Stroke Hexagon; Protocol for Reduction of Stroke Burden in Resource-Poor Settings.

BACKGROUND: Stroke is a neurological emergency, with high prevalence, especially in developing countries where it assumes an epidemic proportion. It is globally the second most common cause of death after ischemic heart disease. The poor indices reported in developing countries are multifactorial and related to late case presentation, ignorance, poverty, and unavailability of comprehensive and well-coordinated stroke care. OBJECTIVES: This manuscript identified and highlighted the available and cheap stroke management pillars in developing countries and recommended measures to strengthen the system to maximize the benefits in the reduction of morbidity and mortality from stroke. RESULTS: The identified stroke management pillars include stroke prevention, hyperacute stroke management, acute stroke management, stroke rehabilitation, stroke research, and stroke support. CONCLUSIONS: A coordinated and concerted stroke management protocol involving the stroke hexagon will reduce stroke morbidity and mortality in resource-poor settings. There is a need to sensitize the stakeholders in stroke management to assume more responsibility.

CONTEXTE: L'AVC est une urgence neurologique, avec une prévalence élevée, en particulier dans les pays en développement où il prend une ampleur épidémique. Il est mondialement la deuxième cause de décès la plus fréquente après la maladie cardiaque ischémique. Les mauvais indices rapportés dans les pays en développement sont multifactoriels et liés à une présentation tardive des cas, à l'ignorance, à la pauvreté et à l'absence de soins coordonnés et complets pour l'AVC. OBJECTIFS: Ce manuscrit a identifié et mis en évidence les piliers bon marché de la prise en charge de l'AVC dans les pays en développement et recommandé des mesures pour renforcer le système afin de maximiser les avantages dans la réduction de la morbidité et de la mortalité dues à l'AVC. RÉSULTATS: Les piliers identifiés de la prise en charge de l'AVC comprennent la prévention de l'AVC, la prise en charge hyperaiguë de l'AVC, la prise en charge aiguë de l'AVC, la rééducation post-AVC, la recherche sur l'AVC et le soutien aux personnes touchées par l'AVC. CONCLUSIONS: Un protocole de prise en charge de l'AVC coordonné et concerté impliquant l'hexagone de l'AVC réduira la morbidité et la mortalité liées à l'AVC dans les milieux à ressources limitées. Il est nécessaire de sensibiliser les parties prenantes à la prise en charge de l'AVC pour qu'elles assument davantage de responsabilités. Mots-clés: Hexagone de l'AVC, Protocole, Fardeau de l'AVC, Milieux à ressources limitées.

Pulmonary Embolism: The Battle to Save Life in a Resource Poor Setting.

INRODUCTION: Pulmonary embolism (PE) is a cardiovascular emergency caused by occlusion of one or more pulmonary arteries by thrombi that originate from a deep venous thrombosis (subsequently called an embolus), typically in the large veins of the lower limb or pelvis. It is a common cause of preventable hospital death and a cause of mortality in obstetrics setting because it largely remains under diagnosed especially in a resource poor setting. CASE REPORT: Mrs OG, a 30-year-old primigravida, had a spontaneous delivery of a baby boy. A few hours after delivery, she had two episodes of syncope and was resuscitated with intra-venous fluids and blood transfusion. Further evaluation, with an abdominopelvic ultrasound scan, showed that she had supra-levator haematoma necessitating emergency exploratory laparotomy. During the induction of anaesthesia for the surgery, she had a cardiac arrest and was again resuscitated with cardiac compression and intravenous adrenaline. She was transferred to ICU on account of cardio-respiratory instability. On the 2nd day post operation, the chest physician reviewed and noted history of cough, haemoptysis and breathlessness of two days duration. She had an associated unilateral (right) leg swelling, with presence of cyanosis, tachypnoea and tachycardia with SPO2 fluctuating between 82-92% (while on oxygen with nasal prongs). The clinical probability of PE using Well's scoring system was high (11.5). In the absence of computerized tomography (CT) pulmonary angiography and ventilation perfusion (V/Q) scan, a Doppler ultrasound of both legs was done which showed dilation of the proximal one-third of the right femoral vein with meshwork of thrombi. She was subsequently commenced on Enoxaparin and intra-venous fluids and antibiotics. She also received supplementary oxygen. The Prothrombin time and International Normalized Ratio (INR) were monitored over the period. She slowly but progressively improved and was discharged home on oral warfarin. The index patient had cardiopulmonary arrest and expectedly, needed urgent intervention with embolectomy or thrombolytic therapy. In the absence of these, anticoagulation with vasopressor agents, supplementary oxygen and close monitoring was able to sustain the patient. SUMMARY: Pulmonary embolism is a killer condition with 10% of the patients dying within one hour of onset. Most times, mortality occurs in patients who were never diagnosed. The best prospect for reducing mortality in patients with PE lies in improving diagnosis.

INRODUCTION: L'embolie pulmonaire (EP) est une urgence cardiovasculaire causée par l'occlusion d'une ou plusieurs artères pulmonaires par des thrombus provenant d'une thrombose veineuse profonde (appelée par la suite embole), généralement dans les grosses veines du membre inférieur ou du bassin. Il s'agit d'une cause fréquente de décès hospitalier évitable et d'une cause de mortalité en obstétrique car elle reste largement sous-diagnostiquée, en particulier dans un contexte de ressources limitées. RAPPORT DE CAS: Mme OG, une primigeste de 30 ans, a accouché spontanément d'un petit garçon. Quelques heures après l'accouchement, elle a eu deux épisodes de syncope et a été réanimée avec des fluides intraveineux et une transfusion sanguine. Une évaluation plus poussée, avec une échographie abdomino-pelvienne, a montré qu'elle avait un hématome supra-levatorien nécessitant une laparotomie exploratoire d'urgence. Pendant l'induction de l'anesthésie pour la chirurgie, elle a fait un arrêt cardiaque et a été réanimée par compression cardiaque et adrénaline intraveineuse. Elle a été transférée aux soins intensifs en raison de son instabilité cardio-respiratoire. Le deuxième jour après l'opération, le médecin thoracique a examiné et noté une histoire de toux, d'hémoptysie et d'essoufflement depuis deux jours. Elle présentait un gonflement unilatéral (droit) de la jambe, une cyanose, une tachypnée et une tachycardie avec une SPO2 fluctuant entre 82 et 92 % (sous oxygène avec des pinces nasales). La probabilité clinique d'EP en utilisant le système de notation de Well était élevée (11,5). En l'absence d'angiographie pulmonaire par tomodensitométrie et de scintigraphie de ventilation et de perfusion (V/Q), une échographie Doppler des deux jambes a été réalisée et a montré une dilatation du tiers proximal de la veine fémorale droite avec un maillage de thrombus. Elle a ensuite été mise sous Enoxaparine, fluides intraveineux et antibiotiques. Elle a également reçu de l'oxygène supplémentaire. Le temps de prothrombine et le rapport international normalisé (INR) ont été surveillés pendant toute la période. Elle s'est lentement mais progressivement améliorée et a été renvoyée chez elle sous warfarine orale. Le patient de référence a fait un arrêt cardio-pulmonaire et, comme on pouvait s'y attendre, a dû subir une intervention urgente avec embolectomie ou thérapie thrombolytique. En l'absence d'une telle intervention, une anticoagulation avec des agents vasopresseurs, un supplément d'oxygène et une surveillance étroite ont permis de maintenir le patient en vie. RÉSUMÉ: L'embolie pulmonaire est une maladie mortelle, 10% des patients décèdent dans l'heure qui suit son apparition. La plupart du temps, la mortalité survient chez des patients qui n'ont jamais été diagnostiqués. La meilleure perspective pour réduire la mortalité chez les patients atteints d'EP réside dans l'amélioration du diagnostic. Mots clés: Embolie pulmonaire, milieu pauvre en ressources, diagnostic, prise en charge.

Hydroxyurea in children with sickle cell disease in a resource-poor setting: Monitoring and effects of therapy. A practical perspective.

BACKGROUND: Although effectiveness of hydroxyurea (HU) in sickle cell disease is well established, unanswered questions persist about its use in African children. We determined real-life issues of acceptability, availability, and monitoring of HU use in Nigeria. METHODS: A retrospective longitudinal review of laboratory data of patients on HU was done from case files, followed by a cross-sectional survey that captured families' perception of medication and clinic adherence, laboratory tests, benefits, side effects, and acceptability. RESULTS: One hundred sixteen patients (1.2-17 years) received HU (mean ± SD = 18.5 ± 4.3 mg/kg/day) in 33 months. Eighty-nine had laboratory analysis. Dose escalation was the initial goal, but only 80% of patients had some form of it. Parents reported improvement in general well-being and reduction in bone pain episodes, hospital admissions, and blood transfusion. While most parents (89.5%) reported satisfaction with HU, 61% reported dissatisfaction with daily drug use, and the frequency and cost of monitoring. Sixteen percent voluntarily stopped therapy. Adherence to daily HU was 88.8%, doctor's appointments 24.5%, hematology tests 18.9%, and organ function tests 37.4%. There were no significant toxicities. Significant increases in hemoglobin, hemoglobin F and mean corpuscular volume, and reduction in absolute neutrophil count occurred despite inconsistent dose escalation. CONCLUSION: HU (10-15 mg/kg/day starting dose) is safe and seems effective and acceptable to parents. Parental commitment to therapy, pre-HU education (that continues during therapy), provision of affordable HU, and subsidized laboratory tests are important considerations for initiating therapy. Special HU clinics may facilitate dose escalation and reduce frequency of monitoring. Studies are needed on feasibility of maximum tolerable dose HU protocols in sub-Saharan Africa without compromising safety.

Community-based rehabilitation offers cost-effective epilepsy treatment in rural Guinea-Bissau.

Treatment of epilepsy in low-income countries is a challenge considering the lack of resources, availability of antiepileptic drugs, and cultural beliefs. We used a community-based rehabilitation (CBR) service for the detection, monitoring, and treatment of epilepsy. A local network of trained community volunteers provided education, good quality antiepileptic drugs, and clinical follow-up for people with epilepsy (PWE). In a period of 2years, approximately 22,500 people were screened in central Guinea-Bissau, and 112 PWE were identified and registered. Monthly check-ups were offered to monitor treatment effect and increase compliance. Retrospective analysis on 81 records of patients under treatment in June 2016 showed a decrease of seizure frequency in 88.8% after treatment initiation and was maintained throughout the clinical follow-up of 15months. A conservative estimation of the treatment and monitoring of a single person with epilepsy revealed a daily cost of $0.73. Despite acknowledging epilepsy as a neglected condition by the World Health Organization (WHO), most PWE still lack appropriate treatment. Although CBR service has been suggested as efficient strategy to reduce the treatment gap, little information is available on the efficacy of the programs. Our experiences show that CBR service is a cost-effective approach to monitor treatment and increase compliance in PWE. This experience may be of value for other resource-poor settings.

Cost analysis of large-scale implementation of the 'Helping Babies Breathe' newborn resuscitation-training program in Tanzania.

BACKGROUND: Helping Babies Breathe (HBB) has become the gold standard globally for training birth-attendants in neonatal resuscitation in low-resource settings in efforts to reduce early newborn asphyxia and mortality. The purpose of this study was to do a first-ever activity-based cost-analysis of at-scale HBB program implementation and initial follow-up in a large region of Tanzania and evaluate costs of national scale-up as one component of a multi-method external evaluation of the implementation of HBB at scale in Tanzania. METHODS: We used activity-based costing to examine budget expense data during the two-month implementation and follow-up of HBB in one of the target regions. Activity-cost centers included administrative, initial training (including resuscitation equipment), and follow-up training expenses. Sensitivity analysis was utilized to project cost scenarios incurred to achieve countrywide expansion of the program across all mainland regions of Tanzania and to model costs of program maintenance over one and five years following initiation. RESULTS: Total costs for the Mbeya Region were $202,240, with the highest proportion due to initial training and equipment (45.2%), followed by central program administration (37.2%), and follow-up visits (17.6%). Within Mbeya, 49 training sessions were undertaken, involving the training of 1,341 health providers from 336 health facilities in eight districts. To similarly expand the HBB program across the 25 regions of mainland Tanzania, the total economic cost is projected to be around $4,000,000 (around $600 per facility). Following sensitivity analyses, the estimated total for all Tanzania initial rollout lies between $2,934,793 to $4,309,595. In order to maintain the program nationally under the current model, it is estimated it would cost $2,019,115 for a further one year and $5,640,794 for a further five years of ongoing program support. CONCLUSION: HBB implementation is a relatively low-cost intervention with potential for high impact on perinatal mortality in resource-poor settings. It is shown here that nationwide expansion of this program across the range of health provision levels and regions of Tanzania would be feasible. This study provides policymakers and investors with the relevant cost-estimation for national rollout of this potentially neonatal life-saving intervention.

Evaluation of a Portable Haemoglobin Metre Performance in Children with Sickle Cell Disease and Implications for Healthcare in Resource-poor Settings.

BACKGROUND: Sub-Saharan Africa has the largest burden and worst outcome of sickle cell disease (SCD). This gloomy outlook has been attributed to the lack of use of simple and cost-effective measures for diagnosis and treatment of the disease. Although haematology analysers are the gold standard for accurate measurement of haemoglobin (Hb) concentration, they are often out of reach of most health facilities in resource-poor settings, thus creating a care gap. We conducted this study to examine the agreement between a point-of-care device and haematology analyser for determining the Hb concentration in children with SCD and its usefulness in resource-poor settings. METHODS: Ethylenediaminetetraacetic acid blood samples collected from participants were processed to estimate their Hb concentration using two devices (Sysmex KX21N haematology analyser and portable mission Hb device). The agreement between the two sets of measurements was assessed by the Bland and Altman method. RESULTS: The intraclass and concordance correlation coefficients were 0.854 and 0.936, respectively. Sensitivity and specificity were 84.2% and 98.6%, respectively. The positive and negative predictive values were 94.1% and 96.0%, respectively. The Bland and Altman's limit of agreement was -2.3 to 1.6 and the mean difference was -0.34 with non-significant variability between the two measurements (p = 0.949). CONCLUSION: Hb concentration determined by the portable testing system is comparable with that determined by the haematology analyser. We recommend its use as a point-of-care device for determining Hb concentration of SCD children in resource-poor settings where haematology analysers are not available.

Improving antibiotic prescribing for children in the resource-poor setting.

Antibiotics are a critically important part of paediatric medical care in low- and middle-income countries (LMICs), where infectious diseases are the leading cause of child mortality. The World Health Organization estimates that >50% of all medicines are prescribed, dispensed or sold inappropriately and that half of all patients do not take their medicines correctly. Given the rising prevalence of antimicrobial resistance globally, inappropriate antibiotic use is of international concern, and countries struggle to implement basic policies promoting rational antibiotic use. Many barriers to rational paediatric prescribing in LMICs persist. The World Health Organization initiatives, such as 'Make medicines child size', the Model List of Essential Medicines for Children and the Model Formulary for Children, have been significant steps forward. Continued strategies to improve access to appropriate drugs and formulations, in conjunction with improved evidence-based clinical guidelines and dosing recommendations, are essential to the success of such initiatives on both a national and an international level. This paper provides an overview of these issues and considers future developments that may improve LMIC antibiotic prescribing.

Can reproductive health services be used to screen for sexual and gender-based violence in post-conflict Northern Uganda? - a pilot study.

Background: Sexual and gender-based violence (SGBV), including rape and child sexual abuse, remains a significant challenge in post-conflict northern Uganda. Many victims have never sought help. Consequently, the scale of the problem is not known, and SGBV victims' injuries, both psychological and physical, remain hidden and unresolved. Objectives: We aimed to explore whether health workers in rural Reproductive Health Services (RHS), following specific training, could provide a valuable resource for SGBV screening and subsequent referral to targeted services. Methods: Our project had three elements. First, RHS workers were trained to use a questionnaire to screen subjects for past SGBV Second, the screening questionnaire was used by RHS workers over a 3-month period, and the data collected were analysed to explore whether the screening approach was an effective one in this setting, and to record the scale and nature of the problem. Third, victims detected were offered referral as appropriate to hospital services or to a dedicated SGBV ActionAid shelter. Results: Of 1656 women screened, 778 (47%) had suffered SGBV: 123 rape, and 505 non-sexual violence. 1,254 (76%) had been directly or indirectly affected by conflict experiences; 1066 had lived in internally displaced persons camps. 145 (9%) requested referral to Gulu SGBV Shelter; 25 attended the shelter and received assistance, and 20 others received telephone counselling. Conclusion: Undetected SGBV remains a significant problem in post-conflict northern Uganda. RHS workers, following specific training, can effectively screen for and identify otherwise unrecognised survivors of SGBV. This matters because without ongoing detection, survivors have no opportunity for resolution, healing or help.

Amitriptyline overdose-an uncommon cause of acute transient exotropia presenting to the emergency setting: a case report.

BACKGROUND: Acute presentations of acquired exotropia or divergent alignment of either or both eyes are commonly observed following intracranial vascular events, trauma, orbital, and endoscopic sinus surgeries. CASE PRESENTATION: The reported case is about a 16-year-old previously healthy Tamil female who presented to the emergency department with a few hours of reduced responsiveness. With the only clue in the history being about a family conflict the previous day, the examination revealed a noticeable exotropia along with a constellation of anticholinergic findings: a low Glasgow Coma Score, mydriasis, tachycardia, floppy limbs, exaggerated reflexes, and a palpable urinary bladder. Amitriptyline overdose leading to significant neurological involvement was suspected, and she was immediately offered urine alkalinization. Resources for urine and blood toxicological studies were not available. The patient gained consciousness 24 hours later and confirmed an overdose of ten amitriptyline tablets. Exotropia, a unique manifestation of this patient's neurotoxicity, spontaneously resolved in 36 hours. DISCUSSION AND CONCLUSIONS: The reported case is about an uncommon clinical finding of exotropia seen in a common toxicological emergency: acute amitriptyline overdose. The importance of having a wide knowledge of various clinical presentations of drug toxicities is highlighted here, as any delay in diagnosis or initiation of life-saving measures could have resulted in fatal consequences.

Successful management of oesophageal atresia in Cameroon, Sub-Saharan Africa.

Background: Oesophageal atresia (EA) is the most common congenital anomaly of the oesophagus. Despite improvement of survival observed over the previous two decades in developed countries, the mortality remains very high and the management greatly challenging in resource-poor settings such as Cameroon. We report our experience of management of EA in this environment, with a successful outcome. Materials and Methods: We prospectively assessed patients diagnosed with EA and operated in January 2019, at the University Hospital Centre of Yaounde. Records were reviewed for demographics, history and physical examinations, radiological findings, surgical procedures and outcomes. The study has received approval from the Institutional Ethics Committees. Results: In total, six patients (three males and three females, sex ratio, 0.5; mean age at diagnosis, 3.6 days; range, 1-7 days) were assessed. A past history of polyhydramnios was found in one patient (16.7%). All patients were classified Waterston Group A at diagnosis, with Ladd-Swenson type III atresia. Early primary repair was performed in four patients (66.7%) and delayed primary repair in two patients (33.3%). Operative repair mainly involved resection of the fistula, suture of trachea and oesophagus end-to-end anastomosis, followed by interposition of vascularised pleural flap. Patients were followed up 24 months. With one late death, the survival rate was 83.3%. Conclusion: Improvement has been achieved in the outcomes of neonatal surgery in Africa in the past two decades, but EA-related mortality remains relatively too high. Using simple techniques and available, reproducible equipment can improve survival in resource-poor settings.

UNVEILING THE REALITIES OF ANAL MELANOMA CARE IN A RESOURCE-CONSTRAINED SETTING.

A 50-year-old lady presented with complaints of a progressively increasing anal mass and occasional bleeding per rectum for the past 4 months. Examination revealed an ulcero-proliferative growth in the anal canal, whose biopsy was suggestive of malignant melanoma. Inguinal lymph nodes, though enlarged, did not show evidence of malignant deposits on FNAC. Radiological investigations revealed a T3 lesion with no evidence of nodal metastasis. She underwent local excision of the mass with uneventful intraoperative and postoperative periods. The purpose of this report is to highlight the formidable challenges encountered in diagnosing this rare tumour, with potential implications for misdiagnosis, particularly within a resource-poor setting. This case highlights the importance of resource-appropriate approaches and surgical options available in a tertiary care hospital in North India.

Management of unexpected placenta accreta spectrum cases in resource-poor settings.

BACKGROUND: On a global scale, cases of placenta accreta spectrum are often just identified during cesarean delivery because they are missed during antenatal care screening. Routine operating teams not trained in the management of placenta accreta spectrum are faced with difficult surgical situations and have to make decisions that may define the clinical outcomes. Although there are general recommendations for the intraoperative management of placenta accreta spectrum, no studies have described the clinical reality of unexpected placenta accreta spectrum cases in resource-poor settings. OBJECTIVE: This study aimed to describe the maternal outcomes of previously undiagnosed placenta accreta spectrum managed in resource-poor settings in Colombia and Indonesia. STUDY DESIGN: This was a retrospective case series of women with histologically confirmed placenta accreta spectrum treated in 2 placenta accreta spectrum centers after referral from remote resource-poor hospitals. Clinical outcomes were analyzed according to the initial type of management: (1) no cesarean delivery; (2) placenta left in situ after cesarean delivery; (3) partial removal of the placenta after cesarean delivery; and (4) post-cesarean hysterectomy. In addition, we evaluated the use of telemedicine by comparing the outcomes of women in hospitals that used the support of the placenta accreta spectrum center during the initial surgery. RESULTS: A total of 29 women who were initially managed in Colombia (n=2) and Indonesia (n=27) were included. The lowest volume of blood loss and the lowest frequency of complications were in women who underwent deferred cesarean delivery (n=5; 17.2%) and in those who had a delayed placental delivery (n=5; 20.7%). Five maternal deaths (14%) occurred in the group that did not receive telehelp, and 4 women died of irreversible shock because of uncontrolled bleeding. CONCLUSION: Previously undiagnosed placenta accreta spectrum in resource-poor hospitals was associated with a high risk of maternal mortality. Open-close abdominal surgery or leaving the placenta in situ seem to be the best choices for unexpected placenta accreta spectrum management in resource-poor settings. Telemedicine with a placenta accreta spectrum center may improve prognosis.

Percutaneous catheter drainage of a pyogenic lung abscess: A case report.

Pyogenic lung abscesses represent a pathological entity with a high mortality rate if left untreated. Most patients respond well to intravenous antibiotics. Following the failure of conservative measures, invasive measures such as open-surgical procedures are required. Minimally-invasive options such as percutaneous catheter drainage of parenchymal lung abscesses, mainly if the respiratory reserve is limited or where the baseline functional status is poor, are also considered viable options. Pyogenic lung abscesses are necrotic cavitary lesions of the lung parenchyma and are often considered to be in the spectrum of anaerobic pleuropulmonary diseases. In this case report, we report on a 33-year-old female who presented with a 3-week history of cough, increasing breathlessness and right-sided pleurisy. She was diagnosed with pyogenic lung abscess and started on intravenous antibiotics. The abscess was drained using a pigtail catheter guided with a bedside ultrasonography.

Outcome of Delayed Administration of Alteplase in a Resource-Poor Area: A Case Report.

An acute ischemic stroke, though carrying the risk of debilitating complications, is a preventable and treatable disease. Thrombolysis and endovascular thrombectomy are important components of its management. However, various challenges in resource-poor countries like Nigeria and other developing nations pose a great limitation in the timely intervention of ischemic stroke treatment. The challenges include late presentation, poor awareness of stroke symptoms even among health care workers, poor ambulance service/transportation network, intra-hospital delay, particularly in neuroimaging, and the unavailability of tissue plasminogen activator (alteplase/tenecteplase). We report a 32-year-old African man with an antecedent history of suspected migraine headaches with aura and a family history of hypertension and stroke, admitted 7½ hours after onset of stroke symptoms, scoring 13 on the National Institutes of Health Stroke Scale (NIHSS) with Medical Research Council (MRC) muscle power grades 1 and 3 on the right upper and lower extremities, respectively. Urgent non-contrast brain CT revealed only a hyperdense sign in the left middle cerebral artery (MCA). Intravenous tissue plasminogen activator (tPA) was administered at a lower dose of 0.6 mg/kg, 15½ hours after symptom onset, and a CT angiogram done 24 hours post-thrombolysis showed partial recanalization of the M1 segment of the MCA and intermediate collateral supply (Alberta stroke program early CT {ASPECT} score: 6). By the third day of admission, he had made a significant clinical improvement and was discharged home able to walk unsupported on the fourth day.

Initial Immunomodulation and Outcome of Children with Multisystem Inflammatory Syndrome Related to COVID-19: A Multisite Study from India.

OBJECTIVE: To determine the outcomes in children with MIS-C receiving different immunomodulatory treatment. METHODS: In this multicentric, retrospective cohort study, data regarding treatment and outcomes of children meeting the WHO case definition for MIS-C, were collected. The primary composite outcome was the requirement of vasoactive/inotropic support on day 2 or beyond or need of mechanical ventilation on day 2 or beyond after initiation of immunomodulatory treatment or death during hospitalization in the treatment groups. Logistic regression and propensity score matching analyses were used to compare the outcomes in different treatment arms based on the initial immunomodulation, i.e., IVIG alone, IVIG plus steroids, and steroids alone. RESULTS: The data of 368 children (diagnosed between April 2020 and June 2021) meeting the WHO case definition for MIS-C, were analyzed. Of the 368 subjects, 28 received IVIG alone, 82 received steroids alone, 237 received IVIG and steroids, and 21 did not receive any immunomodulation. One hundred fifty-six (42.39%) children had the primary outcome. On logistic regression analysis, the treatment group was not associated with the primary outcome; only the children with shock at diagnosis had higher odds for the occurrence of the outcome [OR (95% CI): 11.4 (5.19-25.0), p < 0.001]. On propensity score matching analysis, the primary outcome was comparable in steroid (n = 45), and IVIG plus steroid (n = 84) groups (p = 0.515). CONCLUSION: While no significant difference was observed in the frequency of occurrence of the primary outcome in different treatment groups, data from adequately powered RCTs are required for definitive recommendations.

The Variation in Outcomes of Septic Patients: A Dual-Centre Comparative Study.

Introduction Despite significant advances in the field of medicine, sepsis is constantly growing as a major public health concern. The global epidemic of sepsis imposes a significant economic burden on healthcare systems world-over. Furthermore, its high prevalence in society is inevitably paralleled by an excessive mortality rate, with approximately six million deaths reported every year. The primary aim of this study was to evaluate and compare, the management of acutely septic patients against outcomes in a tertiary teaching institution in Pakistan versus a similar one in the United Kingdom. Methods This study was a dual-centred, retrospective comparative analysis comparing all patients admitted through the emergency department at the respective tertiary centres. Patient details were collected and compared across the two sites to evaluate the effect of individual characteristics on prognosis. The outcomes of these presentations were analysed by comparing rates of in-hospital mortality, admission to the ICU or discharge. Results The total number of patients identified as having sepsis was 60 in the Pakistan cohort, and 92 in the Aberdeen cohort. No significant difference was found when comparing genders, and the results of basic observations were largely similar at presentation. Twenty-five per cent (25%) (n=38) of the total study population were deemed to have a poor outcome at 3 days, but 50% of the Pakistan cohort was deemed to have a poor outcome. Conclusion Managing sepsis has developed significantly in recent years, but most of this development was implemented in high-income countries. There was a significant delay in time to resuscitate septic patients in Pakistan, with significantly raised three-day morbidity and mortality. There is a need for further comparative studies of the management of sepsis in Pakistan and other low-income countries to identify the problems and tackle obstacles on every level of the healthcare system.

Advanced-stage Wilms tumor arising in a horseshoe kidney of a 9-year-old child: a case report.

BACKGROUND: Horseshoe kidney (HK) is one of the most common renal fusion abnormalities, with an incidence of 1:400 in the normal population. However, Wilms tumor (WT) arising in an HK is a rare occurrence. We report the case of a 9-year-old boy who presented with an advanced WT in an HK and also highlight the management challenges in a resource-poor setting such as ours. CASE PRESENTATION: The patient was a 9-year-old Nigerian boy presented to the Pediatrics Outpatient Clinic of the University of Maiduguri Teaching Hospital (UMTH) with a history of progressive abdominal swelling, weight loss, abdominal pain, and cough. Abdominal examination revealed an irregular, firm, and non-tender mass in the right lumbar region. A computed tomography (CT) scan of the abdomen showed a heterogeneously dense mass that was predominantly to the right side of the abdomen and crossed the midline to the left side, where it continued with the relatively normal renal tissue. Chest CT revealed pulmonary metastases. A diagnosis of WT in an HK was made. The patient had a 6-week course of neoadjuvant chemotherapy, and a right nephrectomy and left partial nephrectomy was performed. The final histologic diagnosis of WT was made. Radiotherapy was intended but was not available in our facility, and the parents could not afford referral to another center. CONCLUSIONS: Children with a clinically suspected HK with WT should undergo a careful imaging evaluation such as CT before any surgical intervention. Neoadjuvant chemotherapy to reduce tumor bulk might be a good treatment method to reduce surgical morbidity and aid in complete excision and potential for preserving renal function.

Basic gait pattern and impact of fall risk factors on gait among older adults in India.

BACKGROUND: An unstable gait pattern is an indicator of an increased risk of falls among older adults. Data on basic gait parameters is useful in the early identification of gait impairment. However, reference gait measurements are not available in low- and middle-income countries. RESEARCH QUESTION: What are the normative reference values of gait parameters and do fall risk factors such as impaired balance, functional difficulty, and multimorbidity affect the gait patterns of older adults in India? METHODS: A cross-sectional data of 659 older adults were collected using a semi-structured schedule. Gait parameters were measured using wearable sensors. Descriptive statistics, independent t-test, and one-way ANCOVA were used to determine the significant difference (p < 0.05) in gait parameters across the risk factors. RESULTS: A mean stride length of 123.00 ±â€¯15.19 cm, stride velocity of 110.57 ±â€¯17.57 cm/s, and a cadence of 106.14 ±â€¯11.44 steps/minute were reported in the study. Functional difficulties and balance impairment were the two major risk factors that affected stride velocity, stride length, and cadence after adjusting for age and height. No difference in gait parameters was observed among participants with and without multimorbidity. SIGNIFICANCE: This study provides a baseline or reference values of various gait parameters measured on a large sample of population aged 60 and above from India. Assessment of gait patterns and associated risk factors in a clinical setup will help identify the older adults at risk of falls and reduce the enormous burden of fall injuries. Since gait parameters show a large variation across geographical regions, it is important to have region-specific reference values.

Behavioral Problems, Quality of Life and Caregiver Burden in Children with Idiopathic Nephrotic Syndrome: Improving Outcomes by Pragmatic Interventions in a Resource-Poor Setting.

A cross-sectional questionnaire-based study was conducted on 38 children with idiopathic nephrotic syndrome. The prevalence and pattern of behavioral abnormalities was studied. Except in the conduct domain, the prevalence of behavioral problems was comparable with controls. Severe complications of disease and adverse drug effects were significantly associated with abnormal behavior. The Quality of life (QOL) of these children and their caregivers was assessed. It appeared to be unaffected by illness. Additional findings were high maternal literacy, no disruption of schooling, regular follow-up and good adherence to treatment. Behavioral problems in childhood nephrotic syndrome can be minimized by regular follow-up and supportive interventions to reduce caregiver burden. Such children and their caregivers can do well in terms of QOL, even in a resource-poor setting, with appropriate psycho-social support.

Parasitic Infections in Children with Disability in Resource Poor Settings: The Research Gaps.

The burden of parasitic infections among children with disability in resource-poor settings has not been summarised through a focused review. Here, we have summarised the key studies reporting the burden of parasitic infections among children without and with a disability. In most instances, among children without disability, Giardia or soil-transmitted helminths dominate the epidemiology, while among disabled individuals, enteric protozoa are the predominant parasites to be reported in both resource-rich and resource-poor countries. Cryptosporidium is generally the leading protozoan to be detected among these populations but all other parasites have been detected in varying frequencies. There is a paucity of data on the precise epidemiology of parasitic infections in children with disability. A large-scale epidemiological study, using modern genomic methodology, is a research priority.