Factors in the Neonatal Period Associated With Pulmonary Hypertension at 28 Days of Life in Broncho-Pulmonary Dysplasia

Objectives. To identify factors associated with pulmonary hypertension (PH) at 28 days of life in preterm infants with bronchopulmonary dysplasia (BPD). Methods. This observational study included 128 premature infants with BPD between January 2022 and February 2023 from the neonatal intensive care unit of Vietnam National Children's Hospital. Results. PH was observed using echocardiography in 29 patients (22.66%). The prevalence of severe BPD in the PH group (62.07%) was significantly higher than that in the non-PH group (18.18%). The multivariate logistic regression showed 2 predictors of PH in BPD: invasive mechanical ventilation up to 28 days of life (odds ratio [OR]:9.440; 95% confidence interval [CI]: 3.090-28.833; P < .001) and history of shock (OR: 2.962; 95% CI: 1.067-8.225; P = .037). Conclusion. We found 2 predictors of PH at 28 days of life in BPD: invasive mechanical ventilation up to 28 days of life and history of shock.

4CMenB Vaccination to Prevent Meningococcal B Disease in Vietnam: Expert Review and Opinion

An advisory board meeting was held with experts in Vietnam (Hanoi, August 2022), to review the evidence on invasive meningococcal disease (IMD) epidemiology, clinical management, and meningococcal vaccines to reach a consensus on recommendations for meningococcal vaccination in Vietnam. IMD is a severe disease, with the highest burden in infants and children. IMD presents as meningitis and/or meningococcemia and can progress extremely rapidly. Almost 90% of deaths in children occur within the first 24 h, and disabling sequelae (e.g., limb amputations and neurological damage) occur in up to 20% of survivors. IMD patients are often hospitalized late, due to mild and nonspecific early symptoms and misdiagnosis. Difficulties related to diagnosis and antibiotic misuse mean that the number of reported IMD cases in Vietnam is likely to be underestimated. Serogroup B IMD is predominant in many regions of the world, including Vietnam, where 82% of IMD cases were due to serogroup B (surveillance data from 2012 to 2021). Four component meningococcal B vaccine (4CMenB) is used in many countries (and is part of the pediatric National Immunization Program in 13 countries), with infant vaccination starting from two months of age, and a 2 + 1 dosing schedule. Experts recommend 4CMenB vaccination as soon as possible in Vietnam, starting from two months of age, with a 2 + 1 dosing schedule, and at least completing one dose before 6 months of age.

Prevalence of internet addiction and anxiety, and factors associated with the high level of anxiety among adolescents in Hanoi, Vietnam during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic and the resulting isolation measures created an increase in the usage of smart devices and internet among adolescents. This study aims to estimate the prevalence of internet addiction, the prevalence of high level of anxiety as well as to examine factors associated with the high level of anxiety among adolescents in Hanoi, Vietnam during the COVID-19 pandemic.

METHOD

Data was collected using respondent-driven sampling and Google online survey forms from a sample of 5,325 school students aged 11-17 in Hanoi between October and December 2021. A short scale consisting of 5 items was used to measure internet addiction and the GAD-7 was used to measure adolescent anxiety level.

RESULTS

The findings revealed that 22.8% and 7.32% of adolescents experienced moderate and severe anxiety. About 32.7% of the study sample exhibited at least three internet addiction indicators. Logistic regression analysis identified significant predictors for high levels of adolescent anxiety. Being female, family experiencing economic difficulties, and exposure to domestic violence were associated with higher risk of anxiety disorder (OR 1.78, 1.45, and 2.89, respectively). Both average daily online time and internet addiction demonstrated gradient association with high level of anxiety.

CONCLUSION

The prevalence of internet addiction and high level of anxiety were high among adolescents in Hanoi, Vietnam during the COVID-19 pandemic. The study highlights the importance of implementing measures at the family and school levels to promote a balanced and healthy approach to smart device use among adolescents.

Patterns of antibiotic use, pathogens, and prediction of mortality in hospitalized neonates and young infants with sepsis: A global neonatal sepsis observational cohort study (NeoOBS)

BACKGROUND

There is limited data on antibiotic treatment in hospitalized neonates in low- and middle-income countries (LMICs). We aimed to describe patterns of antibiotic use, pathogens, and clinical outcomes, and to develop a severity score predicting mortality in neonatal sepsis to inform future clinical trial design.

METHODS AND FINDINGS

Hospitalized infants <60 days with clinical sepsis were enrolled during 2018 to 2020 by 19 sites in 11 countries (mainly Asia and Africa). Prospective daily observational data was collected on clinical signs, supportive care, antibiotic treatment, microbiology, and 28-day mortality. Two prediction models were developed for (1) 28-day mortality from baseline variables (baseline NeoSep Severity Score); and (2) daily risk of death on IV antibiotics from daily updated assessments (NeoSep Recovery Score). Multivariable Cox regression models included a randomly selected 85% of infants, with 15% for validation. A total of 3,204 infants were enrolled, with median birth weight of 2,500 g (IQR 1,400 to 3,000) and postnatal age of 5 days (IQR 1 to 15). 206 different empiric antibiotic combinations were started in 3,141 infants, which were structured into 5 groups based on the World Health Organization (WHO) AWaRe classification. Approximately 25.9% (n = 814) of infants started WHO first line regimens (Group 1-Access) and 13.8% (n = 432) started WHO second-line cephalosporins (cefotaxime/ceftriaxone) (Group 2-"Low" Watch). The largest group (34.0%, n = 1,068) started a regimen providing partial extended-spectrum beta-lactamase (ESBL)/pseudomonal coverage (piperacillin-tazobactam, ceftazidime, or fluoroquinolone-based) (Group 3-"Medium" Watch), 18.0% (n = 566) started a carbapenem (Group 4-"High" Watch), and 1.8% (n = 57) a Reserve antibiotic (Group 5, largely colistin-based), and 728/2,880 (25.3%) of initial regimens in Groups 1 to 4 were escalated, mainly to carbapenems, usually for clinical deterioration (n = 480; 65.9%). A total of 564/3,195 infants (17.7%) were blood culture pathogen positive, of whom 62.9% (n = 355) had a gram-negative organism, predominantly Klebsiella pneumoniae (n = 132) or Acinetobacter spp. (n = 72). Both were commonly resistant to WHO-recommended regimens and to carbapenems in 43 (32.6%) and 50 (71.4%) of cases, respectively. MRSA accounted for 33 (61.1%) of 54 Staphylococcus aureus isolates. Overall, 350/3,204 infants died (11.3%; 95% CI 10.2% to 12.5%), 17.7% if blood cultures were positive for pathogens (95% CI 14.7% to 21.1%, n = 99/564). A baseline NeoSep Severity Score had a C-index of 0.76 (0.69 to 0.82) in the validation sample, with mortality of 1.6% (3/189; 95% CI: 0.5% to 4.6%), 11.0% (27/245; 7.7% to 15.6%), and 27.3% (12/44; 16.3% to 41.8%) in low (score 0 to 4), medium (5 to 8), and high (9 to 16) risk groups, respectively, with similar performance across subgroups. A related NeoSep Recovery Score had an area under the receiver operating curve for predicting death the next day between 0.8 and 0.9 over the first week. There was significant variation in outcomes between sites and external validation would strengthen score applicability.

CONCLUSION

Antibiotic regimens used in neonatal sepsis commonly diverge from WHO guidelines, and trials of novel empiric regimens are urgently needed in the context of increasing antimicrobial resistance (AMR). The baseline NeoSep Severity Score identifies high mortality risk criteria for trial entry, while the NeoSep Recovery Score can help guide decisions on regimen change. NeoOBS data informed the NeoSep1 antibiotic trial (ISRCTN48721236), which aims to identify novel first- and second-line empiric antibiotic regimens for neonatal sepsis.

TRIAL REGISTRATION

ClinicalTrials.gov, (NCT03721302).

Neonatal invasive candidiasis in low- and middle-income countries: Data from the NeoOBS study

Neonatal invasive candidiasis (NIC) has significant morbidity and mortality. Reports have shown a different profile of those neonates affected with NIC and of fluconazole-resistant Candida spp. isolates in low- and middle-income countries (LMICs) compared to high-income countries (HICs). We describe the epidemiology, Candida spp. distribution, treatment, and outcomes of neonates with NIC from LMICs enrolled in a global, prospective, longitudinal, observational cohort study (NeoOBS) of hospitalized infants <60 days postnatal age with sepsis (August 2018-February 2021). A total of 127 neonates from 14 hospitals in 8 countries with Candida spp. isolated from blood culture were included. Median gestational age of affected neonates was 30 weeks (IQR: 28-34), and median birth weight was 1270 gr (interquartile range [IQR]: 990-1692). Only a minority had high-risk criteria, such as being born <28 weeks, 19% (24/127), or birth weight <1000 gr, 27% (34/127). The most common Candida species were C. albicans (n = 45, 35%), C. parapsilosis (n = 38, 30%), and Candida auris (n = 18, 14%). The majority of C. albicans isolates were fluconazole susceptible, whereas 59% of C. parapsilosis isolates were fluconazole-resistant. Amphotericin B was the most common antifungal used [74% (78/105)], followed by fluconazole [22% (23/105)]. Death by day 28 post-enrollment was 22% (28/127). To our knowledge, this is the largest multi-country cohort of NIC in LMICs. Most of the neonates would not have been considered at high risk for NIC in HICs. A substantial proportion of isolates was resistant to first choice fluconazole. Understanding the burden of NIC in LMIC is essential to guide future research and treatment guidelines.

Genotyping and macrolide-resistant mutation of Bordetella pertussis in East and South-East Asia

OBJECTIVES

Macrolide-resistant Bordetella pertussis (MRBP) has been emerging and prevailing in mainland China since 2011. In this study, we aimed to investigate the genotype and macrolide resistance of circulating B. pertussis in East and Southeast Asia using genetic analyses.

METHODS

A total of 302 DNA extracts from clinical specimens and isolates from 2010 to 2020 were analyzed: 145 from Vietnam, 76 from Cambodia, 48 from Taiwan, and 33 from Japan. Genotypes were determined by multilocus variable-number tandem-repeat analysis (MLVA). Macrolide-resistant A2047G mutation in B. pertussis 23S rRNA was investigated using the duplex Cycleave real-time polymerase chain reaction (PCR) assay. Whole-genome sequencing was performed on two MRBP isolates that were identified for the first time in Taiwan.

RESULTS

Overall, 286 DNA extracts (95%) generated a complete MLVA genotype and 283 DNA extracts (94%) yielded a complete result for the A2047G mutation analysis. The A2047G mutation was detected in 18 DNA extracts: fourteen from Vietnam, one from Cambodia, two from Taiwan, and one from Japan. Most of them (78%) showed the genotypes MT104 and MT195, which have previously been reported in Chinese MRBP isolates. Further, the Taiwanese MRBP isolates were classified into the MT104 clade of Chinese MRBP isolates.

CONCLUSION

After MRBP emerged and spread in mainland China, it may have spread to East and Southeast Asia in the 2010s. Continued surveillance targeting the A2047G mutation of MRBP is needed to prevent further spread of this emerging pathogen.

Mortality benefits of reduction fine particulate matter in Vietnam, 2019

Introduction and objectives

Studies assessing the health benefits of air pollution reduction in Vietnam are scarce. This study quantified the annual mortality burden due to PM_2.5 pollution in Vietnam above the World Health Organization recommendation for community health (AQG: 5 μg/m³) and the proposed National Technical Regulation on Ambient Air Quality (proposed QCVN: 15 μg/m³).

Methodology

This study applied a health impact assessment methodology with the hazard risk function for non-communicable diseases (NCDs) and lower respiratory infections (LRIs) in the Global Exposure Mortality Model (GEMM) to calculate attributable deaths, Years of Life lost, and Loss of Life expectancy at birth due to air pollution in the Vietnamese population above 25 years of age in 11 provinces. We obtained annual average PM_2.5 concentrations for Vietnam in 2019 at a 3x3 km grid modeled using Mixed Linear regression and multi-data sources. Population and baseline mortality data were obtained from administrative data system in Vietnam. We reported the findings at both the provincial and smaller district levels.

Results

Annual PM_2.5 concentrations in all studied provinces exceeded both the AQG and the proposed QCVN. The maximum annual number of attributable deaths in the studied provinces if they had complied with WHO air quality guidelines was in Ha Noi City, with 5,090 (95%CI: 4,253-5,888) attributable deaths. At the district level, the highest annual rate of attributable deaths if the WHO recommendation for community health had been met was 104.6 (95%CI: 87.0-121.5) attributable deaths per 100,000 population in Ly Nhan (Ha Nam province).

Conclusion

A much larger number of premature deaths in Vietnam could potentially be avoided by lowering the recommended air quality standard. These results highlight the need for effective clean air action plans by local authorities to reduce air pollution and improve community health.

Mutation spectrum of ATP7B gene in pediatric patients with Wilson disease in Vietnam

Background

Wilson disease (WD) is caused by mutations in the copper-transporting P-type adenosine triphosphatase encoded by the ATP7B gene. In this study, we screened and identified the ATP7B mutations among unrelated Vietnamese pediatric patients.

Methods

One-hundred-thirteen pediatric patients with clinically diagnosed WD were recruited. DNA samples were extracted from peripheral blood. Mutations in the ATP7B gene were identified by Sanger sequencing.

Results

Approximately 98% of the clinically diagnosed WD patients carried ATP7B mutations. A total of 35 different ATP7B variants were detected, including five novel mutations (L658P, L792P, T977K, IVS4 + 1G > A and IVS20 + 4A > G). Remarkably, this study revealed that S105* was the most prevalent variant (32.27%), followed by L1371P (9.09%), I1148T (7.27%), R778L (6.36%), T850I (5.45%), V176Sfs*28 and IVS14-2A > G (4.55%). Most ATP7B mutations were located in the exon 2 (37.73%), exon 16 (10.00%), exon 8 (9.55%), exon 20 (9.09%), exon 10 and exon 18 (5.45%), exon 14 (5.00%), exon 13 and intron 14 (4.55%). We developed a streamlined procedure to quickly characterize mutations in the ATP7B gene in the Vietnamese children, starting with sequencing exon 2 and subsequently to exons 8,10,13-16,18, and 20 to allow quick diagnosis of clinically suspected patients.

Conclusion

The mutational spectrum and hotspots of ATP7B gene in the Vietnamese population were fairly different from other East Asian populations. A streamlined procedure was developed to screen exon 2 in ATP7B gene among suspected WD patients to reduce genetically diagnostic cost, to facilitate early detection and intervention in countries with limited resources.

Association Between Real-time Polymerase Chain Reaction Cycle Threshold Value and Clinical Severity in Neonates and Infants Infected With Bordetella pertussis

BACKGROUND

Polymerase chain reaction (PCR) is highly sensitive and is thus the standard method for diagnosing pertussis. Real-time PCR is widely used because of its accuracy and the simplicity of the simultaneous cycle threshold (Ct) value, which represents the copy numbers of the target gene. Little is known of the association of Ct value with pertussis severity in neonates and infants.

METHODS

This study determined Ct values in neonates and infants diagnosed with pertussis by real-time PCR using nasopharyngeal samples at Vietnam National Children's Hospital in Hanoi in 2017 and 2019. The association of disease severity and clinical parameters were analyzed using univariate and multivariate analyses.

RESULTS

We evaluated 108 patients with pertussis [median age: 63 days, interquartile range (IQR): 41-92 days]. Only 6/108 (6%) received at least 1 dose of a pertussis-containing vaccine. Among them, 24 (22.2%) had severe disease requiring care in a pediatric intensive care unit, 16 (13.8%) required mechanical ventilation, and 3 (2.6%) died. The median Ct value was lower in patients with severe disease (19.0, IQR: 16.5-22.0, n = 24) than in those without severe disease (25.5, IQR: 20.0-30.0, n = 84) (P = 0.002). Logistic regression analyses demonstrated that PCR Ct value [odds ratio (OR): 1.783, 95% confidence interval (CI): 1.013-3.138, P = 0.045], age (OR: 3.118, 95% CI: 1.643-5.920, P = 0.001), and white blood cell counts (OR: 0.446, 95% CI: 0.261-0.763, P = 0.003) remained significantly associated with severe disease.

CONCLUSIONS

Real-time PCR Ct values for pertussis might be useful as a predictor of severe disease in neonates and infants.

Genetic Etiology of Neonatal Diabetes Mellitus in Vietnamese Infants and Characteristics of Those With INS Gene Mutations

BACKGROUND

Neonatal diabetes mellitus (NDM) is a rare (1:90,000 newborns) but potentially devastating metabolic disorder characterized by hyperglycemia combined with low levels of insulin. Dominantly-acting insulin (INS) gene mutations cause permanent NDM through single amino acid changes in the protein sequence leading to protein misfolding, which is retained within the endoplasmic reticulum (ER), causing ER stress and β-cell apoptosis. Over 90 dominantly-acting INS gene mutations have been identified in individuals with permanent NDM.

PATIENTS AND METHODS

The study included 70 infants diagnosed with NDM in the first year of life between May 2008 and May 2021 at the Vietnam National Children's Hospital. Sequencing analysis of all the genes known to cause NDM was performed at the Exeter Genomic Laboratory, UK. Clinical characteristics, molecular genetics, and annual data relating to glycemic control (HbA1c) and severe hypoglycemia of those with INS mutations were collected. The main outcomes of interest were HbA1c, daily insulin dose, growth, and cognitive/motor development.

RESULTS

Fifty-five of 70 infants (78.5%) with NDM harbored a mutation in a known disease-causing gene and of these, 10 had six different de novo heterozygous INS mutations. Mean gestational age was 38.1 ± 2.5 weeks and mean birth weight was 2.8 ± 0.5 g. They presented with NDM at 20 ± 17 weeks of age; 6/10 had diabetic ketoacidosis with pH 7.13 ± 0.26; plasma glucose level 32.6 ± 14.3 mmol/l and HbA1C 81 ± 15% mmol/mol. After 5.5 ± 4.8 years of insulin treatment, 9/10 have normal development with a developmental quotient of 80-100% and HbA1C 64 ± 7.3 mmol/mol, 9/10 have normal height, weight, and BMI on follow-up.

CONCLUSIONS

We report a series of Vietnamese NDM cases with dominant INS mutations. INS mutations are the third commonest cause of permanent NDM. We recommend screening of the INS gene in all children diagnosed with diabetes in the first year of life.

Mortality benefits of reduction fine particulate matter in Vietnam, 2019

INTRODUCTION AND OBJECTIVES

Studies assessing the health benefits of air pollution reduction in Vietnam are scarce. This study quantified the annual mortality burden due to PM_2.5 pollution in Vietnam above the World Health Organization recommendation for community health (AQG: 5 μg/m³) and the proposed National Technical Regulation on Ambient Air Quality (proposed QCVN: 15 μg/m³).

METHODOLOGY

This study applied a health impact assessment methodology with the hazard risk function for non-communicable diseases (NCDs) and lower respiratory infections (LRIs) in the Global Exposure Mortality Model (GEMM) to calculate attributable deaths, Years of Life lost, and Loss of Life expectancy at birth due to air pollution in the Vietnamese population above 25 years of age in 11 provinces. We obtained annual average PM_2.5 concentrations for Vietnam in 2019 at a 3x3 km grid modeled using Mixed Linear regression and multi-data sources. Population and baseline mortality data were obtained from administrative data system in Vietnam. We reported the findings at both the provincial and smaller district levels.

RESULTS

Annual PM_2.5 concentrations in all studied provinces exceeded both the AQG and the proposed QCVN. The maximum annual number of attributable deaths in the studied provinces if they had complied with WHO air quality guidelines was in Ha Noi City, with 5,090 (95%CI: 4,253-5,888) attributable deaths. At the district level, the highest annual rate of attributable deaths if the WHO recommendation for community health had been met was 104.6 (95%CI: 87.0-121.5) attributable deaths per 100,000 population in Ly Nhan (Ha Nam province).

CONCLUSION

A much larger number of premature deaths in Vietnam could potentially be avoided by lowering the recommended air quality standard. These results highlight the need for effective clean air action plans by local authorities to reduce air pollution and improve community health.

Successful Treatment of Carbamazepine-Induced Toxic Epidermal Necrolysis With Clinical Gastrointestinal Involvement: A Case Report

BACKGROUND

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare and life-threatening disease of the skin and mucosal surfaces. Although gastrointestinal manifestations in adults are potential prognostic factors for disease severity, there are limited data on such cases and their standard management in the pediatric population.

CASE PRESENTATION

We herein report the case of an 8-year-old girl with a 1-year history of epilepsy, who presented with bilateral conjunctivitis and progressively widespread bullous, and pruritic eruption based on erythematous skin after administration of carbamazepine. A diagnosis of carbamazepine-induced TEN was made, and the drug was immediately discontinued. The result of genetic screening showed that the patient was positive for the HLA-B^*15:02 allele. Then, her condition got worse by developing gastrointestinal involvement, including hematemesis and severe watery bloody diarrhea. A combination of the intravenous immunoglobulin and the appropriate dose of systemic steroids have contributed to a favorable outcome in this case. Multidisciplinary care of mucocutaneous involvement, supplemental nutrition, and fluid replacement was also critically warranted. This report aims to contribute to the current literature on TEN-related gastrointestinal manifestations in pediatrics and highlights the need for further investigations in determining the optimal treatment in such cases.

CONCLUSION

In conclusion, we reported the successful treatment of TEN-related gastrointestinal manifestations in a pediatric patient, which should be critically considered in patients with SJS/TEN. Since it may significantly contribute to the poor prognosis of the illness, further investigations in determining standard management in such cases are necessary.

Pediatric Acute Myocarditis With Short-Term Outcomes and Factors for Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Cohort Study in Vietnam

Objective: Data on the management and outcomes of acute myocarditis treated with extracorporeal membrane oxygenation (ECMO) among low- and middle-income countries are limited. This study aimed to determine the short-term outcomes and also identify factors associated with ECMO use among children with acute myocarditis at a tertiary children's hospital in Vietnam. Methods: A single-center, retrospective observational study was conducted between January 2016 and February 2021. Pediatric patients with acute myocarditis, aged 1 month to 16 years, were included. Results: In total, 54 patients (male, 46%; median age, 7 years) with acute myocarditis were included; 37 of them received ECMO support. Thirty percent (16/54) of the patients died, and 12 of them received ECMO. Laboratory variables that differed between survivors and non-survivors included median left ventricular ejection fraction (LVEF) at 48 h (42 vs. 25%; p = 0.001), platelet count (304 g/L [interquartile range (IQR): 243-271] vs. 219 g/L [IQR: 167-297]; p = 0.014), and protein (60 g/dl [IQR: 54-69] vs. 55 [IQR: 50-58]; p = 0.025). Among patients who received ECMO, compared with the survivors, non-survivors had a low LVEF at 48 h (odds ratio (OR), 0.8; 95% confidence interval (CI): 0.6-0.9; p = 0.006) and high vasoactive-inotropic score (OR, 1.0; 95% CI: 1.0-1.0; p = 0.038) and lactate (OR, 2.8; 95% CI, 1.2-6.1; p = 0.013) at 24 h post-ECMO. Conclusions: The case fatality rate among children with acute myocarditis was 30 and 32% among patients requiring ECMO support. Arrhythmia was an indicator for ECMO in patients with cardiogenic shock.

Feasibility, acceptability, and sustainability of Project ECHO to expand capacity for pediatricians in Vietnam

Background

The Project Extension for Community Healthcare Outcomes (ECHO) model is considered a platform for academic medical centers to expand their healthcare workforce capacity to medically underserved populations. It has been known as an effective solution of continuing medical education (CME) for healthcare workers that used a hub-and-spoke model to leverage knowledge from specialists to primary healthcare providers in different regions. In this study, we aim to explore the views of healthcare providers and hospital leaders regarding the feasibility, acceptability, and sustainability of Project ECHO for pediatricians.

Methods

This qualitative study was conducted at the Vietnam National Children’s Hospital and its satellite hospitals from July to December 2020. We conducted 39 in-depth interviews with hospital managers and healthcare providers who participated in online Project ECHO courses. A thematic analysis approach was performed to extract the qualitative data from in-depth interviews.

Results

Project ECHO shows high feasibility when healthcare providers find motivated to improve their professional knowledge. Besides, they realized the advantages of saving time and money with online training. Although the courses had been covered fully by the Ministry of Health’s fund, the participants said they could pay fees or be supported by the hospital’s fund. In particular, the expectation of attaining the CME-credited certificates after completing the course also contributes to the sustainability of the program. Project ECHO’s online courses should be improved if the session was better monitored with suitable time arrangements.

Conclusions

Project ECHO model is highly feasible, acceptable, and sustainable as it brings great benefits to the healthcare providers, and is appropriate with the policy theme of continuing medical education of the Ministry of Health. We recommend that further studies should be conducted to assess the impact of the ECHO program, especially for patient and community outcomes.

Pertussis Infants Needing Mechanical Ventilation and Extracorporeal Membrane Oxygenation: Single-Center Retrospective Series in Vietnam

OBJECTIVES

Pertussis is an infectious disease that causes epidemics and outbreaks and is associated with a high mortality rate, especially in infants, in both developed and developing countries. We aimed to characterize infants with pertussis with respiratory failure and shock and investigated the factors related to mortality.

DESIGN

A retrospective, observational study conducted between January 2015 and October 2020.

SETTING

This study was conducted at the Vietnam National Children's Hospital, which is a government hospital that serves as a tertiary care center in Hanoi, Vietnam.

PATIENTS

Children who fulfilled the following inclusion criteria were included: 1) admitted to the PICU, 2) less than 16 years old, 3) pertussis confirmed by real-time polymerase chain reaction, and 4) treated with mechanical ventilation due to respiratory failure and shock.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Seventy-three mechanically ventilated children (40 boys; median age, 56 d), whereas 19 patients received extracorporeal membrane oxygenation support. Twenty-six patients (36%) died including 12 who received extracorporeal membrane oxygenation. Those who received extracorporeal membrane oxygenation support had higher leukocyte counts upon admission and were more frequently diagnosed with pulmonary hypertension and stage 3 acute kidney injury. Compared with survivors, nonsurvivors showed increased heart rates, leukocyte and neutrophil counts, and lower systolic and diastolic blood pressure at admission. Increased Vasoactive-Inotropic Score, stage 3 acute kidney injury, fluid overload, the use of renal replacement therapy, and extracorporeal membrane oxygenation use were prevalent among nonsurvivors.

CONCLUSIONS

In this study, around one third of mechanically ventilated patients with pertussis died. Those who received extracorporeal membrane oxygenation had higher leukocyte counts, a higher prevalence of pulmonary hypertension, and advanced stages of acute kidney injury. Higher Vasoactive-Inotropic Score and advanced stages of acute kidney injury were associated with a greater risk of mortality.

Use of Project ECHO Telementoring Model in Continuing Medical Education for Pediatricians in Vietnam: Preliminary Results

The ECHO (Extension for Community Health Outcomes) model has been introduced and implemented in several hospitals and health programs in Vietnam since 2015. In 2018, Vietnam National Children’s Hospital (VNCH) officially implemented the ECHO model to provide continuing medical education (CME) credits on pediatrics topics for medical staff in its satellite hospitals and health centers in the Northern region of Vietnam. This paper presents preliminary results of the ECHO program at VNCH. Methods included pre- and post-program assessments of pediatricians’ clinical knowledge, self-efficacy, and professional satisfaction. The analysis compared the differences between pre/post scores descriptively. Knowledge of participants increased by 22.5% points on average. More than 90% of Project ECHO-Pediatrics participants experienced increased confidence. Overall, there was an improvement in participants’ self-efficacy in the post-training compared to the pre-training (range 14.7%-22.6% difference from pre-training). All participants improved on their results in the clinical test immediately after the training and maintained it after 3 months. The study demonstrated the ability Project ECHO to improve healthcare worker knowledge and satisfaction.

Recombinant human thrombomodulin for pneumonia-induced severe ARDS complicated by DIC in children: a preliminary study

Purpose

Recombinant human soluble thrombomodulin (rTM) has been used to treat disseminated intravascular coagulation (DIC). Recent studies have shown the efficacy of rTM through its anti-inflammatory effects for treatment of adults with acute respiratory distress syndrome (ARDS). However, the safety and efficacy of rTM in children with severe ARDS complicated by DIC have not been reported. In this preliminary study, we reported the feasibility of using rTM for the treatment of pneumonia-induced severe ARDS complicated by DIC in children.

Methods

Six children (age: median 10 months old) with pneumonia-induced severe ARDS complicated by DIC were enrolled in this preliminary study. rTM (380 U/kg) was administered for a maximum of 6 days, in addition to conventional therapies after diagnosis of severe ARDS complicated by DIC. After administration of rTM, we measured changes in the plasma TM concentration and evaluated the clinical course, status of DIC and ARDS, and other laboratory findings, including levels of cytokines, chemokines, and biomarkers.

Results

In all six children, the plasma concentration of TM increased and DIC scores decreased after administration of rTM. Four of the six children recovered from the severe ARDS complicated by DIC after treatment, and were discharged from the hospital with no complications. In survived children, levels of soluble receptors for advanced glycation end products, interleukin-6, interleukin-8 and monocyte chemotactic protein-1 decreased after administration of rTM compared to those before rTM.

Conclusions

The rTM administration is feasible as an adjunctive therapeutic strategy for children over 2 months with pneumonia-induced severe ARDS complicated by DIC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00540-021-02971-3.

Hypocoagulable Tendency on Thromboelastometry Associated With Severity and Anticoagulation Timing in Pediatric Septic Shock: A Prospective Observational Study

Objective: To identify whether coagulation profiles using thromboelastometry are associated with outcomes in pediatric septic shock. The primary outcomes were the development of disseminated intravascular coagulation (DIC) and the severity of the pediatric intensive care unit (PICU) existing scoring systems, while the secondary outcome was hospital mortality. This study aimed to contribute to current findings of the limitations of conventional tests in determining the optimal timing of anticoagulation in sepsis. Design: A prospective, observational study conducted between August 2019 and August 2020. Setting: PICU at a pediatric tertiary hospital in Hanoi, Vietnam. Patients: Fifty-five pediatric patients who met the septic shock criteria were enrolled. Measurements and Main Results: Fifty-five patients with septic shock were recruited. At the time of diagnosis, thromboelastometry revealed normocoagulability, hypercoagulability, and hypocoagulability in 29, 29, and 42% of the patients, respectively (p > 0.05); however, most patients in the overt DIC and non-survival groups progressed to hypocoagulability (82 and 64%, respectively). The overt DIC, PELOD-2 > 8, PRISM-III > 11, and non-survival group had a significant hypocoagulable tendency according to thromboelastometry parameters [prolonged clotting time (CT) and clot formation time (CFT); and reduced α-angle (α), maximum clot firmness (MCF), thrombodynamic potential index (TPI)] compared to the non-overt DIC, PELOD-2 ≤ 8, PRISM-III score ≤ 11 and survival group (p < 0.05). Conventional parameters between the normocoagulable and hypercoagulable groups were not different (p > 0.05). Hypocoagulability was characterized by lower platelet count and fibrinogen level, higher prolonged prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (APTT), and higher D-dimer level than in hypercoagulability (p < 0.05). Hypocoagulable tendency on thromboelastometry had a higher hazard at a PT > 16.1 s [area under the curve (AUC) = 0.747, odds ratio (OR) = 10.5, p = 0.002], INR > 1.4 (AUC = 0.754, OR = 6.9, p = 0.001), fibrinogen <3.3 g/L (AUC = 0.728, OR = 9.9, p = 0.004), and D-dimer > 3,863 ng/mL (AUC = 0.728, OR = 6.7, p = 0.004). Conclusions: Hypocoagulable tendency using thromboelastometry is associated with the severity of septic shock. Conventional coagulation tests may fail to detect hypercoagulability, which is crucial in determining anticoagulation timing.

Molecular Genetics, Clinical Characteristics, and Treatment Outcomes of KATP-Channel Neonatal Diabetes Mellitus in Vietnam National Children's Hospital

BACKGROUND

Neonatal diabetes mellitus (NDM) is defined as insulin-requiring persistent hyperglycemia occurring within the first 6 months of life, which can result from mutations in at least 25 different genes. Activating heterozygous mutations in genes encoding either of the subunits of the ATP-sensitive K⁺ channel (K_ATP channel; KCNJ11 or ABCC8) of the pancreatic beta cell are the most common cause of permanent NDM and the second most common cause of transient NDM. Patients with NDM caused by K_ATP channel mutations are sensitive to sulfonylurea (SU) treatment; therefore, their clinical management can be improved by replacing insulin with oral agents.

PATIENTS AND METHODS

Seventy patients were diagnosed with NDM between May 2008 and May 2021 at Vietnam National Children's Hospital, and molecular genetic testing for all genes known to cause NDM was performed at the Exeter Genomic Laboratory, UK. Patients with ABCC8 or KCNJ11 mutations were transferred from insulin to oral SU. Clinical characteristics, molecular genetics, and annual data relating to glycemic control, SU dose, severe hypoglycemia, and side effects were collected. The main outcomes of interest were SU dose, SU failure (defined as permanent reintroduction of daily insulin), and glycemic control (HbA1c).

RESULTS

Fifty-four of 70 patients (77%) with NDM harbored a genetic mutation and of these; 27 (50%) had activating heterozygous mutations in ABCC8 or KCNJ11. A total of 21 pathogenic mutations were identified in the 27 patients, including 13 mutations in ABCC8 and 8 mutations in KCNJ11. Overall, 51% had low birth weight (below 3rd percentile), 23 (85%) were diagnosed before 3 months of age, and 23 (85%) presented with diabetic ketoacidosis. At diagnosis, clinical and biochemical findings (mean ± SD) were pH 7.16 ± 0.16; HCO3- , 7.9 ± 7.4 mmol/L; BE, -17.9 ± 9.1 mmol/L; HbA1C, 7.98% ± 2.93%; blood glucose, 36.2 ± 12.3 mmol/L; and C-peptide median, 0.09 (range, 0-1.61 nmol/l). Twenty-six patients were successfully transferred from insulin to SU therapy. In the remaining case, remission of diabetes occurred prior to transfer. Glycemic control on SU treatment was better than on insulin treatment: HbA1c and blood glucose level decreased from 7.58% ± 4.63% and 19.04 ± 14.09 mmol/L when treated with insulin to 5.8 ± 0.94% and 6.87 ± 3.46 mmol/L when treated with SU, respectively.

CONCLUSIONS

This is the first case series of NDM patients with ABCC8/KCNJ11 mutations reported in Vietnam. SU is safe in the short term for these patients and more effective than insulin therapy, consistent with all studies to date. This is relevant for populations where access to and cost of insulin are problematic, reinforcing the importance of genetic testing for NDM.

Exposure to air pollution and risk of hospitalization for cardiovascular diseases amongst Vietnamese adults: Case-crossover study

BACKGROUND

Associations between hospital admissions and ambient air pollutants in the Vietnamese population have been reported in previous studies. However, most studies were conducted in Hanoi or Hochiminh city. We used hospital records of seven hospitals in Northern Vietnam to investigate short-term associations between ambient air pollutants and hospital admissions due to cardiovascular conditions.

METHODS

We used 135'101 hospital records of residents (age ≥15) living in three provinces (Hanoi, Quang Ninh, and Phu Tho) and daily ambient air pollutant concentrations to estimate percentage changes and 95% confidence intervals for hospital admissions due to seven cardiovascular conditions per interquartile range (IQR) increases in daily ambient air pollutants. We used a time-stratified case-crossover analysis adjusting for meteorological factors, indicators of holidays and influenza epidemics. We also investigated modification of effects by age groups (<65 and ≥65), seasons (cold and hot) and hospital levels (national and province level).

RESULTS

Particulate matter concentrations were positively associated with daily hospital admissions due to most cardiovascular conditions. For example, an increment in the two-day average (lag1-2) level of PM_2.5 by one IQR (34.4 µg/m³) was associated with a 6.3% (95%CI: 3.0%-9.8%) increase in the daily count of admissions for ischemic heart disease in Hanoi and with 23.2% (95%CI: 11.1%-36.5%) for cardiac failure in Quang Ninh. Moreover, hospitalisations for stroke in Hanoi and cardiac failure in Phu Tho showed strong positive associations with SO₂. The findings also show that estimates varied by age groups, seasons and hospital levels.

CONCLUSION

Ambient air pollutants were associated with daily cardiovascular admissions in Northern Vietnam. The findings underline the important role of ambient air pollutants as a trigger of cardiovascular conditions.

Association of ambient air pollution with lengths of hospital stay for hanoi children with acute lower-respiratory infection, 2007-2016

INTRODUCTION

The association between ambient air pollution and length of hospital stay (LOS) for children with lower-respiratory infection is unclear.

MATERIALS AND METHODS

The association was examined using admission data for 75,432 children in Hanoi, aged 0-5 years, hospitalized with acute lower-respiratory infection (ALRI) and daily air pollutant levels in Hanoi between 2007 and 2016. We estimated the odds ratio of being discharged for an interquartile range (IQR) increment (IQR) of ambient pollutants during one to four days prior to admission date. We used pooled logistic regression models including a B-spline function of calendar time and terms describing the baseline odds, adjusting for meteorological factors, age, gender, residential location, week-day of admission, discharge on weekends or holidays, and number of respiratory hospitalizations one day prior to the discharge date.

RESULTS

An IQR increase in O₃ concentrations (85.8 μg/m³) was associated with a 5% (95%CI: 2%-8%) decrease in the odds of discharge from hospital among children with ALRI. Results were similar for PM₁₀, but only for children aged 2-5 years. For the other pollutants, corresponding associations were close to null or in the opposite direction. For example, increase in CO was associated with shorter LOS.

CONCLUSIONS

Our study provides the first investigation of the associations between lengths of hospital stays and air pollutant levels prior to hospitalization in Asian children. Increased levels of O₃ prior to admission predicted prolonged hospitalizations. The inconsistencies in the findings for other pollutants call for further investigations.

Acute effects of ambient air pollution on lower respiratory infections in Hanoi children: An eight-year time series study

BACKGROUND

Lower respiratory diseases are the most frequent causes of hospital admission in children worldwide, particularly in developing countries. Daily levels of air pollution are associated with lower respiratory diseases, as documented in many time-series studies. However, investigations in low-and-middle-income countries, such as Vietnam, remain sparse.

OBJECTIVE

This study investigated the short-term association of ambient air pollution with daily counts of hospital admissions due to pneumonia, bronchitis and asthma among children aged 0-17 in Hanoi, Vietnam. We explored the impact of age, gender and season on these associations.

METHODS

Daily ambient air pollution concentrations and hospital admission counts were extracted from electronic databases received from authorities in Hanoi for the years 2007-2014. The associations between outdoor air pollution levels and hospital admissions were estimated for time lags of zero up to seven days using Quasi-Poisson regression models, adjusted for seasonal variations, meteorological variables, holidays, influenza epidemics and day of week.

RESULTS

All ambient air pollutants were positively associated with pneumonia hospitalizations. Significant associations were found for most pollutants except for ozone and sulfur dioxide in children aged 0-17. Increments of an interquartile range (21.9μg/m³) in the 7-day-average level of NO₂ were associated with a 6.1% (95%CI 2.5% to 9.8%) increase in pneumonia hospitalizations. These associations remained stable in two-pollutant models. All pollutants other than CO were positively associated with hospitalizations for bronchitis and asthma. Associations were weaker in infants than in children aged 1-5.

CONCLUSION

Strong associations between hospital admissions for lower respiratory infections and daily levels of air pollution confirm the need to adopt sustainable clean air policies in Vietnam to protect children's health.

Short-term association between ambient air pollution and pneumonia in children: A systematic review and meta-analysis of time-series and case-crossover studies

Ambient air pollution has been associated with respiratory diseases in children. However, its effects on pediatric pneumonia have not been meta-analyzed. We conducted a systematic review and meta-analysis of the short-term association between ambient air pollution and hospitalization of children due to pneumonia. We searched the Web of Science and PubMed for indexed publications up to January 2017. Pollutant-specific excess risk percentage (ER%) and confidence intervals (CI) were estimated using random effect models for particulate matter (PM) with diameter ≤ 10 (PM₁₀) and ≤2.5 μm (PM_2.5), sulfur dioxide (SO₂), ozone (O₃), nitrogen dioxide (NO₂), and carbon monoxide (CO). Results were further stratified by subgroups (children under five, emergency visits versus hospital admissions, income level of study location, and exposure period). Seventeen studies were included in the meta-analysis. The ER% per 10 μg/m³ increase of pollutants was 1.5% (95% CI: 0.6%-2.4%) for PM₁₀ and 1.8% (95% CI: 0.5%-3.1%) for PM_2.5. The corresponding values per 10 ppb increment of gaseous pollutants were 2.9% (95% CI: 0.4%-5.3%) for SO₂, 1.7% (95% CI: 0.5%-2.8%) for O₃, and 1.4% (95% CI: 0.4%-2.4%) for NO₂. ER% per 1000 ppb increment of CO was 0.9% (95% CI: 0.0%-1.9%). Associations were not substantially different between subgroups. This meta-analysis shows a positive association between daily levels of ambient air pollution markers and hospitalization of children due to pneumonia. However, lack of studies from low-and middle-income countries limits the quantitative generalizability given that susceptibilities to the adverse effects of air pollution may be different in those populations. The meta-regression in our analysis further demonstrated a strong effect of country income level on heterogeneity.

Childhood hospitalisation and related deaths in Hanoi, Vietnam: a tertiary hospital database analysis from 2007 to 2014

OBJECTIVE

To describe hospital admission and emergency visit rates and potential risk factors of prolonged hospitalisation and death among children in Hanoi.

STUDY DESIGN

A retrospective study reviewed 212 216 hospitalisation records of children (aged 0-17) who attended the Vietnam National Children's Hospital in Hanoi between 2007 and 2014. Four indicators were analysed and reported: (1) rate of emergency hospital visits, (2) rate of hospitalisation, (3) length of hospital stay and (4) number of deaths. The risk of prolonged hospitalisation was investigated using Cox proportion hazard, and the risk of death was investigated through logistic regressions.

RESULTS

During 2007-2014, the average annual rate of emergency visits was 2.2 per 1000 children and the rate of hospital admissions was 13.8 per 1000 children. The annual rates for infants increased significantly by 3.9 per 1000 children during 2012-2014 for emergency visits and 25.1 per 1000 children during 2009-2014 for hospital admissions. Digestive diseases (32.0%) and injuries (30.2%) were common causes of emergency visits, whereas respiratory diseases (37.7%) and bacterial and parasitic infections (19.8%) accounted for most hospital admissions. Patients with mental and behavioural disorders remained in the hospital the longest (median=12 days). Morbidities related to the perinatal period dominated mortality causes (32.5% of deaths among those admitted to the hospital. Among the respiratory diseases, pneumonia was the leading cause of both prolonged hospitalisation and death.

CONCLUSIONS

Preventable health problems, such as common bacterial infections and respiratory diseases, were the primary causes of hospital admissions in Vietnam.

Adenovirus Type 7 Pneumonia in Children Who Died from Measles-Associated Pneumonia, Hanoi, Vietnam, 2014

During a 2014 measles outbreak in Vietnam, postmortem pathologic examination of hospitalized children who died showed that adenovirus type 7 pneumonia was a contributory cause of death in children with measles-associated immune suppression. Adenovirus type 7 pneumonia should be recognized as a major cause of secondary infection after measles.

Modified Lecompte procedure for repair of double-outlet left ventricle

A modification of the Lecompte procedure was used successfully for total correction in 2 boys aged 3 and 6 months with double-outlet left ventricle. The operative procedure and short-term results are evaluated.

Thoracoscopic repair for congenital diaphragmatic hernia: experience with 139 cases

PURPOSE

To analyze indications and to present details of surgical technique and outcomes of thoracoscopic repair for congenital diaphragmatic hernia (CDH) in 139 patients.

METHODS

We reviewed medical records of all patients with CDH who underwent thoracoscopic repair by the same surgical team from June 2001 to October 2009. Patients were placed in the lateral decubitus position. The operations were performed using three trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2-6 mm Hg. The hernia defect was repaired using nonabsorbable interrupted sutures with extracorporeal knots. A prosthetic patch was used when direct closure of the hernia defect was not feasible.

RESULTS

There were 139 patients, including 91 boys and 48 girls. Seventy-five patients were newborns, and 64 were infants or children. The hernia was located on the left side in 113 patients (81.3%) and on the right side in 26 patients (18.7%). The mean operative time for thoracoscopic approach was 66 ± 27 minutes. Conversion was required in 11 patients (7.9%) from 2001 to 2007. There were no conversions in 2008 or 2009. A prosthetic patch was used in 7 patients. There were 14 postoperative deaths (10%). Follow-up was obtained in 114 patients, ranging from 1 to 84 months (mean 26.3 ± 24.7 months). Five patients had recurrence (3.6%).

CONCLUSIONS

Thoracoscopic repair is feasible and safe for children with CDH, including newborns. The conversion rate decreased, and indications increased with surgical team experience.