monitoring was unavailable. Five (9%, n = 5) children died and 10 (28%, n = 36) inpatient survivors had a newly diagnosed unfavorable outcome on discharge. Conclusion: Inpatient management and monitoring capability of pediatric TBI patients in 3 LMIC-based tertiary hospitals was varied. Results support the need for prospective studies to inform development of evidence-based TBI management guidelines tailored to the unique needs and resources in LMICs.

Outcome of diabetic ketoacidosis among paediatric patients managed with modified DKA protocol at Tikur Anbessa specialized hospital and Yekatit 12 hospital, Addis Ababa, Ethiopia.

INTRODUCTION: Diabetic ketoacidosis (DKA) is a serious acute complication of diabetes mellitus that carries a significant risk of mortality with delayed treatment in low-resource countries. This study aimed to determine the outcome of paediatric DKA patients' managed with a modified DKA treatment protocol using intermittent bolus subcutaneous insulin administration. METHODS: A cross-sectional study design with retrospective data collection was conducted among children younger than 14 years of age admitted from January 2013 to February 2017. A modified protocol was prepared based on a reference from the international society for paediatric and adolescent diabetes and other international guidelines. Data were analysed using Statistical package for social science (SPSS) version 22.0. Descriptive statistics were performed. Binary logistic regression was used to identify associations, and significant variables were further considered for multivariate logistic regression to determine the outcome of DKA patients. RESULT: Among the 190 patients, 55.5% (n = 105) were newly diagnosed. The overall average time required for resolution of DKA was 48 ± 27.8 h. Mental status on presentation (p = .001), shock on presentation (p < .01) and severity of DKA (p < .001) were found to have a significant association with the mean time for clearance of DKA. Hypoglycaemia was the most common treatment-related complication, which occurred in 23.7% of patients (n = 45) followed by hypokalaemia in 4.3% of patients (n = 8), and no patient developed cerebral oedema and death. CONCLUSION: The time required for clearance of DKA was prolonged, and hypoglyceamia was a common complication for children younger than 5 years of age. The modified protocol of DKA is reasonable management for low-resource settings with further modification.

A Typical Case of Multisystem Inflammatory Syndrome in a 10-yearold Girl with COVID-19: A Case Report from Ethiopia.

Background: Severe acute respiratory syndrome-Corona Virus -2 (SARS-CoV2) has infected more than 500 million and has claimed the lives of more than 6.1 million people worldwide. Case: We are presenting a 10-year-old girl who fulfilled the criteria of Multisystem inflammatory disease associated with COVID-19(MIS-C). She had fever of > 3 days, muco-cutaneous lesions, hypotension/shock, myocardial dysfunction, acute gastrointestinal symptoms, elevated markers of inflammation, coagulopathy without other microbial causes and positive COVID RT-PCR test. Conclusions: When pediatric patients present with the above symptoms and signs we should have a high index of suspicion of MIS-C for timely action and better outcome.

Admission Pattern and Treatment Outcome in Pediatric Intensive Care Unit, Tertiary Hospital, Addis Ababa, Ethiopia.

Background: Knowledge of the clinical profile and outcomes of critically ill children admitted to Pediatric Intensive Care Unit (PICU) in developing countries aids with the identification of priorities and the resources needed to improve the outcome of critically ill patients. This study aimed to assess the admission pattern, outcomes, and associated factors of patients admitted to the PICU of St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. Methods: Institutional-based cross-sectional study was done. Data was collected through chart abstraction from patients admitted to the PICU between January 2017 and December 2018. SPSS 20.0 was used to analyze the data. Descriptive statistics, cross-tabulations, and logistic regressions were used. Results: A total of 260 pediatric patients were analyzed. The mean age at admission was 48.13 ± 53.65 months, with M: F ratio of 1.4:1. The mean and median duration of PICU stay was 7.26 ±6.87 days, and 6.0 days respectively. The most commonly affected organ systems were the central nervous system (79, 33.2%) and respiratory system (55, 23.1%). Mechanical ventilation and admission after cardiopulmonary resuscitation (p < 0.001) were independent predictors of mortality. Infectious causes of illnesses were the leading causes of admission and death in the PICU. Conclusion: The mortality rate of our PICU was 21.1 %. In this study, post-cardiopulmonary resuscitation admission and use of mechanical ventilation were statistically significant predictors of mortality indicating the need for well equipping and staffing the PICU to improve the outcome of such critically sick patients.

Botulism outbreak in a rural Ethiopia: a case series.

BACKGROUND: Foodborne botulism, a toxin-mediated illness caused by Clostridium botulinum, is a public health emergency. Types A, B, and E C. botulinum toxins commonly cause human disease. Outbreaks are often associated with homemade and fermented foods. Botulism is rarely reported in Africa and has never been reported in Ethiopia. CASE PRESENTATION: In March 2015, a cluster of family members from the Wollega, Oromia region, western Ethiopia presented with a symptom constellation suggestive of probable botulism. Clinical examination, epidemiologic investigation, and subsequent laboratory work identified the cause of the outbreak to be accidental ingestion of botulinum toxin in a traditional chili condiment called "Kochi-kocha," cheese, and clarified butter. Ten out of the fourteen family members who consumed the contaminated products had botulism (attack rate 71.4%) and five died (case fatality rate of 50%). Three of the patients were hospitalized, they presented with altered mental status (n = 2), profound neck and truncal weakness (n = 3), and intact extremity strength despite hyporeflexia (n = 3). The remnant food sample showed botulinum toxin type A with mouse bioassay and C. botulinum type A with culture. Blood drawn on day three of illness from 2/3 (66%) cases was positive for botulinum toxin type-A. Additionally, one of these two cases also had C. botulinum type A cultured from a stool specimen. Two of the cases received Botulism antitoxin (BAT). CONCLUSION: These are the first confirmed cases of botulism in Ethiopia. The disease occurred due to the consumption of commonly consumed homemade foods. Definite diagnoses of botulism cases are challenging, and detailed epidemiologic and laboratory investigations were critical to the identification of this case series. Improved awareness of botulism risk and improved food preparation and storage may prevent future illnesses. The mortality rate of botulism in resource-limited settings remains high. Countries should make a concerted effort to stockpile antitoxin as that is the easiest and quickest intervention after outbreak detection.

Clinical, immunologic and virologic outcomes of children and adolescents receiving second line anti-retroviral therapy in two referral hospitals in Addis Ababa, Ethiopia.

BACKGROUND: Ethiopia launched free access for antiretroviral therapy in 2005. The number of patients on second line antiretroviral treatment has increased with each passing year. The objectives of this study were to describe the clinical, immunological and virologic outcomes of children and adolescents receiving second line anti-retroviral therapy in two referral hospitals, Yekatit 12 and Zewditu Memorial Hospitals, in Addis Ababa, Ethiopia. METHODS: This was a hospital based retrospective cohort study conducted among children and adolescents aged 18 years and less and receiving a second line antiretroviral drugs. Data was collected using structured questionnaires. Means and percentages were used for nominal variables. Statistical analysis was made using statistical software-SPSS 23.0. Kaplan Meier analysis, long rank test and multivariate Cox proportion model were used to identify factors affecting survival. RESULTS: A total of 75 children and adolescents were studied with a mean age of 13.28 years (SD: 4) with a mean treatment period on second line regimens of 35.2 months (SD: 21.8 months). Forty-eight participants were experiencing successful measures (in all three parameters) for their second line anti-retroviral treatment. Ten had virologic treatment failure while seven had died. Both treatment failure and death rates were higher within the first two years of treatment. Poor treatment adherence (Adjusted hazard ratio: 5.1 (95% CI: 1.1-23.2; p-value = 0.02)) and advanced World Health Organization clinical stage at start of the second line antiretrovirals (Adjusted hazard ratio: 7.51 (95% CI: 1.35-18.02; p-value = 0.002)) correlated significantly with survival of children and adolescents receiving treatment. CONCLUSIONS: The study describes clinical, immunological and virologic outcomes of second line antiretroviral treatment in a pediatric cohort under care in two hospitals in Addis Ababa, Ethiopia. Poor adherence and pre-treatment advanced clinical stages were predictors of survival.

Characteristics and Outcomes of Mechanically Ventilated Pediatric Patients in A Tertiary Referral Hospital, Addis Ababa, Ethiopia: Cross Sectional Study.

BACKGROUND: A few studies are available from Africa on the use of mechanical ventilation (MV) in the pediatric intensive care unit (PICU). Knowledge of the outcome of patients on MV is critical for better use of resources. We aimed to assess the characteristics and outcomes of mechanically ventilated pediatric patients in Tikur Anbessa Specialized Referral Hospital, Addis Ababa, Ethiopia. METHODS: A cross-sectional study was done from September 2016 to February 2018. Data were reviewed from the patients' medical records. SPSS version 21 software was used for data entry and analysis. RESULTS: There were 536 patients admitted to PICU; out of these, 202 (41.2%) were on MV. Sixty-three-point six percent of the participants were males and 130 (59.1%) died. The most common indications for the initiation of MV were respiratory problems 46 (20.9%) and 30.59/1000 ventilator days developed complications. Ventilator-associated pneumonia accounted for 18.6% of the complications with 20.9/1000 ventilator days. Survival of medical cases was better than the surgical cases (including trauma); [AOR= 0.13, 95% CI (0.04-0.41)] and those who have MV for more than 3 days are 79% more likely to die (p=0.003). Those who have multi-organ dysfunction syndrome (MODS) [AOR= 0.181, 95% CI (0.08, 0.412)] and high PIM II severity score [AOR= 35, 95% CI (1.7,11)] had higher mortality rate. CONCLUSIONS: higher PIM II score, MODS, length of stay, and being a surgical patient increased the risk of mortality. Early resuscitation and thorough follow up of these ventilated patients are necessary.

Triage guideline for immunocompromised children with fever in an emergency centre in Ethiopia.

Fever in children with neutropenia often portends life-threatening bacteremia that may be ameliorated with early recognition and the rapid administration of antimicrobial therapy. Studies demonstrating this effect have been done in resource-endowed countries, but not in resource-limited settings. We attempted to decrease the time to antibiotics in patients with fever and neutropenia presenting to a paediatric emergency centre at a tertiary care referral hospital in Ethiopia. In 3 phases we performed baseline data collection, instituted triaging and treatment guidelines, and provided antibiotics. We tracked a variety of outcomes, most importantly time from arrival to initiation of antibiotics. While this time was reduced during the guideline institution phase of our intervention, time reductions were inconsistent and not sustained. This was likely due to competing clinical priorities among providers caring for a high volume of ill children. While in the U.S., fever and neutropenia is easy to prioritise within the paediatric emergency centre, future quality improvement measures in this setting may have a greater benefit on critical presentations such as shock or respiratory failure. Alternative strategies geared towards general efficiency improvement and teamwork, rather than focusing on one patient group may be a higher yield approach for improving care in this paediatric emergency centre.

Assessment of the Management of Diarrhoea Among Children Under Five in Addis Ababa, Ethiopia.

PURPOSE: Irrational antibiotic use is a worldwide problem. One of the main reasons for excessive use of antibiotics is the failure to follow the clinical guidelines. Inappropriate use of antibiotics for infectious diarrhea is associated with the risk of increasing the development of antimicrobial resistance and the cost of health care. We therefore pursued to assess the appropriateness of the management of diarrhea in children in Addis Ababa. MATERIALS AND METHODS: A retrospective cross-sectional study was conducted in the health centers of Addis Ababa, Ethiopia, between September 2014 and February 2015. Demographic characteristics, signs of dehydration, stool characteristics, drug types and other relevant information have been collected. Data analysis was performed using version 20 of the SPSS. Logistic regression was used to examine the association between dependent and independent variables. Indicators for the appropriateness of diarrhoea management have been established on the basis of the Standard Treatment Guideline and the guidelines of the World Health Organization. RESULTS: A total of 803 medical records of children have been checked. Of this, 54.4% had received inappropriate management. At least one antimicrobial was prescribed to 73.2% of the children who visited the health centres. Oral rehydration solution (ORS) and zinc were prescribed only in 66.7% and 47.5%, respectively. Appropriate management among children diagnosed with dysentery was found to be 6.38 times higher adjusted odds ratios (AOR=6.38 (3.11, 13.63)) than children with watery diarrhea. Although antibiotics are prescribed inappropriately for most children, it is appropriate when the diarrhea is bloody. Appropriate management of diarrhoea among infants aged 2-11 months was 54% less compared to children aged 12-59 months (AOR=0.46 (0.24, 0.90)). CONCLUSION: The magnitude of inadequate antibiotic prescription while managing diarrhoea in our setting was high. On the contrary, a low prescribing rate of ORS and zinc was observed. Our result highlights the need for urgent action to prevent the development of antibiotic-resistant microorganisms. Health-care professionals should have clear information on the risks of inadequate diarrhoea treatment in children under five.

Traumatic Brain Injury and Infectious Encephalopathy in Children From Four Resource-Limited Settings in Africa.

OBJECTIVES: To assess the frequency, interventions, and outcomes of children presenting with traumatic brain injury or infectious encephalopathy in low-resource settings. DESIGN: Prospective study. SETTING: Four hospitals in Sub-Saharan Africa. PATIENTS: Children age 1 day to 17 years old evaluated at the hospital with traumatic brain injury or infectious encephalopathy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We evaluated the frequency and outcomes of children presenting consecutively over 4 weeks to any hospital department with traumatic brain injury or infectious encephalopathy. Pediatric Cerebral Performance Category score was assessed pre morbidity and at hospital discharge. Overall, 130 children were studied (58 [45%] had traumatic brain injury) from hospitals in Ethiopia (n = 51), Kenya (n = 50), Rwanda (n = 20), and Ghana (n = 7). Forty-six percent had no prehospital care, and 64% required interhospital transport over 18 km (1-521 km). On comparing traumatic brain injury with infectious encephalopathy, there was no difference in presentation with altered mental state (80% vs 82%), but a greater proportion of traumatic brain injury cases had loss of consciousness (80% vs 53%; p = 0.004). Traumatic brain injury patients were older (median [range], 120 mo [6-204 mo] vs 13 mo [0.3-204 mo]), p value of less than 0.001, and more likely male (73% vs 51%), p value of less than 0.01. In 78% of infectious encephalopathy cases, cause was unknown. More infectious encephalopathy cases had a seizure (69% vs 12%; p < 0.001). In regard to outcome, infectious encephalopathy versus traumatic brain injury: hospital lengths of stay were longer for infectious encephalopathy (8 d [2-30 d] vs 4 d [1-36 d]; p = 0.003), discharge rate to home, or for inpatient rehabilitation, or death differed between infectious encephalopathy (85%, 1%, and 13%) and traumatic brain injury (79%, 12%, and 1%), respectively, p value equals to 0.044. There was no difference in the proportion of children surviving with normal or mild disability (73% traumatic brain injury vs 79% infectious encephalopathy; p = 0.526). CONCLUSIONS: The epidemiology and outcomes of pediatric traumatic brain injury and infectious encephalopathy varied by center and disease. To improve outcomes of these conditions in low-resource setting, focus should be on neurocritical care protocols for pre-hospital, hospital, and rehabilitative care.

The clinical presentation, epidemiology, and short-term outcome of Guillain-Barré syndrome in Tikuranbessa hospital: a 6-year retrospective study

Introduction: Gullian-Barré Syndrome (GBS) is an acute monophasic demyelinating polyradiculoneuropathy which is characterized by progressive weakness and areflexia. Different antecedent events are associated with GBS and one of those is an anti-rabies vaccine prepared from infected animal brain.Objective: The study goal was to determine epidemiological features of and to describe the clinical and short-term outcomes of Gullian-Barré syndrome.Materials and Methods: A cross sectional descriptive study with retrospective data collection was done on children admitted with a diagnosis of Gullian-Barré Syndrome from September 2006 to September 2012.Result: 112 children were identified. The male to female ratio was 1.6. All had motor weakness, only one patient (0.9%) had sensory loss, 34(30.3%) had cranial nerve involvement and 37 (32.9%) had dysautonomia. Respiratory involvement which necessitated ventilation was found in 14 (12.5%) of our cases. Antecedent events were recorded in 82 (73.2%) of children and among them; upper respiratory infection (URTI) was the most frequent (43.8%). Of the 15 patients with vaccination antecedents, 7 (6.35%) had received anti-Fermi type rabies vaccine. The GBS subtype distribution among the 31 patients who had electrodiagnostic studies performed was as follows: acute inflammatory demyelinating neuropathy (AIDP) 3 (10%), acute motor axonal neuropathy (AMAN) 24 (80%),acute motor-sensory axonal neuropathy (AMSAN) 1 (3.3%), and both axonal and demyelinating neuropathy 3 (10%). Complete recovery was noted in 31 (27.7%) patients and there were 9 (8%) deaths.Conclusion: Male preponderance and presence of antecedent illness was observed in the majority of subjects. Acute motor axonal neuropathy was the commonest subtype of Guillain-Barré. Prior anti-Fermi-type rabies vaccine may have been one predisposing factor

Early infant diagnosis of HIV infection using DNA-PCR at a referral center: an 8 years retrospective analysis.

BACKGROUND: Over the last decade, Ethiopia adopted different strategies of prevention of mother to child transmission of HIV (PMTCT). Prior to implementation of Option A in 2011, there was no provision of prophylaxis for PMTCT. With 'Option A', PMTCT interventions relied on maternal CD4 count. In early 2013, ''Option B+'' has been started; with this option, antiretroviral therapy is started and continued for life to any HIV positive pregnant mother irrespective of CD4 count with an enhanced treatment for the baby. Though there are a number of studies which evaluated the effectiveness of PMTCT interventions, the current study assessed the real-world effectiveness of PMTCT options in a setting where there is limitation of resources. OBJECTIVE: This study tried to address three questions: what proportion of babies tested by DNA-PCR are HIV infected in the first 2 months of life? How does the type of PMTCT intervention affect presence of HIV infection at this age? What are the factors affecting HIV transmission, after controlling for type of PMCT-HIV intervention? METHODS: We assessed records of 624 registered HIV exposed infants and 412 mothers who were delivered at Bishoftu Hospital from May 2006 to August 2014. Presence of HIV infection at 6-8 weeks of age was assessed from the records. Maternal and infant risk factors for infection at this age were analyzed. Data were collected using standard data abstraction format and were analyzed using SPSS version 20. RESULTS: Among all the infants who were delivered at the hospital during the study period, 624/936 (66.7 %) had undergone early infant diagnosis at 6-8 weeks. Twenty-seven (4.3 %) were positive for HIV DNA PCR at the age of 6-8 weeks. None of the infants who received ''Option B+'' had a positive HIV DNA PCR result. HIV infection rate was highest among those who took either no prophylaxis or single dose Nevirapine (11.5 and 11.1 % respectively). Those who took single dose Nevirapine and Zidovudine had HIV positivity rate of 3.9 %. Many of the covariates which were shown to be predictors on bivariate analysis were found not to be independent predictors on multivariate analysis. CONCLUSION: PMTCT ''Option B+'' resulted in zero HIV infection rates among the included infants. There was a high loss to follow up rate at 6-8 weeks of age. The authors recommend that a better strategy of linkage to care and treatment should be devised for HIV exposed infants.

A cross-sectional study of children with acute poisoning: A three-year retrospective analysis.

BACKGROUND: There is a lack of evidence on description of burden and cases of childhood poisoning in developing countries. This study aimed to assess the characteristics of children with acute poisoning, and factors for time of presentation to health facility and nature of poisoning. METHODS: A cross-sectional study was conducted at three major pediatric referral hospitals in Addis Ababa, Ethiopia. Description of demographics of children with acute poisoning and factors associated with time to presentation and nature of poisoning were analyzed. Data were entered to Epi info 3.5.3 and analyzed with SPSS version 20. RESULTS: Over three years, we retrieved records of a total of 128 children admitted for acute poisoning. The mean age of victims was 5.46 (SD, standard deviation=4.48) years. The majority (29.7%) were poisoned by prescribed drugs. Most poisoning incidents (73.5%) were unintentional in nature. The median time to health facility visit was 15.5 hours. Age less than 2 years was related to earlier presentation to health facility (P=0.010, OR=0.28, 95%CI=0.10-0.74). Children with age more than 5 years was more likely to have intentional poisoning (χ(2)=25.06, P<0.0001). None of the victims was provided psychosocial evaluation and counseling. CONCLUSION: Most poisoning incidents are unintentional. Prescribed drugs are the commonest causes. Psychosocial counseling and care for the affected children is lacking. Family and community education should be given on prevention of poisoning. We recommend that caregivers take the required action in keeping prescribed drugs at home. Psychosocial support should be part of care and treatment of children with poisoning.

A cross-sectional study of children with acute poisoning:A three-year retrospective analysis / 世界急诊医学杂志（英文）

@#BACKGROUND: There is a lack of evidence on description of burden and cases of childhood poisoning in developing countries. This study aimed to assess the characteristics of children with acute poisoning, and factors for time of presentation to health facility and nature of poisoning. METHODS: A cross-sectional study was conducted at three major pediatric referral hospitals in Addis Ababa, Ethiopia. Description of demographics of children with acute poisoning and factors associated with time to presentation and nature of poisoning were analyzed. Data were entered to Epi info 3.5.3 and analyzed with SPSS version 20. RESULTS: Over three years, we retrieved records of a total of 128 children admitted for acute poisoning. The mean age of victims was 5.46 (SD, standard deviation=4.48) years. The majority (29.7％) were poisoned by prescribed drugs. Most poisoning incidents (73.5％) were unintentional in nature. The median time to health facility visit was 15.5 hours. Age less than 2 years was related to earlier presentation to health facility (P=0.010, OR=0.28, 95％CI=0.10–0.74). Children with age more than 5 years was more likely to have intentional poisoning (χ2=25.06, P<0.0001). None of the victims was provided psychosocial evaluation and counseling. CONCLUSION: Most poisoning incidents are unintentional. Prescribed drugs are the commonest causes. Psychosocial counseling and care for the affected children is lacking. Family and community education should be given on prevention of poisoning. We recommend that caregivers take the required action in keeping prescribed drugs at home. Psychosocial support should be part of care and treatment of children with poisoning.

Development of pediatric emergency medicine at Addis Ababa University/Tikuranbessa Specialized Hospital, Ethiopia.

BACKGROUND: In the world emergencies occur everywhere, and each day they consume ressources regardless of whether there are systems capable of achieving good outcomes. Low-income countries suffer the most highest rates of every category of injury--from traffic and the highest rates of acute complications of communicable diseases including tuberculosis, malaria and HIV. OBJECTIVE: To describe the development of pediatrics emergency medicine at Tikur Anbesa Specialized Hospital METHODS: A twinning partnership model was used in developing a pediatric emergency medicine training program helps in development of pediatrics emergency system. RESULTS: Strengthening the capacity of Addis Ababa University (AAU), Tikur Anbessa Hospital (TASH) to provide pediatric emergency medical services through improved organization of the pediatrics emergency department and strengthening of continuing education opportunities for faculty and staff capacity building by this improving quality of care in pediatrics patients in the country. CONCLUSION: The Addis Ababa University, University of Wiscosin and People to People partners intend to continue working together to strengthening and developing effetive systems to deliver quality pediatrics emergency medicine care troughout all regions of Ethiopia.

Enhancing emergency medicine initiatives with a quality improvement program: lessons learned in the emergency department of Tikur Anbessa Hospital, Addis Ababa Ethiopia.

INTRODUCTION: A Twinning Partnership between the University of Wisconsin-Madison (UW) and Addis Ababa University (AAU) in Addis Ababa, Ethiopia was formed to strengthen the development of emergency medical services at AAU's Tikur Anbessa Specialized Hospital (TASHI) through medical education and exchanges. The Twinning philosophy which emphasizes collaboration and joint learning was an ideal program in which QI program was incorporated to maximize success, promote sustainability, and reinforce basic principles for effective healthcare service delivery. This article describes the QI methodology, capacity building strategy, implementation approach, and lessons learned. METHODOLOGY: QI initiative at TASH ED started during EM fellowship in 2010 when Priority problems in the department were identified, and root cause analysis and possible strategies for improvement were devised. Then Baseline and sensitization was undertaken which was followed by Quality Improvement Projects cycles. The Federal Ministry of health key performance indicators (KPI) were used as standard and measurement tool when it was relevant. The findings were analyzed and trends presented to the ED staff and other stakeholders. RESULTS: In the past four years Since QI initiatives started in TASH EM department different achievements have been registered. The main developments were capacity building with QI training of EM fellows, EM residents and EM and critical care nurses. QI Training was also conducted to Tikur Anbessa Hospital and college of health sciences leadership. In addition, various QI projects have been designed and started, while some are finalized and the rest are on implementation. DISCUSSION: The QI experience in the department suggests that a QI program can effectively support, complement, and enhance health system strengthening partnerships, and that establishment of a QI program at the department level is feasible and beneficial, enhancing the adoption and sustainability of health care improvements such as marked improvements in triage, improved infection control and other critical improvements. Therefore, program leaders have determined that scale-up to a hospital-wide QI program is needed to fully realize the potential for increased quality, efficiency and system strengthening.

Time to presentation, pattern and immediate health effects of alleged child sexual abuse at two tertiary hospitals in Addis Ababa, Ethiopia.

BACKGROUND: Children are vulnerable to abuse and violence because their level of development makes them unable to protect themselves. Such adversities during early childhood may have a negative impact on the future lives of the victims.This study was done to determine the delay to hospital presentation, clinical manifestations and immediate health effects of child sexual abuse in two tertiary care hospitals in Ethiopia. METHODS: We reviewed records of all cases of child sexual and physical abuse between January 2011 and December 2012. Bivariate and multivariate logistic regression models were used to test the presence and strength of association between time to reporting to hospital and, age and sex of the victim, place of residence and relation of the victim to the perpetrator. Odds ratio and 95% confidence intervals were generated. Significance was taken as p-value < 0.05. RESULTS: During the study period, we identified records of 275 children who were seen for alleged physical and sexual abuse; they accounted for 0.6% of the outpatient department (OPD) visits. The majority of the victims were cases of sexual abuse (97.3%) and most of them were female (75.7%). The mean age of the victims was 9.5 years (standard deviation (SD) = 4.2 years). The majority of the abusers were known to the victim (73.0%) and male (98.8%). Neighbors (38.95%), teachers (7.9%) and relatives (13.4%) were the most commonly reported perpetrators. The median length of time taken to present to hospital after the abuse incident was 4 days (range = 2 hours to 3 years). Male victims were 2.4 times more likely to have a delay of greater than one week to present to hospital (Adjusted Odds Ratio (AOR), 2.40; 95% Confidence interval (CI), 1.34-4.31; P-value = 0.002). Sexual abuse was associated with various immediate health effects, for example, hymenal tear, urinary tract infection and, perineal laceration or tear. CONCLUSION: Presentation for care was often delayed. Male sex was independently associated with a delayed presentation to care. We recommend that further studies are carried out to identify the reasons for delay to reporting and design mechanisms to address them.

Predictors of treatment failure and time to detection and switching in HIV-infected Ethiopian children receiving first line anti-retroviral therapy.

BACKGROUND: The emergence of resistance to first line antiretroviral therapy (ART) regimen leads to the need for more expensive and less tolerable second line drugs. Hence, it is essential to identify and address factors associated with an increased probability of first line ART regimen failure. The objective of this article is to report on the predictors of first line ART regimen failure, the detection rate of ART regime failure, and the delay in switching to second line ART drugs. METHODS: A retrospective cohort study was conducted from 2005 to 2011. All HIV infected children under the age of 15 who took first line ART for at least six months at the four major hospitals of Addis Ababa, Ethiopia were included. Data were collected, entered and analyzed using Epi info/ENA version 3.5.1 and SPSS version 16. The Cox proportional-hazard model was used to assess the predictors of first line ART failure. RESULTS: Data of 1186 children were analyzed. Five hundred seventy seven (48.8%) were males with a mean age of 6.22 (SD = 3.10) years. Of the 167(14.1%) children who had treatment failure, 70 (5.9%) had only clinical failure, 79 (6.7%) had only immunologic failure, and 18 (1.5%) had both clinical and immunologic failure. Patients who had height for age in the third percentile or less at initiation of ART were found to have higher probability of ART treatment failure [Adjusted Hazard Ratio (AHR), 3.25 95% CI, 1.00-10.58]. Patients who were less than three years old [AHR, 1.85 95% CI, 1.24-2.76], chronic diarrhea after initiation of antiretroviral treatment [AHR, 3.44 95% CI, 1.37-8.62], ART drug substitution [AHR, 1.70 95% CI, 1.05-2.73] and base line CD4 count below 50 cells/mm3 [AHR, 2.30 95% CI, 1.28-4.14] were also found to be at higher risk of treatment failure. Of all the 167 first line ART failure cases, only 24 (14.4%) were switched to second line ART with a mean delay of 24 (SD = 11.67) months. The remaining 143 (85.6%) cases were diagnosed to have treatment failure retrospectively by the authors based on their records. Hence, they were not detected and these patients were not offered second line ARTs. CONCLUSIONS: Having chronic malnutrition, low CD4 at base line, chronic diarrhea after initiation of first line ART, substitution of ART drugs and age less than 3 years old were found to be independent predictors of first line ART failure in children. Most of the first line ART failure cases were not detected early and those that were detected were not switched to second line drugs in a timely fashion. Children with the above risk factors should be closely monitored for a timely switch to second line highly active anti-retroviral therapy.