Pneumonia is the leading cause of death of children. Diagnostic tools include chest radiography, but guidelines do not currently recommend the use of lung ultrasound (LUS) as a diagnostic method. We ...conducted a meta-analysis to summarize evidence on the diagnostic accuracy of LUS for childhood pneumonia.
We performed a systematic search in PubMed, Embase, the Cochrane Library, Scopus, Global Health, World Health Organization-Libraries, and Latin American and Caribbean Health Sciences Literature of studies comparing LUS diagnostic accuracy against a reference standard. We used a combination of controlled key words for age <18 years, pneumonia, and ultrasound. We identified 1475 studies and selected 15 (1%) for further review. Eight studies (765 children) were retrieved for analysis, of which 6 (75%) were conducted in the general pediatric population and 2 (25%) in neonates. Eligible studies provided information to calculate sensitivity, specificity, and positive and negative likelihood ratios. Heterogeneity was assessed by using Q and I(2) statistics.
Five studies (63%) reported using highly skilled sonographers. Overall methodologic quality was high, but heterogeneity was observed across studies. LUS had a sensitivity of 96% (95% confidence interval CI: 94%-97%) and specificity of 93% (95% CI: 90%-96%), and positive and negative likelihood ratios were 15.3 (95% CI: 6.6-35.3) and 0.06 (95% CI: 0.03-0.11), respectively. The area under the receiver operating characteristic curve was 0.98. Limitations included the following: most studies included in our analysis had a low number of patients, and the number of eligible studies was also small.
Current evidence supports LUS as an imaging alternative for the diagnosis of childhood pneumonia. Recommendations to train pediatricians on LUS for diagnosis of pneumonia may have important implications in different clinical settings.
High concentrations of household air pollution (HAP) due to biomass fuel usage with unvented, insufficient combustion devices are thought to be an important health risk factor in South Asia ...population. To better characterize the indoor concentrations of particulate matter (PM2.5) and carbon monoxide (CO), and to understand their impact on health in rural southern Nepal, this study analyzed daily monitoring data collected with DataRAM pDR-1000 and LASCAR CO data logger in 2980 households using traditional biomass cookstove indoor through the Nepal Cookstove Intervention Trial-Phase I between March 2010 and October 2011. Daily average PM2.5 and CO concentrations collected in area near stove were 1,376 (95% CI, 1,331-1,423) μg/m3 and 10.9 (10.5-11.3) parts per million (ppm) among households with traditional cookstoves. The 95th percentile, hours above 100μg/m3 for PM2.5 or 6ppm for CO, and hours above 1000μg/m3 for PM2.5 or 9ppm for CO were also reported. An algorithm was developed to differentiate stove-influenced (SI) periods from non-stove-influenced (non-SI) periods in monitoring data. Average stove-influenced concentrations were 3,469 (3,350-3,588) μg/m3 for PM2.5 and 21.8 (21.1-22.6) ppm for CO. Dry season significantly increased PM2.5 concentration in all metrics; wood was the cleanest fuel for PM2.5 and CO, while adding dung into the fuel increased concentrations of both pollutants. For studies in rural southern Nepal, CO concentration is not a viable surrogate for PM2.5 concentrations based on the low correlation between these measures. In sum, this study filled a gap in knowledge on HAP in rural Nepal using traditional cookstoves and revealed very high concentrations in these households.
Summary Background Influenza immunisation during pregnancy is recommended but not widely implemented in some low-income regions. We assessed the safety and efficacy in mothers and infants of ...year-round maternal influenza immunisation in Nepal, where influenza viruses circulate throughout the year. Methods In this phase 4, randomised, placebo-controlled trial, we enrolled two consecutive sequential annual cohorts of pregnant women from the Sarlahi district in southern Nepal. We randomised mothers 1:1 to receive seasonally recommended trivalent inactivated influenza vaccine or saline placebo in blocks of eight, stratified by gestational age at enrolment (17–25 weeks vs 26–34 weeks). Women were eligible if they were married, 15–40 years of age, 17–34 weeks' gestation at enrolment, and had not previously received any influenza vaccine that season. We collected serum samples before and after immunisation, and cord blood from a subset of women and infants. Staff masked to allocation made home visits every week from enrolment to 6 months after delivery. Midnasal swabs for respiratory virus PCR testing were collected during maternal acute febrile respiratory infections, and from infants with any respiratory symptom. We assessed vaccine immunogenicity, safety, and three primary outcomes: the incidence of maternal influenza-like illness in pregnancy and 0–180 days postpartum, the incidence of low birthweight (<2500 g), and the incidence of laboratory-confirmed infant influenza disease from 0 to 180 days. This trial is registered with ClinicalTrials.gov , number NCT01034254. Findings From April 25, 2011, to Sept 9, 2013, we enrolled 3693 women in two cohorts of 2090 (1041 assigned to placebo and 1049 to vaccine) and 1603 (805 assigned to placebo and 798 to vaccine), with 3646 liveborn infants (cohort 1, 999 in placebo group and 1010 in vaccine group; cohort 2, 805 in placebo group and 798 in vaccine group). Immunisation reduced maternal febrile influenza-like illness with an overall efficacy of 19% (95% CI 1 to 34) in the combined cohorts; 9% efficacy (−16 to 29) in the first cohort, and 36% efficacy (9 to 55) in the second cohort. For laboratory-confirmed influenza infections in infants aged 0–6 months, immunisation had an overall efficacy for the combined cohorts of 30% (95% CI 5 to 48); in the first cohort, the efficacy was 16% (−19 to 41), and in the second cohort it was 60% (26 to 88). Maternal immunisation reduced the rates of low birthweight by 15% (95% CI 3–25) in both cohorts combined. The rate of small for gestational age infants was not modified by immunisation. The number of adverse events was similar regardless of immunisation status. Miscarriage occurred in three (0·2%) participants in the placebo group versus five (0·3%) in the vaccine group, stillbirth occurred in 31 (1·7%) versus 33 (1·8%), and congenital defects occurred in 18 (1·0%) versus 20 (1·1%). Five women died in the placebo group and three died in the vaccine group. The number of infant deaths at age 0–6 months was similar in each group (50 in the placebo group and 61 in the vaccine group). No serious adverse events were associated with receipt of immunisation. Interpretation Year-round maternal influenza immunisation significantly reduced maternal influenza-like illness, influenza in infants, and low birthweight over the entire course of the study, indicating the strategy could be useful in subtropical regions. Funding Bill & Melinda Gates Foundation.
Endophthalmitis is a rare but sight-threatening infection after cataract surgery. Roughly one third of eyes remain blind after treatment. We report United States population-based data on ...microbiological investigations and treatment patterns plus risk factors for poor outcomes.
Retrospective cohort study.
Medicare beneficiaries from 5 states in whom endophthalmitis developed within 6 weeks after cataract surgery in 2003 and 2004.
We identified endophthalmitis cases occurring after cataract surgery using Medicare billing claims. We contacted treating physicians and requested they complete a questionnaire on clinical and microbiological data and submit relevant medical records. Two independent observers reviewed materials to confirm that cases met a standardized definition.
Positive culture results, vitrectomy status, microbiology spectrum, and final visual acuity.
In total, 615 cases met our case definition. Initial visual acuity was counting fingers or worse for 72%. Among 502 cases with known culture results, 291 (58%) had culture positive results. Twelve percent had positive results for streptococci. More than 99% of cases were treated with intravitreal vancomycin. Vitrectomy was performed in 279 cases (45%), including 201 cases with initial acuity better than light perception. Rates of vitrectomy varied across states, with California having the highest rate and Michigan having the lowest (56% and 19% of cases, respectively). Overall, 43% of individuals achieved visual acuity of 20/40 or better. Poor initial acuity (adjusted odds ratio OR, 1.08; 95% confidence interval CI, 1.04-1.12 per 0.10 logarithm of the minimum angle of resolution units), older age at diagnosis (OR, 1.22; 95% CI, 1.03-1.45 per 5-year increase), and more virulent organisms were important predictors of poor final visual acuity. Cases with streptococci infection were 10 times more likely to have poor final acuity than coagulase-negative staphylococci cases (adjusted OR, 11.28; 95% CI, 3.63-35.03). Vitrectomy was not predictive of final visual acuity (adjusted OR, 1.26; 95% CI, 0.78-2.04).
Population-based data on the microbiology of acute postoperative endophthalmitis in the United States after cataract surgery are consistent with prior reports. Vitrectomy usage is higher than that recommended from the Endophthalmitis Vitrectomy Study, with no evidence of increased benefit.
Summary Rationale The standardized use of a stethoscope for chest auscultation in clinical research is limited by its inherent inter-listener variability. Electronic auscultation and automated ...classification of recorded lung sounds may help prevent some of these shortcomings. Objective We sought to perform a systematic review and meta-analysis of studies implementing computerized lung sound analysis (CLSA) to aid in the detection of abnormal lung sounds for specific respiratory disorders. Methods We searched for articles on CLSA in MEDLINE, EMBASE, Cochrane Library and ISI Web of Knowledge through July 31, 2010. Following qualitative review, we conducted a meta-analysis to estimate the sensitivity and specificity of CLSA for the detection of abnormal lung sounds. Measurements and main results Of 208 articles identified, we selected eight studies for review. Most studies employed either electret microphones or piezoelectric sensors for auscultation, and Fourier Transform and Neural Network algorithms for analysis and automated classification of lung sounds. Overall sensitivity for the detection of wheezes or crackles using CLSA was 80% (95% CI 72–86%) and specificity was 85% (95% CI 78–91%). Conclusions While quality data on CLSA are relatively limited, analysis of existing information suggests that CLSA can provide a relatively high specificity for detecting abnormal lung sounds such as crackles and wheezes. Further research and product development could promote the value of CLSA in research studies or its diagnostic utility in clinical settings.
To determine the age-specific prevalence of strabismus in white and African American children aged 6 through 71 months and of amblyopia in white and African American children aged 30 through 71 ...months.
Cross-sectional, population-based study.
White and African American children aged 6 through 71 months in Baltimore, MD, United States. Among 4132 children identified, 3990 eligible children (97%) were enrolled and 2546 children (62%) were examined.
Parents or guardians of eligible participants underwent an in-home interview and were scheduled for a detailed eye examination, including optotype visual acuity and measurement of ocular deviations. Strabismus was defined as a heterotropia at near or distance fixation. Amblyopia was assessed in those children aged 30 through 71 months who were able to perform optotype testing at 3 meters.
The proportions of children aged 6 through 71 months with strabismus and of children aged 30 through 71 months with amblyopia.
Manifest strabismus was found in 3.3% of white and 2.1% of African American children (relative prevalence RP, 1.61; 95% confidence interval CI, 0.97-2.66). Esotropia and exotropia each accounted for close to half of all strabismus in both groups. Only 1 case of strabismus was found among 84 white children 6 through 11 months of age. Rates were higher in children 60 through 71 months of age (5.8% for whites and 2.9% for African Americans RP, 2.05; 95% CI, 0.79-5.27). Amblyopia was present in 12 (1.8%) white and 7 (0.8%) African American children (RP, 2.23; 95% CI, 0.88-5.62). Only 1 child had bilateral amblyopia.
Manifest strabismus affected 1 in 30 white and 1 in 47 African American preschool-aged children. The prevalence of amblyopia was <2% in both whites and African Americans. National population projections suggest that there are approximately 677,000 cases of manifest strabismus among children 6 through 71 months of age and 271 000 cases of amblyopia among children 30 through 71 months of age in the United States.
To determine the age-specific prevalence of refractive errors in white and African-American preschool children.
The Baltimore Pediatric Eye Disease Study is a population-based evaluation of the ...prevalence of ocular disorders in children aged 6 to 71 months in Baltimore, Maryland.
Among 4132 children identified, 3990 eligible children (97%) were enrolled and 2546 children (62%) were examined.
Cycloplegic autorefraction was attempted in all children with the use of a Nikon Retinomax K-Plus 2 (Nikon Corporation, Tokyo, Japan). If a reliable autorefraction could not be obtained after 3 attempts, cycloplegic streak retinoscopy was performed.
Mean spherical equivalent (SE) refractive error, astigmatism, and prevalence of higher refractive errors among African-American and white children.
The mean SE of right eyes was +1.49 diopters (D) (standard deviation SD = 1.23) in white children and +0.71 D (SD = 1.35) in African-American children (mean difference of 0.78 D; 95% confidence interval CI, 0.67-0.89). Mean SE refractive error did not decline with age in either group. The prevalence of myopia of 1.00 D or more in the eye with the lesser refractive error was 0.7% in white children and 5.5% in African-American children (relative risk RR, 8.01; 95% CI, 3.70-17.35). The prevalence of hyperopia of +3 D or more in the eye with the lesser refractive error was 8.9% in white children and 4.4% in African-American children (RR, 0.49; 95% CI, 0.35-0.68). The prevalence of emmetropia (<-1.00 D to <+1.00 D) was 35.6% in white children and 58.0% in African-American children (RR, 1.64; 95% CI, 1.49-1.80). On the basis of published prescribing guidelines, 5.1% of the children would have benefited from spectacle correction. However, only 1.3% had been prescribed correction.
Significant refractive errors are uncommon in this population of urban preschool children. There was no evidence for a myopic shift over this age range in this cross-sectional study. A small proportion of preschool children would likely benefit from refractive correction, but few have had this prescribed.
To estimate small for gestational age birth prevalence and attributable neonatal mortality in low and middle income countries with the INTERGROWTH-21
birth weight standard.
Secondary analysis of ...data from the Child Health Epidemiology Reference Group (CHERG), including 14 birth cohorts with gestational age, birth weight, and neonatal follow-up. Small for gestational age was defined as infants weighing less than the 10th centile birth weight for gestational age and sex with the multiethnic, INTERGROWTH-21
birth weight standard. Prevalence of small for gestational age and neonatal mortality risk ratios were calculated and pooled among these datasets at the regional level. With available national level data, prevalence of small for gestational age and population attributable fractions of neonatal mortality attributable to small for gestational age were estimated.
CHERG birth cohorts from 14 population based sites in low and middle income countries.
In low and middle income countries in the year 2012, the number and proportion of infants born small for gestational age; number and proportion of neonatal deaths attributable to small for gestational age; the number and proportion of neonatal deaths that could be prevented by reducing the prevalence of small for gestational age to 10%.
In 2012, an estimated 23.3 million infants (uncertainty range 17.6 to 31.9; 19.3% of live births) were born small for gestational age in low and middle income countries. Among these, 11.2 million (0.8 to 15.8) were term and not low birth weight (≥2500 g), 10.7 million (7.6 to 15.0) were term and low birth weight (<2500 g) and 1.5 million (0.9 to 2.6) were preterm. In low and middle income countries, an estimated 606 500 (495 000 to 773 000) neonatal deaths were attributable to infants born small for gestational age, 21.9% of all neonatal deaths. The largest burden was in South Asia, where the prevalence was the highest (34%); about 26% of neonatal deaths were attributable to infants born small for gestational age. Reduction of the prevalence of small for gestational age from 19.3% to 10.0% in these countries could reduce neonatal deaths by 9.2% (254 600 neonatal deaths; 164 800 to 449 700).
In low and middle income countries, about one in five infants are born small for gestational age, and one in four neonatal deaths are among such infants. Increased efforts are required to improve the quality of care for and survival of these high risk infants in low and middle income countries.
Introduction Estimates for cause-specific mortality for neonates are generally available for all countries for neonates overall (0 to 28 days). However, cause-specific mortality is generally not ...being estimated at higher age resolution for neonates, despite evidence of heterogeneity in the causes of deaths during this period. We aimed to use the adapted log quadratic model in a setting where verbal autopsy was the primary means of determining cause of death. Methods We examined the timing and causes of death among a cohort of neonates in rural Nepal followed as part of the Nepal Oil Massage Study (NOMS). We adapted methods defined by Wilmoth et al (2012) and Guillot et al. (2022) to estimate age and cause-specific mortality among neonates. We used cross validation to estimate the accuracy of this model, holding out each three month period. We took the average cross validation across hold out as our measure of model performance and compared to a standard approach which did not account for the heterogeneity in cause-specific mortality rate within this age group. Results There were 957 neonates in the NOMS cohort with known age and cause of death. We estimated an average cross-validation error of 0.9 per 1000 live births for mortality due to prematurity in the first week, and 1.1 for mortality due to birth asphyxia, compared to the standard approach, having error 7.4 and 7.8 per 1000 live births, respectively. Generally mortality rates for less common causes such as congenital malformations and pneumonia were estimated with higher cross-validation error. Conclusions The stability and precision of these estimates compare favorably with similar estimates developed with higher quality cause-specific mortality surveillance from China, demonstrating that reliably estimating causes of mortality at high resolution is possible for neonates in low resources areas.
Objectives To estimate small for gestational age birth prevalence and attributable neonatal mortality in low and middle income countries with the INTERGROWTH-21st birth weight ...standard.Design Secondary analysis of data from the Child Health Epidemiology Reference Group (CHERG), including 14 birth cohorts with gestational age, birth weight, and neonatal follow-up. Small for gestational age was defined as infants weighing less than the 10th centile birth weight for gestational age and sex with the multiethnic, INTERGROWTH-21st birth weight standard. Prevalence of small for gestational age and neonatal mortality risk ratios were calculated and pooled among these datasets at the regional level. With available national level data, prevalence of small for gestational age and population attributable fractions of neonatal mortality attributable to small for gestational age were estimated.Setting CHERG birth cohorts from 14 population based sites in low and middle income countries.Main outcome measures In low and middle income countries in the year 2012, the number and proportion of infants born small for gestational age; number and proportion of neonatal deaths attributable to small for gestational age; the number and proportion of neonatal deaths that could be prevented by reducing the prevalence of small for gestational age to 10%.Results In 2012, an estimated 23.3 million infants (uncertainty range 17.6 to 31.9; 19.3% of live births) were born small for gestational age in low and middle income countries. Among these, 11.2 million (0.8 to 15.8) were term and not low birth weight (≥2500 g), 10.7 million (7.6 to 15.0) were term and low birth weight (<2500 g) and 1.5 million (0.9 to 2.6) were preterm. In low and middle income countries, an estimated 606 500 (495 000 to 773 000) neonatal deaths were attributable to infants born small for gestational age, 21.9% of all neonatal deaths. The largest burden was in South Asia, where the prevalence was the highest (34%); about 26% of neonatal deaths were attributable to infants born small for gestational age. Reduction of the prevalence of small for gestational age from 19.3% to 10.0% in these countries could reduce neonatal deaths by 9.2% (254 600 neonatal deaths; 164 800 to 449 700).Conclusions In low and middle income countries, about one in five infants are born small for gestational age, and one in four neonatal deaths are among such infants. Increased efforts are required to improve the quality of care for and survival of these high risk infants in low and middle income countries
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