Improved survival of children and adolescents with classical Hodgkin lymphoma treated on a harmonised protocol in South Africa

BACKGROUND

Historic South African 5-year overall survival (OS) rates for Hodgkin lymphoma (HL) from 2000 to 2010 were 46% and 84% for human immunodeficiency virus (HIV)-positive and HIV-negative children, respectively. We investigated whether a harmonised treatment protocol using risk stratification and response-adapted therapy could increase the OS of childhood and adolescent HL.

METHODS

Seventeen units prospectively enrolled patients less than 18 years, newly diagnosed with classical HL onto a risk-stratified, response-adapted treatment protocol from July 2016 to December 2022. Low- and intermediate-risk patients received four and six courses of adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD), respectively. High-risk patients received two courses of ABVD, followed by four courses of cyclophosphamide, vincristine, prednisone, and dacarbazine (COPDac). Those with a slow early response and bulky disease received consolidation radiotherapy. HIV-positive patients could receive granulocyte colony-stimulating factor and less intensive therapy if stratified as high risk, at the treating clinician's discretion. Kaplan-Meier survival analysis was performed to determine 2-year OS and Cox regression to elucidate prognostic factors.

RESULTS

The cohort comprised 132 patients (19 HIV-positive, 113 HIV-negative), median age of 9.7 years, with a median follow-up of 2.2 years. Risk grouping comprised nine (7%) low risk, 36 (27%) intermediate risk and 87 (66%) high risk, with 71 (54%) rapid early responders and 45 (34%) slow early responders, and 16 (12%) undocumented. Two-year OS was 100% for low-risk, 93% for intermediate-risk, and 91% for high-risk patients. OS for HIV-negative (93%) and HIV-positive (89%) patients were similar (p = .53). Absolute lymphocyte count greater than 0.6 × 109 predicted survival (94% vs. 83%, p = .02).

CONCLUSION

In the first South African harmonised HL treatment protocol, risk stratification correlated with prognosis. Two-year OS of HIV-positive and HIV-negative patients improved since 2010, partially ascribed to standardised treatment and increased supportive care. This improved survival strengthens the harmonisation movement and gives hope that South Africa will achieve the WHO Global Initiative for Childhood Cancer goals.

A Retrospective Observational Study of the Impact of HIV Status on the Outcome of Paediatric Intensive Care Unit Admissions at a Tertiary Hospital in South Africa (2015-2019)

HIV-infected and HIV-exposed but uninfected (HEU) children have unique health risks. Our study looked at how HIV exposure and infection impact presentation and outcomes in PICU in an era of improved ART. A retrospective analysis of children admitted to PICU was performed. The sample was divided into HIV negative, HEU and HIV infected, and presentation and outcomes were compared with a significance level set at α = 0.05. Our study showed that 16% (109/678) of children admitted to PICU were HEU and 5.2% (35/678) were HIV infected. HIV-infected children were admitted at a younger age (median two months) with an increased incidence of lower respiratory infections than HIV-negative children (p < 0.001); they also required longer ventilation and admission (p < 0.001). HIV-infected children had a higher mortality (40%) (p = 0.02) than HIV-negative (22.7%) children; this difference was not significant when comparing only children with a non-surgical diagnosis (p = 0.273). HEU children had no significant difference in duration of ICU stay (p = 0.163), ventilation (p = 0.443) or mortality (p = 0.292) compared to HIV-negative children. In conclusion, HIV-infected children presented with more severe disease requiring longer ventilation and admission. HEU had similar outcomes to HIV-negative children.

SACCSG HL-2018. Barriers and enablers of a harmonized treatment protocol for childhood and adolescent Hodgkin lymphoma in South Africa

Introduction: Collaborative studies have contributed to improved survival of pediatric Hodgkin lymphoma in well-resourced settings, but few are documented in resource-constrained countries. The South Africa Children's Cancer Study Group initiated harmonization of management protocols in 2015. This article analyzes barriers and enablers of the process. Methods: Clinician-researchers at 11 state-funded pediatric oncology units completed preparatory questionnaires in June 2018. Parameters included infrastructure, access to therapeutic modalities and clinician numbers. A reassessment of 13 sites (two new pediatric oncology unit) in February 2021 ascertained changes in resources and identified challenges to full participation. Questions investigated the presence and quality of diagnostic radiology, availability of surgeons, cytology/pathology options and hematology laboratory facilities. Results: The response rate was 11/11 to survey 1 and 13/13 to survey 2. The anticipated pre-study barriers to participation of pediatric oncology units included time constraints and understaffing. PET-CT was unavailable to two centers. The majority of pediatric oncology units met the minimum criteria to participate. The interim survey confirmed chemotherapy and radiotherapy availability nearly 100% of the time. One site reported improved access to radiotherapy while another reported improved access to PET-CT. Barriers to participation included excessive times to obtain regulatory approvals, time constraints and lack of dedicated research staff. Enablers include the simple management algorithm and communication tools. Conclusion: This study demonstrates that multicenter collaboration and harmonization of management protocols are achievable in a middle-income setting. Minimal funding is required but full participation to run high-quality studies requires more financial investment. Focused funding and increased prioritization of research may address systemic barriers to full participation.

Neurodevelopmental Outcomes of Extremely Low Birth Weight Survivors in Johannesburg, South Africa

BACKGROUND

Improved survival in extremely low birth weight infants (ELBWI) in Sub-Saharan Africa has raised the question whether these survivors have an increased chance of adverse neurodevelopmental outcomes.

OBJECTIVES

To describe neurodevelopmental outcomes of ELBWI in a neonatal unit in South Africa.

METHODS

This was a prospective follow-up study. All ELBWI who survived to discharge between 1 July 2013 and 31 December 2017 were invited to attend the clinic. Bayley Scales of Infant and Toddler Development (version III) were conducted at 9 to 12 months and 18 to 24 months.

RESULTS

There were 723 ELBWI admissions during the study period, 292 (40.4%) survived to hospital discharge and 85/292 (29.1%) attended the neonatal follow up clinic. The mean birth weight was 857.7 g (95% CI: 838.2-877.2) and the mean gestational age was 27.5 weeks (95% CI 27.1-27.9). None of the infants had any major complication of prematurity. A total of 76/85 (89.4%) of the infants had a Bayley-III assessment at a mean corrected age of 17.21 months (95% CI: 16.2-18.3). The mean composite scores for cognition were 98.4 (95% CI 95.1-101.7), language 89.9 (95% CI 87.3-92.5) and motor 97.6 (95% CI 94.5-100.6). All mean scores fell within the normal range, The study found 28 (36.8%) infants to be "at risk" for neurodevelopmental delay.

CONCLUSION

Our study demonstrates good neurodevelopmental outcome in a small group of surviving ELBWI, but these results must be interpreted in the context of the high mortality in this group of infants.

Factors influencing survival and short-term outcomes of very low birth weight infants in a tertiary hospital in Johannesburg

BACKGROUND

The neonatal mortality rate in South Africa is lower than the global average, but still approximately five times higher than some European and Scandinavian countries. Prematurity, and its complications, is the main cause (35%) of neonatal deaths.

OBJECTIVE

To review the maternal, delivery period and infant characteristics in relation to mortality in very low birth weight (VLBW) infants at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH).

METHODS

This was a retrospective descriptive study of VLBW infants admitted to CMJAH between 1 January 2017 and 31 December 2018. All infants with a birth weight between 500 to ≤ 1,500 grams were included. The characteristics and survival of these infants were described using univariate analysis.

RESULTS

Overall survival was 66.5%. Provision of antenatal steroids, antenatal care, Cesarean section, female sex, resuscitation at birth, and 5-min Apgar score more than five was related with better survival to discharge. Among respiratory diagnoses, 82.8% were diagnosed with RDS, 70.8% received surfactant therapy and 90.7% received non-invasive respiratory support after resuscitation. At discharge, 59.5% of the mothers were breastfeeding and 30.8% spent time in kangaroo mother care.

CONCLUSION

The two-thirds survival rate of VLBW infants is similar to those in other developing countries but still remains lower than developed countries. This may be improved with better antenatal care attendance, coverage of antenatal steroids, temperature control after birth, improving infection prevention and control practices, breastfeeding rates and kangaroo mother care. The survival rate was lowest amongst extremely low birth weight (ELBW) infants.

The effects of exposure to HIV in neonates at a referral hospital in South Africa

Background

Fewer infants are infected with HIV through mother-to-child transmission, making HIV-exposed but uninfected (HEU) infants a growing population. HIV-exposure seems to affect immunology, early growth and development, and is associated with higher morbidity and mortality rates. Currently, there is a lack of information regarding the clinical effects of HIV-exposure during the neonatal period.

Objectives

To identify a possible difference in mortality and common neonatal morbidities in HEU neonates compared to HIV-unexposed neonates.

Methods

This was a retrospective, descriptive study of all neonates admitted to the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital between 1 January 2017 and 31 December 2018. HEU neonates were compared to HIV-unexposed neonates.

Results

There were 3236 neonates included, where 855 neonates were HEU. The HEU neonates had significantly lower birth weight and gestational age. The HEU neonates had higher rates of neonatal sepsis (19.8% vs 14.2%, OR 1.49, p <  0.001), specifically for late onset sepsis, and required more respiratory support. NCPAP and invasive ventilation was more common in the HEU group (36.3% vs 31.3% required NCPAP, p = 0.008, and 20.1% vs 15,0% required invasive ventilation, p <  0.001). Chronic lung disease was more common among HIV-exposed neonates (12.2% vs 8.7%, OR 1.46, p = 0.003). The difference in mortality rates between the study groups was not significant (10.8% of HEU neonates and 13.3% of HIV-unexposed).

Conclusions

HEU neonates had higher rates of neonatal sepsis, particularly late-onset sepsis, required more respiratory support and had higher rates of chronic lung disease. Mortality of HEU neonates was not different HIV-unexposed neonates.

COVID-19 Preparedness in a Neonatal Unit at a Tertiary Hospital in Johannesburg, South Africa

Background: The novel coronavirus disease 2019 (COVID-19) pandemic has spread to South Africa and poses an infection risk in pregnant women and their newborns, as well as health-care workers and other patients.

Objective: To discuss the implementation of international and local recommendations, and any additional actions undertaken at our Neonatal Unit in order to prepare for COVID-19.

Discussion: Standard precautions in order to prepare a facility and its personnel to safely care for COVID-19 patients as outlined by the World Health Organization procedures have been implemented. Further actions undertaken in our Neonatal Unit included the creation of standard operating procedures, increased communication between neonatal and obstetric teams, limiting staff exposure, the creation of disposable resuscitation boxes to attend deliveries, reallocation of a triage area in the high care ward to an isolation area for sick newborns of suspected or confirmed maternal COVID-19 cases, staff training on personal protective equipment procedures and initiation of an online resources portal for neonatal staff.

Conclusion: A rational approach to suspected cases and infection control in-line with local and international guidelines as well as ongoing education should diminish anxiety amongst health-care professionals and provide the best possible care to patients. South Africa is a low-to-middle income country, and the lack of resources available means we cannot increase our capacity, staffing numbers or available equipment. Yet, we must be as prepared, adaptable and efficient as possible to maximize the resources and equipment we have available to us.

A review of -multidrug-resistant Enterobacteriaceae in a neonatal unit in Johannesburg, South Africa

Background

Multi-drug resistant organisms are an increasingly important cause of neonatal sepsis.

Aim

This study aimed to review neonatal sepsis caused by multi-drug resistant Enterobacteriaceae (MDRE) in neonates in Johannesburg, South Africa.

Methods

This was a cross sectional retrospective review of MDRE in neonates admitted to a tertiary neonatal unit between 1 January 2013 and 31 December 2015.

Results

There were 465 infections in 291 neonates. 68.6% were very low birth weight (< 1500 g). The median age of infection was 14.0 days. Risk factors for MDRE included prematurity (p = 0.01), lower birth weight (p = 0.04), maternal HIV infection (p = 0.02) and oxygen on day 28 (p < 0.001). The most common isolate was Klebsiella pneumoniae (66.2%). Total MDRE isolates increased from 0.39 per 1000 neonatal admissions in 2013 to 1.4 per 1000 neonatal admissions in 2015 (p < 0.001). There was an increase in carbapenem-resistant Enterobacteriaceae (CRE) from 2.6% in 2013 to 8.9% in 2015 (p = 0.06). Most of the CRE were New Delhi metallo—β lactamase- (NDM) producers.

The all-cause mortality rate was 33.3%. Birth weight (p = 0.003), necrotising enterocolitis (p < 0.001) and mechanical ventilation (p = 0.007) were significantly associated with mortality. Serratia marcescens was isolated in 55.2% of neonates that died.

Conclusions

There was a significant increase in MDRE in neonatal sepsis during the study period, with the emergence of CRE. This confirms the urgent need to intensify antimicrobial stewardship efforts and address infection control and prevention in neonatal units in LMICs. Overuse of broad- spectrum antibiotics should be prevented.

Appropriateness of admissions of children with cancer to intensive care facilities in a resource-limited setting

<strong>Background:</strong> The increasing intensity of treatment of paediatric malignancies has led to improved survival rates, but often necessitates intensive supportive care. The decision to admit a child to the paediatric intensive care unit (PICU) is based on the probability of both short-term and long-term survival in the context of severe resource constraints. Resource constraints in South Africa result in limited access of children with cancer to PICU facilities.<br /><strong>Objectives:</strong> The aim of this study was to determine whether referrals by paediatric oncologists to a PICU in Johannesburg were appropriate by analysing indications for admission, underlying diagnoses, duration and costs of admissions, and overall outcomes.<br /><strong>Methods:</strong> A retrospective review of consecutive PICU admissions over a 12-year period was performed. Data from all patients with histologically proven malignant conditions were included and analysed using descriptive statistical methods, Kaplan–Meier curves, log-rank analysis and Fisher’s exact test.<br /><strong>Results:</strong> There were 5704 recorded admissions to PICU in the study period. Of these admissions, 120 (2.1%) were for patients with malignancies. The majority of PICU oncology admissions were for post-operative care, and the median duration of stay was 1 day (interquartile range: 1–3 days). The short-term mortality rate of oncology patients in PICU was 13.3% in comparison with 16.2% in the overall PICU population. The 4-year overall survival rate post PICU discharge was 54%.<br /><strong>Conclusion:</strong> The documented short-term mortality rate indicates that referrals by paediatric oncologists are consistent with current PICU admission policies. Oncologists should assess the prognosis for survival before requesting admission to PICU, and, resources permitting, these patients should be accepted to PICU.

A review of delivery room resuscitation in very low birth weight infants in a middle income country

BACKGROUND

Advanced levels of delivery room resuscitation in very low birth weight infants are reported to be associated with death and complications of prematurity. In resource limited settings, the need for delivery room resuscitation is often used as a reason to limit care in these infants.

METHODS

This was a review of delivery room resuscitation in very low birth weight infants born in a tertiary hospital in South Africa between 01 January 2013 and 30 June 2016. Outcomes included death and serious complications of prematurity. Advanced delivery room resuscitation was defined as the need for intubation, chest compressions or the administration of adrenaline.

RESULTS

A total of 1511 very low birth weight infants were included in the study. The majority (1332/1511 (88.2%) required oxygen in the delivery room. Face mask ventilation was needed in 45.2% (683/1511). Advanced delivery room resuscitation was only required in 10.6% (160/1511). More than half the infants who required advanced delivery room resuscitation died (89/160; 55.6%). Advanced delivery room resuscitation was required in significantly more infants <1000 grams at birth than those infants >1000 grams (83/539 (15.4%) vs 77/972 (7.9%) p < 0.001). Advanced delivery room resuscitation was significantly associated with a 5 minute Apgar score < 6 (OR 13.8 (95%CI 8.6-22.0), supplemental oxygen at day 28 (OR 2.2 (95% CI 1.4-3.9), metabolic acidosis (OR 2.3 (95% CI 1.1-4.8) and death (OR 1.9 95% CI 1.1-3.3). Other serious complications of prematurity were not associated with advanced delivery room resuscitation. Mortality was increased in infants with a low admission temperature (35.1 °C (SD 0.92) vs 36.1 °C (SD 1.4) (p < 0.001).

CONCLUSION

There was a high mortality rate associated with advanced delivery room resuscitation; however complications of prematurity were not increased in survivors..The need for advanced delivery room resuscitation alone should not be used as a predictor of poor outcome in very low birth weight infants. Survivors of advanced delivery room resuscitation should be afforded ventilatory support if required. Special care must be taken to avoid hypothermia in very low birth weight infants requiring resuscitation at birth.

Uncertainty in Antibiotic Dosing in Critically Ill Neonate and Pediatric Patients: Can Microsampling Provide the Answers?

PURPOSE

With a decreasing supply of antibiotics that are effective against the pathogens that cause sepsis, it is critical that we learn to use currently available antibiotics optimally. Pharmacokinetic studies provide an evidence base from which we can optimize antibiotic dosing. However, these studies are challenging in critically ill neonate and pediatric patients due to the small blood volumes and associated risks and burden to the patient from taking blood. We investigate whether microsampling, that is, obtaining a biologic sample of low volume (<50 μL), can improve opportunities to conduct pharmacokinetic studies.

METHODS

We performed a literature search to find relevant articles using the following search terms: sepsis, critically ill, severe infection, intensive care AND antibiotic, pharmacokinetic, p(a)ediatric, neonate. For microsampling, we performed a search using antibiotics AND dried blood spots OR dried plasma spots OR volumetric absorptive microsampling OR solid-phase microextraction OR capillary microsampling OR microsampling. Databases searched include Web of Knowledge, PubMed, and EMbase.

FINDINGS

Of the 32 antibiotic pharmacokinetic studies performed on critically ill neonate or pediatric patients in this review, most of the authors identified changes to the pharmacokinetic properties in their patient group and recommended either further investigations into this patient population or therapeutic drug monitoring to ensure antibiotic doses are suitable. There remain considerable gaps in knowledge regarding the pharmacokinetic properties of antibiotics in critically ill pediatric patients. Implementing microsampling in an antibiotic pharmacokinetic study is contingent on the properties of the antibiotic, the pathophysiology of the patient (and how this can affect the microsample), and the location of the patient. A validation of the sampling technique is required before implementation.

IMPLICATIONS

Current antibiotic regimens for critically ill neonate and pediatric patients are frequently suboptimal due to a poor understanding of altered pharmacokinetic properties. An assessment of the suitability of microsampling for pharmacokinetic studies in neonate and pediatric patients is recommended before wider use. The method of sampling, as well as the method of bioanalysis, also requires validation to ensure the data obtained reflect the true result.

Retrospective cross-sectional review of survival rates in critically ill children admitted to a combined paediatric/neonatal intensive care unit in Johannesburg, South Africa, 2013-2015

OBJECTIVE

Report on survival to discharge of children in a combined paediatric/neonatal intensive care unit (PNICU).

DESIGN AND SETTING

Retrospective cross-sectional record review.

PARTICIPANTS

All children (medical and surgical patients) admitted to PNICU between 1 January 2013 and 30 June 2015.

OUTCOME MEASURES

Primary outcome-survival to discharge. Secondary outcomes-disease profiles and predictors of mortality in different age categories.

RESULTS

There were 1454 admissions, 182 missing records, leaving 1272 admissions for review. Overall mortality rate was 25.7% (327/1272). Mortality rate was 41.4% (121/292) (95% CI 35.8% to 47.1%) for very low birthweight (VLBW) babies, 26.6% (120/451) (95% CI 22.5% to 30.5%) for bigger babies and 16.2% (86/529) (95% CI 13.1% to 19.3%) for paediatric patients. Risk factors for a reduced chance of survival to discharge in paediatric patients included postcardiac arrest (OR 0.21, 95% CI 0.09 to 0.49), inotropic support (OR 0.085, 95% CI 0.04 to 0.17), hypernatraemia (OR 0.16, 95% CI 0.04 to 0.6), bacterial sepsis (OR 0.32, 95% CI 0.16 to 0.65) and lower respiratory tract infection (OR 0.54, 95% CI 0.30 to 0.97). Major birth defects (OR 0.44, 95% CI 0.26 to 0.74), persistent pulmonary hypertension of the new born (OR 0.44, 95% CI 0.21 to 0.91), metabolic acidosis (OR 0.23, 95% CI 0.12 to 0.74), inotropic support (OR 0.23, 95% CI 0.12 to 0.45) and congenital heart defects (OR 0.29, 95% CI 0.13 to 0.62) predicted decreased survival in bigger babies. Birth weight (OR 0.997, 95% CI 0.995 to 0.999), birth outside the hospital (OR 0.21, 95% CI 0.05 to 0.84), HIV exposure (OR 0.54, 95% CI 0.30 to 0.99), resuscitation at birth (OR 0.49, 95% CI 0.25 to 0.94), metabolic acidosis (OR 0.25, 95% CI 0.10 to 0.60) and necrotising enterocolitis (OR 0.23, 95% CI 0.12 to 0.46) predicted poor survival in VLBW babies.

CONCLUSIONS

Ongoing mortality review is essential to improve provision of paediatric critical care.

Is there a role for microsampling in antibiotic pharmacokinetic studies?

INTRODUCTION

Clinical pharmacokinetic studies of antibiotics can establish evidence-based dosing regimens that improve the likelihood of eradicating the pathogen at the site of infection, reduce the potential for selection of resistant pathogens, and minimize harm to the patient. Innovations in small volume sampling (< 50 μL) or 'microsampling' may result in less-invasive sample collection, self-sampling and dried storage. Microsampling may open up opportunities in patient groups where sampling is challenging.

AREAS COVERED

The challenges for implementation of microsampling to assure suitability of the results, include: acceptable study design, regulatory agency acceptance, and meeting bioanalytical validation requirements. This manuscript covers various microsampling methods, including dried blood/plasma spots, volumetric absorptive microsampling, capillary microsampling, plasma preparation technologies and solid-phase microextraction.

EXPERT OPINION

The available analytical technology is being underutilized due to a lack of bridging studies and validated bioanalytical methods. These deficiencies represent major impediments to the application of microsampling to antibiotic pharmacokinetic studies. A conceptual framework for the assessment of the suitability of microsampling in clinical pharmacokinetic studies of antibiotics is provided. This model establishes a 'contingency approach' with consideration of the antibiotic and the type and location of the patient, as well as the more prescriptive bioanalytical validation protocols.

Comparison of morbidity and mortality of very low birth weight infants in a Central Hospital in Johannesburg between 2006/2007 and 2013

Background

Health protocols need to be guided by current data on survival and benefits of interventions within the local context. Periodic clinical audits are required to inform and update health care protocols. This study aimed to review morbidity and mortality in very low birth weight (VLBW) infants in 2013 compared with similar data from 2006/2007.

Methods

We performed a retrospective review of patients’ records from a neonatal computer database for 562 VLBW infants. These neonates weighed between 500 and 1500 g at birth, and were admitted within 48 hours after birth between 01 January 2013 and 31 December 2013. Patients’ characteristics, complications of prematurity, and therapeutic interventions were compared with 2006/2007 data. Univariate analysis and multiple logistic regression were performed to establish significant associations of various factors with survival to discharge for 2013.

Results

Survival in 2013 was similar to that in 2006/2007 (73.4% vs 70.2%, p = 0.27). However, survival in neonates who weighed 750–900 g significantly improved from 20.4% in 2006/2007 to 52.4% in 2013 (p = 0.001). The use of nasal continuous positive airway pressure (NCPAP) increased from 20.3% to 62.9% and surfactant use increased from 19.2% to 65.5% between the two time periods (both p < 0.001). Antenatal care attendance improved from 54.4% to 70.6% (p = 0.001) and late onset sepsis (>72 hours after birth) increased from 12.5% to 19% (p = 0.006) between the two time periods. Other variables remained unchanged between 2006/2007 and 2013. The main determinants of survival to discharge in 2013 were birth weight (odds ratio 1.005, 95% confidence interval 1.003–1.0007, resuscitation at birth (2.673, 1.375–5.197), NCPAP (0.247, 0.109–0.560), necrotising enterocolitis (4.555, 1.659–12.51), and mode of delivery, including normal vaginal delivery (0.456, 0.231–0.903) and vaginal breech (0.069, 0.013–0.364).

Conclusions

There was a marked improvement in the survival of neonates weighing between 750 and 900 g at birth, most likely due to provision of surfactant and NCPAP. Provision of NCPAP, prevention of necrotising enterocolitis, and control of infection need to be prioritised in VLBW infants to improve their outcome.

Background changing patterns of neonatal fungal sepsis in a developing country

BACKGROUND

Candida albicans is the predominant isolate in many neonatal fungal bloodstream infections (BSIs), so fluconazole is used as empiric antifungal therapy.

AIM

To determine the predominant organisms, antifungal sensitivity patterns, clinical and demographic risk factors and crude mortality rate in neonatal fungal BSI cases.

SUBJECTS AND METHODS

This is a review of all neonatal fungal BSI cases between January 2007 and December 2011.

RESULTS

Fifty-nine patients were included in the study. Candida parapsilosis (54.2%) was isolated in majority of the cases, followed by C. albicans (27.1%). Fluconazole resistance was present in 16 of 32 cases of C. parapsilosis versus 1 of 16 cases of C. albicans (P = 0.003). Mortality rate was 45.8%. Surgical problems were present in 55.9%. Death was significantly associated with lower birth weight (P = 0.046) and necrotizing enterocolitis (P = 0.034).

CONCLUSIONS

The increase in neonatal fungal BSI and resistant organisms highlights the need to review use of routine empiric fluconazole and to implement preventive measures.

Bacterial bloodstream infections in neonates in a developing country

Background. Ongoing surveillance of antimicrobial sensitivity patterns of bacteria isolated in bloodstream infections guides empiric antibiotic therapy in neonatal sepsis. Methods. Sensitivity profiles of neonatal bacterial bloodstream infections in a tertiary hospital were reviewed between 01/06/2009 and 30/06/2010 . Results. There were 246 episodes of bloodstream infection in 181 individuals—(14.06 episodes in10.35 patients/1000 patient days or 14.4 episodes in 10.6 babies/1000 live births. The majority were (93.5%) were late onset and most (54.9%) were gram positive. There were 2.28 sepsis-related deaths /1000 patient days or 2.3/1000 live births. Death was significantly associated with gram-negative infections (P < 0.001), multiple gestation (P < 0.001), shock (P = 0.008), NEC (P = 0.002), and shorter duration of hospital stay (P < 0.001). Coagulase-negative staphylococcus was isolated in 19.1%, K. pneumoniae ESBL in 12.1%, and A. baumanni in 10.9%. S. agalactiae predominated in early onset sepsis. Methicillin resistance was present in 86% of CoNS and 69.5% of S. aureus; 46% enterococcal isolates were ampicillin resistant. The majority (65%) of K. pneumoniae isolates were ESBL producers. Ampicillin resistance was present in 96% of E. coli. Conclusions. Penicillin and an aminoglycoside would be suitable empiric therapy for early onset sepsis and meropenem with gentamycin or ceftazidime with amikacin for late onset sepsis.

Developmental outcome of very low birth weight infants in a developing country

Background

Advances in neonatal care allow survival of extremely premature infants, who are at risk of handicap. Neurodevelopmental follow up of these infants is an essential part of ongoing evaluation of neonatal care. The neonatal care in resource limited developing countries is very different to that in first world settings. Follow up data from developing countries is essential; it is not appropriate to extrapolate data from units in developed countries. This study provides follow up data on a population of very low birth weight (VLBW) infants in Johannesburg, South Africa.

Methods

The study sample included all VLBW infants born between 01/06/2006 and 28/02/2007 and discharged from the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Bayley Scales of Infant and Toddler Development Version 111 (BSID) 111 were done to assess development. Regression analysis was done to determine factors associated with poor outcome.

Results

178 infants were discharged, 26 were not available for follow up, 9 of the remaining 152 (5.9%) died before an assessment was done; 106 of the remaining 143 (74.1%) had a BSID 111 assessment. These 106 patients form the study sample; mean birth weight and mean gestational age was 1182 grams (SD: 197.78) and 30.81 weeks (SD: 2.67) respectively. The BSID (111) was done at a median age of 16.48 months. The mean cognitive subscale was 88.6 (95% CI: 85.69 - 91.59), 9 (8.5%) were < 70, mean language subscale was 87.71 (95% CI: 84.85 - 90.56), 10 (9.4%) < 70, and mean motor subscale was 90.05 (95% CI: 87.0 - 93.11), 8 (7.6%) < 70. Approximately one third of infants were identified as being at risk (score between 70 and 85) on each subscale. Cerebral palsy was diagnosed in 4 (3.7%) of babies. Factors associated with poor outcome included cystic periventricular leukomalacia (PVL), resuscitation at birth, maternal parity, prolonged hospitalisation and duration of supplemental oxygen. PVL was associated with poor outcome on all three subscales. Birth weight and gestational age were not predictive of neurodevelopmental outcome.

Conclusion

Although the neurodevelopmental outcome of this group of VLBW infants was within the normal range, with a low incidence of cerebral palsy, these results may reflect the low survival of babies with a birth weight below 900 grams. In addition, mean subscale scores were low and one third of the babies were identified as "at risk", indicating that this group of babies warrants long-term follow up into school going age.

Determinants of survival in very low birth weight neonates in a public sector hospital in Johannesburg

BACKGROUND

Audit of disease and mortality patterns provides essential information for health budgeting and planning, as well as a benchmark for comparison. Neonatal mortality accounts for about 1/3 of deaths < 5 years of age and very low birth weight (VLBW) mortality for approximately 1/3 of neonatal mortality. Intervention programs must be based on reliable statistics applicable to the local setting; First World data cannot be used in a Third World setting. Many neonatal units participate in the Vermont Oxford Network (VON); limited resources prevent a significant number of large neonatal units from developing countries taking part, hence data from such units is lacking. The purpose of this study was to provide reliable, recent statistics relevant to a developing African country, useful for guiding neonatal interventions in that setting.

METHODS

This was a retrospective chart review of 474 VLBW infants admitted within 24 hours of birth, between 1 July 2006 and 30 June 2007, to the neonatal unit of Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in Johannesburg, South Africa. Binary outcome logistic regression on individual variables and multiple logistic regression was done to identify those factors determining survival.

RESULTS

Overall survival was 70.5%. Survival of infants below 1001 grams birth weight was 34.9% compared to 85.8% for those between 1001 and 1500 grams at birth. The main determinant of survival was birth weight with an adjusted survival odds ratio of 23.44 (95% CI: 11.22 - 49.00) for babies weighing between 1001 and 1500 grams compared to those weighing below 1001 grams. Other predictors of survival were gender (OR 3. 21; 95% CI 1.6 - 6.3), birth before arrival at the hospital (BBA) (OR 0.23; 95% CI: 0.08 - 0.69), necrotising enterocolitis (NEC) (OR 0.06; 95% CI: 0.02 - 0.20), hypotension (OR 0.05; 95% CI 0.01 - 0.21) and nasal continuous positive airways pressure (NCPAP) (OR 4.58; 95% CI 1.58 - 13.31).

CONCLUSIONS

Survival rates compare favourably with other developing countries, but can be improved; especially in infants < 1001 grams birth weight. Resources need to be allocated to preventing the birth of VLBW babies outside hospital, early neonatal resuscitation, provision of NCPAP and prevention of NEC.

Intensive care for very low birthweight infants in South Africa: a survey of physician attitudes, parent counseling and resuscitation practices

Improving outcomes have promoted utilization of intensive care for premature infants in developing countries with available fiscal and technological resources. Physician counseling and decision-making have not been characterized where economic restrictions, governmental guidelines, and physician cultural attitudes may influence decisions about the appropriateness of neonatal intensive care. A cross-sectional survey of all neonatologists and pediatricians providing neonatal care in public and private hospitals in South Africa (n=394) was carried out. Physicians returned 93 surveys (24 per cent response rate). Frequency of counseling increased with increasing gestational age (GA) but was not universally provided at any GA. Morbidity and mortality were consistently discussed and fiscal considerations frequently discussed when antenatal counseling occurred. Resuscitation thresholds were 25-26 weeks and 665-685 g, and were higher in public than in private hospitals. Decisions to limit resuscitation were based more on expected outcome than on patients' wishes or economics. At 24-25 weeks, 91 per cent of physicians would not resuscitate despite parents' wishes; 93 per cent of physicians would resuscitate 28-29-week-old infants over parents' refusal. Parents expecting premature infants are not invariably counseled. In making life-support decisions, physicians consider infants' best interests and, less frequently, financial and emotional burdens. Thresholds for resuscitation and intensive care are higher in public hospitals, and higher than in developed countries. Physicians relegate parents to a passive role in life-support decisions.

Parental perception of neonatal intensive care in public sector hospitals in South Africa

BACKGROUND

Little is known about parental experience and decision making with regard to premature infants requiring intensive care in developing countries. We undertook this study to characterise parents' experience of physician counselling and their role in making life-support decisions for very low-birth-weight (VLBW) (birth weight < 1 501 g) infants born in South Africa's public-sector neonatal intensive care units (NICUs).

METHODS

Parents of surviving VLBW infants treated in three Johannesburg-area public hospitals and attending follow-up clinics in August 2001 were interviewed regarding their experience of perinatal counselling on outcomes (pain, survival, disability), perception of actual and optimal decision making, and satisfaction with NICU communication.

RESULTS

Parents of 51 infants were interviewed. Seventy-five per cent of parents reported antenatal counselling by physicians on at least one perinatal topic (severe disability, pain, death, finances or religious/moral considerations). The majority of parents (> 60%) who received counselling thought that these topics had been discussed adequately. Most parents reported that doctors had the primary decision-making role, either without consulting them (41%) or after consulting them (37%). Joint decision making was rare (14%). Parents wanted more input in life-support decisions than they reported being given.

CONCLUSION

Counselling is not consistently provided in public-sector hospitals in Johannesburg. Parents of premature infants want a larger share in NICU decision making than they currently experience. Most parents were satisfied with communication later during their infant's hospitalisation. South Africa presents a unique opportunity to study the use of advanced medical technologies in a nation with marked disparities in access to care.

Serum procalcitonin as an early marker of neonatal sepsis

BACKGROUND

It has recently been suggested that procalcitonin (PCT) is of value in the diagnosis of neonatal sepsis, with varying results. This study was to evaluate the role of PCT as a single early marker of neonatal sepsis.

SETTING

Neonatal Unit, Johannesburg Hospital, and Microbiology Laboratory, National Health Laboratory Service (NHLS), South Africa.

SUBJECTS AND METHODS

Neonates undergoing evaluation for sepsis between April and August 2002 were eligible for inclusion. Patients were categorised into 'no infection', 'possible infection' and 'definite infection' on the basis of C-reactive protein (CRP), white cell count (WCC), platelet count and blood culture results. PCT was correlated with infection categories.

RESULTS

One hundred and eighty-three neonates were enrolled. One hundred and eighteen had no infection, 52 possible infection and 13 definite infection. PCT differed significantly among infection categories (p < 0.0001) and correlated significantly with CRP at presentation (correlation coefficient 0.404, p < 0.001) and CRP at 24 hours (correlation coefficient 0.343, p < 0.001). PCT predicted 89.5% of definite infection. Receiver operating characteristic (ROC) analysis for PCT to predict definite infection showed odds ratio (OR) 1.145 (95% confidence interval (CI): 1.05-1.25) with an area under the curve of 0.778. PCT had a negative predictive value of 0.95 (95% CI: 0.915-0.988) for definite infection.

CONCLUSIONS

Although PCT was significantly related to the category of infection, it is not sufficiently reliable to be the sole marker of neonatal sepsis. PCT would be useful as part of a full sepsis evaluation, but is relatively expensive. A negative PCT on presentation may rule out sepsis, but this needs to be evaluated further.

A comparison of high versus low dose recombinant human erythropoietin versus blood transfusion in the management of anaemia of prematurity in a developing country

The purpose of this study was to evaluate the effectiveness of early treatment with erythropoietin (EPO) in two different treatment regimes (high vs. low dose) in comparison to the conventional treatment of packed red blood cell (PRBC) transfusions in the management of anaemia of prematurity in a country with limited resources. An open controlled trial was conducted on 93 preterm infants (7 days postnatal age, 900-1500 g birthweight). Patients were randomly assigned either to a low dose (250 IU/kg), a high dose (400 IU/kg), or a control group. EPO was administered subcutaneously three times a week and all infants received 6 mg/kg iron orally from study entry to endpoint of therapy. Haematological parameters were measured and compared. The success was defined as an absence of transfusions and a haematocrit that did not fall below 30 per cent during the time period that the infants were in the study. The three groups were statistically comparable at study entry with respect to gestational age, birthweight, Apgar scores, and haematological values. Over the period that the infants were in the study, 75 per cent of the low dose group and 71 per cent of the high dose group met the criteria for success compared with 40 per cent in the control group (p < 0.001). However, there was no significant difference in the number of transfusions when the low and high EPO dose groups (9.5 per cent) were combined and compared with the control group (26.7 per cent) p = 0.0587. It was concluded that in stable infants, 900-1500 g, where phlebotomy losses are minimized and stringent transfusion guidelines are adhered to, EPO does not significantly decrease the number of transfusions. A conservative approach in the management of anaemia of prematurity, is a viable alternative in areas with limited resources.

Hematological reference ranges in black very low birth weight infants

This study compared hematological reference ranges in black very low birth weight infants to previously published values established predominantly on white subjects. Ninety-four healthy, black, premature babies with a birth weight of 800 to 1500 g at 2-7 days of age were enrolled as part of a study comparing blood transfusions and high- versus low-dose recombinant erythropoietin in anaemia of prematurity. Peripheral venous blood was collected for a full blood count and differential, fetal hemoglobin and erythropoietin levels. The hematological parameters observed in black very low birth weight neonates are similar to previously published reference ranges, except that lower limits of normal were observed for hemoglobin and the red cell indices.

Is prophylaxis of early-onset group B streptococcal disease appropriate for South Africa?

BACKGROUND

Early-onset group B streptococcal (GBS) disease in neonates can be prevented by the use of intrapartum chemoprophylaxis. There are two prevention strategies, one based on risk factors and the other on culture screening for GBS. This study sought to establish whether GBS chemoprophylaxis is appropriate in a developing country such as South Africa.

METHODS

All neonates with early-onset GBS disease born at Johannesburg Hospital between 1 January 1995 and 21 December 1997 were reviewed. Data were collected prospectively between 1 January and 31 October 1998. Data included demographic information, obstetric information, disease characteristics, admission details and mortality. The approximate cost of implementing both strategies was determined.

RESULTS

The overall incidence of early-onset GBS was 1.16 per 1,000 live births. The rate was significantly greater in 1998 compared with the previous years. Most of the babies were born preterm (70%), and 60% required admission to the neonatal intensive care unit (ICU) (a total of 81 ICU days). Twelve of the babies died. Assuming that chemoprophylaxis would reduce the number of ICU days by half, this would save an amount of R52,000. Culture-based chemoprophylaxis would cost R10 million, whereas an approach based on risk factors would cost R31,140.

CONCLUSION

In conclusion, we feel that early-onset GBS disease is sufficiently prevalent in our unit to justify the implementation of a chemoprophylaxis strategy based on risk factors. Whether other units should adopt a similar approach would depend on the local incidence of early-onset GBS.

Serial interleukin 6 measurements in the early diagnosis of neonatal sepsis

The objective of the present study was to evaluate serial interleukin 6 (IL6) levels in the early diagnosis of neonatal sepsis. Subjects included 255 neonates from the Neonatal Unit of Johannesburg Hospital evaluated for suspected sepsis between February and May 1998. All infants had IL6, full blood count (FBC), C reactive protein (CRP) and blood cultures done at presentation. CRP and IL6 were repeated after 24 h. Infants were categorized into groups according to the likelihood of infection on the basis of clinical presentation, CRP, FBC and culture results, i.e., group 1 (no infection) to group 4 (definite infection). IL6 was compared between the groups by the U-test of Mann-Whitney; stepwise logistic regression was done to establish the best predictors of infection, sensitivity, specificity, positive and negative predictive values were determined. The initial IL6 level was significantly raised in those infants with possible infection [880.67 pg/ml (2966.04), p value 0.0104], probable infection [422.62pg/ml (4077.7), p value 0.0021] and definite infection [11164.39pg/ml (24139.77), p value 0.0000] as compared to those infants without infection [58.65 (182.4)]. The best predictors of infection were the combination of the initial IL6 value and CRP value after 24 h (goodness of fit 97.7 per cent). An initial IL6 value below 20 pg/ml gave a negative predictive value of 90.18 per cent. It is concluded that an IL6 value done at the time of presentation of signs and symptoms suggestive of infection is useful in the early diagnosis of neonatal sepsis. In particular, an initial IL6 value below 20 pg/ml may allow antibiotics to be withheld in a number of infants evaluated for sepsis. There is no benefit in serial determination of IL6 in the diagnosis of neonatal sepsis.

Use of C-reactive protein to guide duration of empiric antibiotic therapy in suspected early neonatal sepsis

BACKGROUND

Serial C-reactive protein (CRP) measurements have been shown to be useful for guiding duration of antibiotic therapy in neonates. This study sought to determine whether this is a safe and practical approach in a developing country.

METHODS

The study was conducted at the Johannesburg Hospital between September 15, 1998, and January 15, 1999. Subjects included all neonates evaluated for suspected sepsis in the first 24 h of life who had negative initial and repeat CRP values (< or = 10 mg/l) [corrected]. Repeat CRP measurements were performed between 24 and 48 h after birth. Antibiotic therapy was stopped in these infants at 24 to 48 h, and they were observed until 72 h, when the final blood culture results were available. The number of positive blood cultures in this group was determined.

RESULTS

The repeat CRP estimation correctly identified 99 of 100 infants in the study as not requiring further antibiotic therapy (negative predictive value, 99%; 95% confidence intervals, 95.6 to 99.97%). The 1 infant with a positive blood culture was premature with a gestational age of 31 weeks. Eight babies required repeat evaluation for suspected sepsis, 4 presented on Day 3 to 4 and one of these babies died. All these neonates were of < or =33 weeks gestation.

CONCLUSION

The use of serial CRP measurements to guide antibiotic therapy is a safe and practical approach in neonates with suspected sepsis in a developing country.

Factors associated with poor prognosis in very-low-birth-weight infants

OBJECTIVE

To evaluate predictors of poor outcome, including the CRIB (Clinical Risk Index for Babies) score, in a local population of very-low-birth-weight (VLBW) infants, in order to provide guidelines for selection of these babies for expensive tertiary care.

SUBJECTS

Two hundred and thirty-one neonates born at less than 31 weeks' gestation and/or weighing between 1001 g and 1500 g, enrolled prospectively as part of a multicentre study evaluating the CRIB score.

DESIGN

Univariate analysis (chi-square/t-tests) and multivariate analysis (stepwise logistic regression) on the above sample to determine predictors of poor outcome.

SETTING

Neonatal Unit, Johannesburg Hospital.

OUTCOME MEASURES

Death or impairment (namely oxygen therapy > 28 days, grade 3 or 4 intraventricular haemorrhage, or ventricular enlargement).

RESULTS

Poor outcome was predicted by birth weight, lowest oxygen requirement in the first 12 hours (which are two components of the CRIB score), and maximum partial arterial carbon dioxide pressure (PaCO2) in the first 72 hours. Other factors, including the full CRIB score, were not predictive of outcome.

CONCLUSIONS

One method of selection of infants for expensive tertiary care is on the basis of predicted outcome. Birth weight remains a reasonable basis for this selection, but the inclusion of other factors, such as oxygen requirement, would improve accuracy. The CRIB score was not a suitable means to select infants in the local context, but may be of value in international comparisons.

Selection of paediatric patients for intensive care

OBJECTIVES

To determine characteristics of older infants and children admitted to the paediatric intensive care unit (PICU) at Johannesburg Hospital; and to evaluate an admission score based on the PRISM score (an index of severity of illness) as a possible means for selection of patients for admission to the PICU.

DESIGN

Retrospective review of patient records and calculation of admission score from data.

SETTING

Paediatric intensive care unit at Johannesburg Hospital.

SUBJECTS

All patients older than 3 months of age admitted to the PICU from July 1993 to 31 March 1994.

RESULTS

There were 117 admissions during the study period with a mean age of 4,6 years. The mortality rate was 29.1%. The mean duration of ICU stay was 4,2 days. A review of requests for admission showed that over a 7-month period, 53 patients (> 3 months) could not be accommodated. In 71 patients with complete data, the admission score was significantly higher in non-survivors than survivors. The area under the ROC curve for predicting mortality from the admission score was 0.73 (SE 0.054). An admission score > or = 16 predicted mortality with a sensitivity of 42% and a specificity of 98%.

CONCLUSIONS

PICU facilities at Johannesburg Hospital are insufficient to meet the demand. An admission score based on the PRISM score could assist in the selection of patients for these limited PICU facilities.

Reasons for failure to administer antenatal corticosteroids in preterm labour

A retrospective review of 101 preterm infants delivered at Johannesburg Hospital was conducted to determine the use of antenatal corticosteroids (ACs). Overall there were 38 opportunities for the use of ACs of which 18 were missed. Of the remaining mothers, 32 presented in advanced labour, 22 presented with obstetric emergencies and 6 were managed as inevitable abortions. There was a significant association between lack of antenatal care and presentation in advanced labour. Therefore, although only 20% of mothers received ACs, there was no opportunity for their use in the majority of patients. The use of a safe and cost-effective measure such as ACs should not be ignored in a country with limited health resources. Better antenatal care as well as increased awareness among obstetricians is required to improve the situation.

The cost and effectiveness of surfactant replacement therapy at Johannesburg Hospital, November 1991-December 1992

OBJECTIVE

To assess the impact of surfactant replacement therapy (SRT) on the outcome of hyaline membrane disease (HMD) and to assess the cost implications of a policy of selective administration of artificial surfactant.

DESIGN

The short-term outcome of 103 newborns ventilated for HMD (61 selected for SRT according to initial and/or ongoing oxygen requirements) was compared with that of a historical control group of 173 infants ventilated for HMD before the introduction of SRT.

MAIN OUTCOME MEASURES

Mortality and morbidity of HMD including death, bronchopulmonary dysplasia, pneumothorax, pulmonary haemorrhage, patent ductus arteriosus and intraventricular haemorrhage.

RESULTS

There were significant demographic differences between the treatment and control groups (black patients 74% v. 28%, P < 0.0001; unbooked mothers 72% v. 15%, P < 0.0001) as well as evidence of more severe lung disease in the treatment group (pressor support 44% v. 27%, P < 0.005; and paralysis during ventilation 38% v. 25%, P < 0.005). Pneumothorax was reduced in the SRT group (7% v. 17%, P < 0.01). There were no significant differences between the two groups in the incidence of BPD or mortality. The use of SRT added to the total cost of treating a patient ventilated for HMD.

CONCLUSION

The selective use of SRT had the effect of converting severe disease into moderate disease rather than achieving maximal benefit in all cases of HMD through routine use of the product. A policy of restricting use may result in cost savings where resources are limited.

The selection of infants for surfactant replacement therapy under conditions of limited financial resources

The cost of surfactant replacement therapy (SRT) will restrict its use under conditions of limited health resources. Before the local advent of SRT, infants ventilated for hyaline membrane disease (HMD) had an overall survival rate of 87% and an incidence of bronchopulmonary dysplasia of 6.4%. This, together with the cost of SRT, prompted a study to identify those infants who would benefit the most from SRT. Twenty-two infants assessed as having severe HMD were randomised to receive SRT at 3 - 4 hours (9) or at 6 - 8 hours (13) after birth. Two infants (15%) in the latter group did not require SRT. The outcome of these two groups was the same. Of 56 infants assessed as having moderate HMD, only 24 (43%) qualified for SRT from 6 hours of age. The outcome of the SRT and non-SRT infants was comparable. The group of infants with moderate HMD had a significantly better outcome than those with severe HMD. A limited period of observation to assess the severity of illness did not compromise outcome in this group of 78 infants with moderate to severe HMD.

The introduction of surfactant replacement therapy into South Africa

Within the context of limited financial and physical resources in South Africa, academic neonatologists have established strict criteria for ventilation of neonates with hyaline membrane disease (HMD). In the private sector neonatal care is less structured. Following the introduction of the artificial surfactant (Survanta) in November 1991 it was considered important to monitor its use in the public and private sectors. In collaboration with the marketing company a data sheet containing demographic information and clinical details was drawn up to be completed in each case where Survanta was administered to babies with HMD. Data from 155 babies treated at 10 hospitals were included in the final analysis (70 babies from 4 State-funded academic hospitals and 85 from 6 privately funded hospitals). Within the group of private hospitals there were some which treated large numbers of babies weighing > 2,000 g, while in a few others there was a relative excess of babies weighing < 1,000 g. There was a higher incidence of patent ductus arteriosus and intraventricular haemorrhage, and a higher mortality rate at the academic hospitals. Poor outcome at these institutions may largely have been due to poor antenatal care.

The late administration of surfactant

Current recommendations for surfactant replacement therapy (SRT) in the treatment of hyaline membrane disease (HMD) are to administer the drug as soon as possible after starting ventilation in order to prevent ventilator lung damage. We present a review of 18 infants (gestational age 32.4 +/- 1.9 weeks and birth weight 1,795 +/- 427 g) who received the initial dose of SRT after they were 12 hours old. Fourteen infants were assessed as having HMD and 4 as having congenital pneumonia. Overall there was a significant and sustained improvement in oxygenation as measured by arterial/alveolar oxygen ratios. The outcome of these infants was good, with a duration of ventilation of 7.9 +/- 4.3 days and a duration of hospitalisation of 26.2 +/- 12.6 days. No infant developed bronchopulmonary dysplasia. Of particular interest is that 3 infants weighing > 2,400 g with congenital pneumonia responded to a single delayed dose of SRT. Late SRT is effective and there may be a place for SRT in the treatment of conditions other than HMD.

Does hypoxemia prevent brain damage in birth asphyxia?

The clinical syndrome of hypoxic ischemic encephalopathy (HIE) which occurs in association with birth asphyxia, is thought to represent a reperfusion injury consequent upon the generation of cytotoxic oxygen derived free radicals. It has recently been suggested that resuscitation of asphyxiated infants with unrestricted oxygen may aggravate the brain damage by causing hyperoxia and increased free radical production. To determine whether sustained hypoxemia may be protective in birth asphyxiated infants, we investigated the relationship between HIE and persistent pulmonary hypertension of the neonate (PPHN). The latter condition is also related to intrauterine and intrapartum birth asphyxia but is associated with persistent hypoxemia in the infant. In a retrospective analysis of 39 asphyxiated neonates admitted to the neonatal intensive care unit, we found that 28 had HIE, 10 had PPHN and only 1 had both HIE and PPHN. We therefore suggest that the hypoxemia due to PPHN may limit the production of oxygen derived free radicals in asphyxiated neonates and hence protect against the development of HIE. These findings lend support to current research into air vs. oxygen resuscitation for infants with birth asphyxia.

Congenital syphilis as a notifiable disease

A review of the notification of congenital syphilis at Johannesburg Hospital from 1 May 1991 to 30 April 1992 was conducted to evaluate the effect of the recently introduced notification programme. A total of 209 Wassermann reaction (WR)-positive mothers were delivered during this time; 12 pregnancies (5.7%) resulted in stillbirths and 8 (3.8%) in incomplete abortions, and there were 2 (0.96%) early neonatal deaths. Only 45 (21.5%) of this group of WR-positive mothers had received antenatal care, and of these 9 (20%) had had adequately documented treatment. There were thus 200 potentially notifiable cases of congenital syphilis according to the Centers for Disease Control classification, of which 24 (12.0%) were actually notified. The goals of the notification programme, namely to increase awareness of congenital syphilis among health care providers and to evaluate the extent of the problem accurately, are clearly not being met.

Speech and hearing problems in a high-risk population

A retrospective study was conducted on 85 neonatal intensive care unit (NICU) survivors, all of whom had been mechanically ventilated. Mean birth weight was 1,726 +/- 778 g and mean gestational age was 32.3 +/- 3.8 weeks. Infants were evaluated for various risk factors previously reported to cause hearing loss. Language development was assessed using the Early Language Milestone (ELM) scale and hearing was tested by free field responses (FFR). Twenty-four children (28.2%) had an abnormal ELM or FFR result. Seventeen children failed an FFR; 14 of these were normal on follow-up and 3 defaulted. There was thus no permanent sensorineural hearing loss in the sample assessed. Eleven children failed an ELM, of whom 5 had speech problems on long-term follow-up. There was a significant correlation between the ELM and neurodevelopmental scores (P = 0.045). Intraventricular haemorrhage also correlated significantly with the ELM score (P = 0.0016). Thus the overall incidence of hearing loss in this NICU population was low, but there was a significant occurrence of speech problems, which correlated with neurological damage.

Fortification of curry powder with NaFe(111)EDTA in an iron-deficient population: initial survey of iron status

A survey of iron status was conducted in 984 volunteers (404 males and 580 females) from an Fe-deficient population before an Fe-fortification trial. Hemoglobin, percentage saturation of transferrin, and serum ferritin were used to assess Fe status and to calculate body Fe stores. Almost 30% of males and 60% of females had evidence of Fe deficiency. The distribution of body Fe stores for both males and females was shifted to the left compared with a population in the United States. In females 24% had Fe-deficiency anemia, 13% Fe-deficient erythropoiesis, and 16% depleted stores. Multiple regression analysis failed to show any relationship in women between age, parity, and duration of menses and measurements of Fe status. In males Fe deficiency was more frequent for those less than 18 y and alcohol abusers had increased serum ferritin and calculated body Fe compared with nondrinkers.

Fortification of curry powder with NaFe(111)EDTA in an iron-deficient population: report of a controlled iron-fortification trial

A targeted, double-blind controlled iron fortification trial using Fe(111)-EDTA in masala (curry powder) was directed towards an Fe-deficient Indian population for 2 y. The Fe status of the fortified group improved more than that of control subjects. Improvement reached significance over control subjects for females in hemoglobin (p = 0.0005), ferritin (p = 0.0002), and body Fe stores (p = 0.001) and for males in ferritin (p = 0.04). The prevalence of Fe-deficiency anemia (IDA) decreased from 22 to 5% in fortified females. Premenopausal women, multipara women, and women with prolonged menstruation or initial IDA benefitted most from fortification. The mean increase in body Fe stores in females with initial IDA was 9.0 +/- 1.3 mmol, representing an increased absorption of 12 mumol/d. Fortified subjects with normal Fe status did not accumulate excessive body Fe and there was no alteration in serum Zn concentrations. Targeted fortification is a safe and effective means of combatting Fe deficiency.

Percutaneous nephrostomy for bilateral ureteric obstruction in carcinoma of the cervix. A case report

A patient with cervical cancer had renal failure secondary to bilateral ureteric obstruction. Percutaneous nephrostomy was performed, allowing restoration of renal function while radiotherapy was administered. This technique offers a temporary means of bypassing obstructed ureters and is associated with low morbidity and minimal surgical risk.