Mortality in relation to profiles of clinical features in Ghanaian severely undernourished children aged 0-59 months: an observational study.

Severe acute malnutrition (SAM) is associated with a complex pattern of various clinical conditions. We investigated how risk factors cluster in children with SAM, the relationship between clusters of risk factors and mortality as well as length of stay in children with SAM. A prospective observational study design was used. Data were extracted from medical records of 601 infants and children aged 0-59 months admitted and treated for SAM in three Ghanaian referral hospital between June 2013 and June 2018. Among the 601 medical records extracted, ninety-nine died. Three clusters of medical features clearly emerged from data analyses. Firstly, an association was defined by eye signs, pallor, diarrhoea and vomiting with gastrointestinal infections and malaria. In this cluster, pallor and eye signs were related to 2- to 5-fold increased mortality risk. Secondly, HIV, oedema, fast pulse, respiratory infections and tuberculosis; among those features, HIV increased child mortality risk by 2-fold. Thirdly, shock, convulsions, dermatitis, cold hands and feet, weak pulse, urinary tract infections and irritability were clustered. Among those features, cold hands and feet, dermatitis, convulsions and shock increased child mortality risk in a range of 2- to 9-fold. Medical conditions and clinical signs in children diagnosed with SAM associate in patterns and are related to clinical outcomes.

Alcohol marketing and adolescent alcohol consumption: Results from the International Alcohol Control study (South Africa).

BACKGROUND: A complete ban on alcohol advertisements has been proposed for South Africa (SA), but there has been limited local research on the association between exposure to alcohol advertisements and alcohol consumption. OBJECTIVES: To examine the role of demographic factors, exposure to alcohol marketing and liking of alcohol advertisements in predicting use of alcohol in the past 6 months among older adolescents in Tshwane, Gauteng Province, SA. METHODS: Participants comprised the adolescent sub-sample (N=869) of the International Alcohol Control study survey that was conducted in SA. They consisted of 408 males and 461 females aged 16 and 17 years who took part in structured interviews on their alcohol consumption and various alcohol-related attitudes and behaviours. A multiple survey logistic regression analysis of the dependent variable alcohol use in the past 6 months on the independent variables age, gender, educational status, socioeconomic status, exposure to alcohol brand marketing and liking of alcohol advertisements was used. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. RESULTS: The prevalence of drinking in the past 6 months was 10.6% (95% CI 5.9 - 18.3). The number of modes of alcohol brand/product advertising to which the adolescents were exposed was positively associated with alcohol use in the past 6 months. An additional mode of alcohol brand/product advertising exposure led to a relative increase of 1.13 (95% CI 1.01 - 1.28) in the odds of alcohol use in the past 6 months (e.g. a participant who was exposed to advertisements via seven different channels was 2.08 times more likely to have used alcohol in the past 6 months than a participant with exposure via a single channel). Having a strong dislike of alcohol advertisements was associated negatively (protective) with alcohol use in the past 6 months, with the odds ratio being 0.35 (95% CI 0.19 - 0.64). Having only a moderate dislike or a liking of alcohol advertisements was positively associated with alcohol use in the past 6 months among the study participants (OR 2.90 and 2.84, respectively). Age, gender, educational status and socioeconomic status were not independently associated with alcohol consumption. CONCLUSIONS: Exposure to alcohol marketing and not being strongly averse to advertisements of alcohol brands and products were associated with alcohol use among adolescents. The results have implications for policies on alcohol marketing in SA.

Treatment-refractory vulvodynia from nutcracker syndrome: A case report.

BACKGROUND: Pelvic venous disorders are often undiagnosed due to the symptom variability and similarity to other disease presentations. 'Pelvic congestion syndrome' is a term often used as a diagnosis of exclusion, since there is currently no standardized diagnostic approach for pelvic venous disorders, which further delays treatment. CASE: A 25-year-old woman with treatment-refractory vulvodynia presented with symptoms that included left-sided vaginal wall pain, pruritis, dysmenorrhea, dyspareunia, muscle tension, and a chronic vaginal ulceration. Abnormal pelvic varices were discovered, and she was referred to vascular surgery for treatment of nutcracker syndrome causing ovarian vein reflux and abnormal engorgement of pelvic varices. CONCLUSION: Patients presenting with signs of pelvic venous insufficiency such as vaginal pruritis, irritation, pain, recurrent vaginitis, or chronic ulcerations should be examined for pelvic venous disorders.

Severe acute malnutrition.

PURPOSE OF REVIEW: The mortality and morbidity associated with severe acute malnutrition (SAM) remain high. A summary of recent studies that are of interest to clinicians treating children with SAM is provided. RECENT FINDINGS: Three important themes emerged in 2015: the use of anthropometry in the diagnosis of SAM and its correlation with body composition; the composition of ready-to-use therapeutic feeds (RUTF); and an improved understanding of the pathophysiology of SAM. SUMMARY: Standard anthropometry does not accurately predict body composition and mid-upper arm circumference more accurately reflects fat mass in children. As single measure, mid-upper arm circumference identifies those children who are most likely to die from SAM and is not influenced by dehydration. However, a significant proportion of SAM children requiring treatment will not be detected. Present RUTF formulations are deficient in long chain polyunsaturated fatty acids. Current evidence suggests that preformed docosahexaenoic acid should be added and/or the content of linoleic acid reduced in RUTF. In contrast to an animal model, stabile children with SAM have the same cardiac index as children without SAM. The situation in haemodynamically unstable children is unknown, continued conservative use of intravenous fluids seems advisable. A reduction in variability of the faecal DNA virome may account for increased susceptibility to malnutrition in vulnerable children.

The Competencies of the Shift Leader in the Intensive Care Unit Setting; in a Private Hospital Group in South Africa

Newly qualified intensive care nurses are forced into positions of authority and responsibility as shift leaders at an early stage and are not given a chance to consolidate their new knowledge with practice. They have to be responsible and accountable not only for their own actions; but also for those of their staff. The purpose of this study was to explore and describe the competencies of the shift leader in the intensive care unit setting to determine whether there is a gap between what is expected of the shift leader and what is happening in reality. A quantitative; descriptive design was used and cluster sampling was implemented. Questionnaires were used to gather data from three clusters; comprising 11 hospitals from a single private hospital group. Of the 251 questionnaires that were handed out to intensive care personnel (including trained and non-trained staff); 98 were returned; resulting in a response rate of 39. An in-depth literature study and submission of questionnaires to experts before being administered to respondents ensured validity and reliability. Results were used to describe a typology of the competencies of the shift leader in the intensive care setting and indicated that respondents classified competencies related to the application of the nursing process in the intensive care unit in all its facets as essential competencies. None were classified as a critical competency and only four were classified as specific competencies. All respondents in the three clusters regarded their shift leaders as competent

The diagnostic value and safety of transbronchial needle aspiration biopsy in children with mediastinal lymphadenopathy.

INTRODUCTION: Anterior mediastinal masses in children can have different causes which includes, Mycobacterium tuberculosis (MTB) or malignant lymphadenopathy. Transbronchial needle aspiration (TBNA) has been described as a safe and effective diagnostic procedure in adult patients with lung cancer. AIM: To describe the use of TBNA as a diagnostic test in children with large subcarinal lymphadenopathy and to determine the safety of the procedure in children. PATIENTS AND METHODS: Prospective descriptive study of children with subcarinal mediastinal lymph nodes who underwent TBNA. The majority of the children were referred due to treatment failure. Children were enrolled if the diagnosis remained unclear after computer tomography of the chest. RESULTS: Thirty patients were enrolled in this study; TBNA was done in 28 patients. A definitive diagnosis was made by TBNA in 54% (n = 15) of patients; MTB lymphadenopathy (n = 13), metastatic nephroblastoma (n = 1), and fibrosing mediastinitis (n = 1). In seven (25%) cases the TBNA was the sole source of the specimens from which the definitive diagnosis was made. No serious complications were encountered during or after the procedure. CONCLUSION: TBNA is a safe procedure in children with mediastinal lymphadenopathy of unknown cause resulting in a definitive diagnosis in 57% of cases. TBNA adds additional value to flexible bronchoscopy in the diagnosis of mediastinal lymphadenopathy in children.

CMV pneumonia in HIV-infected ventilated infants.

BACKGROUND: The contributing role of cytomegalovirus (CMV) in infants treated for Pneumocystis jiroveci pneumonia (PJP) is unknown. High dose steroids used in the treatment of PJP may further immunocompromise these infants contributing to the development of CMV pneumonia. AIM: The aim of this study was to determine the role of CMV pneumonia in infants being ventilated for suspected PJP. METHODS: In this prospective study HIV infected infants being treated with trimethoprim-sulfamethoxazole (TMP/SMX) and ventilated for suspected PJP were included if they had not responded to treatment. Open lung biopsy was performed if there was no improvement in ventilatory requirements. RESULTS: Twenty-five HIV positive infants with a mean age of 3.3 months were included. Lung biopsy was performed in 17 (68%) and post-mortem lung tissue was obtained in 8 (32%). After evaluation of the histology, immunohistochemistry, and viral cultures from lung tissue, the most likely causes of pneumonia were: CMV and PJP dual infection 36% (n = 9), CMV pneumonia 36% (n = 9), and PJP 24% (n = 6). The pp65 test for CMV antigen was falsely negative in 24%. The mean blood CD4 count was 287/microl. There was an association between the CD4 lymphocyte status and the final diagnosis, with the CMV and PJP group (CD4 110/microl) having the lowest CD4 status (P = 0.0128). Pediatric Intensive Care Unit (PICU) mortality was 72% (n = 18) and in hospital mortality 88%. CONCLUSION: Of the ventilated infants failing to respond to treatment, 72% had histologically confirmed CMV pneumonia, probably accounting for the high mortality in this cohort. The incidence of CMV disease in HIV infected infants being ventilated for severe pneumonia warrants that ganciclovir is used empirically until CMV disease is excluded. The role of lung biopsy in these circumstances needs to be researched.

Percutaneous Injuries in Doctors in the School of Medicine; University of the Free State: Prevalence; Reporting and Adherence to Precautionary and Management Procedures

"Background: Despite the official precautionary measures against percutaneous injuries; incidents still occur. Consequently; it is possible that healthcare workers could contract infections like HBV; HCV; HGV (hepatitis B; C and G viruses) and HIV (human immune deficiency virus). The most serious problem lies in the fact that percutaneous injuries are often underestimated; resulting in non-reporting of the incident. The aim of this study was to determine the incidence of percutaneous injuries in doctors in the School of Medicine at the University of the Free State (UFS); whether the incidents were reported; and the reasons for non-reporting. The use of gloves during procedures was also evaluated. Methods: A mainly descriptive study design was used. Questionnaires were administered from October 2006 through January 2007 to collect information. Participants were selected randomly; and the respondents were divided into surgical and non-surgical groups. Results: The respondents fulfilled the following roles and/or functions in their respective departments of employment: 35 (67.3) were registrars; 12 (23.1) were specialists/consultants; four (7.7) were medical officers; and one (1.9) was exclusively involved in student training. Two of the respondents did not indicate their roles and functions in their respective departments. A total of 82 incidents of percutaneous injuries occurred. Although the surgical groups handled sharp objects more frequently per week than the non-surgical groups (p-value = 0.04); more incidents occurred in the non- surgical groups (p-value = 0.02). Only 39 (47.6) of the incidents were reported; while 44.4of the respondents were aware of the correct reporting procedures. The reasons given for the non-reporting of these incidents were ""too busy"" (58.1); ""did not think it was serious"" (48.8); and ""was not aware of the reporting procedures"" (7). Only 13.7of the respondents indicated that they always used gloves when drawing blood; 17.4used them when injections were administered; and 22.4used gloves during intravenous cannulation. However; 86.8of the respondents wore gloves when they used a scalpel or any other incision object. The respondents (n = 51) suggested that the three most important precautionary measures to take into consideration when working with sharp objects were (i) the use of gloves (23/51; 45.1); (ii) never recapping a needle (9/51; 17.6); and (iii) keeping the container for disposing of sharp objects close at hand (6/51; 11.8). Conclusions: Despite the risk of percutaneous injuries; non-reporting still occurs. Although the rate of reporting these incidents could be compared with international findings published in the literature; it remains too low. Drastic measures should be taken to ensure that physicians are informed of the hazards of percutaneous injuries; as well as of the appropriate mechanisms of reporting these incidents."

Evidence-Based Nursing Interventions and Guidelines for Prone Positioning of Adult; Ventilated Patients: a Systematic Review

Although the prone positioning of a critically ill patient poses a challenge to nursing interventions; it remains the responsibility of nurses to develop a way to provide the same basic and intensive care to those patients lying prone as to those lying supine. The purpose of this study was firstly to conduct a systematic review of the literature as explora-tion and description of the evidence in support of the beneficial nursing interventions during prone positioning of ventilated patients; and secondly to develop evidence-based nursing guidelines for the nursing process. This exploratory; descriptive and retrospective systematic review includes data from 45 clinical trials; with a total population of 2 148 patients. Data was extracted onto data abstraction forms; assessed for methodological quality and finally summarised in evidence tables. All statistical calculations for the meta-analysis were performed by the RevMan 4.2.8 program. Prone positioning showed significant (p 0.0001) increases in the partial pressure of oxygen in arterial blood (PaO2) weighted mean difference (WMD CI = 11.36; 31.8). The effects of complications; oxygenation and haemodynamic outcomes compared with the different prone-positioning protocols produced in conclusive results. Nursing guidelines for prone positioning were developed based on the best available evidence. The lack of related articles on nursing care of prone positioning was a drawback. Based on these results; recommendations are made towards further study on the nursing care of prone-positioned patients

Patients with Coronary Artery Disease : Maintaining Planned Lifestyle Adaptations

The purpose of this study was to describe how patients with coronary artery disease; who have had one or more cardiac interventions; were maintaining their planned lifestyle adaptations at four months after the intervention. Furthermore; the study aimed to develop guidelines to further assist patients in maintaining lifestyle adaptations. A descriptive study was undertaken using the survey method. The population consisted of 65 participants (42 males; 23 females) from five private hospitals in Gauteng. The questions for a questionnaire were derived from a conceptual framework. The participants first completed the questionnaire immediately before they were discharged; and again over the telephone four months after the intervention. Descriptive statistics were used to analyse the data obtained. The results showed that patients suffering from coronary artery disease do adapt their lifestyle after interventions; but most patients find it problematic to stop smoking. It is essential for patients with coronary artery disease to maintain lifestyle adaptations to ensure further health and prevention of recurrence of the same problems. These adaptations should be a lifelong commitment

Viral Infections In Children Receiving Anticancer Chemotherapy

OBJECTIVE: To determine the presence of bacterial and viral infectious agents in children with fever during anticancer chemotherapy. DESIGN: Analysis of data obtained during a prospective cohort study. SETTING: The pediatric oncology unit of Tygerberg Children's Hospital; Cape Town. SUBJECTS: All patients up to the age of 15 years who deve- loped fever secondary to anticancer chemotherapy from February 9th 2000 to April 9th 2001. OUTCOME MEASURES: Viruses were isolated or antigens detected on venous blood samples; nasopharyngeal aspirates; throat swabs; urine and feces where possible. Blood for aerobic and anaerobic culture was obtained from an indwelling intravenous catheter and/or a peripheral vein. RESULTS: Thirty-four children were analyzed for a total of 102 febrile episodes. The absolute neutrophil count on admission was below 0.5*109/L in 57 (56) episodes and thus considered neutropenic. Thirty-five viral isolates were identified in 31 (30) febrile episodes: HSV-1 (n=14); HSV-2 (n=2); CMV (n=10); rotavirus (n=5); adenovirus (n=2); Para influenza type 3 (n=1) and hepatitis B (n=1). The blood culture was positive in 24 (24) febrile episodes. Within these; a combined viral and bacterial infection was demonstrated in 6 (6) episodes. Infections were more frequent in neutropenic compared to non-neutropenic episodes; however; this was not significant. CONCLUSIONS: Viral infections clearly are an important cause of fever in children receiving anticancer therapy and may occur together with a bacterial infection. Diagnostic tests for viral infections should be used more frequently and could be of considerable value in evaluating fever and establishing appropriate treatment in these patients

Common Opportunistic Infections in HIV Infected Infants and Children : Part 2 Non-Respiratory Infections

Increased susceptibility to infections is the major cause of disease; end organ damage and death in human immunodeficiency virus (HIV)-infected children. This article will focus on prevention; diagnosis and management of the most common and less common severe infections that are specifically associated with HIV-related immune compromise; as well as some aspects relating to immune reconstitution inflammatory syndrome (IRIS)

Tuberculous meningitis and miliary tuberculosis in young children.

OBJECTIVES: To document the clinical and diagnostic features of tuberculous meningitis (TBM) in young children with and without concomitant miliary tuberculosis (TB). METHODS: A retrospective comparative study. RESULTS: Of 104 children with TBM, 32 (31%), median age 17.0 months, had a miliary appearance on chest radiograph; 72 (69%), median age 30.5 months, had TBM only (P = 0.04). Mediastinal adenopathy was noted in 27 (84%) of the children with miliary TB and 33 (46%) of those with TBM only (P = 0.0005). The mean cerebrospinal fluid (CSF) lymphocyte and polymorphonuclear counts of all children (no significant differences between groups) were 137 x 10(6)/l and 38 x 10(6)/l and the mean protein and glucose concentrations were 1.45 g/l and 0.72 mmol/l, respectively. Polymorphonuclear leukocytes were predominant in the CSF of 17% of children, in 16% the CSF glucose was > 2.2 mmol/l and in 26% the CSF protein was < 0.8 g/l. On Mantoux testing 37 (65%) of 57 children with TBM only and 12 (48%) of 25 children with TBM and miliary TB had an induration of > or = 10 mm (P = 0.23). Ten children (10%) died, five (7%) who had TBM only and five (16%) who had TBM and miliary TB. CONCLUSION: Children with TBM and miliary TB were younger and more likely to have mediastinal adenopathy on chest radiography than those with TBM only. Diagnostic features and investigations in both groups may be misleading at times.

Organ donation: attitude and knowledge of nurses in South Africa.

Various factors influence the process of organ donation. As a result, there is a shortage of organs for transplant. Poor communication and cooperation between transplant coordinators and intensive care nursing staff can lead to the non-referral of potential organ donors, which is detrimental to the process. The purpose of this research was to ascertain the attitude and knowledge of the transplant coordinators and intensive care nursing staff that work in intensive care units during organ donation. Contextual descriptive research was carried out by compiling literature-based questionnaires, one each for the transplant coordinators and intensive care nursing staff, and then analysing responses. The indications are that problem areas exist between the role players in the organ transplant process. Guidelines were drawn up for the improvement of communication and cooperation between them in order to promote organ donation.

Factors influencing successful closure with indomethacin of the patent ductus arteriosus in premature infants.

The incidence of persistent patency of the ductus arteriosus (PDA) is inversely related to birth weight. A PDA contributes to pathological conditions in the neonate and timely closure in these low-L birth-L weight infants could potentially prevent these complications. Prostaglandin inhibition with indomethacin is one treatment strategy currently available. This retrospective descriptive study evaluated the parameters that influenced the effectiveness of indomethacin in closure of the PDA in 101 consecutive premature infants and the adverse effects of indomethacin in these infants. Independent variables found to increase the risk of unsuccessful closure with indomethacin significantly were caesarean section, lower haematocrit at delivery and severity of hyaline membrane disease. Non-L closure also resulted in prolonged ventilation. No significant adverse effects were recorded in the infants who received indomethacin but neonatal jaundice was more common in those infants who responded to indomethacin.

Diagnosis of haemodynamically significant patent ductus arteriosus in neonates-- is the ECG of diagnostic help?

The presence of a haemodynamically significant patent ductus arteriosis (PDA) in the premature newborn may contribute to the development of brochopulmonary dysplasia, intraventricular haemorrhage and necrotising enterocolitis. It is therefore essential that the diagnosis of such a PDA be made in time in order to intervene medically or surgically. Echocardiography is at present the prime diagnostic tool, but it is mainly available in tertiary hospitals. Chest roentgenography is of little diagnostic value especially in the presence of respiratory disease, which is often present in premature babies. Very little is known about the diagnostic value of the electrocardiogram (ECG) in premature babies. The aim of this study was to describe the standard 12-lead ECG findings in low-birth-weight babies with haemodynamically significant PDAs. Thirty-two babies with haemodynamically significant PDAs, as established by echocardiography, were included in the study. Standard 12-lead ECGs were done in all these babies. In 15 patients ECG abnormalities were found; only 22% had left atrial and left ventricular enlargement indicative of significant left-to-right shunting, while 78% had no ECG changes indicative of left-to-right shunting. In conclusion, the ECG cannot be used to identify haemodynamically significant PDAs.

Neonatal meningitis: mortality, cerebrospinal fluid, and microbiological findings.

This study describes the bacteriology, cerebrospinal fluid (CSF) findings, and mortality of neonatal meningitis over an 11-year period. The minimum incidence of neonatal meningitis at Tygerberg Hospital is 0.72/1000 live births/year. Eighty-eight patients were included in the study. Median birthweight and age at diagnosis were 2320 g and 12 days, respectively. CSF culture was positive in 77 (88 per cent), blood culture was positive in 51 (57 per cent), and Gram stain was positive in 58 (66 per cent). The most frequently cultured organisms were Group B Streptococcus, Klebsiella pneumoniae, and E. coli. Thirty (34 per cent) patients died, the majority within 72 h after admission. The death rate was significantly increased in babies with a birthweight of less than 1500 g (59 per cent). Increased total CSF protein was associated with an increased risk of death. Normal CSF cell count, total CSF protein and CSF glucose were found in six infants.

Haematological abnormalities in children with tuberculosis.

Over a 16 month period 307 children with suspected tuberculosis (TB) and an available full blood count (FBC) seen at Tygerberg Hospital in South Africa were evaluated and categorized as confirmed (A), probable (B), and no TB (C) according to WHO criteria. There was no difference in the mean age of the 168 group A (33.6 months), 83 group B (34.4 months), and the 56 group C (31.6 months) children. A lower mean haemoglobin (Hb 10.2 vs. 10.8 g/dl) was the only significantly different haematological parameter in children with TB compared with the comparison group (Group C). There were no differences in median total white cell count, neutrophils, lymphocytes, monocytes, platelets, or the proportion of children in each group with anaemia, microcytosis, neutrophilia, neutropenia, lymphocytosis, lymphopenia, monocytosis, thrombocytosis or thrombocytopenia. The most common haematological abnormalities in children with TB were the presence of anaemia, neutrophilia, and monocytosis but these changes were found with equal frequency in control patients. Although haematological abnormalities are fairly common in children with TB, in a developing country these abnormalities also occur frequently in children with other non-tuberculosis respiratory infections. An FBC has no diagnostic predictive value when investigating a child for TB.