Equilibration time of haemoglobin concentration after packed red blood cell transfusion in children seen in the emergency unit of a tertiary hospital in Southeast, Nigeria

Blood transfusion is an important treatment modality for severe anaemia. Monitoring post-transfusion haemoglobin (Hb) concentration helps the clinician in assessing the success of blood transfusion. Previous authors have reported different timings for post-transfusion equilibration using varied time intervals for post-transfusion Hb concentration assessment. This study was therefore aimed at determining the appropriate time to assess Hb concentration after packed red blood cell (pRBC) transfusion in children using 5 different time intervals. It was a longitudinal observational study carried out in a tertiary care hospital in Southeast, Nigeria and involved 108 children aged 1-10 years without active bleeding or significant haemolysis that were transfused with pRBC. The Hb concentration was measured using a portable haemoglobinometer just before the blood transfusion and after the blood transfusion at 1, 6, 12, 24, and 48th-hour. The 1-hour (6.8 ± 1.5 g/dl) post-transfusion Hb concentration was significantly different (p 0.001) from the 6th-hour (10.2 ± 1.5 g/dl), but no further significant (p > 0.05) changes occurred after the 6th-hour till the 48th-hour. This finding suggests that equilibration of Hb concentration had occurred by the 6th hour after blood transfusion. This study, therefore, recommends that Hb concentration assessment in children without ongoing bleeding or haemolysis can be done at the 6th hour after pRBC transfusion.

Low-field magnetic resonance image enhancement via stochastic image quality transfer

Low-field (<1T) magnetic resonance imaging (MRI) scanners remain in widespread use in low- and middle-income countries (LMICs) and are commonly used for some applications in higher income countries e.g. for small child patients with obesity, claustrophobia, implants, or tattoos. However, low-field MR images commonly have lower resolution and poorer contrast than images from high field (1.5T, 3T, and above). Here, we present Image Quality Transfer (IQT) to enhance low-field structural MRI by estimating from a low-field image the image we would have obtained from the same subject at high field. Our approach uses (i) a stochastic low-field image simulator as the forward model to capture uncertainty and variation in the contrast of low-field images corresponding to a particular high-field image, and (ii) an anisotropic U-Net variant specifically designed for the IQT inverse problem. We evaluate the proposed algorithm both in simulation and using multi-contrast (T1-weighted, T2-weighted, and fluid attenuated inversion recovery (FLAIR)) clinical low-field MRI data from an LMIC hospital. We show the efficacy of IQT in improving contrast and resolution of low-field MR images. We demonstrate that IQT-enhanced images have potential for enhancing visualisation of anatomical structures and pathological lesions of clinical relevance from the perspective of radiologists. IQT is proved to have capability of boosting the diagnostic value of low-field MRI, especially in low-resource settings.

Detection of acute promyelocytic leukemia in peripheral blood and bone marrow with annotation-free deep learning

While optical microscopy inspection of blood films and bone marrow aspirates by a hematologist is a crucial step in establishing diagnosis of acute leukemia, especially in low-resource settings where other diagnostic modalities are not available, the task remains time-consuming and prone to human inconsistencies. This has an impact especially in cases of Acute Promyelocytic Leukemia (APL) that require urgent treatment. Integration of automated computational hematopathology into clinical workflows can improve the throughput of these services and reduce cognitive human error. However, a major bottleneck in deploying such systems is a lack of sufficient cell morphological object-labels annotations to train deep learning models. We overcome this by leveraging patient diagnostic labels to train weakly-supervised models that detect different types of acute leukemia. We introduce a deep learning approach, Multiple Instance Learning for Leukocyte Identification (MILLIE), able to perform automated reliable analysis of blood films with minimal supervision. Without being trained to classify individual cells, MILLIE differentiates between acute lymphoblastic and myeloblastic leukemia in blood films. More importantly, MILLIE detects APL in blood films (AUC 0.94 ± 0.04) and in bone marrow aspirates (AUC 0.99 ± 0.01). MILLIE is a viable solution to augment the throughput of clinical pathways that require assessment of blood film microscopy.

Content aware multi-focus image fusion for high-magnification blood film microscopy

Automated digital high-magnification optical microscopy is key to accelerating biology research and improving pathology clinical pathways. High magnification objectives with large numerical apertures are usually preferred to resolve the fine structural details of biological samples, but they have a very limited depth-of-field. Depending on the thickness of the sample, analysis of specimens typically requires the acquisition of multiple images at different focal planes for each field-of-view, followed by the fusion of these planes into an extended depth-of-field image. This translates into low scanning speeds, increased storage space, and processing time not suitable for high-throughput clinical use. We introduce a novel content-aware multi-focus image fusion approach based on deep learning which extends the depth-of-field of high magnification objectives effectively. We demonstrate the method with three examples, showing that highly accurate, detailed, extended depth of field images can be obtained at a lower axial sampling rate, using 2-fold fewer focal planes than normally required.

Haematological Changes Associated with Hepatitis B Virus Infection in Individuals with and without Sickle Cell Disease

BACKGROUND

Hepatitis B virus infection, a major public health problem that primarily affects the liver, may cause reduction in the levels of haemoglobin, haematocrit and in the extreme, could cause aplastic anaemia. The haematological characteristics could be detected with a complete blood count which could provide invaluable information for diagnosis and management of the disease.

AIM

To determine the effect of HBV infection on the blood count of individuals with sickle cell disease (SCD) and apparently normal healthy (Non-SCD).

SETTING

Non-SCD participants were recruited from the community while SCD patients in steady state were recruited from SCD routine clinics.

METHODS

The study was a cross - sectional study carried out on 1017 non-SCD and 1017 SCD individuals. Haematology Autoanalyzer was used to determine the complete blood count. Granulocyte-to-lymphocyte ratio (GLR), platelet to white blood cell count ratio (PWR) and platelet-to-lymphocyte ratio (PLR) were calculated. ELISA for HBsAg and HBV core antigen IgM antibodies were used to identify participants with HBV.

RESULTS

The non- SCD individuals infected with HBV had significantly higher WBC (7.51 ± 5.8 X109/L)) compared to a WBC (6.1 ± 3.4 X109/L) in uninfected individuals (p =0.001). PWR for HBV negative (49.9±28.6) was higher than that for HBV positive participants (41.4±17.6) (p=0.034). Mean platelet volume (MPV) of 9.93 ± 1.1fl in SCD individuals with HBV was significantly higher than 8.30 ± 0.95fl in SCD individuals without HBV (p=.001).

CONCLUSIONS

PWR and MPV may be useful as surrogate marker for detection of HBV disease progression in apparently normal healthy non - SCD and SCD populations to institute prompt appropriate ancillary investigation and treatment.

Clinicopathologic Features of Childhood Rhabdomyosarcoma and Treatment Outcomes in Ibadan, Nigeria: A 10-year Review

The objectives of this study were to describe the clinicopathologic features and treatment outcomes of childhood rhabdomyosarcoma in a resource-constrained setting. All cases of childhood rhabdomyosarcoma seen over a 10-year period (July 2006 to June 2016) at the University College Hospital, Ibadan, Nigeria were reviewed. Data were extracted from the database of the pediatric Hematology/Oncology Unit of the hospital and analyzed. Ethical approval was obtained from the Institutional Ethics Committee. Fifty children were seen comprising 30 men and 20 women with bimodal ages of 4 and 5 years. Median duration of illness was 16 weeks and the most common primary tumor site was the head-and-neck region in 27 (54%) of cases. The histologic subtypes were embryonal in 30 (60%), alveolar in 9 (18%), and not specified in 11 (22%). The Intergroup Rhabdomyosarcoma Study group TNM Pretreatment stages were stage I in 15 (30%), stage III in 17 (34%), and stage IV in 18 (36%). Treatment included chemotherapy, surgery, and radiotherapy and abandoned in 20 (40%) cases. Median survival was 45 weeks (95% confidence interval: 16.4-73.6) and 5 (10%) patients were alive and disease free, 4 years or more after diagnosis. Outcome of childhood rhabdomyosarcoma is poor and early diagnosis and improved access to treatment are recommended.

Optical mesoscopy, machine learning, and computational microscopy enable high information content diagnostic imaging of blood films

Automated image-based assessment of blood films has tremendous potential to support clinical haematology within overstretched healthcare systems. To achieve this, efficient and reliable digital capture of the rich diagnostic information contained within a blood film is a critical first step. However, this is often challenging, and in many cases entirely unfeasible, with the microscopes typically used in haematology due to the fundamental trade-off between magnification and spatial resolution. To address this, we investigated three state-of-the-art approaches to microscopic imaging of blood films which leverage recent advances in optical and computational imaging and analysis to increase the information capture capacity of the optical microscope: optical mesoscopy, which uses a giant microscope objective (Mesolens) to enable high-resolution imaging at low magnification; Fourier ptychographic microscopy, a computational imaging method which relies on oblique illumination with a series of LEDs to capture high-resolution information; and deep neural networks which can be trained to increase the quality of low magnification, low resolution images. We compare and contrast the performance of these techniques for blood film imaging for the exemplar case of Giemsa-stained peripheral blood smears. Using computational image analysis and shape-based object classification, we demonstrate their use for automated analysis of red blood cell morphology and visualization and detection of small blood-borne parasites such as the malarial parasite Plasmodium falciparum. Our results demonstrate that these new methods greatly increase the information capturing capacity of the light microscope, with transformative potential for haematology and more generally across digital pathology. © 2021 The Authors. The Journal of Pathology published by John Wiley & Sons, Ltd. on behalf of The Pathological Society of Great Britain and Ireland.

Utilization of Pneumococcal Vaccine and Penicillin Prophylaxis in Sickle Cell Disease in Three African Countries: Assessment among Healthcare Providers in SickleInAfrica

Sickle cell disease is a genetic disease with a predisposition to infections caused by encapsulated organisms, especially Streptococcus pneumoniae. Pneumococcal vaccines and prophylactic penicillin have reduced the rate of this infection and mortality in sickle cell disease. However, implementation of these interventions is limited in Africa. The objectives of the study were to assess health care providers' behaviors with the implementation of pneumococcal vaccination and penicillin prophylaxis and to identify barriers to their use. A 25-item online questionnaire was administered through SickleinAfrica: a network of researchers, and healthcare providers, in Ghana, Nigeria, and Tanzania, working to improve health outcomes of sickle cell disease in Africa. Data was collected and managed using the Research Electronic Data Capture (REDCap), tools and data analysis was done using STATA version 13 and R statistical software. Eighty-two medical practitioners responded to the questionnaire. Only 54.0 and 48.7% of respondents indicated the availability of published guidelines on sickle cell disease management and pneumococcal vaccine use, respectively, at their facilities. The majority (54.0%) perceived that the vaccines are effective but over 20.0% were uncertain of their usefulness. All respondents from Ghana and Tanzania affirmed the availability of guidelines for penicillin prophylaxis in contrast to 44.1% in Nigeria. Eighty-five percent of respondents affirmed the need for penicillin prophylaxis but 15.0% had a contrary opinion for reasons including the rarity of isolation of Streptococcus pneumoniae in African studies, and therefore, the uncertainty of its benefit. Lack of published guidelines on the management of sickle cell disease and doubts about the necessity of prophylactic measures are potential barriers to the implementation of effective interventions.

Paediatric soft tissue sarcomas in a resource constraint setting: Grade and stage at presentation and at oncologic intervention are usually of poor prognostic characteristics

AIM

To describe the pattern of paediatric Rhabdomyosarcomas (RMS) and Non-Rhabdomyosarcomas (NRMS) with emphasis on the indices that affect survival outcomes.

METHODS

We reviewed all patients with histologically confirmed RMS and NRMS in the Departments of Pathology and Paediatrics, University College Hospital (UCH), Ibadan, Nigeria; in children aged 0-14 years. The study period was January 1991 to December 2016. Information obtained included age, gender, morphology and site of the tumours. The tumour grade and pathologic/clinical staging of all patients were also obtained and verified by the clinical records. Tumour grading was carried out using the Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) Sarcoma group grading system and staging was done using TNM. Follow up, survival information and final outcome were retrieved.

RESULTS

The 104 patients included in the study had almost equal male-to-female ratio, age ranged between 5 months and 14 years (median 8.2 years). Rhabdomyosarcoma had mean age of 5.6 (±3.8) years while that of NRMS was 9.2(±4.1) years. Overall, the modal age group was 5-9 years. Rhabdomyosarcoma was the commonest histological type (76%), undifferentiated sarcomas (6.7%), fibrosarcoma (3.8%) and 2.9% each for synovial sarcoma and dermatofibrosarcoma protuberans. The common primary sites were the head and neck (including the orbit) 49 (47.1%), and the abdominopelvic 26 (25%) regions. Majority (89%) had histologic grade 3 at presentation. Seventy per cent and 64% of patients with RMS and NRMS, respectively, had high stage tumour at presentation. Median survival for all patients with Rhabdomyosarcoma was 45 weeks with a 1-year survival of 43% and 2-year survival of 25%. Non-RMS (Dermatofibrosarcoma protuberans and Solitary fibrous tumours) had survival of over 4 year's duration.

CONCLUSION

Majority of our patients presented at a late stage with histologic high grade which confers poor prognosis and reduced chances for good overall survival outcome.

Transcranial Doppler screening in Nigerian children with sickle cell disease: A 10-year longitudinal study on the SPPIBA cohort

BACKGROUND

Primary stroke prevention programmes for children with sickle cell disease (SCD) have been shown to be feasible interventions in resource-poor countries. Different hydroxyurea (HU) regimens have been utilised in ameliorating the severity of SCD.

OBJECTIVE

To determine the long-term outcomes of the stroke prevention programme for children with SCD in Ibadan (SPPIBA), Nigeria.

METHODS

A longitudinal study of 396 children with haemoglobin SS disease who had been on the stroke prevention programme for a minimum period of 5 years. All enrollees had nonimaging TCD performed at baseline and thereafter 3-monthly or annually. Children with TCD velocities ≥170 cm/s were treated with HU by dose-escalation regimen.

RESULTS

The mean age at first TCD examination was 102 ± 46.7 months and the period of follow-up ranged from 5 to 10 years (mean = 7.2 ± 1.7). Time to significant decline in TCD velocities ranged from 5 to 35 months, (median = 10.0 months). The minimum dose of HU required to achieve significant decline in TCD velocities ranged from 15 to 31 mg/kg/day, mean 23.7 (±3.9). HU dose escalation beyond 20 mg/kg/day was required to attain significant reductions in the time-averaged mean of maximal velocities (TAMMV) in 69.1% of the cases. Two stroke events occurred giving a stroke incidence of 0.08 per 100 patient-years.

CONCLUSION

The majority of Nigerian children with SCD and elevated TCD velocities achieved significant decline in TAMMV within the first year of HU therapy but on higher doses of HU. It might be important to individualise HU doses for optimal outcomes in primary stroke prevention.

Data-driven malaria prevalence prediction in large densely populated urban holoendemic sub-Saharan West Africa

Over 200 million malaria cases globally lead to half-million deaths annually. The development of malaria prevalence prediction systems to support malaria care pathways has been hindered by lack of data, a tendency towards universal "monolithic" models (one-size-fits-all-regions) and a focus on long lead time predictions. Current systems do not provide short-term local predictions at an accuracy suitable for deployment in clinical practice. Here we show a data-driven approach that reliably produces one-month-ahead prevalence prediction within a densely populated all-year-round malaria metropolis of over 3.5 million inhabitants situated in Nigeria which has one of the largest global burdens of P. falciparum malaria. We estimate one-month-ahead prevalence in a unique 22-years prospective regional dataset of > 9 × 10⁴ participants attending our healthcare services. Our system agrees with both magnitude and direction of the prediction on validation data achieving MAE ≤ 6 × 10^-2, MSE ≤ 7 × 10^-3, PCC (median 0.63, IQR 0.3) and with more than 80% of estimates within a (+ 0.1 to - 0.05) error-tolerance range which is clinically relevant for decision-support in our holoendemic setting. Our data-driven approach could facilitate healthcare systems to harness their own data to support local malaria care pathways.

Acute leukemia in sickle cell disease patients in a tertiary health facility in Nigeria: a case series

BACKGROUND AND OBJECTIVES

Sickle cell disease(SCD) is a disorder of red cells resulting from the co-inheritance of haemoglobin S (HbS) with another abnormal haemoglobin. The diagnosis of acute leukaemia is uncommon in our patients with sickle cell disease more so the patients have high morbidity and mortality due to the sickling process. Acute leukemia is a malignant clonal disorder of haemopoietic precursor cells resulting in accumulation of immature blood cells in the bone marrow and blood. The objective of the case series was to highlight the challenges of diagnosis and management of SCD patients with acute leukaemia, the importance of peripheral blood film review and propound a possible risk factor.

METHODS

Records of 58 patients diagnosed and managed for acute leukaemia over a 7 year period at the University College Hospital, Ibadan were reviewed. The diagnosis of acute leukaemia was based on clinical features in addition to peripheral and bone marrow smears findings. Microsoft excel version 2013 was used for statistical analysis.

RESULTS

Five (8.6%) of the patients with acute leukaemia also had sickle cell disease: 3 males and 2 females were described. Recurrent fever and anaemia were the most consistent presenting features in the patients. All the patients were not on any routine medications meant for SCD patients and had poor history of clinic attendance prior to the diagnosis of acute leukaemia. The diagnosis of acute leukaemia was not made until the patients were seen by a haematologist. The principal tool of diagnosis in all the patients was peripheral blood film review. Two patients were discharged against medical advice. The treatment period ranged between one month and one year in the remaining three patients.

CONCLUSION

SCD patients are not exempted from developing acute leukaemias and the diagnoses of the two conditions overwhelms the social and economic support of patients and care givers. The study also underscores the relevance of high level of suspicion and prompt review of peripheral blood film of SCD patients particularly when patients present with unremitting symptoms associated with anaemia and fever.

Expert-level automated malaria diagnosis on routine blood films with deep neural networks

Over 200 million malaria cases globally lead to half a million deaths annually. Accurate malaria diagnosis remains a challenge. Automated imaging processing approaches to analyze Thick Blood Films (TBF) could provide scalable solutions, for urban healthcare providers in the holoendemic malaria sub-Saharan region. Although several approaches have been attempted to identify malaria parasites in TBF, none have achieved negative and positive predictive performance suitable for clinical use in the west sub-Saharan region. While malaria parasite object detection remains an intermediary step in achieving automatic patient diagnosis, training state-of-the-art deep-learning object detectors requires the human-expert labor-intensive process of labeling a large dataset of digitized TBF. To overcome these challenges and to achieve a clinically usable system, we show a novel approach. It leverages routine clinical-microscopy labels from our quality-controlled malaria clinics, to train a Deep Malaria Convolutional Neural Network classifier (DeepMCNN) for automated malaria diagnosis. Our system also provides total Malaria Parasite (MP) and White Blood Cell (WBC) counts allowing parasitemia estimation in MP/μL, as recommended by the WHO. Prospective validation of the DeepMCNN achieves sensitivity/specificity of 0.92/0.90 against expert-level malaria diagnosis. Our approach PPV/NPV performance is of 0.92/0.90, which is clinically usable in our holoendemic settings in the densely populated metropolis of Ibadan. It is located within the most populous African country (Nigeria) and with one of the largest burdens of Plasmodium falciparum malaria. Our openly available method is of importance for strategies aimed to scale malaria diagnosis in urban regions where daily assessment of thousands of specimens is required.

Depleted circulatory complement-lysis inhibitor (CLI) in childhood cerebral malaria returns to normal with convalescence

BACKGROUND

Cerebral malaria (CM), is a life-threatening childhood malaria syndrome with high mortality. CM is associated with impaired consciousness and neurological damage. It is not fully understood, as yet, why some children develop CM. Presented here is an observation from longitudinal studies on CM in a paediatric cohort of children from a large, densely-populated and malaria holoendemic, sub-Saharan, West African metropolis.

METHODS

Plasma samples were collected from a cohort of children with CM, severe malarial anaemia (SMA), uncomplicated malaria (UM), non-malaria positive healthy community controls (CC), and coma and anemic patients without malaria, as disease controls (DC). Proteomic two-dimensional difference gel electrophoresis (2D-DIGE) and mass spectrometry were used in a discovery cohort to identify plasma proteins that might be discriminatory among these clinical groups. The circulatory levels of identified proteins of interest were quantified by ELISA in a prospective validation cohort.

RESULTS

The proteome analysis revealed differential abundance of circulatory complement-lysis inhibitor (CLI), also known as Clusterin (CLU). CLI circulatory level was low at hospital admission in all children presenting with CM and recovered to normal level during convalescence (p < 0.0001). At acute onset, circulatory level of CLI in the CM group significantly discriminates CM from the UM, SMA, DC and CC groups.

CONCLUSIONS

The CLI circulatory level is low in all patients in the CM group at admission, but recovers through convalescence. The level of CLI at acute onset may be a specific discriminatory marker of CM. This work suggests that CLI may play a role in the pathophysiology of CM and may be useful in the diagnosis and follow-up of children presenting with CM.

Protocol for the Process Evaluation of the Online Remote Behavioural Intervention for Tics (ORBIT) randomized controlled trial for children and young people

BACKGROUND

Process evaluations are an important component in the interpretation and understanding of outcomes in trials. The Online Remote Behavioural Intervention for Tics (ORBIT) study is a randomized controlled trial evaluating the effectiveness of an Internet-delivered behavioural intervention (called BIP TIC) compared to an Internet-delivered education programme aimed at children and young people with tics. A process evaluation will be undertaken alongside the main trial to determine precisely how the behavioural intervention works and ascertain whether, and if so, how, the intervention could be successfully implemented in standard clinical practice. This protocol paper describes the rationale, aims, and methodology of the ORBIT trial process evaluation.

METHODS

The process evaluation will have a mixed-methods design following the UK Medical Research Council 2015 guidelines, comprising both quantitative and qualitative data collection. This will include analysing data usage of participants in the intervention arm; purposively sampled, semi-structured interviews of parents and children, therapists and supervisors, and referring clinicians of the ORBIT trial, as well as analysis of qualitative comments put into the online therapy platform by participants at the end of treatment. Qualitative data will be analysed thematically. Quantitative and qualitative data will be integrated in a triangulation approach, to provide an understanding of how the intervention works, and what resources are needed for effective implementation, uptake and use in routine clinical care.

DISCUSSION

This process evaluation will explore the experiences of participants, therapists and supervisors and referring clinicians of a complex online intervention. By contextualising trial efficacy results, this will help understand how and if the intervention worked and what may be required to sustain the implementation of the treatment long term. The findings will also aid in our understanding of factors that can affect the success of complex interventions. This will enable future researchers developing online behavioural interventions for children and young people with mental health and neurological disorders to gain invaluable information from this process evaluation.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Number, ISRCTN70758207. Registered on 20 March 2018. ClinicalTrials.gov, NCT03483493. Registered on 30 March 2018.

Annual stroke incidence in Nigerian children with sickle cell disease and elevated TCD velocities treated with hydroxyurea

BACKGROUND

Elevated transcranial Doppler (TCD) velocities accurately predict stroke risk in children with sickle cell disease (SCD). Chronic blood transfusion, the gold standard for primary stroke prevention, is faced with numerous challenges in Africa. Hydroxyurea (HU) has been shown to reduce elevated TCD velocities in children with SCD.

AIM

To determine the effectiveness of HU in reducing the risk of primary stroke in a cohort of Nigerian children with SCD and elevated velocities treated with HU.

METHODS

Children with SCD and TCD velocities ≥170 cm/sec treated with HU were prospectively followed with 3-monthly TCD and neurological evaluations for ≥12 months to determine the incidence of primary stroke.

RESULTS

One hundred and four children, 53 males, and 51 females were enrolled into the study. Their ages ranged from 2 to 16 years with a mean of 6 years. At first TCD examination, velocities ranged from 173 to 260 cm/sec with conditional and abnormal risk velocities in 60 (57.7%) and 44 (42.3%) children, respectively. Follow up ranged from 1 to 8 years with a mean of 3.6 years. Mean TCD velocities showed a significant decline from 198.2 (standard deviation [SD] = 15.6) cm/sec to 169.3 (SD = 21.4) cm/sec (P < 0.001). One stroke event occurred in the cohort, giving a stroke incidence of 0.27/100 person years.

CONCLUSION

HU significantly reduces TCD velocities in Nigerian children with SCD and elevated TCD velocities, with a corresponding reduction in the incidence of primary stroke. HU may represent a potential alternative for primary stroke prevention in low and middle income countries where the burden of SCD resides.

Low plasma haptoglobin is a risk factor for life-threatening childhood severe malarial anemia and not an exclusive consequence of hemolysis

Severe Malarial Anemia (SMA), a life-threatening childhood Plasmodium falciparum malaria syndrome requiring urgent blood transfusion, exhibits inflammatory and hemolytic pathology. Differentiating between hypo-haptoglobinemia due to hemolysis or that of genetic origin is key to understand SMA pathogenesis. We hypothesized that while malaria-induced hypo-haptoglobinemia should reverse at recovery, that of genetic etiology should not. We carried-out a case-control study of children living under hyper-endemic holoendemic malaria burden in the sub-Saharan metropolis of Ibadan, Nigeria. We show that hypo-haptoglobinemia is a risk factor for childhood SMA and not solely due to intravascular hemolysis from underlying schizogony. In children presenting with SMA, hypo-haptoglobinemia remains through convalescence to recovery suggesting a genetic cause. We identified a haptoglobin gene variant, rs12162087 (g.-1203G > A, frequency = 0.67), to be associated with plasma haptoglobin levels (p = 8.5 × 10^-6). The Homo-Var:(AA) is associated with high plasma haptoglobin while the reference Homo-Ref:(GG) is associated with hypo-haptoglobinemia (p = 2.3 × 10^-6). The variant is associated with SMA, with the most support for a risk effect for Homo-Ref genotype. Our insights on regulatory haptoglobin genotypes and hypo-haptoglobinemia suggest that haptoglobin screening could be part of risk-assessment algorithms to prevent rapid disease progression towards SMA in regions with no-access to urgent blood transfusion where SMA accounts for high childhood mortality rates.

White Paper: Pathways to Progress in Newborn Screening for Sickle Cell Disease in Sub-Saharan Africa

Sickle Cell Disease (SCD) is among the most common single-gene diseases in the world but evidence-based comprehensive health care has not been implemented where the highest prevalence of SCD occurs, in sub-Saharan Africa (SSA). It represents an urgent health burden, both in terms of mortality and morbidity with an estimated mortality of 8-16% in children under 5 years in SSA. Addressing the high mortality of SCD in SSA and for effective management of SCD, newborn screening (NBS) should be incorporated with prevention of infections (including pneumococcal septicaemia and malaria), parental education and support at all levels of healthcare provision to enable timely recognition. The NBS working group of the Africa Sickle Cell Research Network (AfroSickleNet) collaboration surveyed current projects in NBS in SSA, and current conditions that hinder more widespread implementation of NBS for SCD. Solutions based on new point-of-care testing technology to disseminate education, and implementation science approaches that leverage existing resources are proposed.

A Multi-centre Survey of Acceptability of Newborn Screening for Sickle Cell Disease in Nigeria

Background

Sickle cell disease (SCD) is a major genetic disease that manifests early in life and may lead to significant morbidities. One of the health care services that have been effective in reducing the burden of SCD in developed countries is newborn screening (NBS) followed by pneumococcal vaccines, penicillin prophylaxis, and hydroxyurea treatment. Yet, in sub-Saharan African countries, where about 75% of annual affected babies worldwide are born, NBS programmes are largely unavailable. It is not clear whether this is due to technical challenges associated with setting up such programmes, or significant cultural and social barriers to its acceptance in such settings.

Objective

Our aim was to ascertain the attitudes to and acceptability of NBS in Nigeria among various socio-demographic groups including health professionals, undergraduate students, parents of children with SCD and SCD patients.

Methods

Data on socio-demographic characteristics, knowledge of SCD and attitude towards NBS were collected using a semi-structured pre-tested questionnaire from April to July 2014 across 15 health institutions and university campuses in Nigeria. Data were collected from 1,301 respondents across Nigeria.

Results

There was good knowledge of SCD as an inherited blood disorder. Although 86% of respondents (n = 1,119) supported NBS, there was a statistically significant relationship between support for NBS and age (p = 003), educational status (p = 000) and religion (p = 000).

Conclusion

This study suggests that there is a good acceptability of NBS across Nigeria. The main barriers to its use are likely to be financial and practical, rather than social or cultural.

Preliminary Evaluation of a Point-of-Care Testing Device (SickleSCAN™) in Screening for Sickle Cell Disease

Sickle cell disease affects about 150,000 births annually in Nigeria. Early diagnosis is hampered by factors such as centralized and urban localization of laboratories, high cost of diagnostic equipment and inadequate skilled manpower to operate them. The need for a low-cost, portable, easy-to-use diagnostic test for sickle cell disease is critical, especially in resource-poor countries. In this study, we evaluated the performance characteristics of a novel point-of-care testing device (SickleSCAN™), and its acceptability and feasibility, as a possible screening tool for sickle cell disease. In the first phase, we assessed the performance characteristics of SickleSCAN™ by evaluating 57 subjects comprising both children and adults attending a primary health center, for Hb SS (β^S/β^S; HBB: c.20A>T), Hb SC (β^S/β^C; HBB: c.19G>A) and Hb AS (β^A/β^S) using SickleSCAN™, cellulose acetate electrophoresis (CAE) and high performance liquid chromatography (HPLC). Performance characteristics such as diagnostic sensitivity and specificity were compared to HPLC as a standard method. We subsequently undertook a second phase wherein the acceptability and feasibility of the device for sickle cell disease screening, was evaluated using semi-structured and structured questionnaires among 197 healthcare personnel and 221 subjects, respectively. Sickle cell disease was carried by 3.4% of the subjects. The diagnostic sensitivity, specificity and test efficiency of SickleSCAN™ for sickle cell disease (Hb SS and Hb SC), were 100.0, 98.2 and 98.2%, respectively. Findings from this study showed SickleSCAN™ to be a viable screening tool that can easily be applied in community-based screening for early diagnosis of sickle cell disease with little expertise and low cost.

A COMPARISON OF RAPID DIAGNOSTIC TESTING (BY PLASMODIUM LACTATE DEHYDROGENASE), AND QUANTITATIVE BUFFY COAT TECHNIQUE IN MALARIA DIAGNOSIS IN CHILDREN

BACKGROUND

The World Health Organization (WHO) considers early and rapid diagnosis as one of the strategies to control malaria. This study compared the performance of Quantitative Buffy Coat (QBC) test and the Plasmodium lactate dehydrogenase (pLDH) rapid diagnostic test (RDT) with microscopy as the gold standard.

MATERIALS AND METHODS

The study involved children ages 0-5 years who presented with a history of fever at the University College Hospital, Ibadan, Nigeria. Blood was collected from each patient and used for RDT, QBC and Giemsa-stained blood films for malaria parasites (MP). Results of QBC and RDT were compared with microscopy results for the diagnosis of malaria.

RESULTS

A total of 370 cases (194 boys and 176 girls) were studied giving a male: female ratio of 1.1:1. Of the 370 cases tested using Giemsa-stained thick blood films for MP, 78 (21 %) were positive. For the QBC test, 78 (21%) of the cases were positive with sensitivity, specificity, positive and negative predictive values of 70.5 %, 92.1%, 70.5 % and 92.1 % respectively. Seventy-six (20%) of the cases were positive by RDT with sensitivity, specificity, positive and negative predictive values of 84.2 %, 95.2 %, 82.1 %, and 95.9 % respectively. There was no significant difference in the sensitivity of QBC compared with the RDT.

CONCLUSION

Both the QBC and the pfLDH (RDT) performed reasonably well in this study Malaria rapid diagnostic tests are recommended in malaria endemic clinical settings to avoid unnecessary antimalarial treatment. List of Abbreviations: AO: Acridine orange, AIDS: Acquired immunodeficiency syndrome, ACT: Artemisinin-based combination therapy, CM:Cerebral malaria, BCP:Benzothiocarboxypurine, DDT:Dichloro-diphenyl-trichloroethane, DNA:DeoxyriboNucleic Acid, ELAM-1: Endothelial leukocyte adhesion molecule, G6PD: Glucose-6-Phosphate Dehydrogenase, HIV: Human immuno deficiency virus, HRP 2: Histidine Rich Protein 2, ICAM -1: Inter cellular adhesion molecule1, ICER: Incremental cost effectiveness ratio, IL-1: Interleukin -1, IFN-g: Interferon-gamma, IgG: Immunoglobulin G, MP: Malaria parasite, NADP: Oxidised Nicotinamide Adenine Dinucleotide Phosphate, NADPH: Reduced Nicotinamide Adenine Dinucleotide Phosphate, PCV: Packed Cell Volume (haematocrit), P. falciparum: Plasmodium falciparum, PLDH: Plasmodium lactate dehydrogenase, PCR: Polymerase Chain Reaction, PPV: Positive predictive value, QBC: Quantitative Buffy Coat examination, TNF: Tumour necrosis factor, NPV: Negative predictive value, RDT: Rapid diagnostic test, SP: Sulphadoxine -Pyrimethamine, SMA: Severe malarial anaemia, UM: Uncomplicated malaria, USA:United States of America, VCAM-1: Vascular cell adhesion molecule, WBC: White Blood Cell, WHO: World Health Organization.

Utility of retrograde ureterocelogram in management of complex ureterocele

INTRODUCTION

Symptomatic pediatric ureterocele has diverse manifestations, making evidence-based management impractical. Thus, detailed visualization of ureterocele anatomy prior to first surgical incision is invaluable. Retrograde ureterocelogram (RUC) is a simple, underutilized radiologic technique that can be performed during cystoscopy. This study sought to determine whether RUC changes surgical management by more accurately depicting the complex ureteral and ureterocele anatomy, compared with renal ultrasound (US) and voiding cystourethrography (VCUG).

METHODS

Patients who underwent surgical management of ureterocele from 2003 to 2015 were identified; those who received concomitant fluoroscopic RUC were selected for the case series. Data collected included: demographics, pre-operative evaluation, surgical interventions, and outcomes. The RUC images were individually examined, and the anatomic impression compared with previous renal US and VCUG. Novel RUC findings not previously appreciated by the pre-operative evaluation were noted. The RUC was performed by cystoscopically inserting a needle into the ureterocele and injecting contrast retrograde. If indicated, simultaneous PIC (Positioning the Instillation of Contrast) cystography was performed.

RESULTS

Of the 43 patients that underwent surgery for suspected ureterocele, 28 underwent cystoscopy + RUC (10 M: 18 F) at a median age of 4.6 months and median follow-up of 37.0 months. All patients had prior US, 25 had prior VCUG, and 20 had prior radionuclide studies. Ureteroceles were either duplex system (n = 21) or single system (n = 7); 17 were ectopic into the bladder neck or urethra; seven were intravesical; and four were pseudoureteroceles. Fourteen patients underwent concomitant transurethral incision of the ureterocele (TUIU); two were deferred for surgery; and 11 received concomitant definitive surgery (e.g., nephrectomy). The RUC illuminated novel aspects of the anatomy in 20 of the 28 patients. No adverse events occurred. Notably, in nine of the 28 children, significant observations from RUC prompted change to the pre-operative surgical plan.

DISCUSSION

Retrograde ureterocelogram clearly revealed ureterocele ectopy, pseudoureterocele, ureterocele disproportion, and unsuspected duplex systems, making it a useful adjunct to standard US and VCUG studies. Retrograde ureterocelogram can also be used to fluoroscopically verify decompression of the ureterocele post incision, document severity of ureteral dilation, and teach residents about the great damage generated by ureterocele variations. Limitations of RUC included increasing radiation dose and overall cost. The study design was limited by its small size, retrospective approach, selection bias, and availability of RUC images.

CONCLUSIONS

While not indicated in routine ureterocele management, intraoperative RUC further defined ureterocele anatomy in nearly all cases and yielded changes to the original surgical plan frequently enough to merit greater use in complex patients.

A Functional IL22 Polymorphism (rs2227473) Is Associated with Predisposition to Childhood Cerebral Malaria

Cerebral malaria (CM) is a severe complication of Plasmodium falciparum infection. This encephalopathy is characterized by coma and is thought to result from mechanical microvessel obstruction and an excessive activation of immune cells leading to pathological inflammation and blood-brain barrier alterations. IL-22 contributes to both chronic inflammatory and infectious diseases, and may have protective or pathogenic effects, depending on the tissue and disease state. We evaluated whether polymorphisms (n = 46) of IL22 and IL22RA2 were associated with CM in children from Nigeria and Mali. Two SNPs of IL22, rs1012356 (P = 0.016, OR = 2.12) and rs2227476 (P = 0.007, OR = 2.08) were independently associated with CM in a sample of 115 Nigerian children with CM and 160 controls. The association with rs2227476 (P = 0.01) was replicated in 240 nuclear families with one affected child from Mali. SNP rs2227473, in linkage disequilibrium with rs2227476, was also associated with CM in the combined cohort for these two populations, (P = 0.004, OR = 1.55). SNP rs2227473 is located within a putative binding site for the aryl hydrocarbon receptor, a master regulator of IL-22 production. Individuals carrying the aggravating T allele of rs2227473 produced significantly more IL-22 than those without this allele. Overall, these findings suggest that IL-22 is involved in the pathogenesis of CM.

Iron deficiency among apparently healthy children aged 6 to 24 months in Ibadan, Nigeria

Iron deficiency remains a global public health challenge, with a higher burden in children in the tropics. When it occurs early in life, it may have long-term effects on neurodevelopment. The aims of this study were to assess the iron status of children aged 6-24 months, to determine the prevalence of iron deficiency and its associated factors in Ibadan, Nigeria. The authors conducted a cross-sectional study between March and June 2014. A total of 202 apparently healthy children aged between 6 and 24 months attending 2 major immunization clinics in Ibadan were included. A questionnaire was used to collect information on sociodemographic characteristics, pregnancy and birth history, and nutritional history. Physical examination was carried out on all the subjects, and serum ferritin level was determined using an enzyme-linked immunosorbent assay (ELISA) technique. Iron deficiency was defined using a cutoff value of <30 µg/L. Fifty-nine children (29.2%) had iron deficiency. No clinical features were found to be significantly associated with iron deficiency. Iron deficiency was associated with breastfeeding (P = .020) and younger age (P = .015) in the study population. One hundred and forty-three (70.8%) of the study participants had anemia, and 39 (19.3%) had iron deficiency anemia. The prevalence of iron deficiency among apparently healthy children aged 6-24 months in Ibadan, Nigeria, is high. There is the need for a national policy on routine screening for iron deficiency and iron supplementation for infants and young children as recommended by the World Health Organization.

Mucocutaneous Disorders of Pediatric HIV in South West Nigeria

Objectives:

Nigeria has the world’s highest burden of pediatric HIV. In the face of paucity of monitoring tests in Nigeria, we studied the spectrum of pediatric mucocutaneous manifestations and evaluated their clinical utility as surrogate markers for immunodeficiency and plasma viral load levels.

Methods:

Cross-sectional study comparing mucocutaneous manifestations in 155 HIV-positive children aged 12 weeks to 14 years with 155 HIV-negative children. Relationships between mucocutaneous manifestations in HIV-infected patients and their immunologic and virologic indices were analyzed.

Results:

Mucocutaneous lesions were seen in 53.5% of HIV-infected children compared with 18.1% of the controls. Prevalence of lesions increased with worsening levels of immunodeficiency and increasing viral loads ( P < .01). Oral candidiasis, angular stomatitis, and fluffy hair were associated with more severe degrees of immunodeficiency.

Conclusion:

Mucocutaneous disorders are common in HIV-infected children. Oral candidiasis and nutritional dermatoses can be used as surrogates for advanced or severe immunodeficiency.

Hydroxyurea lowers transcranial Doppler flow velocities in children with sickle cell anaemia in a Nigerian cohort

BACKGROUND

Sickle cell anaemia (SCA) is the leading genetic disorder in Nigeria. Elevated velocities ≥170 cm/sec occur in about a third of Nigerian children with SCA. Chronic blood transfusion for stroke prevention is faced with a myriad of challenges in our practice.

OBJECTIVES

To evaluate the effectiveness of hydroxyurea (HU) in reducing flow velocities in a cohort of Nigerian children with SCA and elevated velocities treated with HU.

METHODS

An observational study was carried out on a cohort of Nigerian children with SCA and elevated velocities identified on routine transcranial Doppler (TCD) screening. HU was recommended in those with TCD velocities ≥ 170cm/sec as stipulated in our hospital protocol. Outcomes were compared after ≥12 months of observation.

RESULTS

Fifty children with elevated TCD velocities were studied; 31 consented to HU therapy and 19 declined. Children on HU showed a statistically significant decline in mean velocities from 199.7 [17.1] cm/sec to 165.8 [20.7] cm/sec (P < 0.001) with a significant increase in mean packed cell volume from 21.1 [3.4] to 25.0 [2.8]%. Children without treatment had a significant rise in mean velocities from 190.2 [10.8] cm/sec to 199.7 [14.9] cm/sec (P = 0.003). Children with conditional risk velocities on HU were less likely to convert to abnormal risk (P < 0.001). Two stroke events occurred, one in each group. No adverse effects of HU were recorded in the cohort.

CONCLUSION

HU appears to significantly reduce TCD velocities in Nigerian children with SCA and elevated velocities ≥170 cm/sec with beneficial effect on the haematological profile. HU may provide an effective approach to primary stroke prevention, particularly in Africa.

Pattern of childhood cancer in University College Hospital, Ibadan during 1991-2010 and comparison with the previous three decades

BACKGROUND

Cancer is an important cause of morbidity and mortality worldwide in children under 15 years of age, with the incidence and mortality rate varying from 40 to 155 per million children.

AIM

To describe the pattern of childhood cancer in Ibadan, Nigeria.

OBJECTIVE

To compare the findings of this study with those of previous studies in Ibadan and internationally.

METHODS

A retrospective review of histologically and cytologically confirmed cases of cancer in children aged <15 years diagnosed at University College Hospital (UCH), Ibadan between January 1991 and December 2010 was undertaken. The cases were categorised using the International Classification of Childhood Cancer, third edition (ICCC-3).

RESULTS

There were 625 cases comprising 360 (57·6%) males with a modal age of 3 years. The most common neoplasms were lymphomas (140, 22·4%), of which 90% were non-Hodgkin lymphomas, with Burkitt lymphoma constituting the majority of cases (73). Other common neoplasms were retinoblastomas (21%), soft tissue sarcomas (14·9%), leukaemias (10·2%) and CNS tumours (6·9%). Lymphomas, bone tumours, malignant hepatic tumours and other malignant epithelial neoplasms had the highest mean and modal ages, while retinoblastomas, neuroblastomas, germ cell tumours and renal tumours had the lowest mean and modal ages. During 1960-72 there were 1326 cases and during 1973-90 there were 1881 cases and the proportion of lymphomas was 58·9% and 45·4%, respectively. The present study demonstrated a marked decline in the number of cases and proportion of lymphomas (22·4%), particularly Burkitt lymphomas.

CONCLUSION

During the last 20 years, there has been a decline in the number of cases of childhood cancer seen at UCH, Ibadan. This may be due to the establishment of additional specialist centres in the sub-region. Owing to a persistent decline in the frequency of Burkitt lymphoma, retinoblastoma is now the most common individual childhood cancer seen at Ibadan.

PERCEPTION AND EXPERIENCE AND OF NIGERIAN PAEDIATRICIANS TO DENTAL REFERRAL FOR CHILDREN WITH CHRONIC ILLNESSES

BACKGROUND

Interdisciplinary collaboration in the management of patients offers several advantages especially for children with chronic illnesses who are often at risk for other health conditions. Diseases in other parts of the body can be detected by a physician and lead to subsequent referral to the appropriate managing team. This study assessed the perception and experience of dental referral among Nigerian paediatricians as well as factors that may influence their decision to refer to a dentist.

METHODS

Self administered questionnaires were used to obtain socio-demographic data, history of exposure to dental teachings as well as experience with dental referral. Two hundred and sixty nine paediatricians and paediatric practitioners were involved in the study. Descriptive statistics and measures of central tendencies generated. Associations were tested with Chi Squares and Statistical significance was set at P <0.05.

RESULTS

A total of 269 respondents participated in the study out of whom 142(52.8%) trained at institutions where there was a sister dental school, but 243(90.3%) of them had no official dentistry postings. Majority of the respondents 259(96.3%) were in favour of routine professional oral check-up for children but only 83(30.9%) endorsed the recommended bi annual oral checks. A referral rate of 0.76-1.9% was obtained.

CONCLUSION

Although paediatricians are a known source of dental referral for children globally, a lot needs to be done to equip the physicians with the necessary knowledge and skill that will enable them participate more actively in the promotion of oral health for Nigerian children.

Pattern of childhood leukaemia in University College Hospital, Ibadan

BACKGROUND

Leukaemias are haematological malignancies characterized by unregulated clonal proliferation of haematopoietic cells.

OBJECTIVE

To determine the pattern of childhood leukaemia in Ibadan.

METHODOLOGY

This was a retrospective study of leukaemia cases diagnosed at the University College Hospital (UCH), Ibadan between January 1991 and December 2010 in children less than 15 years of age. Data obtained was subjected to statistical analysis using the Statistical Package for Social Sciences version 20.

RESULTS

There were 64 cases of childhood leukaemia, accounting for 10.2% of childhood cancers seen during this study period. The male to female ratio was 2:1 and modal age group was between 10 and 14 years. Thirty (46.9%) cases were acute lymphoblastic leukaemia (ALL), 22 (34.4%) were acute myelogenous leukaemia (AML) and 12 (18.8%) were unspecified acute leukaemias. There was no case of chronic myeloid or lymphocytic leukaemia.

CONCLUSION

There has been a relative increase in the frequency of leukaemia cases at UCH, Ibadan, which may be largely explained by increased awareness and referrals. There is a need for further collaborative multicentre studies of childhood leukaemias in Nigeria and other developing countries and focused research on childhood leukaemias in order to unravel the aetiology.

Affinity proteomics reveals elevated muscle proteins in plasma of children with cerebral malaria

Systemic inflammation and sequestration of parasitized erythrocytes are central processes in the pathophysiology of severe Plasmodium falciparum childhood malaria. However, it is still not understood why some children are more at risks to develop malaria complications than others. To identify human proteins in plasma related to childhood malaria syndromes, multiplex antibody suspension bead arrays were employed. Out of the 1,015 proteins analyzed in plasma from more than 700 children, 41 differed between malaria infected children and community controls, whereas 13 discriminated uncomplicated malaria from severe malaria syndromes. Markers of oxidative stress were found related to severe malaria anemia while markers of endothelial activation, platelet adhesion and muscular damage were identified in relation to children with cerebral malaria. These findings suggest the presence of generalized vascular inflammation, vascular wall modulations, activation of endothelium and unbalanced glucose metabolism in severe malaria. The increased levels of specific muscle proteins in plasma implicate potential muscle damage and microvasculature lesions during the course of cerebral malaria.

Why do some malaria-infected children develop severe and lethal forms of the disease, while others only have mild forms? In order to try to find potential answers or clues to this question, we have here analyzed more than 1,000 different human proteins in the blood of more than 500 malaria-infected children from Ibadan in Nigeria, a holoendemic malaria region. We identified several proteins that were present at higher levels in the blood from the children that developed severe malaria in comparison to those that did not. Some of the most interesting identified proteins were muscle specific proteins, which indicate that damaged muscles could be a discriminatory pathologic event in cerebral malaria compared to other malaria cases. These findings will hopefully lead to an increased understanding of the disease and may contribute to the development of clinical algorithms that could predict which children are more at risks to severe malaria. This in turn will be of high value in the management of these children in already overloaded tertiary-care health facilities in urban large densely-populated sub-Saharan cities with holoendemic malaria such as in the case of Ibadan and Lagos.

Chronic blood transfusion for primary and secondary stroke prevention in Nigerian children with sickle cell disease: a 5-year appraisal

BACKGROUND

Chronic blood transfusion (CBT) diminishes the risk of primary and secondary stroke in sickle cell disease (SCD). We appraised CBT and assessed its feasibility as an option for stroke prevention in a setting of limited resources.

METHODS

All new cases of SCD seen in the Paediatric Hematology/Neurology units of the University College Hospital, Ibadan, Nigeria over a 5-year period were screened and followed up to identify those who had an indication for CBT for stroke prevention. Caregivers were counseled and offered CBT when indicated. Children of caregivers who accepted chronic transfusion were carefully followed up and outcomes documented.

RESULTS

Five (10%) of the caregivers of the 50 children who had an indication for CBT for stroke prevention consented to the treatment. They all had homozygous sickle cell anemia and had suffered a stroke. None of the children with abnormal TCD velocities consented to CBT. Two children experienced transfusion reactions, fatal in one. The mean annual cost of chronic transfusion (without chelation) was $3,276 (SD = 1,168). Major reasons given for declining CBT were high costs of blood transfusion, unavailability of blood, the need to regularly seek for blood donors, and the indefinite duration of blood transfusions.

CONCLUSION

High economic costs, unavailability of blood, need to regularly seek for blood donors, cultural beliefs, and high frequency of transfusion reactions are major challenges to a successful CBT program in Nigeria. There is a need for government subsidy on blood transfusions and improved efforts towards provision of safe and affordable blood.

Current sickle cell disease management practices in Nigeria

BACKGROUND

Although Nigeria has the highest burden of sickle cell disease (SCD) worldwide, there is still variable and poor utilisation of standard-of-care practices for SCD patients in the country.

METHODS

This was a questionnaire survey of doctors in some dedicated SCD clinics in Nigeria in order to document the facilities available and common management practices.

RESULTS

There were responses from 18 clinics based in 11 institutions. The number of patients being followed in each centre ranged from 15 to approximately 11 000. All clinics provided malaria prophylaxis and folic acid routinely to their patients. Only eight clinics prescribe penicillin prophylaxis. Eight prescribe hydroxyurea to patients who can afford it when indicated. All of the centres except three have electronic cell counters, but all had access to haemoglobin electrophoresis. Three had high-performance liquid chromatography machines installed but none was being routinely used. One institution had a functioning molecular biology laboratory. There is no official newborn screening programme in the country. All had access to microbiology and chemistry laboratories. Nine institutions had CT, six had MRI and three had transcranial Doppler facilities.

CONCLUSION

The care available for SCD in Nigeria is still suboptimal and there is an urgent need for concerted effort to tackle the problem, but to make a significant impact on the burden of the disease would require more focus at the primary care level. Some steps to achieving this are outlined.

Blood Transfusion-Associated HIV Infection in Children in Ibadan, Nigeria

INTRODUCTION

This study describes the epidemiologic features and clinical course of children with blood transfusion-associated HIV infection (TAHI) in Ibadan, Nigeria.

METHODOLOGY

All children diagnosed to have TAHI at the University College Hospital, Ibadan, were studied and compared with children who acquired HIV vertically using the pediatric HIV database in the hospital.

RESULTS

Transfusion-associated HIV infection accounted for 14 (2.3%) of the 597 children diagnosed to have HIV infection between January 2004 and December 2011. The mean age at diagnosis of TAHI was 10.2 years and that of vertically acquired HIV infection was 3.9 years ( P < .001). In 9 cases, blood transfusion took place in private hospitals and in 5 cases in public hospitals. Median interval between infection and diagnosis of AIDS was 84 months in cases with TAHI and 48 months in vertically acquired cases ( P = .542).

CONCLUSION

Optimal blood safety practices are advocated for prevention of TAHI in Nigeria.

Stroke recurrence in Nigerian children with sickle cell disease treated with hydroxyurea

AIMS AND OBJECTIVES

To compare the outcome after a first clinical stroke, following treatment with and without hydroxyurea (HU).

SUBJECTS AND METHODS

A retrospective review of a cohort of Nigerian children with SCD, who had suffered a first stroke, was carried out. Outcomes in the group of children who received and did not receive HU were compared.

RESULTS

Thirty two children presented with stroke and one died of haemorrhagic stroke at presentation. All the children had haemoglobin SS phenotype, and ischaemic stroke was the predominant form seen. Mean age at first clinical stroke was 7 years, 7 months (SD=2 years, 4 months). Thirteen children received HU while 18 declined HU therapy. Maximum dose of HU ranged from 20-25 mg/kg/ day. The secondary stroke incidence of 7/100 person years in the HU group was significantly lower than the 28/100 person years in the non-HU group (P=0.001, OR 3.808, 95% CI 1.556, 9.317). Children who did not receive HU were more likely to drop out of school and to have moderate-severe motor disabilities requiring caregiver assistance for daily living.

CONCLUSION

In settings where facilities for chronic blood transfusion are not accessible or feasible, HU therapy should be considered for secondary stroke prevention in children with SCD.

Health status of children in institutionalised homes in South West Nigeria

AIMS AND OBJECTIVES

To determine the nutritional and immunisation status as well as morbidity pattern of children in institutionalised care in south-western Nigeria.

SUBJECTS AND METHODS

The study was cross sectional and involved children under the age of fifteen years in seven institutions in Oyo and Ogun states, south western Nigeria. Children admitted into these homes were either orphans or those separated from their parents through child abandonment, illness and juvenile delinquency. A history of current and recent illnesses in the preceding one month as well as immunisation was obtained for each child. Physical examination including growth assessment was then performed after which blood specimens were collected for haematocrit estimation, haemoglobin electrophoresis and examination for malaria parasites.

RESULTS

A total of 161 children were studied comprising 74 (46.0%) males and 87 (54.0%) females. Their ages ranged from 1.12 to 168 months with a mean (standard deviation) of 94.5 (47.0) months. Only 24.5 % of the children were reported to have completed the immunisation schedule. Fifty five (34.2%) of the 161 children were reported to have been ill in the preceding period of one month, the leading symptoms being fever (14.9%), cough (10.3%) and diarrhoea (3.9%). Forty six (28.6%) of the children were stunted, 34 (21.1%) underweight and 106 (65.8%) anaemic.

CONCLUSION

The health status of children in institutionalised care is poor and needs better supervision and support to facilitate growth and wellbeing.

Childhood rhabdomyosarcoma in Ibadan, Nigeria: 1984–2003

BACKGROUND

Rhabdomyosarcoma is the most common soft tissue sarcoma in children under 15 years of age. There is, however, a paucity of reports on the pattern of its occurrence in Nigeria and other parts of Africa.

AIM

To describe the pattern of childhood rhabdomyosarcoma in Ibadan with respect to demography, morphology and tumour site.

METHODS

This retrospective study was based on data obtained from the Ibadan cancer registry, College of Medicine, University of Ibadan. All histologically confirmed cases of rhabdomyosarcoma in children under 15 years of age seen at the University College Hospital Ibadan between 1984 and 2003 were included. Information obtained includes age, gender, morphology and sites of the tumours.

RESULTS

Ninety-one children were seen with a male:female ratio of 1.5:1. Ages ranged from <1 to 14 years with a mean (SD) of 6.2 (4.1) years. The embryonal variant was the most common histological subtype (61.5%). Other subtypes were alveolar (13.2%), pleomorphic (4.4%) and rhabdomyosarcoma 'not otherwise specified' (20.9%). The majority (50.6%) of tumours were in the head and neck region and the common primary sites were soft tissue of the head, face (24.2%) and orbit (14.3%). Other sites included soft tissue of the pelvis (11.0%), genito-urinary tract (9.9%) and abdomen (9.9%).

CONCLUSION

The pattern of rhabdomyosarcoma in Nigeria is similar to that in the United States and Europe, except for the rarity of parameningeal sites and extremities. There is a need for larger descriptive studies on childhood rhabdomyosarcoma in Africa.

Severe childhood malaria syndromes defined by plasma proteome profiles

BACKGROUND

Cerebral malaria (CM) and severe malarial anemia (SMA) are the most serious life-threatening clinical syndromes of Plasmodium falciparum infection in childhood. Therefore it is important to understand the pathology underlying the development of CM and SMA, as opposed to uncomplicated malaria (UM). Different host responses to infection are likely to be reflected in plasma proteome-patterns that associate with clinical status and therefore provide indicators of the pathogenesis of these syndromes.

METHODS AND FINDINGS

Plasma and comprehensive clinical data for discovery and validation cohorts were obtained as part of a prospective case-control study of severe childhood malaria at the main tertiary hospital of the city of Ibadan, an urban and densely populated holoendemic malaria area in Nigeria. A total of 946 children participated in this study. Plasma was subjected to high-throughput proteomic profiling. Statistical pattern-recognition methods were used to find proteome-patterns that defined disease groups. Plasma proteome-patterns accurately distinguished children with CM and with SMA from those with UM, and from healthy or severely ill malaria-negative children.

CONCLUSIONS

We report that an accurate definition of the major childhood malaria syndromes can be achieved using plasma proteome-patterns. Our proteomic data can be exploited to understand the pathogenesis of the different childhood severe malaria syndromes.

Adverse neurological outcomes in Nigerian children with sickle cell disease

Sickle cell disease (SCD) is reported to be the most common genetic disorder affecting Nigerians. Children with SCD are at a high risk of neurological morbidity. The main objective of this study was to determine the pattern of adverse neurological outcomes among a cohort of Nigerian children with SCD. All children with SCD seen in the Department of Paediatrics, University College Hospital, Ibadan, Nigeria, over a period of 2 years were carefully evaluated for symptoms and signs of neurological complications, defined as clinical outcomes referable to the central nervous system. Of the 214 children evaluated, 187 were diagnosed with Hb SS disease and 27 with Hb SC disease. Neurological complications were identified in 78 (36.4 %) of the cases. The most common complications were headache (17.8 %), seizure (9.3 %) and stroke (8.4 %). Other less frequent complications included bacterial meningitis (2.8 %), spontaneous visual loss (1.4 %), paraplegia (0.9 %) and transient ischaemic attacks (0.9 %). Neurological complications occurred more frequently in children with sickle cell anaemia than in those with Hb SC disease (P = 0.002, 95 % CI 1.450-82.870). Adverse neurological events are common in Nigerian children with SCD, with a significantly higher risk in Hb SS than Hb SC disease. Stroke represents a major underlying cause of symptomatic epilepsy in SCD. Institution of primary preventive measures for stroke in SCD will significantly reduce the burden of stroke and epilepsy associated with SCD in Nigeria.

Treatment of Burkitt lymphoma in equatorial Africa using a simple three-drug combination followed by a salvage regimen for patients with persistent or recurrent disease

Prior to the introduction of the International Network for Cancer Treatment and Research (INCTR) protocol INCTR 03-06, survival of patients with Burkitt lymphoma at four tertiary care centres in equatorial Africa was probably no more than 10-20%. The results reported here for 356 patients have demonstrated marked improvement in survival through the use of a uniform treatment protocol consisting of cyclophosphamide, methotrexate, vincristine, and intrathecal therapy, and the introduction of non-cross resistant second-line (salvage) therapy, consisting of ifosfamide, mesna, etoposide and cytarabine, when patients failed to achieve a complete response to first-line therapy or relapsed early. Overall survival rates of 67% and 62% were observed at 1 and 2 years (relapse is rare after 1 year of remission). Of interest was the small impact of cerebrospinal fluid (CSF) and bone marrow involvement on outcome. However, the presence or absence of abdominal involvement clearly defined two prognostic groups. An additional finding was the association between CSF pleocytosis and orbital tumours, suggesting that spread of tumour cells to the central nervous system may sometimes occur via direct involvement of cranial nerves in the orbit. Survival rates may be increased in patients with abdominal involvement by combining first- and second-line therapy, but verification will require a further clinical study.

Early deaths and other challenges to childhood cancer survival in Ibadan, Nigeria

OBJECTIVES

To determine the frequency of early deaths and the associated risk factors in children suffering from cancer at the University College Hospital, Ibadan.

DESIGN

A retrospective study involving review of case notes of children suffering from cancer.

SETTING

Department of Paediatrics, University College Hospital, Ibadan, Nigeria.

SUBJECTS

All cases of childhood cancer managed in the Department between January 1998 and December 2004. Inclusion criteria were histological or cytological confirmation of diagnosis, suggestive clinical features and availability of details about the course of the illness.

MAIN OUTCOME MEASURES

Interval between diagnosis and death, rate of early death (death within 30 days of diagnosis) and risk factors for early death.

RESULTS

Eighty eight cases of childhood cancer were seen out of whom 52 died during the period. Four cases with incomplete data were excluded from subsequent statistical analysis. There were 29 (34.5%) early deaths defined as death within 30 days of diagnosis. The odds of early death were increased in the presence of bilateral kidney involvement, masses in the liver, splenic masses, pulmonary metastasis and stage D of Burkitt lymphoma. Logistic regression analysis revealed that pulmonary metastasis was a significant independent predictor ofearly death.

CONCLUSIONS

Early childhood cancer mortality rate is high. Early diagnosis and referral for appropriate care may reduce childhood cancer mortality in Nigeria.

Prevalence and clinical pattern of paediatric HIV infection at the University College Hospital, Ibadan, Nigeria: a prospective cross-sectional study

BACKGROUND

The prevalence of Paediatric HIV infection is largely unknown in many countries in sub-Saharan Africa. This study was aimed at determining the prevalence, clinical pattern of HIV infection and outcome among new patients aged <15 years using age-specific diagnostic methods.

METHODS

A prospective cross sectional study was carried out using the provider initiated HIV testing and counselling (PITC) model. HIV rapid test in parallel was used for screening and confirmation was with HIV DNA PCR in children <18 months and Western Blot in children ≥ 18 months.

RESULTS

A total of 600 children were enrolled with ages ranging between one day and 179 months. Male: female ratio was 1.2:1. HIV seroprevalence was 12.3% and after confirmatory tests, the prevalence was 10%. Fourteen (37.8%) of the children aged less 18 months were exposed but not infected. Mother-to-child transmission accounted for 93.3% of cases. Features predictive of HIV infection were diarrhoea, cough, weight loss, ear discharge generalized lymphadenopathy, presence of skin lesions, parotid swelling and oral thrush. About 75% presented in advanced or severe clinical stages of the disease, 56.8% had severe immunodeficiency while 50% had viral loads more than 100,000 copies/ml. Mortality rate was 14.3% among HIV positive compared with 11.3% in HIV negative children but was not significant. Among the HIV positive children, 26.7% were orphans.

CONCLUSIONS

The prevalence rate of HIV infection among new patients screened using the PITC model was high, majority resulting from mother-to-child transmission. Most children presented in advanced stages of the disease and mortality rate among them was high. Though, the study site being a referral centre might have contributed to the high prevalence observed in this study, there is a need to expand access to PMTCT services, ensure implementation of PITC in paediatric settings and expand support services for HIV infected children.

Disclosure of HIV status to infected children in a Nigerian HIV Care Programme

With increasing survival of HIV-infected children, parents face the challenges of disclosure to the children. The aim of this study was to assess the rate of HIV disclosure to children in Ibadan and the factors influencing it in order to guide design of strategies for successful disclosure. A semi-structured questionnaire was administered to consecutive consenting caregivers of HIV-infected children aged ≥6 years attending the Paediatric Infectious Disease Clinic of the University College Hospital, Ibadan, between November 2008 and October 2009. Caregivers of 96 children (46 boys, 50 girls) infected with HIV were interviewed. The ages of the children ranged from 6 to 14 years with a mean (SD) of 8.8 (2.2) years. Disclosure had been done in only 13 (13.5%) of the children; ages at disclosure ranged from 4.5 to 13 years with a mean of 8.7 (SD = 2.2). Disclosure was associated with age above 10 years. Reasons given by carers for non-disclosure in 83 caregivers included inability of the children to understand in 53 (63.9%), fear of disclosure to other children 34 (41.0%), fear of disclosure to family/friends in 28 (33.7%), fear of psychological disturbance of the children in 26 (31.3%) and fear of blaming the parents in 22 (26.5%). Twenty (20.8%) of the children have asked questions relating to their diagnosis and the responses are often evasive. Caregivers felt disclosure had helped adherence to antiretroviral therapy in 7 (63.6%) of the 11 children on antiretroviral drugs in whom there was disclosure but no effect on the remaining. There is a need to assist parents and health care providers in successfully disclosing HIV status to infected children without adverse consequences.

Infant-feeding pattern of HIV-positive women in a prevention of mother-to-child transmission (PMTCT) programme

OBJECTIVES

To evaluate the infant-feeding choices, practices and possible determinants among HIV-positive women enrolled in a prevention of mother-to-child transmission programme in Ibadan, Nigeria.

METHODS

A cross-sectional survey involving HIV-positive women who had received infant-feeding counselling prior to delivery. A structured questionnaire was administered at < or = 72 hrs and not > or = 6 weeks of delivery and was complemented with an in-depth interview.

RESULTS

A total of 241 women were studied. The choice of infant feeding was formula for 223 (93.5%) and in actual practice, 9 (3.7%) mothers admitted mixed feeding. There was no statistical significant difference between the feeding pattern and the socio-demographic characteristics. The major factor influencing the choice of infant feeding was "The desire to reduce the risk of transmission" which was recorded among 204 (84.6%) of the women. Greatest support in maintaining infant-feeding option was the spouse (36.1%). From the in-depth interview of 23 non-breastfeeding (infant formula) mothers, the major challenge faced was stigmatisation.

CONCLUSION

Despite the premium placed on breastfeeding in this locality, with infant-feeding counselling, most HIV-positive women chose and practiced formula feeding. It is necessary to address how best HIV-positive mothers could handle or overcome criticisms and stigmatisation by others.

HIV/AIDS in 3 generations: case series

BACKGROUND

The HIV pandemic is one of the greatest challenges facing humanity, and generations may be wiped out if effective prevention, treatment, and care are not in place.

CASE REPORTS

A total of 3 families are presented. In the first 2, the children represented the third generation in their families to be infected with HIV and probably had mother-to-child transmission of the disease. The children in the third family were HIV negative. The mothers and grandmothers in all the families were infected with HIV. Risky sexual behavior involving multiple sexual partnering was recorded among them, some of whom had died from AIDS-related illness. This has serious implications in the care of the infected and affected children as they had been made vulnerable by their circumstances.

CONCLUSION

HIV/AIDS has been around long enough now to cross generations as shown in the reported cases, which resulted in serious health and socioeconomic effects in the affected families.

Age at diagnosis of sickle cell disease in a developing country

In order to determine the age at diagnosis of sickle cell disease and some of the factors that influence the same at the University College Hospital Ibadan, a retrospective study of children with sickle cell disease who attended the children's outpatient department of the hospital between June 2000 and June 2009 was conducted by reviewing their case notes. A total of 457 children were studied (Male: Female ratio 1.1:1). Haemoglobin phenotype was SS in 421 children (92.1%) and SC in 36 children (7.9 %). Median age at diagnosis was 2.0 years (2.5 months - 14.0 years). Age at diagnosis was lower in children with Hb SS than HbSC (p = 0.01), in children from higher socioeconomic classes (p = 0.003) and in children with a history of dactylitis (N = 354, p = 0.000). Late diagnosis of haemogobinopathies in Ibadan calls for institution of neonatal screening to improve chances of survival.

Service uptake and performance of the prevention of mother-to-child transmission (PMTCT) programme in Ibadan, Nigeria

The Prevention of Mother to Child Transmission (PMTCT) programme in the University College Hospital (UCH), Ibadan has been in existence for more than five years and has scaled up to other sites. The study evaluated the service uptake and performance of the programme using national key indicators. Antenatal and delivery records of women enrolled between July 2002 and June 2007 were reviewed. A total of 51952 women attended first antenatal visits and received HIV pre-test counselling. Of these, 51614 (99.5%) accepted HIV test and 49134 (95.2%) returned for their results. Out of the tested patients, 2152 (4.2%) were identified to be HIV positive. Partners of positive patients accepting HIV testing were 361 (16.7%) with 87 (18.6%) testing positive. There were a total of 942 deliveries out of which 39.2% of the mothers and 95.2% of the babies respectively received ARV prophylaxis. In all, 85.8% (788/918) of the mothers opted for formula as the method of infant feeding. Out of the 303 babies eligible for ELISA testing, 68.3% reported for the test and 17 (8.7%) tested positive. There has been progress in the programme, reflected in the increase in the number of new clients accessing the PMTCT service. However, partner testing and follow up of mother-infant pairs remain formidable challenges that deserve special attention.

Burden of health-care of carers of children with sickle cell disease in Nigeria

Sickle cell anaemia in children is characterised by recurrent crises that frequently involve intensive medical care which may impact on the health and well-being of their carers. The psychosocial impact of sickle cell disease on 67 carers of children with sickle cell disease attending the Paediatric Haematology/Oncology clinic of the University College Hospital, Ibadan, Nigeria, was determined between February and May 2007 using a structured questionnaire adapted from an instrument earlier validated for the study of carer burden in sickle cell disease and relevant to the Nigerian culture. Data analysis was performed using the Statistical Package for Social Sciences (SPSS) version 15.0. Demographic factors as well as frequency of hospitalisations and blood transfusions were each categorised into groups and the Mann-Whitney U-test was used to test for differences in stress scores between any two groups while the Kruskal-Wallis test was used to test for differences in more than two groups. Level of statistical significance was set at P < 0.05. Family finances were adversely affected in 39 (58.2%) families. Financial stress was frequently associated with a history of two or more hospitalisations in the previous year and more so in families with more than three children. Majority (80.6%) of the carers said they had minimal or no difficulty coping with their children. There was also a significant correlation between financial stress and difficulty in parental coping. Caring for the illnesses in the children often caused disruptions in family interactions; worst in the first year after diagnosis and improved over the years. Regular assessment of psychosocial areas of need is necessary to guide provision of necessary support.