Factors influencing time to diagnosis of childhood cancer in Ibadan, Nigeria

BACKGROUND

Early diagnosis of cancer allows an opportunity for timely treatment while disease burden is in its earliest stages. Unfortunately, late presentation and delayed diagnosis of childhood cancers remains a problem in developing countries.

OBJECTIVES

To describe the pre-diagnostic symptomatic intervals and the factors influencing these time intervals in childhood cancer at the University College Hospital, Ibadan, Nigeria.

METHODS

Information was obtained from the case notes of children seen between March 2006 and August 2008. Information included socio-demographic variables, stage of the cancer, duration of illness at diagnosis and other health seeking activities.

RESULTS

Sixty-four children (40 males, 24 females) were studied. Median overall lag time was 13.1 weeks; median parent delay was 2 weeks and median health system delay was 8.8 weeks. Median lag times were shortest in acute leukaemia (8.1 weeks) and Wilms. tumour (8.7 weeks) and longest in Hodgkin lymphoma (101.7 weeks).

CONCLUSION

Lag times were longer than those in developed countries. Factors contributing to delayed diagnosis included delayed referral by doctors, seeking health care from alternate sources and financial constraints. Education of parents and physicians on early presentation and early referral for early diagnosis is recommended.

Situation analysis of the existing infant feeding pattern at the commencement of the prevention of mother to child transmission (PMTCT) of HIV programme in Ibadan

OBJECTIVES

To evaluate breastfeeding and weaning practices associated socio-demographic factors and knowledge about mother-to-child transmission of HIV among mothers in Ibadan.

METHODS

A cross sectional survey was conducted among 513 mothers of children aged 6- 24 months, attending infant welfare clinics. Data collection was by a structured questionnaire, which was supplemented by focus group discussions to further explore some of the issues covered in the survey.

RESULTS

Breast-feeding rate was 99.4%, the duration of which ranged from 1-22 months with a median of 14 months among those who had stopped breastfeeding. Only 145 (28.3%) mothers breastfed their babies exclusively for six months and 259(50.8%) initiated breastfeeding within one hour of birth; both were associated with at least secondary level of education. The main obstacle to exclusive breastfeeding was the belief that water is required to quench thirst in babies. Expression of breast milk was not favoured by majority of the mothers (68%) most of whom felt that the milk would get contaminated. Wet nursing was rarely practiced (0.4%). Most of the mothers, 436 (85%) were aware that HIV could be transmitted through breast milk but the attitude towards a mother who did not breast feed was negative in 96.8% ofrespondents.

CONCLUSIONS

Adherence to recommended infant feeding options for HIV-exposed infants are likely to be faced with challenges in a culture where breastfeeding is the norm and exclusive breastfeeding rate is low. There is need for counseling and health education on prevention of mother-to-child transmission of HIV.

A case of human bite by an 11-year old HIV positive girl in a paediatrics ward

Biting is a possible mode of transmission of HIV infection, though the risk of such transmission is believed to be low. Children infected with HIV are at risk of psychological complications as a result of direct or indirect effects associated with the disease. We report the case of an 11 year old HIV positive girl with clinical stage IV disease, who was involved in multiple disputes while on admission on the ward. During one of the disputes she inflicted a deep bite injury on a 10-year old boy, HIV post-exposure prophylaxis (PEP) was commenced 6 hours after the bite and he has remained HIV negative 12 months later. What is peculiar about this case is that the incident occurred in a hospital setting and biting is not usually expected among children of this age. In the era of HIV/AIDS, it is recommended that persons involved in childcare be aware of this potential risk during interactions among children. It is also essential for health care personnel to have sufficient knowledge about PEP in order to reduce the risk of HIV transmission in similar settings. In addition, a multidisciplinary approach to the management of children living with HIV is important in order to identify and address psychosocial factors that may influence symptoms and medical treatment outcome. The risk of transmission of HIV through human bites and the psychosocial impact of the disease on children are also discussed.

Causes of death in childhood cancer at the Department of Paediatrics, University College Hospital, Ibadan

There is a dearth of information on the mortality of children with cancer in Nigeria but the few available reports suggest a poor outcome. The objectives of this study were to determine the underlying and immediate causes of death from childhood cancer. The mortality summary cards of all cases of childhood cancer seen at the Department of Paediatrics, University College Hospital, Ibadan between January 1998 and December 2004 were reviewed. Eighty-eight cases of childhood cancer were seen, out of whom 52 (59.1%) died, but only the 48 deaths with complete data were analyzed. These deaths comprised of 37 males and 11 females giving a male:female ratio of 3.4:1. Their ages ranged from 1 to 13 years with a mean of 7.3 +/- 3.4 years. The majority (71.4%) of all patients presented with diffuse or metastatic disease at diagnosis and this was associated with increased risk of dying. Of the 48 cases reviewed, 39 (81.3%) died without any remission of the primary tumour including 5 (10.4%) with disease progression despite treatment and 15 (31.3%) who died before treatment; only 4 cases (8.3%) died from tumour relapse. The immediate causes of death were infections (39.6%), bone marrow suppression (29.2%), treatment-related mortality (27.1%), organ failure (22.9%), bleeding (16.7%) and other metabolic causes (8.3%). Potentially reversible factors such as infections, bone marrow suppression and treatment-related events are the commonest causes of death from childhood cancer in Ibadan. Therefore, early presentation, prompt identification and effective management of these problems may reduce childhood cancer mortality in Nigeria.

Hodgkin lymphoma in a child with sickle cell anemia

There are reports of patients with sickle cell disease who developed hematological malignancies but the relationship between these malignancies and sickle cell disease (SCD) is not yet defined. The co-existence of a hematological malignancy with SCD poses certain challenges for the management of each condition. We describe a 7-year-old boy with sickle cell anemia who developed Hodgkin's lymphoma and the challenges of management. He presented with a 4-year history of bilateral neck swelling and a 2-month history of weight loss and high-grade fever. Histology of a lymph node biopsy was consistent with mixed cellularity Hodgkin's lymphoma. He was treated with five cycles of Cyclophosphamide, Vincristine, Procarbazine and Prednisolone (COPP) and had complete clinical response. Chemotherapy was associated with an increase in frequency of painful crises and complicated by septicaemia. Blood transfusion needs were minimal; apart from the transfusion preceding the first cycle of chemotherapy, there was no need for further transfusion. Myelosuppression was not a problem in the patient; he responded well to antibiotics during the two episodes of septicemia without the use of hemopoetic growth factor. Patients with sickle cell anaemia who develop Hodgkin's lymphoma can be successfully treated with chemotherapy along with supportive management for crises and infections.

A comparison of the results of regulatory compliance inspections in 1999 by the states of Texas, Maine, and Washington

Inspection outcome data provided by the state of Washington Department of Health, Division of Radiation Protection, for licensees of radioactive materials was encoded according to a system established by the Texas Department of Health, Bureau of Radiation Control. The data, representing calendar year 1999 inspection activities, were then analyzed and the results compared to previously published studies for the same year in the states of Texas and Maine. Despite significant differences in regulatory program size, age, and geographic proximity, the most frequently cited violation for radioactive materials licensees were shown to be similar for all three states. Of particular note were the violations that were identified to be consistently issued in all three states. These included physical inventories and utilization logs not performed, not available, or incomplete; leak testing not performed or not performed on schedule; inadequate or unapproved operating and safety procedures; radiation survey and disposal records not available or incomplete; detection or measurement instrument calibration not performed or records not available; and radiation surveys or sampling not performed or performed with a noncalibrated instrument. Comparisons were made in an attempt to generate a summary of the most commonly issued violations that could be generalized to users of radioactive materials across the United States. A generalized list of common violations would be an invaluable tool for radiation protection programs, serving to aid in the reduction of the overall instance of program non-compliance. Any reduction in instances of non-compliance would result in the conservation of finite public health resources that might then be directed to other pressing public health matters.

Antimicrobial sensitivity pattern of organisms causing urinary tract infection in children with sickle cell anaemia in Ibadan, Nigeria

As part of a larger project on childhood urinary tract infection, antimicrobial sensitivity tests were carried out on the bacterial isolates from the urine of febrile children seen at the University College Hospital, Ibadan, Nigeria.

METHODOLOGY

Midstream urine specimens were collected from 171 sickle cell anaemia children and from an equal number of haemoglobin-A controls and cultured by standard methods. Sensitivity to eleven antimicrobials was tested using the disc-diffusion technique of Stokes.

RESULTS

Significant bacteriuria was obtained from 37 children with sickle cell anemia and 27 controls. The isolates were Escherichia coli, Klebsiella species, Non-haemolytic streptococcus, beta-haemolytic Streptococcus, Salmonella, Proteus and Pseudomonas species. Sensitivity was highest to Pefloxacin to which over 94% of the organisms were sensitive followed by Ceftriaxone (over 85%) and ceftazidime (over 85%). Sensitivities to nalidixic acid and cefuroxime were between 67.6% and 74.1%. Most of the isolates were resistant to gentamicin, amoxycillin, cotrimoxazole and ampicillin. In general the sensitivity pattern in the sickle cell anaemia group was similar to the pattern in the control group.

CONCLUSION

Aetiological agents of childhood UTI in this environment are resistant to most of the drugs commonly recommended for its treatment. Nalixidic acid and cefuroxime are recommended as first line drugs while awaiting results of sensitivity testing. Ceftriazone and ceftazidime should be reserved for cases of non-response to first line drugs and in severe cases. Pefloxacin should be considered potential drug of treatment particularly in multi-drug resistant infections.

Urinary tract infection in febrile children with sickle cell anaemia in Ibadan, Nigeria

A prospective study to determine the prevalence of bacteriuria and bacterial isolates in the urine of febrile children with sickle cell anaemia (SCA) was carried out at University College Hospital, Ibadan. Altogether, 171 febrile children (aged 1-15 years) with SCA and 171 age- and sex-matched controls were studied. After obtaining a history of the illness from the parents or guardians, each child was physically examined and a mid-stream urine specimen collected and subjected to microscopy and culture. The prevalence of bacteriuria in children with SCA was 21.6% compared with 15.8% in the controls. Escherichia coli and Klebsiella species were the predominant isolates from the urine, accounting for 64.9% and 18.9%, respectively, of the isolates from the SCA group and 63% and 22.2%, respectively, in the controls. In the SCA group, significant bacteriuria also occurred with other conditions such as pneumonia and osteomyelitis. Urinary tract infection (UTI) is common in children with SCA. Routine screening for it is therefore recommended during febrile illnesses. Children with fever from other overt causes, however, should not be exempted from the urine screening procedure in case there might be concomitant UTI.

Beckwith-Wiedemann Syndrome (BWS): a case report and literature review

Beckwith-Wiedemann Syndrome (BWS), also known as the EMG (Exomphalos, Macroglossia, Gigantism) syndrome was recognised independently by Beckwith in 1963 and Wiedemann in 1964 and is now a well established entity having been reported in more than two hundred individuals. It constitutes a wide spectrum of clinicopathologic entity with varied combinations of congenital and time dependent abnormalities that often make diagnosis and management tasking. There is paucity of report in the literature on this entity from the developing world. We present a case recently seen at the University College Hospital (UCH) Ibadan, Nigeria in order to create further awareness and highlight peculiarity of management as may be applicable in a setting as ours.

The language of mental health nursing reports: firing paper bullets?

A great deal of the caring work of nursing is accomplished and mediated through language. This paper attempts to characterize some of this language in quantitative and stylistic terms in an attempt to characterize the genre of nursing report language. Nursing students (n = 26) and graduate nurses (n = 3) viewed a videotape of a person being interviewed by a psychiatrist and produced written reports. These showed a large proportion of words relating to the person and to feelings and needs, compared to existing databases of the English language in general. The language produced by the participants also contained many modal or modifying words and is similar to spoken rather than written English in terms of the proportion of lexical content. There was much diversity in their descriptions and the vocabulary used to refer to the client. Graduate nurses showed more scepticism of the evidence provided by the video and advocated more investigation and questioning of the client. The use of standard forms and techniques of expression suggests that these reports were assembled on a language production line. Finally, we advocate a more systematic approach to educating nursing students about the power of the language they use.

Old yellow enzyme: reduction of nitrate esters, glycerin trinitrate, and propylene 1,2-dinitrate

The reaction of the old yellow enzyme and reduced flavins with organic nitrate esters has been studied. Reduced flavins have been found to react readily with glycerin trinitrate (GTN ) (nitroglycerin) and propylene dinitrate, with rate constants at pH 7.0, 25 degrees C of 145 M(-1)s(-1) and 5.8 M(-1)s(-1), respectively. With GTN, the secondary nitrate was removed reductively 6 times faster than the primary nitrate, with liberation of nitrite. With propylene dinitrate, on the other hand, the primary nitrate residue was 3 times more reactive than the secondary residue. In the old yellow enzyme-catalyzed NADPH-dependent reduction of GTN and propylene dinitrate, ping-pong kinetics are displayed, as found for all other substrates of the enzyme. Rapid-reaction studies of mixing reduced enzyme with the nitrate esters show that a reduced enzyme--substrate complex is formed before oxidation of the reduced flavin. The rate constants for these reactions and the apparent K(d) values of the enzyme--substrate complexes have been determined and reveal that the rate-limiting step in catalysis is reduction of the enzyme by NADPH. Analysis of the products reveal that with the enzyme-catalyzed reactions, reduction of the primary nitrate in both GTN and propylene dinitrate is favored by comparison with the free-flavin reactions. This preferential positional reactivity can be rationalized by modeling of the substrates into the known crystal structure of the enzyme. In contrast to the facile reaction of free reduced flavins with GTN, reduced 5-deazaflavins have been found to react some 4--5 orders of magnitude slower. This finding implies that the chemical mechanism of the reaction is one involving radical transfers.

Tympanic thermometry in Nigerian children

Rectal and aural temperatures were recorded at the same time in 378 children aged < or = 60 months and were found to be similar across the various age groups, correlation coefficients (r) ranging from 0.61 to 0.91. The mean differences between rectal and aural temperatures varied between -0.06 and 0.25 degree C. Concordance between the two methods ranged from 88.9% to 98% across the temperature range. Tympanic thermometry is simpler, safer and quicker than rectal thermometry and these findings justify the use of aural thermometry in any busy clinical facility for children.

Determination of metal cations on miniaturised planar polymeric separation devices using isotachophoresis with integrated conductivity detection

The feasibility of using miniaturised planar polymeric separation devices for the isotachophoretic separation of metal cations was demonstrated. Devices were produced in silicone rubber using a cast moulding fabrication technique. Detection was performed using an integrated single electrode conductivity detector, a design which offers simple fabrication and high resolution. The electrical characteristics of the devices were found to be suitable for performing electroseparations with a power dissipation of up to 1.5 W m-1 being achieved. The separation of a sample containing a mixture of the four metal ions lithium, lanthanum, dysprosium and ytterbium was reproducibly achieved using miniaturised devices. A comparison with a capillary scale separation of the same mixture was made. The miniaturised separations were achieved in under 600 s, which is less than half the time taken for the capillary scale separations.

On the active site of Old Yellow Enzyme. Role of histidine 191 and asparagine 194

Old Yellow Enzyme (OYE) binds phenolic ligands forming long wavelength (500-800 nm) charge-transfer complexes. The enzyme is reduced by NADPH, and oxygen, quinones, and alpha,beta-unsaturated aldehydes and ketones can act as electron acceptors to complete catalytic turnover. Solution of the crystal structure of OYE1 from brewer's bottom yeast (Fox, K. M., and Karplus, P. A. (1994) Structure 2, 1089-1105) made it possible to identify histidine 191 and asparagine 194 as amino acid residues that hydrogen-bond with the phenolic ligands, stabilizing the anionic form involved in charge-transfer interaction with the FMN prosthetic group. His-191 and Asn-194 are also predicted to interact with the nicotinamide ring of NADPH in the active site. Mutations of His-191 to Asn, Asn-194 to His, and a double mutation, H191N/N194H, were made of OYE1. It was not possible to isolate the N191H mutant enzyme, but the other two mutant forms had the expected effect on phenolic ligand binding, i.e. decreased binding affinity and decreased charge-transfer absorbance. Reduction of the H191N mutant enzyme by NADPH was similar to that of OYE1, but the reduction rate constant for NADH was greatly decreased. The double mutant enzyme had an increased rate constant for reduction by NADPH, but the reduction rate constant with NADH was lower by a factor of 15. The reactivity of OYE1 and the mutant enzymes with oxygen was similar, but the reactivity of 2-cyclohexenone was greatly decreased by the mutations. The crystal structures of the two mutant forms showed only minor changes from that of the wild type enzyme.

Isolation and characterization of the integration host factor genes of Pasteurella haemolytica

Using a bacteriophage lambda complementation system in Escherichia coli, we cloned genes encoding subunits of the heterodimeric DNA binding/bending protein, integration host factor, from the bovine pathogen, Pasteurella haemolytica. Complementation of ihfA and ihfB mutations in E. coli demonstrated that the P. haemolytica gene products form functional heterologous heterodimers. The ihfA and ihfB genes encode polypeptides predicted to be 99 and 93 amino acids long, respectively, and are very similar to integration host factor subunits from other Gram-negative bacteria, although phylogenetic analysis indicated that the P. haemolytica sequences are distantly related to those from other bacteria. Most significant amino acid differences were restricted to the amino-terminal domains of the predicted peptides.