1
|
Bangirana P, Boehme AK, Birabwa A, Opoka RO, Munube D, Mupere E, Kasirye P, Muwanguzi G, Musiimenta M, Ru G, Green NS, Idro R. Neurocognitive impairment in Ugandan children with sickle cell anemia compared to sibling controls: a cross-sectional study. FRONTIERS IN STROKE 2024; 3:1372949. [PMID: 38903696 PMCID: PMC11188974 DOI: 10.3389/fstro.2024.1372949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
Introduction The neurocognitive functions in Ugandan children aged 1-12 years with sickle cell anemia (SCA) were compared to their non-SCA siblings to identify risk factors for disease-associated impairment. Methods This cross-sectional study of the neurocognitive functions in children with SCA (N = 242) and non-SCA siblings (N = 127) used age- and linguistically appropriate standardized tests of cognition, executive function, and attention for children ages 1-4 and 5-12. Test scores were converted to locally derived age-normalized z-scores. The SCA group underwent a standardized stroke examination for prior stroke and transcranial Doppler ultrasound to determine stroke risk by arterial flow velocity. Results The SCA group was younger than their siblings (mean ages 5.46 ± 3.0 vs. 7.11 ± 3.51 years, respectively; p < 0.001), with a lower hemoglobin concentration (7.32 ± 1.02 vs. 12.06 ± 1.42, p < 0.001). The overall cognitive SCA z-scores were lower, -0.73 ± 0.98, vs. siblings, -0.25 ± 1.12 (p < 0.001), with comparable findings for executive function of -1.09 ± 0.94 vs. -0.84 ± 1.26 (p = 0.045), respectively. The attention z-scores for ages 5-12 for the SCA group and control group were similar: -0.37 ± 1.4 vs. -0.11 ± 0.17 (p = 0.09). The overall differences in SCA status were largely driven by the older age group, as the z-scores in the younger subsample did not differ from controls. Analyses revealed the strongest predictors of poor neurocognitive outcomes among the SCA sample to be the disease, age, and prior stroke (each p < 0.001). The impacts of anemia and SCA were indistinguishable. Discussion Neurocognitive testing in children with SCA compared to non-SCA siblings revealed poorer SCA-associated functioning in children older than age 4. The results indicate the need for trials assessing the impact of disease modification on children with SCA.
Collapse
Affiliation(s)
- Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Amelia K. Boehme
- Department of Neurology, Columbia University Vagelos Medical Center, New York, NY, United States
| | - Annet Birabwa
- Department of Mental Health and Community Psychology, Makerere University College of Humanities and Social Sciences, Kampala, Uganda
| | - Robert O. Opoka
- Global Health Uganda, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Deogratias Munube
- Global Health Uganda, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Phillip Kasirye
- Directorate of Paediatrics and Child Health, Mulago National Referral Hospital, Kampala, Uganda
| | | | | | - George Ru
- Department of Pediatrics, Columbia University Vagelos Medical Center, New York, NY, United States
| | - Nancy S. Green
- Department of Pediatrics, Columbia University Vagelos Medical Center, New York, NY, United States
| | - Richard Idro
- Global Health Uganda, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| |
Collapse
|
2
|
Tesfaye SH, Seboka BT, Sisay D. Application of machine learning methods for predicting childhood anaemia: Analysis of Ethiopian Demographic Health Survey of 2016. PLoS One 2024; 19:e0300172. [PMID: 38603735 PMCID: PMC11008879 DOI: 10.1371/journal.pone.0300172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 02/22/2024] [Indexed: 04/13/2024] Open
Abstract
Childhood anaemia is a public health problem in Ethiopia. Machine learning (ML) is a growing in medicine field to predict diseases. Diagnosis of childhood anaemia is resource intensive. The aim of this study is to apply machine learning (ML) algorithm to predict childhood anaemia using socio-demographic, economic, and maternal and child related variables. The study used data from 2016 Ethiopian demographic health survey (EDHS). We used Python software version 3.11 to apply and test ML algorithms through logistic regression, Random Forest (RF), Decision Tree, and K-Nearest Neighbours (KNN). We evaluated the performance of each of the ML algorithms using discrimination and calibration parameters. The predictive performance of the algorithms was between 60% and 66%. The logistic regression model was the best predictive model of ML with accuracy (66%), sensitivity (82%), specificity (42%), and AUC (69%), followed by RF with accuracy (64%), sensitivity (79%), specificity (42%), and AUC (63%). The logistic regression and the RF models of ML showed poorest family, child age category between 6 and 23 months, uneducated mother, unemployed mother, and stunting as high importance predictors of childhood anaemia. Applying logistic regression and RF models of ML can detect combinations of predictors of childhood anaemia that can be used in primary health care professionals.
Collapse
Affiliation(s)
| | - Binyam Tariku Seboka
- School of Public Health, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
| | - Daniel Sisay
- School of Public Health, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
| |
Collapse
|
3
|
Bangirana P, Boehme AK, Birabwa A, Opoka RO, Munube D, Mupere E, Kasirye P, Muwanguzi G, Musiimenta M, Ru G, Green NS, Idro R. Neurocognitive Impairment in Ugandan Children with Sickle Cell Anemia Compared to Sibling Controls: A cross-sectional study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.11.09.23298329. [PMID: 38014206 PMCID: PMC10680894 DOI: 10.1101/2023.11.09.23298329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Introduction Neurocognitive function in Ugandan children aged 1-12 years with sickle cell anemia (SCA) were compared to their non-SCA siblings to identify risk factors for disease-associated impairment. Methods This cross-sectional neurocognitive function study of children with SCA (N=242) and non-SCA siblings (N=127) used age- and linguistically-appropriate standardized tests of cognition, executive function and attention for children ages 1-4 and 5-12 years. Test scores were converted to locally derived age-normalized z-scores. The SCA group underwent standardized stroke examination for prior stroke and transcranial doppler ultrasound (TCD) to determine stroke risk by arterial flow velocity. Results The SCA group was younger than siblings (mean ages 5.46±3.0 versus 7.11±3.51 years, respectively; p <.001), with lower hemoglobin concentration (7.32±1.02 vs. 12.06±1.42, p <.001). Overall cognitive SCA z-scores were lower: -0.73 ±0.98 vs. siblings -0.25 ±1.12 (p<.001), with comparable findings for executive function of -1.09±0.94 versus -0.84±1.26 (p=0.045), respectively. Attention z-scores for ages 5-12 for the SCA group and controls were similar: -0.37±1.4 vs. -0.11±0.17 (p=.09). Overall differences by SCA status were largely driven by the older age group, as z-scores in the younger sub-sample did not differ from controls. Analyses revealed the strongest predictors of poor neurocognitive outcomes among the SCA sample to be the disease, age and prior stroke (each p<.001). Impact from anemia and SCA were indistinguishable. Discussion Neurocognitive testing in children with SCA compared to non-SCA siblings revealed poorer SCA-associated functioning in children older than age 4. Results indicate need for trials assessing impact from disease modification for children with SCA.
Collapse
Affiliation(s)
- Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Amelia K. Boehme
- Department of Neurology, Columbia University Vagelos Medical Center, New York, United States
| | - Annet Birabwa
- Department of Mental Health and Community Psychology, Makerere University College of Social Sciences, Kampala, Uganda
| | - Robert O. Opoka
- Global Health Uganda, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Deogratias Munube
- Global Health Uganda, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Phillip Kasirye
- Directorate of Paediatrics and Child Health, Mulago National Referral Hospital
| | | | | | - George Ru
- Department of Pediatrics, Columbia University Vagelos Medical Center, New York, United States
| | - Nancy S. Green
- Department of Pediatrics, Columbia University Vagelos Medical Center, New York, United States
| | - Richard Idro
- Global Health Uganda, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| |
Collapse
|
4
|
Piel FB, Rees DC, DeBaun MR, Nnodu O, Ranque B, Thompson AA, Ware RE, Abboud MR, Abraham A, Ambrose EE, Andemariam B, Colah R, Colombatti R, Conran N, Costa FF, Cronin RM, de Montalembert M, Elion J, Esrick E, Greenway AL, Idris IM, Issom DZ, Jain D, Jordan LC, Kaplan ZS, King AA, Lloyd-Puryear M, Oppong SA, Sharma A, Sung L, Tshilolo L, Wilkie DJ, Ohene-Frempong K. Defining global strategies to improve outcomes in sickle cell disease: a Lancet Haematology Commission. Lancet Haematol 2023; 10:e633-e686. [PMID: 37451304 DOI: 10.1016/s2352-3026(23)00096-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/12/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Frédéric B Piel
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| | - David C Rees
- Department of Paediatric Haematology, King's College London, King's College Hospital, London, UK
| | - Michael R DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence for Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Obiageli Nnodu
- Department of Haematology and Blood Transfusion, College of Health Sciences and Centre of Excellence for Sickle Cell Disease Research and Training, University of Abuja, Abuja, Nigeria
| | - Brigitte Ranque
- Department of Internal Medicine, Georges Pompidou European Hospital, Assistance Publique-Hopitaux de Paris Centre, University of Paris Cité, Paris, France
| | - Alexis A Thompson
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russell E Ware
- Division of Hematology and Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Miguel R Abboud
- Department of Pediatrics and Adolescent Medicine, and Sickle Cell Program, American University of Beirut, Beirut, Lebanon
| | - Allistair Abraham
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA
| | - Emmanuela E Ambrose
- Department of Paediatrics and Child Health, Bugando Medical Centre, Mwanza, Tanzania
| | - Biree Andemariam
- New England Sickle Cell Institute, University of Connecticut Health, Connecticut, USA
| | - Roshan Colah
- Department of Haematogenetics, Indian Council of Medical Research National Institute of Immunohaematology, Mumbai, India
| | - Raffaella Colombatti
- Pediatric Oncology Hematology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Nicola Conran
- Department of Clinical Medicine, School of Medical Sciences, Center of Hematology and Hemotherapy (Hemocentro), University of Campinas-UNICAMP, Campinas, Brazil
| | - Fernando F Costa
- Department of Clinical Medicine, School of Medical Sciences, Center of Hematology and Hemotherapy (Hemocentro), University of Campinas-UNICAMP, Campinas, Brazil
| | - Robert M Cronin
- Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Mariane de Montalembert
- Department of Pediatrics, Necker-Enfants Malades Hospital, Assistance Publique-Hopitaux de Paris Centre, Paris, France
| | - Jacques Elion
- Paris Cité University and University of the Antilles, Inserm, BIGR, Paris, France
| | - Erica Esrick
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Anthea L Greenway
- Department Clinical Haematology, Royal Children's Hospital, Parkville and Department Haematology, Monash Health, Clayton, VIC, Australia
| | - Ibrahim M Idris
- Department of Hematology, Aminu Kano Teaching Hospital/Bayero University Kano, Kano, Nigeria
| | - David-Zacharie Issom
- Department of Business Information Systems, School of Management, HES-SO University of Applied Sciences and Arts of Western Switzerland, Geneva, Switzerland
| | - Dipty Jain
- Department of Paediatrics, Government Medical College, Nagpur, India
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zane S Kaplan
- Department of Clinical Haematology, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Allison A King
- Departments of Pediatrics and Internal Medicine, Divisions of Pediatric Hematology and Oncology and Hematology, Washington University School of Medicine, St Louis, MO, USA
| | - Michele Lloyd-Puryear
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Samuel A Oppong
- Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leon Tshilolo
- Institute of Biomedical Research/CEFA Monkole Hospital Centre and Official University of Mbuji-Mayi, Mbuji-Mayi, Democratic Republic of the Congo
| | - Diana J Wilkie
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL, USA
| | - Kwaku Ohene-Frempong
- Division of Hematology, Children's Hospital of Philadelphia, Pennsylvania, USA; Sickle Cell Foundation of Ghana, Kumasi, Ghana
| |
Collapse
|
5
|
Pendergrast J, Ajayi LT, Kim E, Campitelli MA, Graves E. Sickle cell disease in Ontario, Canada: an epidemiologic profile based on health administrative data. CMAJ Open 2023; 11:E725-E733. [PMID: 37582620 PMCID: PMC10435244 DOI: 10.9778/cmajo.20220145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND The number of patients with sickle cell disease in Ontario, Canada, is unknown. In the absence of a formal registry, we performed a study to determine an approximate census via analysis of health administrative databases. METHODS We identified Ontario patients with a diagnosis of sickle cell disease through queries of the Discharge Abstract Database, National Ambulatory Care Reporting System and Newborn Screening Ontario database. The period of inquiry was Apr. 1, 2007, through Mar. 31, 2017. We identified repeat interactions by the same patient by cross-referencing provincial health insurance plan numbers. RESULTS We documented health care system interactions for 3418 unique patients (1912 [55.9%] female, median age at the time of identification 24 yr). Over the 10-year study period, patients visited the emergency department a median of 2 (interquartile range [IQR] 1-7) times and an average of 6.69 (standard deviation [SD] 26.71) times, and were admitted to hospital a median of 1 (IQR 1-5) time and an average of 4.38 (SD 8.53) times for treatment related to sickle cell disease. A total of 229 patients (6.7%) died during the study period, with an average age at death of 55 years. Even without accounting for the effects of immigration, the rate of natural increase slowed slightly over the study period owing to a decrease in the annual number of affected births. INTERPRETATION The estimated prevalence of patients with sickle cell disease in Ontario in 2007/08-2016/17 was 1 in 4200, and affected patients' need for hospital-based care was substantial, although highly variable. Similar queries of health administrative databases may be feasible in other Canadian provinces.
Collapse
Affiliation(s)
- Jacob Pendergrast
- Department of Medical Oncology and Hematology (Pendergrast), University Health Network; Department of Medicine (Pendergrast), University of Toronto; Sickle Cell Awareness Group of Ontario (Tunji Ajayi); ICES Central (Kim, Campitelli, Graves), Toronto, Ont.
| | - Lanre Tunji Ajayi
- Department of Medical Oncology and Hematology (Pendergrast), University Health Network; Department of Medicine (Pendergrast), University of Toronto; Sickle Cell Awareness Group of Ontario (Tunji Ajayi); ICES Central (Kim, Campitelli, Graves), Toronto, Ont
| | - Eliane Kim
- Department of Medical Oncology and Hematology (Pendergrast), University Health Network; Department of Medicine (Pendergrast), University of Toronto; Sickle Cell Awareness Group of Ontario (Tunji Ajayi); ICES Central (Kim, Campitelli, Graves), Toronto, Ont
| | - Michael A Campitelli
- Department of Medical Oncology and Hematology (Pendergrast), University Health Network; Department of Medicine (Pendergrast), University of Toronto; Sickle Cell Awareness Group of Ontario (Tunji Ajayi); ICES Central (Kim, Campitelli, Graves), Toronto, Ont
| | - Erin Graves
- Department of Medical Oncology and Hematology (Pendergrast), University Health Network; Department of Medicine (Pendergrast), University of Toronto; Sickle Cell Awareness Group of Ontario (Tunji Ajayi); ICES Central (Kim, Campitelli, Graves), Toronto, Ont
| |
Collapse
|
6
|
Isa H, Okocha E, Adegoke SA, Nnebe-Agumadu U, Kuliya-Gwarzo A, Sopekan A, Ofakunrin AO, Ugwu N, Hassan AA, Ohiaeri C, Madu A, Diaku-Akinwumi I, Ekwem L, Dogara LG, Okoh D, Jasini J, Girei A, Ekwere T, Okolo A, Kangiwa U, Lawson J, Chianumba R, Brown B, Akinola N, Nwegbu M, Nnodu O. Strategies to improve healthcare services for patients with sickle cell disease in Nigeria: The perspectives of stakeholders. Front Genet 2023; 14:1052444. [PMID: 36816043 PMCID: PMC9936139 DOI: 10.3389/fgene.2023.1052444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Background: Sickle cell disease (SCD) continues to pose physical and psychosocial burdens to patients, caregivers and health workers. Stakeholder engagement in the processes of policy making and implementation is increasingly becoming the cornerstone of best practices in healthcare. Aim and Objectives: To engage stakeholders with a view to assessing the knowledge of SCD; ascertain the challenges associated with accessibility and affordability of healthcare services; improve the quality of care, and thereby effect behavioral change through increasing attendance and follow-up of patients in the clinics. Methodology: A Stakeholders' Engagement meeting organized by the Sickle Pan Africa Research Consortium Nigeria Network (SPARC-NEt) was attended by patients, caregivers and members of patient support groups, healthcare providers and management/policymakers. The engagement was through PowerPoint presentations, structured questionnaires and an interactive session. The structured questionnaire assessed the knowledge of stakeholders about SCD; the quality of healthcare services; challenges with access and affordability; and SCD-related government policies. Results: Three hundred and twelve stakeholders attended the engagement meeting. Of the 133 that participated in the study, medical workers were the most represented. The majority had good knowledge of what causes SCD (96.2%) and the best place to get help during SCD crisis (98.5%). However, knowledge of the specific preventive measures of SCD and its crisis was not optimal. In terms of the role of community engagement and education, only about one-quarter of the study participants, 34 (25.6%) knew about their positive role in reducing the prevalence of SCD and alleviating SCD crises. Challenges identified include inadequate healthcare personnel and facilities, delay in obtaining laboratory results, long waiting time in the clinic, poor communication, absence of holistic consultation, uncoordinated healthcare services, high cost of care, ignorance, non-prioritization of SCD by government, lack of multisectoral collaboration and partnership with NGOs and international organizations. Strategies proffered to improve healthcare services include, community/stakeholder engagement and health education, sickle cell daycare services, access to a willing and dedicated multidisciplinary workforce, collaboration with support groups and government policies and programs. Conclusion: There is need for regular stakeholder engagement to improve access to healthcare services for SCD patients in Nigeria.
Collapse
Affiliation(s)
- Hezekiah Isa
- Centre of Excellence for Sickle Cell Research and Training, University of Abuja (CESRTA) Federal Capital Territory (FCT), Abuja, Nigeria,Department of Haematology and Blood Transfusion, University of Abuja, Abuja, Nigeria,*Correspondence: Hezekiah Isa,
| | - Emmanuel Okocha
- Department of Haematology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambara State, Nigeria
| | - Samuel Ademola Adegoke
- Department of Paediatrics and Child health, Obafemi Awolowo University, Ile Ife, Osun State, Nigeria
| | - Uche Nnebe-Agumadu
- Department of Paediatrics, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Aisha Kuliya-Gwarzo
- Department of Haematology, Aminu Kano University Teaching Hospital, Kano, Kano State, Nigeria
| | - Alayo Sopekan
- Non Communicable Disease Unit, Federal Ministry of Health, Federal Secretariat, Abuja, Nigeria
| | | | - Ngozi Ugwu
- Department of Haematology, Alex Ekweme Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
| | - Abdul-Aziz Hassan
- Department of Haematology and Blood Transfusion, Ahmadu Bello University, Zaria, Kaduna State, Nigeria
| | - Chinatu Ohiaeri
- Department of Paediatrics, Federal Medical Centre Keffi, Keffi, Nasarawa State, Nigeria
| | - Anazoeze Madu
- Department of Haematology, University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria
| | - Ijeoma Diaku-Akinwumi
- Department of Paediatrics, Lagos State University Teaching Hospital, Ikeja, Lagos State, Nigeria
| | - Lilian Ekwem
- Department of Paediatrics, General Hospital Nyanya, Abuja, Nigeria
| | - Livingstone Gayus Dogara
- Departments of Haematology and Blood Transfusion, Kaduna State University Teaching Hospital, Kaduna, Kaduna State, Nigeria
| | - Dorothy Okoh
- Department of Haematology, Rivers State University, Port Harcourt, Rivers State, Nigeria
| | - James Jasini
- Department of Haematology, Federal Medical Centre, Yola, Adamawa State, Nigeria
| | - Ahmed Girei
- Department of Haematology, Federal Teaching Hospital Gombe, Gombe, Gombe State, Nigeria
| | - Timothy Ekwere
- Department of Haematology, University of Uyo, Uyo, Akwa IbomState, Nigeria
| | - Angela Okolo
- Federal Medical Centre Asaba, Asaba, Delta State, Nigeria
| | - Umar Kangiwa
- Department of Haematology, Federal Medical Centre, Birnin Kebbi, Kebbi State, Nigeria
| | - Juliet Lawson
- Department of Paediatrics, Zankli Medical Centre, Abuja, Nigeria
| | - Reuben Chianumba
- Centre of Excellence for Sickle Cell Research and Training, University of Abuja (CESRTA) Federal Capital Territory (FCT), Abuja, Nigeria
| | - Biobele Brown
- Department of Paediatrics, University College Hospital, Ibadan, Oyo State, Nigeria
| | - Norah Akinola
- Department of Haematology, Obafemi Awolowo University Teaching Hospital, Ile Ife, Osun State, Nigeria
| | - Maxwell Nwegbu
- Centre of Excellence for Sickle Cell Research and Training, University of Abuja (CESRTA) Federal Capital Territory (FCT), Abuja, Nigeria,Department of Chemical Pathology, University of Abuja, Abuja, Nigeria
| | - Obiageli Nnodu
- Centre of Excellence for Sickle Cell Research and Training, University of Abuja (CESRTA) Federal Capital Territory (FCT), Abuja, Nigeria,Department of Haematology and Blood Transfusion, University of Abuja, Abuja, Nigeria
| |
Collapse
|
7
|
Khan H, Krull M, Hankins JS, Wang WC, Porter JS. Sickle cell disease and social determinants of health: A scoping review. Pediatr Blood Cancer 2023; 70:e30089. [PMID: 36495544 PMCID: PMC9790038 DOI: 10.1002/pbc.30089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/27/2022] [Accepted: 10/18/2022] [Indexed: 12/14/2022]
Abstract
Social determinants of health (SDoH) may impact outcomes in sickle cell disease (SCD). We conducted a comprehensive literature review of five electronic databases to elucidate the relationship between SDoH and SCD, and identify gaps in the literature. Our search yielded 59 articles, which we organized into five SDoH areas: Neighborhood and Built Environment, Health and Healthcare, Social and Community Context, Education, and Economic Stability. We found that social determinants, such as access to healthcare, were inconsistently evaluated. Improved recognition and understanding of SDoH should enhance the development of programs that directly address its detrimental effects on patients with SCD.
Collapse
Affiliation(s)
- Hamda Khan
- Departments of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Mathew Krull
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jane S. Hankins
- Departments of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Winfred C. Wang
- Departments of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jerlym S. Porter
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN
| |
Collapse
|
8
|
Abstract
BACKGROUND Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and a reduced life expectancy. Hydroxyurea (hydroxycarbamide), an oral chemotherapeutic drug, ameliorates some of the clinical problems of SCD, in particular that of pain, by raising foetal haemoglobin (HbF). This is an update of a previously published Cochrane Review. OBJECTIVES The aims of this review are to determine through a review of randomised or quasi-randomised studies whether the use of hydroxyurea in people with SCD alters the pattern of acute events, including pain; prevents, delays or reverses organ dysfunction; alters mortality and quality of life; or is associated with adverse effects. In addition, we hoped to assess whether the response to hydroxyurea in SCD varies with the type of SCD, age of the individual, duration and dose of treatment, and healthcare setting. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Haemoglobinopathies Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. The date of the most recent search was 17 February 2022. SELECTION CRITERIA Randomised and quasi-randomised controlled trials (RCTs and quasi-RCTs), of one month or longer, comparing hydroxyurea with placebo or standard therapy in people with SCD. DATA COLLECTION AND ANALYSIS Authors independently assessed studies for inclusion, carried out data extraction, assessed the risk of bias and assessed the quality of the evidence using GRADE. MAIN RESULTS We included nine RCTs recruiting 1104 adults and children with SCD (haemoglobin SS (HbSS), haemoglobin SC (HbSC) or haemoglobin Sβºthalassaemia (HbSβºthal) genotypes). Studies lasted from six to 30 months. We judged the quality of the evidence for the first two comparisons below as moderate to low as the studies contributing to these comparisons were mostly large and well-designed (and at low risk of bias); however, the evidence was limited and imprecise for some outcomes such as quality of life, deaths during the studies and adverse events, and the results are applicable only to individuals with HbSS and HbSβºthal genotypes. We judged the quality of the evidence for the third and fourth comparisons to be very low due to the limited number of participants, the lack of statistical power (both studies were terminated early with approximately only 20% of their target sample size recruited) and the lack of applicability to all age groups and genotypes. Hydroxyurea versus placebo Five studies (784 adults and children with HbSS or HbSβºthal) compared hydroxyurea to placebo; four recruited individuals with only severe disease and one recruited individuals with all disease severities. Hydroxyurea probably improves pain alteration (using measures such as pain crisis frequency, duration, intensity, hospital admissions and opoid use) and life-threatening illness, but we found no difference in death rates (10 deaths occurred during the studies, but the rates did not differ by treatment group) (all moderate-quality evidence). Hydroxyurea may improve measures of HbF (low-quality evidence) and probably decreases neutrophil counts (moderate-quality evidence). There were no consistent differences in terms of quality of life and adverse events (including serious or life-threatening events) (low-quality evidence). There were fewer occurrences of acute chest syndrome and blood transfusions in the hydroxyurea groups. Hydroxyurea and phlebotomy versus transfusion and chelation Two studies (254 children with HbSS or HbSβºthal also with risk of primary or secondary stroke) contributed to this comparison. There were no consistent differences in terms of pain alteration, death or adverse events (low-quality evidence) or life-threatening illness (moderate-quality evidence). Hydroxyurea with phlebotomy probably increased HbF and decreased neutrophil counts (moderate-quality evidence), but there were more occurrences of acute chest syndrome and infections. Quality of life was not reported. In the primary prevention study, no strokes occurred in either treatment group but in the secondary prevention study, seven strokes occurred in the hydroxyurea and phlebotomy group (none in the transfusion and chelation group) and the study was terminated early. Hydroxyurea versus observation One study (22 children with HbSS or HbSβºthal also at risk of stoke) compared hydroxyurea to observation. Pain alteration and quality of life were not reported. There were no differences in life-threatening illness, death (no deaths reported in either group) or adverse events (very low-quality evidence). We are uncertain if hydroxyurea improves HbF or decreases neutrophil counts (very low-quality evidence). Treatment regimens with and without hydroxyurea One study (44 adults and children with HbSC) compared treatment regimens with and without hydroxyurea. Pain alteration, life-threatening illness and quality of life were not reported. There were no differences in death rates (no deaths reported in either group), adverse events or neutrophil levels (very low-quality evidence). We are uncertain if hydroxyurea improves HbF (very low-quality evidence). AUTHORS' CONCLUSIONS There is evidence to suggest that hydroxyurea may be effective in decreasing the frequency of pain episodes and other acute complications in adults and children with sickle cell anaemia of HbSS or HbSβºthal genotypes and in preventing life-threatening neurological events in those with sickle cell anaemia at risk of primary stroke by maintaining transcranial Doppler velocities. However, there is still insufficient evidence on the long-term benefits of hydroxyurea, particularly with regard to preventing chronic complications of SCD, or recommending a standard dose or dose escalation to maximum tolerated dose. There is also insufficient evidence about the long-term risks of hydroxyurea, including its effects on fertility and reproduction. Evidence is also limited on the effects of hydroxyurea on individuals with the HbSC genotype. Future studies should be designed to address such uncertainties.
Collapse
Affiliation(s)
- Angela E Rankine-Mullings
- Sickle Cell Unit, Caribbean Institute for Health Research, University of the West Indies, Kingston, Jamaica
| | - Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| |
Collapse
|
9
|
Abdullahi SU, Jibir BW, Bello-Manga H, Gambo S, Inuwa H, Tijjani AG, Idris N, Galadanci A, Hikima MS, Galadanci N, Borodo A, Tabari AM, Haliru L, Suleiman A, Ibrahim J, Greene BC, Ghafuri DL, Rodeghier M, Slaughter JC, Kirkham FJ, Neville K, Kassim A, Trevathan E, Jordan LC, Aliyu MH, DeBaun MR. Hydroxyurea for primary stroke prevention in children with sickle cell anaemia in Nigeria (SPRING): a double-blind, multicentre, randomised, phase 3 trial. Lancet Haematol 2022; 9:e26-e37. [PMID: 34971579 PMCID: PMC10072240 DOI: 10.1016/s2352-3026(21)00368-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND In high-income countries, standard care for primary stroke prevention in children with sickle cell anaemia and abnormal transcranial Doppler velocities results in a 92% relative risk reduction of strokes but mandates initial monthly blood transfusion. In Africa, where regular blood transfusion is not feasible for most children, we tested the hypothesis that initial moderate-dose compared with low-dose hydroxyurea decreases the incidence of strokes for children with abnormal transcranial Doppler velocities. METHODS SPRING is a double-blind, parallel-group, randomised, controlled, phase 3 trial of children aged 5-12 years with sickle cell anaemia with abnormal transcranial Doppler velocities conducted at three teaching hospitals in Nigeria. For randomisation, we used a permuted block allocation scheme with block sizes of four, stratified by sex and site. Allocation was concealed from all but the pharmacists and statisticians. Participants were assigned in a 1:1 ratio to low-dose (10 mg/kg per day) or moderate-dose (20 mg/kg per day) oral hydroxyurea taken once daily with monthly clinical evaluation and laboratory monitoring. The primary outcome was initial stroke or transient ischaemic attack, centrally adjudicated. The secondary outcome was all-cause hospitalisation. We used the intention-to-treat population for data analysis. The trial was stopped early for futility after a planned minimum follow-up of 3·0 years to follow-up for participants. This trial was registered with ClinicalTrials.gov, number NCT02560935. FINDINGS Between Aug 2, 2016, and June 14, 2018, 220 participants (median age 7·2 years [IQR 5·5-8·9]; 114 [52%] female) were randomly allocated and followed for a median of 2·4 years (IQR 2·0-2·8). All participants were Nigerian and were from the following ethnic groups: 179 (82%) people were Hausa, 25 (11%) were Fulani, and 16 (7%) identified as another ethnicity. In the low-dose hydroxyurea group, three (3%) of 109 participants had strokes, with an incidence rate of 1·19 per 100 person-years and in the moderate-dose hydroxyurea group five (5%) of 111 had strokes with an incidence rate of 1·92 per 100 person-years (incidence rate ratio 0·62 [95% CI 0·10-3·20], p=0·77). The incidence rate ratio of hospitalisation for any reason was 1·71 (95% CI 1·15-2·57, p=0·0071), with higher incidence rates per 100 person-years in the low-dose group versus the moderate-dose group (27·43 vs 16·08). No participant had hydroxyurea treatment stopped for myelosuppression. INTERPRETATION Compared with low-dose hydroxyurea therapy, participants treated with moderate-dose hydroxyurea had no difference in the stroke incidence rate. However, secondary analyses suggest that the moderate-dose group could lower incidence rates for all-cause hospitalisations. These findings provide an evidence-based guideline for the use of low-dose hydroxyurea therapy for children with sickle cell anaemia at risk of stroke. FUNDING National Institute of Neurological Disorders and Stroke.
Collapse
Affiliation(s)
- Shehu U Abdullahi
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Binta W Jibir
- Department of Pediatrics, Hasiya Bayero Pediatric Hospital, Kano, Nigeria
| | - Halima Bello-Manga
- Department of Haematology and Blood Transfusion, Kaduna State University/Barau Dikko Teaching Hospital, Kaduna, Nigeria
| | - Safiya Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Hauwa Inuwa
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Aliyu G Tijjani
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Nura Idris
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Aisha Galadanci
- Department of Haematology and Blood Transfusion, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Mustapha S Hikima
- Department of Radiology, Muhammad Abdullahi Wase Teaching Hospital, Kano, Nigeria
| | - Najibah Galadanci
- Department of Epidemiology, School of Public health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Awwal Borodo
- Department of Medicine, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Abdulkadir M Tabari
- Department of Radiology, Kaduna State University, Barau Dikko Teaching Hospital, Kaduna, Nigeria
| | - Lawal Haliru
- Department of Pediatrics, Kaduna State University, Barau Dikko Teaching Hospital, Kaduna, Nigeria
| | - Aisha Suleiman
- Department of Pediatrics, Kaduna State University, Barau Dikko Teaching Hospital, Kaduna, Nigeria
| | - Jamila Ibrahim
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Brittany C Greene
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Djamila L Ghafuri
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - James C Slaughter
- Department of Biostatistics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fenella J Kirkham
- Developmental Neurosciences, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Kathleen Neville
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adetola Kassim
- Department of Hematology and Oncology, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edwin Trevathan
- Vanderbilt Institute for Global Health, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Neurology, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lori C Jordan
- Department of Pediatrics, Neurology, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Muktar H Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael R DeBaun
- Vanderbilt Institute for Global Health, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA.
| |
Collapse
|
10
|
Ghafuri DL, Greene BC, Musa B, Gambo A, Sani A, Abdullahi S, Widil BJ, Bello-Manga H, Gambo S, Ghafuri M, Cassell H, Neville K, Kirkham F, Kassim AA, Aliyu MH, DeBaun MR, Jordan LC. Capacity Building for Primary Stroke Prevention Teams in Children Living With Sickle Cell Anemia in Africa. Pediatr Neurol 2021; 125:9-15. [PMID: 34563875 PMCID: PMC8559257 DOI: 10.1016/j.pediatrneurol.2021.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nigeria has the highest proportion of children with sickle cell anemia (SCA) globally; an estimated 150,000 infants with SCA are born annually. Primary stroke prevention in children with SCA must include Nigeria. We describe capacity-building strategies in conjunction with two National Institutes of Health-funded primary stroke prevention trials (a feasibility trial and phase III randomized controlled trial) with initial hydroxyurea treatment for children with SCA and abnormal transcranial Doppler (TCD) velocities in Nigeria. We anticipated challenges to conducting clinical trials in a low-resource setting with a local team that had not previously been involved in clinical research and sought a sustainable strategy for primary stroke prevention. METHODS This is a descriptive, prospective study of challenges, solutions, and research teams in two trials that enrolled a total of 679 children with SCA. RESULTS As part of the capacity-building component of the trials, over eight years, 23 research personnel (physicians, nurses, research coordinators, a statistician, and a pharmacist) completed a one-month research governance and ethics training program at Vanderbilt University Medical Center, USA. A lead research coordinator for each site completed the Society of Clinical Research Professionals certification. TCD machines were donated; radiologists and nonradiologists were trained and certified to perform TCD. A scalable E-prescription was implemented to track hydroxyurea treatment. We worked with regional government officials to support ongoing TCD-based screening and funding for hydroxyurea for children with SCA at a high risk of stroke. CONCLUSIONS Our trials and capacity building demonstrate a sustainable strategy to initiate and maintain pediatric SCA primary stroke prevention programs in Africa.
Collapse
Affiliation(s)
- Djamila L. Ghafuri
- Vanderbilt-Meharry Sickle Cell Center for Excellence, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, U.S.A
| | - Brittany Covert Greene
- Vanderbilt-Meharry Sickle Cell Center for Excellence, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, U.S.A
| | - Bilya Musa
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Awwal Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Abdulrasheed Sani
- Department of Pediatrics, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria
| | - Shehu Abdullahi
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Binta J. Widil
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Halima Bello-Manga
- Department of Hematology and Blood Transfusion, Barau Dikko Teaching Hospital/Kaduna State University, Kaduna, Nigeria
| | - Safiya Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Matin Ghafuri
- Vanderbilt-Meharry Sickle Cell Center for Excellence, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, U.S.A
| | - Holly Cassell
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, U.S.A
| | - Kathleen Neville
- Department of Pediatrics, Divisions of Pediatric Hematology-Oncology and Clinical Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Fenella Kirkham
- Department of Pediatrics, University of Arkansas for Medical Sciences/Arkansas Children’s Hospital, Little Rock, AR, U.S.A
| | - Adetola A. Kassim
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Vanderbilt-Ingram Cancer Center, Nashville, TN, U.S.A
| | - Muktar H. Aliyu
- Health Policy, Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Tennessee, U.S.A
| | - Michael R. DeBaun
- Vanderbilt-Meharry Sickle Cell Center for Excellence, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, U.S.A
| | - Lori C. Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University of Medicine, Tennessee, U.S.A
| |
Collapse
|
11
|
Darshana T, Rees D, Premawardhena A. Hydroxyurea and blood transfusion therapy for Sickle cell disease in South Asia: inconsistent treatment of a neglected disease. Orphanet J Rare Dis 2021; 16:148. [PMID: 33757549 PMCID: PMC7989007 DOI: 10.1186/s13023-021-01781-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/16/2021] [Indexed: 04/12/2024] Open
Abstract
Background Hydroxyurea and blood transfusion therapies remain the main therapeutic strategies for Sickle cell disease. Preliminary data suggest substantial variation and inconsistencies in practice of these two therapeutic modalities in South Asia. In this systematic review we searched Medline, Cochrane library and Scopus for articles on usage of hydroxyurea and blood transfusion therapies for sickle cell disease in South Asia published in English between October 2005 and October 2020. Results We selected 41 papers: 33 from India, 3 from Sri Lanka, 2 each from Pakistan and Bangladesh and one from Nepal. Only 14 prospective trials focused on hydroxyurea therapy from which majority (n = 10; 71.4%) adopted fixed low dose (10 mg/kg/day) regimen. With hydroxyurea therapy, 12 and 9 studies reported significant reductions in vaso-occlusive crises and transfusion requirement respectively. Severe anaemia (haemoglobin level < 6–7 g/dl) was the commonest indicator (n = 8) for transfusion therapy followed by vaso-occlusive crisis. Conclusions Published data on the hydroxyurea and transfusion therapies in South Asia are limited and heterogeneous. A clear gap of knowledge exists about the nature of the sickle cell disease in the Indian subcontinent particularly from countries outside India necessitating further evidence-based assessments and interventions.
Collapse
Affiliation(s)
- Thamal Darshana
- Department of Medical Laboratory Sciences, Faculty of Allied Health Sciences, University of Sri Jayewardenepura, Gangodawila, 10250, Nugegoda, Sri Lanka.
| | | | | |
Collapse
|
12
|
Olatunya OS. Poverty and severity of childhood sickle cell disease. Br J Haematol 2020; 190:819-821. [PMID: 32525576 DOI: 10.1111/bjh.16816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Oladele Simeon Olatunya
- Department of Paediatrics, College of Medicine, Ekiti State University, Ado Ekiti, Ekiti State, Nigeria
| |
Collapse
|