HIV exposure and its association with paediatric ICU outcomes in children admitted with severe pneumonia at Chris Hani Baragwanath Academic Hospital, South Africa

Background. Pneumonia is one of the leading causes of under-5 death in South Africa and accounts for a substantial burden of paediatric intensive care unit (PICU) admissions. However, little is known about PICU outcomes in HIV-exposed uninfected (HIV-EU) children with pneumonia, despite the growing size of this vulnerable population. Objectives. To determine whether HIV exposure without infection is an independent risk factor for mortality and morbidity in children admitted to PICU with pneumonia. Methods. This retrospective review included all patients with pneumonia admitted to the PICU at Chris Hani Baragwanath Academic Hospital between 1 January 2013 and 31 December 2014. Patients were classified as HIV-unexposed (HIV-U), HIV-EU and HIV-infected. Medical records were reviewed to determine survival to PICU discharge, duration of PICU admission and duration of mechanical ventilation. Survival analysis was used to determine the association between HIV infection/exposure with mortality, and linear regression was used to examine the association with length of stay and duration of mechanical ventilation. This study included 107 patients: 54 were HIV-U; 28 were HIV-EU; 23 HIV-positive; and 2 had an unknown HIV status. Results. Overall, 84% (n=90) survived to PICU discharge, with no difference in survival based on HIV infection or exposure. Both HIV-EU and HIV-U children had significantly shorter PICU admissions and fewer days of mechanical ventilation compared with HIV-infected children (p=0.011 and p=0.004, respectively). Conclusion. HIV-EU children behaved similarly to HIV-U children in terms of mortality, duration of PICU admission and length of mechanical ventilation. HIV infection was associated with prolonged length of mechanical ventilation and ICU stay but not increased mortality.

Pharmacological management of post-traumatic seizures in a South African paediatric intensive care unit

Background. Traumatic brain injury (TBI) is a common cause of paediatric intensive care unit (PICU) admissions in South Africa. Optimal care of these patients includes the prevention and control of post-traumatic seizures (PTS) in order to minimise secondary brain injury. Objectives. To describe the demographics of children admitted to a South African PICU, to describe the characteristics of PTS, and to describe the prophylactic and therapeutic management of PTS within the unit. Method. A 3-year retrospective chart review was conducted at the PICU of the Chris Hani Baragwanath Academic Hospital (CHBAH) in Soweto, Johannesburg, from 1 July 2015 to 30 June 2018. Results. Seventy-eight patients were admitted to the PICU, all with severe TBI. A total of 66 patient files were available for analysis. The median age of admission was 6 years (interquartile range (IQR) 4 - 9) with the majority of trauma secondary to mechanical injury (89%). Prophylactic anti-epileptic drugs (AEDs) were initiated in 44 (79%) patients. Early PTS occurred in 11 (25%) patients who received prophylaxis and 4 (33%) who did not. Three (5%) patients developed late PTS, resulting in an overall incidence of PTS of 43%. The most common seizure type was generalised tonic clonic (82%). Children diagnosed with PTS were a median of 2 years younger than those without PTS, with increased prevalence of seizures (83% v. 38%) in children below 2 years of age. Maintenance therapy was initiated in all patients consistent with recommended dosages. Of the total 167 anti-epileptic levels taken during maintenance, only 56% were within target range. Of the initial 78 patients, 8 died (10%). The median length of stay was 7 (IQR 5 - 12) and 8 (IQR 8 - 24) days longer in ICU and hospital respectively, in children with PTS. Conclusion. PTS is a frequent complication of severe TBI in children. There was considerable variation in the approach to both prophylaxis and maintenance therapy of PTS in terms of choice of agent, dosage, frequency of drug monitoring and approach to subtherapeutic levels. It is clear that more high-level studies are required in order to better inform these practices

Children caught in the long shadow of COVID-19

Despite the more transmissible delta variant being associated with higher rates of COVID-19 in unvaccinated adolescents, children have remained relatively spared from severe disease. Nevertheless, children are indirectly affected by the COVID-19 pandemic, which threatens to have far-reaching consequences. The effect of disruptions of seasonal patterns of circulation of respiratory pathogens on future immunity against such pathogens, childhood immunization programmes, and HIV and tuberculosis treatment programmes poses a threat to the future wellbeing of children. Furthermore, the economic devastation caused by the pandemic, including an increase in unemployment, gives rise to numerous challenges, such as food insecurity, which is likely to worsen childhood nutritional status. Also, COVID-19 has ongoing effects on the mental wellbeing of children, driven in part by the interruption of schooling and other opportunities to socialize. An increase in psychological illnesses has manifested in children consequent to the stresses of the pandemic, lockdowns, caregiver deaths. In this article, we highlight the indirect effects of COVID-19 on children, and suggest solutions to mitigate against the long-term sequelae. A focused health, nutrition, education and child protection response is required from government and healthcare practitioners to safeguard the health and wellbeing of South African children.

Choreoathetosis and dystonia in a child with COVID­19 and multisystem inflammatory syndrome

Neurological complications of COVID-19 or multisystem inflammatory syndrome in children (MIS-C) are well described. We report an unusual presentation in a 9-year-old girl presenting with status epilepticus, who thereafter developed choreoathetosis and dystonia. She was initially managed with intravenous immunoglobulins and methylprednisolone for presumed autoimmune encephalitis. However, she tested positive for SARS-CoV-2 and met the clinical and laboratory criteria for MIS-C. She remained encephalopathic with abnormal movements and dystonia for 8 days from presentation but was discharged home with complete clinical recovery after 2 weeks.

Improving survival with tuberculosis & HIV treatment integration: A mini-review

Tuberculosis (TB) is a leading cause of morbidity and mortality among HIV-infected patients while HIV remains a key risk factor for the development of active TB infection. Treatment integration is a key in reducing mortality in patients with HIV-TB co-infection. However, this opportunity to improve outcomes of both infections is often missed or poorly implemented. Challenges in TB-HIV treatment integration range from complexities involving clinical management of co-infected patients to obstacles in health service-organization and prioritization. This is evident in high prevalence settings such as in sub-Saharan Africa where TB-HIV co-infection rates reach up to 80 per cent. This review discusses published literature on clinical trials and cohort studies of strategies for TB-HIV treatment integration aimed at reducing co-infection mortality. Studies published since 2009, when several treatment guidelines recommended treatment integration, were included. A total of 43 articles were identified, of which a total of 23 observational studies and nine clinical trials were informative on TB-HIV treatment integration. The data show that the survival benefit of AIDS therapy in patients infected with TB can be maximized among patients with advanced immunosuppression by starting antiretroviral therapy (ART) soon after TB treatment initiation, i.e. in patients with CD4+ cell counts <50 cells/?l. However, patients with greater CD4+ cell counts should defer initiation of ART to no less than eight weeks after initiation of TB treatment to reduce the occurrence and extent of immune reconstitution disease and subsequent hospitalization. Addressing operational challenges in integrating TB-HIV care can significantly improve patient outcomes, generate substantial public health impact by decreasing morbidity and death in settings with a high burden of HIV and TB.

High-frequency oscillatory ventilation in a tertiary paediatric intensive care unit in an academic hospital in Johannesburg, South Africa

Background. High-frequency oscillatory ventilation (HFOV) remains an option for the management of critically ill children when conventional mechanical ventilation fails. However, its use is not widespread, and there is wide variability reported with respect to how it is used. Objectives. To describe the frequency, indications, settings and outcomes of HFOV use among paediatric patients with a primary respiratory disorder admitted to a tertiary paediatric intensive care unit (PICU). Methods. The study was a 2-year, single-centre, retrospective chart review. Results. Thirty-four (32.7%) patients were managed with HFOV in the PICU during the study period. Thirty-three of the 34 patients had paediatric acute respiratory distress syndrome. Indications for HFOV were inadequate oxygenation in 17 patients (50%), and refractory respiratory acidosis in 15 patients (44.1%) (2 patients did not fit into either category). Approaches to the setting of HFOV varied considerably, particularly with respect to initial pressure around the airways. HFOV was effective at improving both oxygenation, with a median (interquartile range (IQR)) decrease in oxygenation index of 6.34 (5.0 - 9.5), and ventilation with a the median decrease in PaCO2 of 67.6 (46.2 - 105.7) mmHg after 24 hours. Overall mortality was 29.4% in the HFOV group, which is consistent with other studies. Conclusion. HFOV remains an effective rescue ventilatory strategy, which resulted in rapid and sustained improvement in gas exchange in patients with severe hypoxaemia and/or severe respiratory acidosis, particularly in the absence of extracorporeal support. However, the variability in practice and the adverse effects described highlight the need for future high-quality randomised controlled trials to allow for development of meaningful guidelines to optimise HFOV use

Feeding patterns of infants admitted with lower respiratory tract infections in an HIV-endemic area

Background. Lower respiratory tract infections (LRTIs) remain a major cause of mortality and morbidity in infants in South Africa (SA).Exclusive breastfeeding has been shown to decrease mortality and morbidity in infants with LRTIs, especially in the context of HIV/AIDS.Major effort has been put into educating HIV-positive mothers on the benefits of exclusive breastfeeding within effective prevention of mother-to-child transmission (PMTCT) programmes.Objectives. To determine the feeding practices among infants admitted with LRTIs in an HIV-endemic area.Methodology. The study was a retrospective chart review of all infants admitted with a diagnosis of LRTI between 1 January 2015 and 31December 2015 at King Edward VIII Hospital, Durban, SA. Data on feeding patterns, socioeconomic status, maternal HIV status and clinical outcomes of LRTI admissions were collected.Results. Of the 308 infants enrolled, 63% were male. Exclusive breastfeeding rates of those aged <6 months with LRTIs were higher thant hose found in previous studies; however, these feeding patterns were significantly associated with the HIV status of the mother(p=0.003).Mothers who were HIV-negative were twice as likely to breastfeed as those who were HIV-positive (odds ratio 2.25; 95% confidence interval 1.32- 3.88). There was no association between the type of feeding and the clinical outcomes for LRTIs.Conclusion. Maternal HIV status influenced the feeding patterns of infants admitted with LRTIs with lower exclusive breastfeeding rates in the HIV-exposed group. Despite extensive efforts to promote breastfeeding within effective PMTCT programmes, HIV-positive mothers are still not harnessing the benefits that exclusive breastfeeding provides

Predictors of site choice and eventual learning experiences in a decentralised training programme designed to prepare medical students for careers in underserved areas in south Africa

Background. There is a dire need for medical schools in South Africa to train medical doctors who have the capacity and willingness to work in primary healthcare facilities; particularly in rural areas. Objectives. To assess the effect of students' gender; race; place of birth and place of high school completion on their choice of training site location and to assess the extent to which the training programme enhanced students' learning experiences relevant to primary care across training sites. Methods. A survey design involving six cohorts of 4th-year undergraduate medical students (N=187) who were part of the 2013 Family Medicine rotation at the Nelson R Mandela School of Medicine. Self-administered questionnaires were completed by students at the end of each rotation. Data analyses involved descriptive computations and inferential statistical tests; including non-parametric tests for group comparison and generalised polynomial logistic regression. Results. Students believed that their knowledge and skills relevant to primary care increased after the rotation (p0.0001). There were statistically significant differences between rural and urban sites on certain measures of perceived programme effectiveness. Male students were less likely to choose urban sites. Black students were less likely to choose rural sites compared with their white and Indian counterparts; as were students who attended rural high schools (odds ratio (OR) 9.3; p0.001). Students from a rural upbringing were also less likely to choose rural sites (OR 14; p0.001). Conclusion. Based on the findings; an objective approach for student allocation that considers students' background and individual-level characteristics is recommended to maximise learning experiences

Dietary Intake and Metabolic Control of Children with Type 1 Diabetes Mellitus Aged 6-10 Years in KwaZulu-Natal

Objectives: The objective of this study was to assess the dietary intake and metabolic control of children with type 1 diabetes. Design: A cross-sectional observational study was carried out. Subjects: A total of 30 subjects whose ages ranged from six to ten years were included in the study. Setting: The study was conducted at the Paediatric Diabetic Clinics at Grey's Hospital; Pietermaritzburg and Inkosi Albert Luthuli Central Hospital (IALCH); Durban; in KwaZulu-Natal. Outcome measures: Dietary intake was assessed using a three-day dietary record. Metabolic control was assessed using glycosylated haemoglobin (HbA1c). Results: The mean percentage contributions of macronutrients to total energy as determined by the three-day dietary records were as follows: carbohydrate - 52; added sucrose - 2; protein - 16; fat - 32. The mean intakes were similar to the recommendations of the International Society for Pediatric and Adolescent Diabetes (ISPAD) Consensus Guidelines (2002). Micronutrient intake was generally adequate. The mean latest glycosylated haemoglobin (HbA1c) for the sample as at the time of the study was 9.7. Five of the thirty subjects had HbA1c values that were within the recommended levels for children with type 1 diabetes. Conclusions: The macronutrient intake in this sample was found to be similar to the ISPAD Consensus Guidelines (2002) while micronutrient intake was adequate in most cases. Overall the sample had poor metabolic control

Post-marketing stability surveillance: Amoxicillin

BackgroundTo ensure the successful treatment of infectious disease using antimicrobial therapy; a sufficient concentration of the stable; active drug is required at the site of infection. For the achievement of this with respect to the Beta-lactam group of antibiotics; of which amoxicillin is a member; the presence of an intact Beta-lactam ring is essential. Destruction of this sensitive ring can lead to the ingestion of an inactive drug. This can contribute to treatment failure and antibiotic resistance. Thus; the aims of this study were to determine whether the types of packaging in which amoxicillin preparations are dispensed and the temperature and humidity conditions under which they are stored by patients are adequate and appropriate to ensure drug stability.Methods A mini-survey of pharmacies and patients was conducted in order to determine the types of packaging in which amoxicillin preparations are dispensed and the temperature and humidity conditions under which they are stored by patients. The amoxicillin preparations in the identified types of packaging were subjected to simulated conditions that represented the identified temperature and humidity stresses that occurred under patient storage conditions for a duration of 14 days. The extent of breakage of the Beta-lactam ring was then chemically determined on day 1; day 7 and day 14; using an iodometric titration method. ResultsThe mini-survey identified four types of packaging in which amoxicillin capsules are dispensed - plastic packets; flip-top amber bottles; flip-top amber bottles with cotton wool and flip-top transparent bottles with cotton wool. The laboratory analyses showed that only those amoxicillin capsules stored between 20 and 25 0C and protected from moisture were stable in all four identified types of packaging for 14 days. The mini-survey also indicated that 47of the patient sample did not store their antibiotic suspensions in the refrigerator. The laboratory analyses showed that only amoxicillin suspensions stored between 2 and 8 0C for seven days showed the lowest level of degradation. ConclusionThe results of this study indicate that reconstituted amoxicillin suspensions should be stored in the temperature range 2 to 8 0C; and that the reconstitution and dispensing of a 14-day supply of amoxicillin suspensions should be discouraged; even if the drug is stored in this temperature range. For amoxicillin capsules; the results obtained in this study indicate that significant breakage of the Beta-lactam ring of amoxicillin capsules can occur in hot and humid climatic conditions if inadequate types of packaging are used and storage occurs under inappropriate conditions. The results of the study point to the importance of drug stability knowledge as a prerequisite for the dispensing of medicines; the importance of the provision of patient counselling with regard to drug storage requirements; as well as a requirement for amoxicillin capsules to be dispensed in the original manufacturers' containers in geographical areas that are hot and humid

Post-Marketing Stability Surveillance: Amoxicillin

Background: To ensure the successful treatment of infectious disease using antimicrobial therapy; a sufficient concentration of the stable; active drug is required at the site of infection. For the achievement of this with respect to the Beta-lactam group of antibiotics; of which amoxicillin is a member; the presence of an intact Beta-lactam ring is essential. Destruction of this sensitive ring can lead to the ingestion of an inactive drug. This can contribute to treatment failure and antibiotic resistance. Thus; the aims of this study were to determine whether the types of packaging in which amoxicillin preparations are dispensed and the temperature and humidity conditions under which they are stored by patients are adequate and appropriate to ensure drug stability.Methods: A mini-survey of pharmacies and patients was conducted in order to determine the types of packaging in which amoxicillin preparations are dispensed and the temperature and humidity conditions under which they are stored by patients. The amoxicillin preparations in the identified types of packaging were subjected to simulated conditions that represented the identified temperature and humidity stresses that occurred under patient storage conditions for a duration of 14 days. The extent of breakage of the Beta-lactam ring was then chemically determined on day 1; day 7 and day 14; using an iodometric titration method.Results: The mini-survey identified four types of packaging in which amoxicillin capsules are dispensed - plastic packets; flip-top amber bottles; flip-top amber bottles with cotton wool and flip-top transparent bottles with cotton wool. The laboratory analyses showed that only those amoxicillin capsules stored between 20 and 25 0C and protected from moisture were stable in all four identified types of packaging for 14 days. The mini-survey also indicated that 47 of the patient sample did not store their antibiotic suspensions in the refrigerator. The laboratory analyses showed that only amoxicillin suspensions stored between 2 and 8 0C for seven days showed the lowest level of degradation.Conclusion: The results of this study indicate that reconstituted amoxicillin suspensions should be stored in the temperature range 2 to 8 0C; and that the reconstitution and dispensing of a 14-day supply of amoxicillin suspensions should be discouraged; even if the drug is stored in this temperature range. For amoxicillin capsules; the results obtained in this study indicate that significant breakage of the Beta-lactam ring of amoxicillin capsules can occur in hot and humid climatic conditions if inadequate types of packaging are used and storage occurs under inappropriate conditions. The results of the study point to the importance of drug stability knowledge as a prerequisite for the dispensing of medicines; the importance of the provision of patient counselling with regard to drug storage requirements; as well as a requirement for amoxicillin capsules to be dispensed in the original manufacturers' containers in geographical areas that are hot and humid