Management of paediatric asthma

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Primary immunodeficiency in Africa ­ a review

Background. Efforts have been made worldwide to improve awareness and treatment of primary immunodeficiency (PID). This has also gained momentum on the African continent albeit at a slower pace. Objective. This review reports on the current status of PID on the African continent regarding its prevalence, distribution, genetic mutations and challenges in diagnosis and treatment of affected patients. Method. We evaluated all studies published from the African continent in the field of PID dealing with prevalence, epidemiology, case reports and genetic findings. Results. The prevalence of PID on the African continent has been estimated to be as high as 902 631 individuals. PID still is mostly underdiagnosed in Africa and although progress has been made in parts of the continent manychallenges still remain regarding awareness, diagnosis, registration and care of these patients. Conclusion. Given the unique genetic mutations reported in PID patients on the African continent and the feasibility of hematopoietic stem cell transplantation and gene therapy, increased awareness should be encouraged and new therapeutic options considered

Tumours of the Chest in Children: A Review

Tumours of the chest in children constitute an array of pathology and clinical symptomatology. These tumours can be benign or malignant; cystic or solid; primary or as a result of secondary metastases. Collectively; tumours of the chest in children are very rare; the exact incidence of which is largely unknown globally. Non neoplastic lesions of the lung including bronchogenic cysts; sequestrations; congenital pulmonary airway malformations as well as infective and inflammatory disorders are 60 times more common than neoplastic causes.1 A tumour of the chest is considerably difficult to diagnose since patients can be asymptomatic for many years before symptoms evolve. Even more so; the symptoms are non-specific and can suggest more common and less sinister pathology. Clinically patients present with a variety of symptoms that depend largely on the location of the tumour.Airway tumours can be symptomatic or can present with chronic cough; wheeze; haemoptysis; atelectasis or persistent pneumonia. Secondary malignant parenchymal tumours are likely to be symptomatic from the primary lesion. Anterior mediastinal tumours can cause compression of the large airways or superior vena caval structures.It stands to reason that the physician needs to have a very high index of suspicion when dealing with these non-specific signs and symptoms. This article provides an approach to tumours of chest and reviews the common aetiology in the different compartments of the chest. The article will focus on common tumours of the airway; lung parenchyma; mediastinum; cardiac and chest wall pathology

Adjunctive Corticosteroid Treatment of Clinical PCP Pneumonia in Infants Less than 18 Months of Age : a Randomized Controlled Trial

"Objectives. To determine the efficacy and safety of adjunctive corticosteroid therapy in clinical PCP pneumonia (Pneumocystis jiroveci pneumonia) in infants exposed to HIV infection. Design. Double blind randomised placebo-controlled trial. Methods: Infants with a clinical diagnosis of PCP; based on an ""atypical"" pneumonia with: 1) hypoxia out of proportion to the clinical findings on auscultation; 2) CRP less than 10 IU; 3) LDH above 500 IU; 4) compatible CXR findings and 5) positive HIV ELISA test were included in the study. Patients were randomised to receive either prednisone or placebo. The protocol provided for the addition of prednisone to the treatment at 48 hours if there was clinical deterioration or an independent indication for steroid therapy. Other treatment was carried out in accordance with established guidelines. in room air. Results. One hundred patients were included; 47 in the prednisone and 53 in the placebo group. Patients in the prednisone group had a 43 better chance of survival than the placebo group (HR 0.57; 95CI 0.30-1.07; p=0.08). No significant differences could be demonstrated between groups in respect of other parameters of recovery. Conclusions. In HIV exposed infants with clinical PCP pneumonia; adjunctive corticosteroid treatment does not appear to add benefit regarding time to recovery or oxygen independency; but early administration may improve survival. A large multi-centred trial is needed to confirm these findings.The primary study endpoint was in hospital survival. Secondary outcome was time from admission to the first day of mean oxygen saturation above 90"

Understanding the Concept of 'Family History' in Black Asthmatic Children

Background. Despite the fact that 71.6 of children at Chris Hani Baragwanath Hospital (CHBH) Asthma Clinic in Soweto; Johannesburg were found to have one or more positive skin-prick tests (SPTs) to common aero-allergens; they reported a low rate of positive family history for atopic conditions (22.2reason(s) why a positive family history has been found so seldom in these children. Methods. A random group of parents of the atopic asthmatic children attending the CHBH Children's Asthma Clinic completed a detailed questionnaire regarding their atopic status. Skin-prick testing was performed. Results. Fifty-four sets of parents and 15 single mothers were studied. Of the 48 atopic children; 37 (77). In the past this has minimised the importance of family history in determining the nature of chest symptoms in children in this population group; suggesting that some new environmental exposure; rather than the established familial factor; was creating the allergic milieu in this group. Objective. To determine the predictive value of a family history of symptoms of atopic disease (and allergy) by seeking evidence for this condition in the parents of asthmatic children attending the CHBH Children's Asthma Clinic; and the ) had at least 1 parent with a positive SPT. Fifty-five per cent of mothers had a positive SPT; while 48 of fathers had at least 1 positive SPT. Seven of 69 mothers (10) had a definitive diagnosis of asthma. Of these; 5 (71) were SPT-positive. Only 3 of the fathers (5.5) had asthma. All had positive SPTs. However; if all the symptoms suggestive of asthma; namely chronic cough or wheeze; were taken into account; the number of potential atopic fathers and mothers increased to 10 (19) and 18 (26) respectively. Conclusion. Simple questioning for family history of atopic disease is therefore not a good predictor of atopy in offspring in this cohort of patients. In order to get maximal yield from this question; parents must rather be asked about specific symptoms suggestive of asthma and/or allergic rhinitis

Cost-effectiveness of asthma therapy

An important management strategy in asthma is the application of a cost-effectiveness review to the selected management principles. Efficacy; in the clinical trial setting; is the first determinant of effectiveness. However; in comparing the costeffectiveness of two or more therapeutic strategies or drugs the determinants of cost-effectiveness may require more than the simple comparison of Rand value and clinical efficacy end-points. The Rand value of a successful outcome is vital. One of the main goals of long-term asthma management is to avoid asthma-related hospital admissions. An effective asthma education programme can resolve most; if not all of the shortcomings in asthma care. In addition; adherence to guideline recommendations would result in a a decrease in unnecessary and costly (cost-ineffective) therapies. Many asthmatics in South Africa are not being treated according to local or international guideline recommendations and lastly adherence is a serious problem in asthma therapy; significantly increasing asthma management costs