Introduction:
Two of the most common and life-threatening non-communicable diseases (NCD) among children in Nigeria are malnutrition and sickle cell anemia (SCA). SCA is one of the most common ...monogenic disorders, with an annual 305,000 births worldwide, 150,000 births in Nigeria, as compared to 1,700 births in the United States. Severe acute malnutrition is a previously unrecognized epidemic in children with SCA living in Sub-Saharan Africa, the impact of which usually falls on children under the age of five. Previous studies have reported poor growth and delayed maturation in children with SCA when compared to children without SCA, due to increased resting metabolic rate (proposed mechanism includes; decreased intake, hypermetabolism, increased hemolysis, red cell turnover and cardiac demand) and poor nutritional intake. The World Health Organization (WHO), UNICEF and World Bank have not established standards of care for children with severe acute malnutrition above 5 years of age. Additionally, these organizations have not acknowledged that children with SCA could be at risk for severe acute malnutrition. A recent study in Nigeria conducted in children with SCA, using the WHO-growth standards, demonstrated a high prevalence of wasting and severe wasting, as well as, stunting and severe stunting, 22.7% and 11.6%, respectively. However, WHO expected normal ranges for height and weight describes the growth of healthy children, not children with SCA. In a multi-institution cross-sectional study, we tested the hypothesis that severe acute malnutrition is more prevalent in older children (5 to 12 years old) with SCA in Nigeria when compared to an age-matched multi-institutional pediatric cohort of SCA from high-income countries.
Methods:
The study population in Nigeria included children with SCA between 5 to 12 years old, who were being screened for eligibility for National Institute of Health (NIH)-funded randomized controlled trial; the Primary Prevention of Stroke in Children with SCD in Sub-Saharan Africa (SPRING trial), from July 2016 to July 2017. The study population in the high-income countries (the U.S. and U.K), the comparison group, included children enrolled in the Sickle Cell Anemia Sleep and Asthma Cohort (SAC). Height, weight, age and sex were used to calculate body mass index (BMI). Anthropometric indices included weight-for-age and height-for-age, BMI-for-age, and were expressed as Z-scores to assess the nutritional status. The following definitions were used; underweight; weight-for-age Z-score below −2, stunting; height-for-age Z-score below −2, wasting; weight-for-height or BMI-for-age Z-score below −2. Severe acute malnutrition was defined as a very low BMI Z-score of below -3. These values were set from the median values of the WHO international growth reference.
Result:
A total of 803 in the Nigerian cohort and 153 children in the high-income countries cohort with SCA were included in the study. The median age in the Nigerian and in the high-income countries cohort was 8.2 and 10 years (range 4.9-13.8), respectively, and half were male (49.6 and 51.3%). The mean BMI in the Nigerian cohort was significantly lower when compared to high-income countries (13.7 versus 16.9 kg/m2 (p<0.001) Figure I.
Of the 803 children in the Nigerian cohort, 34.2% were underweight, 36% had height-for-age below 2, and 42.6% had BMI-for-age Z-score below −2. A total of 20% in the Nigerian cohort met the criteria of severe acute malnutrition compared to 0.7% in the cohort in high-income countries (p <0.001) Baseline characteristics and Nutritional Status are summarized in Table I.
Conclusion:
We demonstrate a significant unrecognized challenge of severe acute malnutrition among older children with SCA living in Nigeria, when compared to children with SCA living in high-income countries. Severe acute malnutrition is a devastating co-morbidity in children with SCA in northern Nigeria and perhaps in other regions of Africa. Future studies are needed to elucidate the public health impact, morbidity and mortality of severe acute malnutrition in this population. Currently no formal evidence-based strategies are available to treat severe acute malnutrition in children with SCA, but are greatly needed to decrease morbidity and even potentially mortality.
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Rodeghier:Rodeghier consultants: Consultancy.
The mathematical method used to calculate chest compression (CC) rate during cardiopulmonary resuscitation varies in the literature and across device manufacturers. The objective of this study was to ...determine the variability in calculated CC rates by applying four published methods to the same dataset.
This study was a secondary investigation of the first 200 pediatric cardiac arrest events with invasive arterial line waveform data in the ICU-RESUScitation Project (NCT02837497). Instantaneous CC rates were calculated during periods of uninterrupted CCs. The defined minimum interruption length affects rate calculation (e.g., if an interruption is defined as a break in CCs ≥ 2 s, the lowest possible calculated rate is 30 CCs/min). Average rates were calculated by four methods: 1) rate with an interruption defined as ≥ 1 s; 2) interruption ≥ 2 s; 3) interruption ≥ 3 s; 4) method #3 excluding top and bottom quartiles of calculated rates. American Heart Association Guideline-compliant rate was defined as 100–120 CCs/min. A clinically important change was defined as ±5 CCs/min. The percentage of events and epochs (30 s periods) that changed Guideline-compliant status was calculated.
Across calculation methods, mean CC rates (118.7–119.5/min) were similar. Comparing all methods, 14 events (7%) and 114 epochs (6%) changed Guideline-compliant status.
Using four published methods for calculating CC rate, average rates were similar, but 7% of events changed Guideline-compliant status. These data suggest that a uniform calculation method (interruption ≥ 1 s) should be adopted to decrease variability in resuscitation science.
Background: In children with sickle cell anemia (SCA), the routine use of transcranial Doppler (TCD) measurements and regular blood transfusion therapy for those with elevated velocities > 200 ...cm/sec, has dramatically decreased the rate of strokes. However, blood transfusion therapy for primary stroke prevention is not an option for most children in Africa. In preparation for a phase III trial of hydroxyurea therapy (20 mg/kg/day vs 10 mg/kg/day) for primary prevention of strokesin children with SCA in Africa, we conducted a single site, single-arm feasibility trial of hydroxyurea therapy for primary stroke prevention in children with SCA. Participants were between 5 and 12 years of age, attending the pediatric sickle cell disease clinic of Aminu Kano Teaching Hospital, in Kano, Nigeria. The main objectives of the feasibility trial were to determine the acceptability rate of a hydroxyurea therapy trial to families, and to obtain preliminary evidence of hydroxyurea safety in Africa.
Methods:
All eligible participants were screened with TCD, non-imaging technique, to determine increased stroke risk; defined as time-averaged maximum velocity (TAMV) greater than or equal to 200cm/sec in the middle cerebral artery (MCA). Families were offered moderate fixed dose hydroxyurea (~20mg/kg/day) for initially 2 years. Primary outcome measures of acceptability were based on three key components required for phase II randomized controlled trial: recruitment rate, retention rate and adherence to the study medication. To determine the expected background rate of adverse events and serious adverse events in this population, children with TCD velocities less than 200cm/sec who were not on hydroxyurea therapy were enrolled.
Results: A total of 375 families were approached to be screened for elevated TCD measurements, of which 90% (330 of 375) enrolled; 8% (27 of 330) had two consecutive elevated TCD measurements; and 92% (25 of 27) participated in the trial. A total of 210 participants were identified with TCD velocities less than 200 cm, signed informed consents, and agreed to be followed prospectively in a comparison group. The median age for the trial participants and comparison group were 8 and 6.8 years, respectively. No statistically significant difference was observed in age, sex, ethnicity, height and weight of the treatment and comparison groups. The median time on therapy was 2.1 years (range: 0 to 2.8 years), and the average mean cell volume increased from 85 fl at baseline to 101.3 fl at 2 years. As per protocol, all patients were expected to attend monthly research visits and none were missed (n=total 603 visits). No participant in the treatment group dropped voluntarily from the trial, though one participant was withdrawn due to development of progressive renal failure. After follow up visits, participants in the comparison group with subsequent TCD measurements, were given the option to receive hydroxyurea therapy, and the only 2 with elevated TCD values elected to do so. No stroke occurred in the treatment group and 1 stroke occurred in the comparison group. Hospitalization rates in treatment and comparison groups were 35.1 and 48.0 per 100 patient years respectively, (p=0.06). A total of 9 deaths occurred, 1 death in the treatment group, but after participant withdrew from the trial because of progressive renal disease (1.76 per 100 patient-years) and 8 deaths in the comparison group (1·88 per 100 patient-years) p = 0.94. No participants that died received any PCV-13 vaccinations and only 2 received Hib vaccinations. At the time of death, all participants were prescribed malaria prophylaxis, and 8 of 9 participants were prescribed penicillin prophylaxis.
Conclusion:
In Nigeria, participants in SPIN Trial with elevated TCD measurements treated with moderate dose of hydroxyurea, showed high rates of successful recruitment, retention and adherence rates to trial medication. Importantly hydroxyurea therapy did not reveal any evidence of excessive toxicity when compared to those not treated with hydroxyurea. Our results provide strong preliminary evidence supporting the current multi-center randomized controlled trial comparing hydroxyurea therapy (20 mg/kg/day vs 10 mg/kg/day) for preventing primary strokes in children with SCA living in Nigeria (1R01NS094041-01;clinical trials.gov NCT 02560935).
No relevant conflicts of interest to declare.
Abdominal pain with a discoloured dialysate in a patient on peritoneal dialysis (PD) is usually attributed to infective peritonitis. Although acute pancreatitis (AP) is not usually a complication of ...end-stage renal disease, some studies suggest an increased risk especially in patients on PD. We report a case of idiopathic AP in a 41-year-old female on PD who presented with abdominal pain, fever, vomiting and a clear dark dialysate. Initial diagnosis of PD-associated infective peritonitis was made but dialysate cultures proved negative. Serum amylase showed a mild rise and computed tomography revealed necrotising pancreatitis. No common risk factors for AP were identified and she was successfully treated with conservative therapy. A literature review was carried out using a PubMed search with the words 'acute pancreatitis and peritoneal dialysis'. The literature search found a total of 94 cases of AP in the setting of PD. In more than a quarter, no cause for AP was found. Serum amylase was normal in 12.8% of episodes. Complications developed in 25 cases, and 28 patients died from the condition. Therefore, AP can be a rare, but serious complication of PD with a high mortality and must be considered in the differential diagnosis of abdominal pain in a PD patient.
Introduction
HIV care and treatment programmes worldwide are transforming as they push to deliver universal access to essential prevention, care and treatment services to persons living with HIV and ...their communities. The characteristics and capacity of these HIV programmes affect patient outcomes and quality of care. Despite the importance of ensuring optimal outcomes, few studies have addressed the capacity of HIV programmes to deliver comprehensive care. We sought to describe such capacity in HIV programmes in seven regions worldwide.
Methods
Staff from 128 sites in 41 countries participating in the International epidemiologic Databases to Evaluate AIDS completed a site survey from 2009 to 2010, including sites in the Asia‐Pacific region (n=20), Latin America and the Caribbean (n=7), North America (n=7), Central Africa (n=12), East Africa (n=51), Southern Africa (n=16) and West Africa (n=15). We computed a measure of the comprehensiveness of care based on seven World Health Organization‐recommended essential HIV services.
Results
Most sites reported serving urban (61%; region range (rr): 33–100%) and both adult and paediatric populations (77%; rr: 29–96%). Only 45% of HIV clinics that reported treating children had paediatricians on staff. As for the seven essential services, survey respondents reported that CD4+ cell count testing was available to all but one site, while tuberculosis (TB) screening and community outreach services were available in 80 and 72%, respectively. The remaining four essential services – nutritional support (82%), combination antiretroviral therapy adherence support (88%), prevention of mother‐to‐child transmission (PMTCT) (94%) and other prevention and clinical management services (97%) – were uniformly available. Approximately half (46%) of sites reported offering all seven services. Newer sites and sites in settings with low rankings on the UN Human Development Index (HDI), especially those in the President's Emergency Plan for AIDS Relief focus countries, tended to offer a more comprehensive array of essential services. HIV care programme characteristics and comprehensiveness varied according to the number of years the site had been in operation and the HDI of the site setting, with more recently established clinics in low‐HDI settings reporting a more comprehensive array of available services. Survey respondents frequently identified contact tracing of patients, patient outreach, nutritional counselling, onsite viral load testing, universal TB screening and the provision of isoniazid preventive therapy as unavailable services.
Conclusions
This study serves as a baseline for on‐going monitoring of the evolution of care delivery over time and lays the groundwork for evaluating HIV treatment outcomes in relation to site capacity for comprehensive care.
Abstract Objective This study was part of a larger demonstration project integrating chiropractic care into publicly funded Canadian community health centers. This pre/post study investigated the ...effectiveness of chiropractic care in reducing pain and disability as well as improving general health status in a unique population of urban, low-income, and multiethnic patients with musculoskeletal (MSK) complaints. Methods All patients who presented to one of two community health center–based chiropractic clinics with MSK complaints between August 2004 and December 2005 were recruited to participate in this study. Outcomes were assessed by a general health measure (Short Form-12), a pain scale (VAS), and site-specific disability indexes (Roland-Morris Questionnaire and Neck Disability Index), which were administered before and after a 12-week treatment period. Results Three hundred twenty-four patients with MSK conditions were recruited into the study, and 259 (80.0%) of them were followed to the study's conclusion. Clinically important and statistically significant positive changes were observed for all outcomes (Short Form-12: physical composite score mean change = 4.9, 95% confidence interval CI = 3.8-6.0; VAS: current pain mean change = 2.3, 95% CI = 1.9-2.6; Neck Disability Index: mean change = 6.8, 95% CI = 5.4-8.1; Roland-Morris Questionnaire: mean change = 4.3, 95% CI = 3.6-5.1). No adverse events were reported. Conclusions Patients of low socioeconomic status face barriers to accessing chiropractic services. This study suggests that chiropractic care reduces pain and disability as well as improves general health status in patients with MSK conditions. Further studies using a more robust methodology are needed to investigate the efficacy and cost-effectiveness of introducing chiropractic care into publicly funded health care facilities.
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