BACKGROUND
In low-resource settings, limited laboratory capacity adds to the burden of central nervous system (CNS) infections in children and spurs overuse of antibiotics. The commercially available BioFire® FilmArray® Meningitis/Encephalitis Panel (FA-ME) with its capability to simultaneously detect 14 pathogens in cerebrospinal fluid (CSF), could potentially narrow such a diagnostic gap.
METHODS
In Mbarara, Uganda, we compared clinical utility (clinical turnaround time [cTAT], microbial yield, and influence on patient outcome and antibiotic exposure) of FA-ME with bacterial culture, in children 0–12 years with suspected CNS infection.
RESULTS
Of 212 enrolled children, CSF was sampled from 194. All samples underwent bacterial culture, of which 193 also underwent FA-ME analyses. FA-ME analyses prospectively influenced care for 169 of the 193 patients, and they constituted an ‘Index group’. The remaining 43/212 patients constituted a ‘Reference group’. Of all 194 CSF-sampled patients, 87% (168) had received antibiotics before lumbar puncture. Median cTAT for FA-ME was 4.2 h, vs. two days for culture. Bacterial yield was 12% (24/193) and 1.5% (3/194) for FA-ME and culture, respectively. FA-ME viral yield was 12% (23/193). Fatality rate was 14% in the Index group vs. 19% in the Reference group (P = 0.20). From clinician receival of FA-ME results, median antibiotic exposure was 6 days for bacteria-negative vs. 13 days for bacteria-positive patients (P = 0.03). Median hospitalization duration was 7 vs. 12 days for FA-ME negative and positive patients, respectively (P < 0.01).
CONCLUSIONS
In this setting, clinical FA-ME utility was found in a higher and faster microbial yield and shortened hospitalization and antibiotic exposure of patients without CSF pathology. More epidemiologically customized pathogen panels may increase FA-ME utility locally, although its use in similar settings would require major cost reductions.
Severely malnourished patients can present with bilateral pitting oedema, which is a common sign of Kwashiorkor. However, bilateral pitting oedema can also be an expression of other pathologies. In Mali and DRC, the number of children presenting with bilateral pitting oedema at MSF (Médecins Sans Frontiers/Doctors Without Borders) hospitals are up to 30% (Mali) and 49% (DRC) higher than in other countries, however, the reasons underlying this trend are unknown. Through this qualitative study, we aimed to explore the perspectives and lived experiences of health professionals on the diagnosis and management of children with bilateral pitting oedema. Using a participatory approach, we conducted 21 in-depth interviews, and 2 focus groups with health professionals at MSF health facilities who had worked in the settings of Koutiala (Mali) and Rutshuru (DRC) for at least 6 months. The understanding of the bilateral pitting oedema phenomenon is complex. Health workers described clinical obstacles to reducing mortality, including: i) difficulties making the diagnosis due to a lack of specialized staff and insufficient resources, ii) challenges treating complications that may arise due to the complexity of the diseases associated with bilateral pitting oedema, and iii) lack of scientific evidence in the literature explaining the physiopathology of bilateral pitting oedema. Study participants shared several key recommendations for reducing mortality among children presenting with bilateral pitting oedema, including prevention of bilateral pitting oedema at the community level, standardization of the diagnostic process, strengthening of medical training, and better collaboration both within the medical teams and between teams and the children’s families.
OBJECTIVES
The main objective of this study was to implement an online pediatric case‐based POCUS course in low‐resource medical settings and examine learning outcomes and feasibility.
METHODS
This was a multicenter prospective cohort study conducted in a convenience sample of clinicians affiliated with Médecins Sans Frontières (MSF) training sites. MSF POCUS trainers provided the standard hands‐on, on‐site POCUS training and supplemented this with access to a web‐based course. Participants provided diagnoses for 400 image‐based POCUS cases from four common pediatric POCUS applications until they achieved the mastery learning standard of 90% accuracy, sensitivity (cases with pathology), and specificity (cases without pathology). Each participant also completed a course evaluation.
RESULTS
From 10 MSF sites, 110 clinicians completed 82,206 cases. There were significant learning gains across the POCUS applications with respect to accuracy (delta 14.2%; 95% CI 13.1, 15.2), sensitivity (delta 13.2%; 95% CI 12.1, 14.2), and specificity (delta 13.8%; 95% CI 12.7, 15.0). Furthermore, 90 (81.8%) achieved the mastery learning standard in at least one application, and 69 (62.7%) completed a course evaluation on at least one application for a total of 231 evaluations. Of these, 206 (89.2%) agreed/strongly agreed that the experience had relevance to their practice, met expectations, and had a positive user design. However, 59/110 (53.6%) clinicians reported a lack of protected time, and 54/110 (49.0%) identified challenges with accessing internet/hardware.
CONCLUSIONS
In resource‐limited MSF settings, implementing web‐based POCUS case practice demonstrated successful learning outcomes despite approximately half of the participants encountering significant technical challenges.
Insulin-like growth factor 1 (IGF-1) is an important growth factor in childhood. We aimed to investigate the impact of food supplements for treatment of moderate acute malnutrition (MAM) on serum IGF-1 (sIGF-1). Secondary analysis of a randomized 2×2×3 factorial nutrition trial was performed. Children aged 6-23 months with MAM received 2093 kJ/day as lipid-based nutrient supplement (LNS) or corn-soy blend (CSB), containing either dehulled soy or soy isolate and different quantities of dried skimmed milk (0%, 20% or 50% of total protein) for 12 weeks. The trial was double-blind with regard to soy and milk, but not to matrix (LNS vs. CSB). sIGF-1 was measured at inclusion and after 12 weeks supplementation. Of 1609 children enrolled, 1455 (90%) had sIGF-1 measured at both time points. During supplementation sIGF-1 increased 6.7 (95%CI 6.1; 7.3) ng/ml compared with an expected age-dependent decrease of 0.3 (95%CI 0.2; 0.4) ng/ml. Children who received LNS vs. CSB had lower increase in sIGF-1 (-8%, 95%CI -12; -3). The effect of LNS was partly attenuated when sIGF-1 was corrected for inflammation. Children who received soy isolate compared with dehulled soy had higher increase in sIGF-1 (6%, 95%CI 1; 12). Milk content did not affect sIGF-1. Overall, sIGF-1 increased during supplementation. The lower increase with LNS vs. CSB was only partly explained by increased inflammation with LNS, and needs further investigation. Isolate vs. dehulled soy led to a higher increase which may be due to antinutrients in dehulled soy.
BACKGROUND
Circulating markers of immune and endothelial activation risk stratify infection syndromes agnostic to disease aetiology. However, their utility in children presenting from the community remains unclear.
METHODS
This study recruited children aged 1-59 months presenting with community-acquired acute febrile illnesses to seven hospitals in Bangladesh, Cambodia, Indonesia, Laos, and Viet Nam. Clinical parameters and biomarker concentrations were measured at presentation. The outcome measure was death or receipt of vital organ support within two days of enrolment. Prognostic performance of endothelial (Ang-1, Ang-2, sFlt-1) and immune (CHI3L1, CRP, IP-10, IL-1ra, IL-6, IL-8, IL-10, PCT, sTNFR-1, sTREM-1, suPAR) activation markers, WHO Danger Signs, and two validated severity scores (LqSOFA, SIRS) was compared.
RESULTS
3,423 participants were recruited. 133 met the outcome (weighted prevalence: 0.34%; 95% CI 0.28-0.41). sTREM-1 exhibited highest prognostic accuracy (AUC 0.86; 95% CI 0.82-0.90), outperforming WHO Danger Signs (AUC 0.75; 95% CI 0.70-0.80; p < 0.001), LqSOFA (AUC 0.74; 95% CI 0.70-0.78; p < 0.001), and SIRS (AUC 0.63; 95% CI 0.58-0.68; p < 0.001). Discrimination of immune and endothelial activation markers was particularly strong for children who deteriorated later in the course of their illness. Compared to WHO Danger Signs, an sTREM-1-based triage strategy improved recognition of children at risk of progression to life-threatening infection (sensitivity: 0.80 vs. 0.72), while maintaining comparable specificity (0.81 vs. 0.79).
CONCLUSIONS
Measuring circulating markers of immune and endothelial activation may help earlier recognition of febrile children at risk of poor outcomes in resource-constrained community settings.
BACKGROUND
There are few data on the treatment of children and adolescents with multidrug-resistant (MDR) or rifampicin-resistant (RR) tuberculosis, especially with more recently available drugs and regimens. We aimed to describe the clinical and treatment characteristics and their associations with treatment outcomes in this susceptible population.
METHODS
We conducted a systematic review and individual participant data meta-analysis. Databases were searched from Oct 1, 2014, to March 30, 2020. To be eligible, studies must have included more than five children or adolescents (0-19 years of age) treated for microbiologically confirmed or clinically diagnosed MDR or RR tuberculosis within a defined treatment cohort, and reported on regimen composition and treatment outcomes. Abstracts were screened independently by two authors to identify potentially eligible records. Full texts were reviewed by two authors independently to identify studies meeting the eligiblity criteria. For studies meeting eligiblity criteria, anonymised individual patient data was requested and individiual level data included for analysis. The main outcome assessed was treatment outcome defined as treatment success (cure or treatment completed) versus unfavourable outcome (treatment failure or death). Multivariable logistic regression models were used to identify associations between clinical and treatment factors and treatment outcomes. This study is registered with Prospero (CRD42020187230).
FINDINGS
1417 studies were identified through database searching. After removing duplicates and screening for eligibility, the search identified 23 369 individual participants from 42 studies, mostly from India and South Africa. Overall, 16 825 (72·0%) were successfully treated (treatment completed or cured), 2848 died (12·2%), 722 (3·1%) had treatment failure, and 2974 (12·7%) were lost to follow-up. In primary analyses, the median age was 16 (IQR 13-18) years. Of the 17 764 (87·1%) participants with reported HIV status, 2448 (13·8%) were living with HIV. 17 707 (89·6%) had microbiologically confirmed tuberculosis. After adjusting for significant factors associated with treatment outcome, the use of two (adjusted odds ratio [OR] 1·41 [95% CI 1·09-1·82]; p=0·008) or three (2·12 [1·61-2·79]; p<0·0001) WHO-classified group A drugs (bedaquiline, moxifloxacin, levofloxacin, and linezolid) compared with the use of no group A drugs at all was positively associated with treatment success.
INTERPRETATION
Younger and clinically diagnosed children are underrepresented among those treated for MDR and RR tuberculosis and should be a focus for case-finding efforts. Overall treatment outcomes in our analysis were better than in adults but lower than the international targets of 90% or more individuals successfully treated. Treatment with more group A drugs was associated with better treatment outcomes in children and adolescents, highlighting the need for more rapid access to these drugs and improved regimens.
BACKGROUND
Humanitarian crises bring unique, and potentially growing challenges to people with type 1 diabetes (T1D). We aimed to determine, in youth with T1D (mean age (± 1SD) 0–17.9 years) within and coming from humanitarian crises settings (HCS), the reported prevalence that meet international consensus targets for glycaemic, blood pressure and lipid management, and incidence of severe hypoglycaemia or diabetic ketoacidosis.
METHODS
A narrative review of quantitative data was conducted, using a systematic process. MEDLINE (Ovid), Global Health, Web of Science, Scopus, Embase, CINAHL, APA PsycINFO, Cochrane trials, and the reference lists of eligible records were searched (January 2014-February 2024); ten records covering ten separate studies were retrieved.
RESULTS
Glycaemic management was consistently suboptimal in HCS. However, among individuals coming from HCS, glycaemia varied. Across both groups, data relating to blood pressure, lipids, severe hypoglycaemia or diabetic ketoacidosis were either unavailable or limited.
CONCLUSION
Findings expose the dearth of data relating to defined youth with T1D within and coming from HCS, leaving the status of this population largely uncharacterised. With limited data indicating suboptimal T1D management, there is a pressing need for the development of a consensus guideline on, and core indicators relating to such youth within and coming from HCS, plus monitoring systems and outcome data.
BACKGROUND
Conflict is known to impact maternal and neonatal health in Eastern Democratic Republic of the Congo (DRC), an area of longstanding insecurity. We conducted a systematic review on pregnancy and neonatal outcomes in this region to provide a comprehensive overview of maternal and neonatal outcomes over a 20-year period.
METHODS
We systematically searched databases, such as Medline, EMBASE, Global Health, ClinicalTrials.gov and the Cochrane Library, along with grey literature, for articles published between 2001 and 2021. These articles provided quantitative data on selected pregnancy and neonatal outcomes in the provinces of Ituri, Maniema and North and South Kivu, Eastern DRC. We conducted a descriptive analysis, combining results from different data sources and comparing incidence of outcomes in North Kivu with those in other provinces in Eastern DRC.
RESULTS
A total of 1,065 abstracts from peer-reviewed publications and 196 articles from the grey literature were screened, resulting in the inclusion of 14 scientific articles in the review. The most frequently reported pregnancy complications were caesarean sections (11.6%–48.3% of deliveries) and miscarriage (1.2%–30.0% of deliveries). The most common neonatal outcomes were low birth weight (3.8%–21.9% of live births), preterm birth (0.9%–74.0%) and neonatal death (0.2%–43.3%).
CONCLUSION
Our review provides data on pregnancy and neonatal outcomes in Eastern DRC, which will be valuable for future studies. Despite the area's ongoing armed conflict, the percentages of complications we noted in Eastern DRC are comparable with those observed in other countries in the region.
AIM
Dorsal metatarsal artery perforator flap (DMTAPF) reconstructions were reviewed to assess indications for application, variation of surgical technique and the long-term impact of growth.
METHOD
A cohort of 15 children presented with 17 DMTAPFs on 16 feet. Patient demographics, the aetiology and timing of primary injury and details of flap reconstruction were recorded. Flap pedicle location, the soft tissue composition and complications were recorded. The active range of motion (AROM) of ankle and toes was compared to the uninjured side. Photographic records of both feet were compiled.
RESULTS
Post-reconstruction follow-up attendance was 94%. Motor Vehicle Accidents (MVA) were the most common primary cause of injury. Most DMTAPF reconstructions were applied electively at toe-extension contracture release. One DMTAPF was applied acutely for a traumatic defect. The mean age at flap review was 10 years. The mean interval between DMTAPF reconstruction and outcome-review clinic was 2 years. The flap was composed of skin +/- scar tissue with an intact adipo-fascial component. A single perforator pedicle was employed in most. Direct donor site closure was supplemented with skin graft (predominantly full-thickness). There were no major donor site complications or skin graft loss. Flap complications were rare and minor. No post-operative revisions were required. Recurrent extension contracture was rare. Post-operative AROM was within a functional range.
CONCLUSIONS
DMTAPF provides a vascularised cover for exposed bones, joints and tendons. Previous scarring, or grafting, are not contraindications to donor site selection. All four webspace perforators are potential pedicles. Flap and donor site complications are rare. This pliable flap kept pace with growth avoiding recurrence of extension deformity. Patients' activities and comfort improved after reconstruction.