Outcomes of paediatric patients ventilated in a high-care area outside an intensive care unit.

BACKGROUND: Limited availability of paediatric intensive care beds in the public sector is a major challenge in South Africa. It often results in patients being ventilated in a high-care area (HCA) outside an intensive care setting. The outcomes of paediatric patients ventilated outside a paediatric intensive care unit (ICU) are not well documented. OBJECTIVES: To describe characteristics and outcomes of patients ventilated in a paediatric HCA. METHODS: A retrospective chart review of children (0 - 16 years) requiring mechanical ventilation in the HCA at Chris Hani Baragwanath Academic Hospital, Johannesburg, between 1 February and 31 October 2015 was performed. RESULTS: A total of 214 patients required mechanical ventilation during the study period. Fifty-four percent were male and 91.1% were HIV-negative. The most common diagnoses were acute lower respiratory tract infections (59.3% of the post-neonatal group, 28.8% of the neonatal group) and sepsis (6.8% of the post-neonatal group, 28.8% of the neonatal group). The ultimate rate of acceptance to an ICU was 69.0%. Only 41.6% of cases referred to an ICU were initially accepted, with limited bed availability being the main reason for refusal. Patients with respiratory illnesses were more likely and those with neurological illness less likely to be accepted to an ICU. Patients with low-risk diagnoses were more likely to be accepted than those with very high-risk diagnoses. The overall mortality rate was 32.2%, with 52.2% of these deaths occurring in the HCA. Patients aged 1 - 5 years had the highest mortality rate (48.0%). Lower respiratory tract infections (36.8%) and sepsis (20.6%) were the main causes of death. The mortality rate of suitable ICU candidates in the HCA was higher than that in an ICU (33.3% v. 24.3%). The standardised mortality ratio (SMR), as predicted by the Paediatric Index of Mortality 3 score, for all patients who died in the HCA was 3.3, while the SMR for patients who died in an ICU was 1.3. The odds ratio for mortality of suitable candidates ventilated in the HCA v. patients who were ventilated in an ICU was 1.80 (95% confidence interval 1.39 - 6.03). CONCLUSIONS: Although a reasonable number of paediatric patients ventilated in an HCA survive, survival is lower than in those ventilated in an ICU. However, offering life-supporting therapies in an HCA may offer benefit where ICU care is unavailable. Emphasis needs to be placed on improving access to ICU care as well as optimising the use of available resources.

Outcomes of Kasai hepatoportoenterostomy in children with biliary atresia in Johannesburg, South Africa.

BACKGROUND: Without timely surgical intervention, most children with biliary atresia (BA) are not expected to live beyond 2 years of age. The initial intervention, the Kasai hepatoportoenterostomy (KPE), aims to achieve biliary drainage. Liver transplantation (LT) is performed if jaundice fails to clear or when biliary cirrhosis occurs. In under-resourced South African (SA) academic state hospitals, KPE procedures are the standard of care for the majority of children with BA, but LT is becoming more routinely available. OBJECTIVES: To describe the outcomes of children with BA undergoing KPE, and to identify presenting clinical, laboratory and histological features that were associated with a more favourable outcome. METHODS: All children with BA who underwent KPE between January 2009 and June 2012 at the Johannesburg academic-hospital complex were included. Clinical and laboratory parameters, including paediatric end-stage liver disease (PELD) score at the time of KPE, liver histology fibrosis score, clearance of jaundice at 6 months and 24-month survival were determined. RESULTS: Of 70 children with BA diagnosed during the study period, 43 (61.4%) underwent KPE, but only 12 (27.9%) achieved early resolution of jaundice. By 24 months, 14 (32.6%) of 43 children undergoing KPE were alive with their native liver, and 2 (4.7%) other children underwent LT. PELD score <15 and early resolution of jaundice, but not age at surgery or histological fibrosis score, predicted a favourable outcome. CONCLUSION: Children with BA undergoing KPE in SA state hospitals have a poor prognosis. The PELD score at the time of KPE best predicts 24-month survival.

Population-based prevalence of high blood pressure among adults in an urban slum in Enugu, South East Nigeria.

In sub-Saharan Africa (SSA), rapid urbanization and changing lifestyle have modified the profile and pattern of various medical disorders. Apart from high prevalence rates, recent trends with regard to hypertension in Africa include: low levels of awareness, treatment and control. Although a large number of studies provide data about hypertension in SSA, few studies focused on special populations such as urban slum dwellers. The WHO STEP-wise approach to surveillance of noncommunicable diseases was used to access the prevalence of hypertension among adults in one of the urban slums in Enugu. Out of the 811 individuals aged 20 years and above surveyed, 774 (95.4%) cases were analyzed. About 4.7% and 2.7% reported a past history of diabetes and stroke, respectively, whereas 15% had a positive family history of hypertension. The mean (95% confidence interval (CI)) body mass index (BMI) was 23.7 (23.2-24.2) kg m(-2) among males and 26.6 (25.7-26.7) kg m(-2) among females (P<0.0001). The prevalence of hypertension was 52.5% (95% CI: 48.9-56.0) and 55.4% (95% CI: 49.5-61.3) in males and 50.8% (95% CI: 46.4-55.1) in females (P=0.23). It increased with age peaking at 45-54 years in females and ⩾55 years in males. About 40.1% were aware of their hypertension and 28.8% of those aware had normal blood pressure. In regression analysis, systolic (R(2)=0.192) and diastolic (R(2)=0.129) blood pressures increased with age and BMI. The prevalence of high blood pressure among adults in Enugu slums is very high and a cause for concern, and calls for urgent attention.