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.

Rolling Up the Sleeve: Equitable, Efficient, and Safe COVID-19 Mass Immunization for Academic Medical Center Employees

BACKGROUND

Novel coronavirus disease 2019 (COVID-19) vaccine administration has faced distribution barriers across the United States. We sought to delineate our vaccine delivery experience in the first week of vaccine availability, and our effort to prioritize employees based on risk with a goal of providing an efficient infrastructure to optimize speed and efficiency of vaccine delivery while minimizing risk of infection during the immunization process.

OBJECTIVE

This article aims to evaluate an employee prioritization/invitation/scheduling system, leveraging an integrated electronic health record patient portal framework for employee COVID-19 immunizations at an academic medical center.

METHODS

We conducted an observational cross-sectional study during January 2021 at a single urban academic center. All employees who met COVID-19 allocation vaccine criteria for phase 1a.1 to 1a.4 were included. We implemented a prioritization/invitation/scheduling framework and evaluated time from invitation to scheduling as a proxy for vaccine interest and arrival to vaccine administration to measure operational throughput.

RESULTS

We allotted vaccines for 13,753 employees but only 10,662 employees with an active patient portal account received an invitation. Of those with an active account, 6,483 (61%) scheduled an appointment and 6,251 (59%) were immunized in the first 7 days. About 66% of invited providers were vaccinated in the first 7 days. In contrast, only 41% of invited facility/food service employees received the first dose of the vaccine in the first 7 days (p < 0.001). At the vaccination site, employees waited 5.6 minutes (interquartile range [IQR]: 3.9-8.3) from arrival to vaccination.

CONCLUSION

We developed a system of early COVID-19 vaccine prioritization and administration in our health care system. We saw strong early acceptance in those with proximal exposure to COVID-19 but noticed significant difference in the willingness of different employee groups to receive the vaccine.

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.

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.

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.

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.

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.

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.

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.

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.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

The threat of communicable diseases following natural disasters: a public health response

Natural disasters, such as the recent Indian Ocean tsunami, can have a rapid onset, broad impact, and produce many factors that work synergistically to increase the risk of morbidity and mortality caused by communicable diseases. The primary goal of emergency health interventions is to prevent epidemics and improve deteriorating health conditions among the population affected. Morbidity and mortality due to infectious diseases can be minimized providing these intervention efforts are implemented in a timely and coordinated fashion. This article presents a review of some of the major issues relevant to preparedness and response for natural disasters.

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

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

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

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

METHODOLOGY

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

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

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

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

Tympanic thermometry in Nigerian children

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

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

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

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

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

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

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

Primary structure of human plasma membrane Ca(2+)-ATPase isoform 3

The complete coding sequence of the human plasma membrane calcium ATPase (PMCA) isoform 3 was determined from overlapping genomic and cDNA clones. The cDNAs for the two major alternative splice variants 3a (3CII) and 3b (3CI) code for proteins of 1173 and 1220 amino-acid residues, respectively, which show 98% identity with the corresponding rat isoforms. On a multiple human tissue Northern blot, a major PMCA3 transcript of about 7 kb was detected exclusively in the brain, demonstrating the highly restricted pattern of expression of this isoform to human neuronal tissues. With the elucidation of the human PMCA3 primary structure, complete sequence information is now available for the entire family of human PMCA isoforms.

Comparison of Fatty Acid Methyl Ester Analysis with the Use of API 20E and NFT Strips for Identification of Aquatic Bacteria

Aquatic bacteria grown on MacConkey agar and modified nutrient agar were identified by using API 20E and NFT strips and fatty acid methyl ester (FAME) analysis. Identifications agreed at the species level 35.7% of the time when API 20E strips and FAME analysis were used and in 4.3% of the cases when API NFT strips and FAME analysis were used. These techniques require further development before extended use in ecological studies.