1,720,969 research outputs found
Lumbar punctures in the paediatric emergency medicine department at Red Cross War Memorial Children's Hospital: An evaluation
No full textBackground: Lumbar punctures (LPs) are frequently performed in the paediatric medical emergency unit (MEU) department to diagnose or exclude meningitis. Unsuccessful lumbar punctures (LPs) cause diagnostic uncertainty which may prolong hospital stay and result in unnecessary antibiotic treatment and increased costs to the hospital and patients. It is important to determine factors that may be effective in reducing unsuccessful LPs. There is a paucity of studies on this topic from sub-Saharan Africa. Previous studies have shown inconsistent results and the use of sedation has not previously been studied. Aims: To determine the prevalence of unsuccessful lumbar punctures(LPs) and the factors influencing this in the medical emergency unit (MEU) and short stay ward (SSW) at Red Cross War Memorial Children's Hospital, Cape Town
Acute post streptococcal glomerulonephritis at Red Cross War Memorial Children's Hospital, Cape Town, South Africa - a five-and half-year descriptive review
Get PDFBackground: Acute post streptococcal glomerulonephritis (APSGN), although not a common cause of progressive kidney failure, is an important cause of paediatric hospital admission, parental worry, and acute kidney injury (AKI). In well-resourced settings, there has been a decline over the last three decades in the incidence of APSGN in children with this condition almost disappearing in Central Europe. However, this is not the case in less privileged countries such as in South Africa (SA) where APSGN is still a major public health problem and a frequent cause of paediatric hospital admission and AKI. Nevertheless, APSGN in South Africa has not been studied adequately in recent times and not currently addressed as an important public health issue. Objectives: In this retrospective study we describe the occurrence of APSGN, the aetiology, clinical presentation, and complications among children (<14years) admitted to the Red Cross War Memorial Children's Hospital (RCWMCH) in Cape Town, SA from January 2015 to June 2020. Methods: The hospital electronic database with recorded ICD-10 coding was used to identify potential cases of acute nephritic syndrome. Children were included if they presented with at least two signs of acute nephritis, associated with evidence of activation of an alternative pathway complement system (low C3 serum level) or clinical and serological evidence of previous or current streptococcal infection. Demographic, clinical features, investigations, management, and outcome data were collected. Data were presented as median and interquartile ranges (IQR) or means and standard deviation (SD) depending on normality of data while proportions of categorical data were presented as percentages. Population incidences were calculated from the four major health districts within the drainage areas for RCWMCH. This study was conducted in accordance with the 2013 Declaration of Helsinki and was approved by RCWMCH administration and the University of Cape Town's Human Research Ethics Committee, (HREC: 623/2020). Results: There were 157 children with suspected acute nephritic syndrome (haematuria, oedema, oliguria and hypertension), of whom 96 met the inclusion criteria and were recruited. Of the 96 children included in the study, 89 (93%) cases had confirmed APSGN, and seven (7%) children had a clinical diagnosis of rapidly progressive glomerulonephritis (RPGN), with positive streptococcal serology and crescentic glomerulonephritis in the kidney biopsy. APSGN occurred in 61 (63%) children aged five to ten years with 62 (65%) males (ratio of 1.9:1). APSGN was more often associated with streptococcal skin infections (55%). The majority 95 (99%) of cases presented with haematuria, while proteinuria was noted in 85 children. Seventy-one (74%) children presented in stage 2 hypertension, with 10 (10%) presenting with hypertensive seizures. Serum C3 levels were low in 83 (87%) children. 90 (94%) children had elevated anti-deoxyribonuclease B antibodies (anti-DNase-B) levels, and 77 (80%) also had elevated anti-streptolysin O titres (ASOT) titres at presentation. Eighty-eight (92%) children received a diuretic agent, 60 (63%) required an anti-hypertensive agent, and 90 (94%) received a penicillin antibiotic for 10 days. The median length of hospital stay was five (IQR 3-6) days. There were no deaths. Eighty-one (85%) children with APSGN recovered. Five (5%) progressed to end stage kidney disease (ESKD). A percutaneous kidney biopsy was indicated in eleven (11%) children. Seven (64%) biopsies confirmed type II crescentic glomerulonephritis, and four (36%) biopsies showed histological features of post-infectious nephritis. Conclusion: APSGN during childhood remains an important health problem in SA and commonly follows streptococcal skin infection. The outcome is favourable in most children; however, our study revealed an important sub-group with crescentic glomerulonephritis who progressed to ESKD. We recommend active case seeking at primary care level by checking urine dipstick, blood pressure and serum creatinine and better post-discharge follow up
Use of the PCR technique to diagnose meningitis in children admitted to Red Cross War Memorial Children’s Hospital
Get PDFIntroduction: Viral meningitis (VM) is more common than bacterial meningitis (BM) and is a self-limiting disease. Clinicians still tend to admit patients with VM and treat them for BM because they fear the morbidity and mortality that is associated with a delay in treating or not treating BM. Unnecessary admissions have huge cost implications and they separate children from their parents while exposing them to painful procedures and unnecessary antibiotics.
Methods: A structured literature review was undertaken to see whether clinical manifestation and examination findings and laboratory findings including viral PCR of cerebrospinal fluid can help to diagnose viral meningitis and avoid unnecessary admissions.
Results: Viral and bacterial meningitis have similar clinical findings. CSF examination is crucial in confirming the diagnosis of meningitis. Microscopy and culture remain the gold standard in making the diagnosis. The introduction of the Haemophilus influenzae type b and pneumococcal vaccines into the South African Expanded Programme on immunization (EPI) markedly reduced the incidence of invasive Haemophilus influenzae type b and pneumococcal disease in children under 5 years-of-age as in other countries where they are used. Viral meningitis is the leading cause of childhood meningitis however the clinical and CSF findings in viral meningitis and bacterial meningitis overlap. The sensitivity of CSF culture has been shown to be around 81.3%, but is very much affected by prior antibiotics. Traumatic/bloody CSF taps also make it difficult to interpret 10 results. Inflammatory markers have been used in conjunction with CSF results in differentiating between BM and VM however, the use of polymerase chain reaction technique in the diagnostic methodology improves the sensitivity to more than 95%.
Conclusion: Viral meningitis is common worldwide. Real-time multiplex PCR offers value in accurately detecting common viral and bacterial pathogens thus allowing for appropriate patient management. In order to avoid the risk of not identifying organisms not included in the PCR assay and further not being able to do susceptibility testing on those organisms, it important to realize that PCR testing would have to be done in addition to culture, and not as a replacement
Examining the reliability of discharge ICD coding in the Red Cross War Memorial Children's Hospital administrative database
Get PDFBackground: Discharge diagnostic data from hospital administrative databases are often used to inform decisions relating to a variety of vital applications. These may include the allocation of resources, quality of care assessments, clinical research and for the formulation of healthcare policy to name a few. Having accurately coded and reliably captured discharge data for patients is of paramount importance for any hospital and health system to function efficiently. Objectives: 1. Retrospectively examine the reliability of the ICD discharge coding in the Red Cross War Memorial Children’s Hospital (RCWMCH) administrative database for primary and secondary discharge diagnoses. 2. Formulate recommendations for improvement to the current system. Methods: This study was a retrospective folder review of 450 patient admissions to the short stay and general paediatric wards at the RCWMCH between 1 August 2013 and 1 September 2014. International Classification of Diseases version 10 (ICD-10) discharge coding was completed for each admission by the principal investigator and compared with the corresponding admission data captured for each patient within the Clinicom® Health Information System. Agreement comparison was done to both four-character and three-character ICD-10 code specificity. Results: Of the initial 450 randomly selected folders, 396 (88%) were analysed during the folder review process. The median number of total diagnoses (primary diagnosis plus secondary diagnoses) coded by the principal investigator (PI) folder review was 3 with a distribution of 1 to 10 (IQR 2 - 4). The median number of total diagnoses coded in Clinicom® was 1 with a distribution of 1 to 3 (IQR 1 - 1). Agreement of primary diagnosis coding to four characters was 26.3% with slight improvement to 34.3% when assessed to three characters. Agreement for secondary diagnoses to four characters was 14.9% and 27.7% when assessed to three characters. Conclusion: Reliability of administrative discharge data from RCWMCH is poor. Inadequacies with regard to the employment of dedicated and/or adequately trained coding personnel may be significant contributors to the problem
A prospective study to assess the value of liquid chromatography-tandem mass spectrometry in the management of paediatric poisoning at Red Cross War Memorial Children's Hospital, Cape Town, South Africa
Get PDFBackground: Paediatric poisoning is a common presentation to emergency departments worldwide. There is a paucity of data on the role of liquid chromatography-tandem mass spectrometry (LC-MS/MS), in the management of paediatric poisoning in low-and middle-income countries (LMICs). In high-income countries, most studies are retrospective, and few include children. Objective: The study describes the prevalence of liquid chromatography-tandem mass spectrometry confirmed paediatric poisoning at Red Cross War Memorial Children's Hospital, Cape Town, South Africa. Methods Children admitted with suspected poisoning between 1 January 2017 and 31 December 2017, were recruited. All patients had a urine and/or blood sample sent for LC-MS/MS toxicology. Data collected included demographic data, clinical features, investigations, management, outcome and social interventions. Results 152 children, with median age of 39 (IQR 25 -61) months were enrolled of which 128 (84%) were poisoning cases. Of the 128 poisoning cases, 88 (69%) presented with a history of ingesting a known substance, 16(12%) an unknown substance and 24(19%) were cases of occult poisoning. LC-MS/MS was able to identify a substance in 92% of the cases of occult poisoning. In those who had presented with a seemingly known substance, LC-MS/MS found a different substance in 15 cases. LC-MS/MS was also able to detect multiple drugs in 40 patients. Of the poisoning cases, six (5%) cases were attempted homicide cases and 5 (4%) cases were attempted suicide cases. No children died. Individualized social interventions were instituted in poisoning cases. Emergency placement safety reasons was required in 6 children. Conclusion: When the limitations are known, LC-MS/MS is useful in identifying cases of occult poisoning; identifying patients who have ingested multiple substances and/or an unknown substance and when targeted towards child protection. As LC-MS/MS is an expensive test, it should be used judiciously in LMICs
The clinical use and indications for head computed tomography scans in paediatric ambulatory care (short stay ward and medical emergencies) at a children’s hospital over a one-year period, 1st January-31st December 2013
Get PDFBackground: Computed tomography (CT) imaging is an indispensable tool in the management of acute paediatric illness. It offers quick answers, allowing timely lifesaving decision-making. Clinical evidence is required to maximise its benefits against radiation-exposure risks to patients and cost to the healthcare system.
Aims: The study aimed to retrospectively investigate clinical presentation and indications of head CT at a tertiary paediatric hospital.
Methods: Records of children presenting with acute illness to the medical emergency unit, excluding trauma, of Red Cross War Memorial Children’s Hospital, Cape Town, over one year (2013) were retrospectively reviewed. Participants were included if they underwent head CT scan within 24 hours of presentation. Clinical data were extracted from records and CT findings reported by a paediatric radiologist.
Results: Inclusion criteria were met by 311 patients; 188 (60.5%) were boys. The median age was 39.2 (IQR 12.6-84.0) months. Commonest indications were seizures (n=169;54.3%), reduced level of consciousness (n=140;45.0%), headache (n=74;23.8%) and suspected ventriculoperitoneal shunt (VPS) malfunction (n=61;19.7%). In 217 (69.8%) patients CT showed no adverse findings. In the 94 (30.2%) patients in whom CT abnormalities were detected, the predominant findings were hydrocephalus (n=54;57.4%) and cerebral oedema (n=29;30.9%). Abnormal CT findings were commoner in patients with nausea or vomiting (n=21;9.3%, p=0.05) papilloedema (n=3;1.3%, p=0.015) and long tract signs (n=23;10.2%, p=0.02). Forty-seven patients (15.1%) required surgical intervention after CT of which 40 (85.1%) needed a ventricular drainage procedure. A larger proportion of patients with VPS (25/62;40.3%) required surgical intervention compared to patients without VPS (22/249;8.8%, p <0.001)
Conclusion: Most children presenting with acute illness (excluding trauma) and undergoing emergency head CT have normal findings. Patients with ventriculoperitoneal shunts constituted a large proportion of patients requiring intervention after CT. Considerations should be made to use clinical presentation to select patients most likely to benefit from CT
Laboratory findings that occur in Klebsiella pneumoniae blood stream infection in HIV-infected children compared to HIV uninfected children, at a South African children's hospital, Cape Town, 2006–2011: a nested-descriptive cross-sectional study
Get PDFBackground: Bloodstream infection (BSI) caused by Klebsiella pneumoniae (KP), is a leading cause of hospitalassociated childhood mortality. There are limited data on how poor outcomes of KPBSI can be predicted in poorly resourced areas. This study aimed to assess if the profile of differential counts from full blood counts (FBC) taken at two time points in children <13 years with KPBSI could be used to predict the risk of death. Methods We conducted a retrospective study of a cohort of children admitted to hospital between 2006-2011 with KPBSI. FBC collected within 48 hours (T1) of blood culture and 5-14 days later (T2), were reviewed. Differential counts were classified as abnormal if they were higher or lower than laboratory ranges for normal results. The risk of death was assessed for each category of differential counts. Risk ratios adjusted (aRR) for potential confounders were used to estimate the effect of cell counts on risk of death using multivariable analysis. Data were stratified by HIV status. Results: Of 296 children included, median age 5 (IQR:2-13) months, 82 were HIV -infected. Ninety-five (32%) of the children with KPBSI died. Mortality in HIV-infected and uninfected children was 39/82 (48%) and 56/214 (26%), respectively (p <0.001). Independent associations with mortality were observed with leucopenia, neutropenia and thrombocytopenia. Risk of mortality in children with thrombocytopenia at T1 and T2 was aRR 2.5 (95% CI: 1.34-4.64) and 3.18 (95% CI: 1.31-7.73) respectively in the HIV-uninfected group, whereas the risk for mortality in the HIV-infected group with thrombocytopaenia at T1 and T2 was aRR 1.99 (95% CI: 0.94-4.19) and 2.01 (95% CI: 0.65-5.99) respectively. Neutropenia in the HIV-uninfected group at T1 and T2, showed aRR 2.17 (95% CI: 1.22- 3.88) and 3.70 (95% CI 1.30-10.51) respectively, while in the HIV-infected group, they were aRR 1.18 (95% CI 0.69-2.03) and 2.05 (0.87-4.85) at similar time points. Risk of mortality related to leucopenia at T2 was associated with mortality in HIV-uninfected and HIV-infected patients was aRR 3.22 (95%CI 1.22-8.51) and 2.34 (1.09-5.04) respectively. Persistently high band cell percentage at T2 in HIVinfected children indicated a risk of mortality of aRR 2.91 (95% CI 1.20-7.06). Conclusion Abnormal neutrophil counts and thrombocytopenia are independently associated with significant mortality in children with KPBSI. In resource-limited countries haematological markers have the potential to predict KPBSI mortality
Patterns of mortality in children presenting to a tertiary paediatric emergency unit in Sub-Saharan Africa: a cross sectional study
Get PDFBackground Pneumonia, diarrhoea and perinatal factors are the foremost killers of South African children as in other low- and middle-income countries. Poverty, poor access to care and pre-hospital care are reported major pre-hospital factors and lack of triage, poor skills, delays, poor adherence to treatment protocols and inadequate emergency care determining mortality have been reported to increase in-hospital mortality. Objectives To describe the clinical presentation and management of children admitted via the medical emergency unit (MEU) of the Red Cross War Memorial Children's Hospital (RCWMCH) who subsequently died. Methods We did a retrospective study undertaking a cross-sectional review of children who died following admission via RCWMCH MEU in 2008. Demographic information, clinical data, time factors and mortality data were reviewed and summarised by descriptive and inferential statistics. The unit utilised the WHO Emergency Triage Assessment and Treatment (ETAT) triage tool, categorising children into Red (emergency), orange (priority) and Green (non-urgent). Patient management was assessed by means of ETAT and the Integrated Management of Childhood Illness (IMCI) tools, which is used to identify severity of illness and strategize treatment plans accordingly. Results A total of 135 children met the inclusion criteria. The crude mortality rate was of 6.25 per 1000 admissions. Of the 135 children who died, 119 (88%) were under five years of age, 33(24%) were HIV-infected, of whom (88%) were under 5 years old. In 67 (50%), a chronic medical condition could be identified while 67 (50 %) were moderately or severely malnourished. There were 29 (22%) deaths within 24 hours of arrival at the MEU. Fifty-five (41%) presented after hours. Community health centres referred 65 (48%) patients, general practitioners referred 20 (15%) and 38 (28%) were self-referred. Ambulance services provided pre-hospital transport to 69 (51%). The two top presenting illnesses in 88 (65%) of the children were acute respiratory illness and acute gastroenteritis. Prior to referral, oxygen was not provided in 57 (59%) children, 35 (71%) with suspected sepsis did not receive antibiotics and glucose was not checked in 39 (80%) with depressed level of consciousness. The median time to ward transfer was 3.23 (IQR: 2.12-4.92) hours. Twelve deaths (9%) occurred in the MEU, 57 (42%) in PICU, 56 (42%) in medical wards and 10 (7%) in specialist wards. The five most common causes of death were acute respiratory infections in 45 (33%), acute gastroenteritis in 27 (20%), septicaemia 22 (16%), meningitis in 13 (10%) and cardiac conditions in 12 (9%) children. Conclusion The top causes of mortality in this hospital cohort in 2008 were pneumonia, acute gastroenteritis, and septicaemia. Using the IMCI and ETAT standard of care, suboptimal management was identified in pre-hospital management, as well as MEU management. Appropriate training and protocol implementation to improve morbidity and mortality should be undertaken
Going Beyond Counting First Authors in Author Co-citation Analysis
Get PDFThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
- …
