Red Cross War Memorial Children Research Articles

Dialysis for paediatric acute kidney injury in Cape Town, South Africa.

Dialysis is lifesaving for acute kidney injury (AKI), but access is poor in less resourced settings. A "peritoneal dialysis (PD) first" policy for paediatric AKI is more feasible than haemodialysis in low-resource settings. Retrospective review of modalities and outcomes of children dialysed acutely at Red Cross War Memorial Children's Hospital between 1998 and 2020. Of the 593 children with AKI who received dialysis, 463 (78.1%) received PD first. Median age was 9.0 (range 0.03-219.3; IQR 13.0-69.6) months; 57.6% were < 1year old. Weights ranged from 0.9 to 2.0kg (median 7.0kg, IQR 3.0-16.0kg); 38.6% were < 5kg. PD was used more in younger children compared to extracorporeal dialysis (ECD), with median ages 6.4 (IQR 0.9-30.4) vs. 73.9 (IQR 17.5-113.9) months, respectively (p = 0.001). PD was performed with Seldinger soft catheters (n = 480/578, 83%), predominantly inserted by paediatricians at the bedside (n = 412/490, 84.1%). Complications occurred in 127/560 (22.7%) children receiving PD. Overall, 314/542 (57.8%) children survived. Survival was significantly lower in neonates (< 1month old, 47.5%) and infants (1-12months old, 49.2%) compared with older children (> 1year old, 70.4%, p < 0.0001). Survival was superior in the ECD (75.4%) than in the PD group (55.6%, p = 0.002). "PD First for Paediatric AKI" is a valuable therapeutic approach for children with AKI. It is feasible in low-resourced settings where bedside PD catheter insertion can be safely taught and is an acceptable dialysis modality, especially in settings where children with AKI would otherwise not survive.

Evaluation of the implementation of a "Pediatric Feasibility Assessment for Transplantation" tool in children and adolescents at Red Cross War Memorial Children's Hospital, Cape Town, South Africa.

Kidney transplantation remains the treatment of choice for children with kidney failure (KF). In South Africa, kidney replacement therapy (KRT) is restricted to children eligible for transplantation. This study reports on the implementation of the Paediatric Feasibility Assessment for Transplantation (pFAT) tool, a psychosocial risk score developed in South Africa to support transparent transplant eligibility assessment in a low-resource setting. Single-center retrospective descriptive analysis of children assessed for KRT using pFAT tool from 2015 to 2021. Using the pFAT form, 88 children (median [range] age 12.0 [1.1 to 19.0] years) were assessed for KRT. Thirty (34.1%) children were not listed for KRT, scoring poorly in all domains, and were referred for supportive palliative care. Fourteen of these 30 children (46.7%) died, with a median survival of 6 months without dialysis. Nine children were reassessed and two were subsequently listed. Residing >300 km from the hospital (p = .009) and having adherence concerns (p = .003) were independently associated with nonlisting. Of the 58 (65.9%) children listed for KRT, 40 (69.0%) were transplanted. One-year patient and graft survival were 97.2% and 88.6%, respectively. Only one of the four grafts lost at 1-year posttransplant was attributed to psychosocial issues. Short-term outcomes among children listed using the pFAT form are good. Among those nonlisted, the pFAT highlights specific psychosocial/socioeconomic barriers, over which most children themselves have no power to change, which should be systemically addressed to permit eligibility of more children and save lives.

Pediatric vocal cord mobility: Translaryngeal ultrasound application for resource-limited laryngologists

Background: Flexible fibreoptic laryngoscopy (FFL) is currently the gold standard for assessment of true vocal cord (TVC) mobility but is invasive and not without risk. The aim of this study was to determine the accuracy of an application-based translaryngeal ultrasonography (TLUS) as a screening tool for mobility of TVCs and to assess the feasibility of its use by an otolaryngologist not formally trained in ultrasonography.Methods: Forty children were recruited at the ear, nose and throat (ENT) clinic at Red Cross War Memorial Children’s Hospital (RCWMCH). The first author (DR), an ENT trainee, was trained by a consultant radiologist (MJ) on the use of an ultrasound probe to assess TVC mobility. Two qualified ENT specialists (neither trained in ultrasonography) consented to evaluate TLUS and FFL videos for TVC mobility.Results: In total, 135 videos were obtained from 40 participants. Ages ranged from 10 days to 9 years, and the genders were equally represented. The overall accuracy of TLUS evaluation was 95.5% (sensitivity of 100%, specificity of 60%). The reliability of TLUS when compared to FFL showed a p 0.001 and a 100% agreement between ENT specialists evaluating the shared videos.Conclusion: Our study shows TLUS to be a reliable method of assessing TVC mobility.Contribution: Translaryngeal ultrasonography is portable, noninvasive and easy to use, making it a potentially useful screening tool for practitioners other than radiologists, for example, otolaryngologists, who have a good understanding of laryngeal anatomy, especially in resource-limited settings, where FFL might not be readily available.

Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children’s Hospital

BackgroundAt Red Cross War Memorial Children’s Hospital (RCCH), it is the preferred practice to use non-ventriculoperitoneal (non-VP) shunts when the peritoneum is ineffective or contraindicated for cerebrospinal fluid (CSF) diversion and when endoscopy is not an option. The objective of this study is to evaluate the clinical course of patients having undergone these procedures.MethodA single-centre retrospective review at RCCH wherein 43 children with a total of 59 episodes of non-VP shunt placement over a 12-year period were identified for inclusion.ResultsTwenty-five ventriculoatrial (VA) and 32 ventriculopleural (VPL) shunts were analysed with a median age at insertion of 2.9 (0.3–14.9) and 5.3 years (0.5–13.4), respectively. The median number of previous shunt procedures prior to VA or VPL shunt insertion was 6.0 (2–28) versus 4.5 (2–17), respectively. Three VA (12.0%) and three VPL (9.4%) shunt patients were lost to follow-up. Of those remaining, 10 VA shunts (45.5%) compared to 19 (65,5%) VPL shunts required revision. One ventriculovesical shunt and one ventriculocholecystic shunt were placed in the same patient after 21 and 25 shunt-related procedures, respectively, and both were revised within 3 weeks of insertion. Median shunt survival was 8 months longer for the VA compared to the VPL shunts, being 13.5 (0–67) and 5 months (0–118), respectively. Complications for VA shunts were low, with the overall shunt sepsis rate in the VA group at 4% (n = 1) compared to 15.6% (n = 5) in the VPL group.ConclusionOur findings support that VA and VPL shunts are acceptable second-line options in an already compromised group of patients where safe treatment options are limited, provided attention is paid to the technical details specific to their placement.

A descriptive study of vancomycin use at Red Cross War Memorial Children's Hospital, Cape Town.

Antimicrobial stewardship principles guide the clinical use of antimicrobials, including vancomycin, but paediatric vancomycin prescribing practices have not been evaluated in South Africa. To document the use, prescribing practices and monitoring of intravenous vancomycin and the spectrum of bacteria isolated on microbiological culture in children treated with intravenous vancomycin during a 12-month period at Red Cross War Memorial Children's Hospital (RCWMCH). A retrospective audit of intravenous vancomycin use in children admitted to RCWMCH during 2019 was performed. All 158 vancomycin prescription episodes for 143 children were included. Overall usage of intravenous vancomycin was 63 days of therapy per 1000 patient days (interquartile range [IQR]: 38-72). The median starting dose was 15 mg/kg per dose (IQR: 14-15) and median daily dose was 45 mg/kg per day (IQR: 43-60). Vancomycin was prescribed as empiric (127/158, 80%) and directed (31/158, 20%) treatment. The median duration of treatment for the directed group (7 days) was longer than the empiric group (4 days) (p = 0.001). Vancomycin serum trough concentrations were performed in 65/98 (66%) episodes where vancomycin treatment exceeded 3 days, with only 16/65 (25%) of these samples obtained before the fourth dose. Prolonged antibiotic treatment of 14 days or more was not associated with Gram-positive bacteria on culture (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 0.17-4.2). Dosing errors, prolonged empiric treatment and inappropriate vancomycin monitoring were problems associated with vancomycin prescriptions. The study identified multiple opportunities for improved vancomycin prescribing and monitoring. Further research and implementation of improved prescribing practices could contribute to the preservation of vancomycin as an effective antibiotic.

PAEDIATRIC-11 EPIDEMIOLOGY OF PINEALOBLASTOMA IN CAPE TOWN, SOUTH AFRICA

Abstract OBJECTIVE To compare the experience with pinealoblastoma (PB) of the neuro-oncology services of the University of Cape Town to the WHO 2021 classification. METHODS A retrospective analysis was performed on folders of patients diagnosed at Red Cross War Memorial Children’s Hospital and Groote Schuur Hospital from 2000-2022. Routine molecular testing is not available nor is testing for DICER mutations. Patients with PB associated with retinoblastoma (RB) were assumed to be Rb1-altered and were treated with ophthalmic local control and chemotherapy, and those without associated RB (assumed to be non-Rb1-altered) were mostly treated with surgery, chemotherapy and craniospinal radiotherapy. Convenience sampling was performed by age with respect to disease characteristics and outcome to try and disaggregate miRNA-processing-altered-1 and -2 from MYC/FOXR2-altered PB. RESULTS Twenty-five patients were identified, 6 with Rb1-altered PB, aged 0.33-1.88 years (median 0.79) and 19 with non-Rb1-altered PB, aged 0.17-12.99 years (median 6.23). The whole cohort was balanced in terms of gender but there were slightly more girls (11) than boys (8) among the non-Rb1-altered PBs. One of these children was a 5-year-old boy with DICER syndrome who was identified through family screening. One Rb1-altered PB had metastatic disease outside the pineal gland. Among the non-Rb1-altered PBs 47% had metastases, 0% of those under 3 years, 40% of those aged 3-9 years and 80% of those older than 9 years. Estimated 5-year OS for the whole group was 49%, 50% for Rb1-altered PB and 49% for non-Rb1-altered PBs. OS by age among non-Rb1-altered PBs was 0% for 0-3 years, 90% for 3-9 years and 20% for those older than 9 years. CONCLUSION DICER testing and molecular typing would be very useful in helping to stratify our non-Rb1-altered PBs, both for prognostication and to allow consideration of high-risk strategies. Multi-disciplinary treatment of PB in LMIC is essential.

PAEDIATRIC-12 MANAGEMENT OF PAEDIATRIC LOW-GRADE GLIOMA IN CAPE TOWN, SOUTH AFRICA

Abstract OBJECTIVE To assess the management of paediatric low-grade gliomas by the combined neuro-oncology services of the University of Cape Town. METHODS A retrospective analysis was performed on the folders of patients diagnosed at the Red Cross War Memorial Children’s Hospital (RCWMCH) and Groote Schuur Hospital (GSH) between 2000 and 2022. The data includes 2 patient cohorts, the first cohort being patient data collected from 2000-2016 and the second from 2017-2022. RESULTS A total of 127 patients, aged 0.38-13.76 years (mean 5.71) were treated at RCWMCH and GSH. Predisposition syndromes observed included Neurofibromatosis 1 11, Tuberous sclerosis 6, and Trisomy 21 1. The most common sites were the cerebellum 27%, hypothalamus 17%, cerebrum 12%, and optic pathway 13%. Metastatic disease was noted in 12 patients (9%). Gross total resection (or debulking) was performed in 67 (53%) of patients, 40 had biopsy only, and 20 had no surgery (mostly OPGs). Histology was predominantly Juvenile Pilocytic Astrocytoma 70%, Diffuse Astrocytoma 9%, Low-Grade Glioma Nos 8%,5% Subependymal Giant cell Astrocytoma, and 5% Pilomyxoid Astrocytoma. BRAF v600E mutation was tested in 17 patients: all were negative. Forty-four (35%) received chemotherapy and 36 (82%) as first-line therapy with vincristine and carboplatin as the most used agents. Newer therapies Bevacizumab/irinotecan and Trametinib were recently used in 10 patients as third or fourth-line regimens. There was an increase in chemotherapy usage for patients with irresectable tumours between the 2 cohorts, from 27% in the first cohort to 49% in the second. Thirty (23.6%) patients received radiotherapy and of those 8 were in an upfront setting. There was no difference in the 5-year OS between the 2 cohorts, 84% in the first and 85.7% in the second. CONCLUSION Multi-disciplinary treatment of paediatric LGG in LMIC is essential. Patterns of management have changed without affecting outcomes.

Effects of aminophylline therapy on urine output and kidney function in children with acute kidney injury

BackgroundAcute kidney injury (AKI) is a frequent complication of children admitted to the paediatric intensive care unit. One key management modality of AKI is the use of diuretics to reduce fluid overload. Aminophylline, a drug that is well known for its use in the treatment of bronchial asthma, is also purported to have diuretic effects on the kidneys. This retrospective cohort study assesses the effect of aminophylline in critically ill children with AKI.MethodsA retrospective chart review of children admitted to the paediatric intensive care unit of the Red Cross War Memorial Children’s Hospital (RCWMCH) with AKI who received aminophylline (from 2012 to June 2018) was carried out. Data captured and analyzed included demographics, underlying disease conditions, medications, urine output, fluid balance, and kidney function.ResultsData from thirty-four children were analyzed. Urine output increased from a median of 0.4 mls/kg/hr [IQR: 0.1, 1.1] at six hours prior to aminophylline administration to 0.6 mls/kg/hr [IQR: 0.2, 1.9] at six hours and 1.6 mls/kg/hr [IQR:0.2, 4.2] at twenty-four hours post aminophylline therapy. The median urine output significantly varied across the age groups over the 24-h time period post-aminophylline, with the most response in the neonates. There was no significant change in serum creatinine levels six hours post-aminophylline administration [109(IQR: 77, 227)—125.5(IQR: 82, 200) micromole/l] P-value = 0.135. However, there were significant age-related changes in creatinine levels at six hours post-aminophylline therapy.ConclusionsAminophylline increases urine output in critically ill children with AKI.Graphical abstractA higher resolution version of the Graphical abstract is available as Supplementary information

Equity in access to ASMs - who has the right to decide and what are the consequences of crisis decisions?

EpilepsiaAccepted Articles COMMENTARY Equity in access to ASMs – who has the right to decide and what are the consequences of crisis decisions? Jo M. Wilmshurst, Corresponding Author Jo M. Wilmshurst [email protected] orcid.org/0000-0001-7328-1796 Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, South Africa Correspondence Jo M. Wilmshurst. Email: [email protected]Search for more papers by this authorMichael R. Sperling, Michael R. Sperling orcid.org/0000-0003-0708-6006 Department of Neurology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this author Jo M. Wilmshurst, Corresponding Author Jo M. Wilmshurst [email protected] orcid.org/0000-0001-7328-1796 Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, South Africa Correspondence Jo M. Wilmshurst. Email: [email protected]Search for more papers by this authorMichael R. Sperling, Michael R. Sperling orcid.org/0000-0003-0708-6006 Department of Neurology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this author First published: 16 June 2023 https://doi.org/10.1111/epi.17685 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/epi.17685. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

Lessons learned from regional training of paediatric nephrology fellows in Africa.

Access to care for children with kidney disease is limited in less well-resourced regions of the world and paediatric nephrology (PN) workforce development with good practical skills is critical. Retrospective review of a PN training program and trainee feedback from 1999 to 2021, based at Red Cross War Memorial Children's Hospital (RCWMCH), University of Cape Town. A regionally appropriate 1-2-year training program enrolled 38 fellows with an initial 100% return rate to their country of origin. Program funding included fellowships from the International Pediatric Nephrology Association (IPNA), International Society of Nephrology (ISN), International Society of Peritoneal Dialysis (ISPD), and the African Paediatric Fellowship Program (APFP). Fellows were trained on both in- and out-patient management of infants and children with kidney disorders. "Hands-on skills" training included examination, diagnosis and management skills, practical insertion of peritoneal dialysis catheters for management of acute kidney injury and kidney biopsies. Of 16 trainees who completed > 1year of training, 14 (88%) successfully completed subspecialty exams and 9 (56%) completed a master's degree with a research component. PN fellows reported that their training was appropriate and enabled them to make a difference in their respective communities. This training program has successfully equipped African physicians with the requisite knowledge and skills to provide PN services in resource-constrained areas for children with kidney disease. The provision of funding from multiple organizations committed to paediatric kidney disease has contributed to the success of the program, along with the fellows' commitment to build PN healthcare capacity in Africa. A higher resolution version of the Graphical abstract is available as Supplementary information.

Primary nephrotic syndrome in children in Cape Town, South Africa

Background. Histopathological patterns of childhood primary nephrotic syndrome (PNS) and clinical response to steroids have beenassociated with certain race groups in parts of South Africa. However, there are no recent studies of childhood PNS in Cape Town.Objectives. To describe the demographics, histological subtypes and steroid response of patients with PNS who underwent kidney biopsiesat Red Cross War Memorial Children’s Hospital (RCWMCH) over a 10-year period.Methods. Details of patients with PNS who underwent kidney biopsies in the Paediatric Nephrology Department at RCWMCH between2006 and 2015 were retrospectively recorded.Results. A total of 103 patients were included in the study. Most patients were either of mixed race (42%) or black (36%), with a mean age of6.8 years and a male-to-female ratio of 1.19:1. The most identified histopathological subtype was mesangioproliferative glomerulonephritis(MesPGN; 60% (n/N=62/103)). Of the patients with focal segmental glomerulosclerosis (FSGS), MesPGN and minimal change disease(MCD) 45% (n/N=43/95) were steroid-resistant, and 54% (n/N=51/95) were steroid-sensitive. There was no significant associationbetween any race group and steroid response. Patients with FSGS were more likely to be black, while MCD was more common in mixed-race patients (p=0.04). There was no difference in the likelihood of being mixed race or black between patients with FSGS and MesPGN(p=0.472).Conclusion. MesPGN was the most common histopathological subtype found in our study. There was no significant association betweenrace and steroid response. Patients with FSGS were more likely to be black than mixed race when compared with MCD patients. Race wasnot otherwise significantly associated with any histopathological subtype

Prevalence and Incidence of Pediatric Acute Respiratory Distress Syndrome in a Tertiary Academic PICU in South Africa.

To determine the prevalence and incidence of pediatric acute respiratory distress syndrome (pARDS) among infants and children admitted to the PICU. A single-center descriptive point prevalence study with twice weekly data collection over a 6 months (August 2020 to February 12, 2021). Red Cross War Memorial Children's Hospital, Cape Town, South Africa. All infants and children admitted to the PICU on study days were included. Data were captured electronically on a standardized case record form using a Research Electronic Data Capture electronic database. The Pediatric Acute Lung Injury Consensus Conference criteria were used to define pARDS cases. Prevalence was calculated as the total number of pARDS cases/1,000 PICU bed days. The study included 354 patients (median [interquartile range]) 10.1 months old (1.5-61.3 mo old), with 204 males (57.6%), who occupied 879 bed days. Of these 879 bed days, 266 (30.3%; 95% CI, 27.2-33.3%) were occupied by pARDS cases, with a calculated prevalence and incidence of 302.6 of 1,000 bed days (30.3%) and 29.7% (95% CI, 26.7-32.7%), respectively. Three cases from the cohort were defined using the oxygen saturation index calculation. In cases receiving invasive ventilation ( n = 494; 56.2%), pARDS severity was classified as mild ( n = 143; 16.3%), moderate ( n = 44; 5.0%), and severe ( n = 29, 3.3%). A further 205 beds (23.3%) were occupied by patients classified as being at risk of pARDS. The prevalence and incidence of pARDS in a South African PICU appears substantially higher than findings described in international reports. Further investigation of risk factors and outcomes is warranted.

Issue Information

Cover LegendDr Sawsan Yassin engages a patient at the Red Cross War Memorial Children's Hospital during her sub‐specialty training under the African Paediatric Fellowship Programme, University of Cape Town, South Africa. Photo credit: African Paediatric Fellowship Program www.apfp.uct.ac.za. See Gray, p 399.image

Risk factors and predictors of adverse outcomes of in paediatric febrile neutropenia

Background: Febrile neutropenia (FN) is the commonest acute complication of cancer treatment in children. The identification of patients at risk for FN as well as adverse outcomes has been described.Aim: To evaluate the prevalence and potential risk factors for FN and describe adverse outcomes in a cohort of children treated for cancer.Setting: The study was carried out in a paediatric oncology unit in a children’s hospital, Cape Town, South Africa.Methods: A retrospective study from 01 January 2017 to 31 December 2019 on children with cancer at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa.Results: Two hundred and sixty-seven episodes of FN occurred in 179 patients. Independent predictors of FN were acute myeloid leukaemia (AML) (p = 0.039), acute lymphocytic leukaemia (ALL) (p = 0.020) and intensive chemotherapy (p ≤ 0.001). Mucositis (p = 0.001), central venous access device (CVAD) placement (p = 0.004), haematologic malignancies (p = 0.040), blood transfusion during FN episode (p 0.001) and severe neutropenia (white cell counts 0.3 × 109 cells/L) (p ≤ 0.001) were risk factors for adverse outcomes. The mortality rate from FN was 3.57%. Independent predictors of adverse outcomes in those with FN were AML (p = 0.001), CVAD placement (p = 0.019) and severe neutropenia (p = 0.005).Conclusion: Treatment related adverse outcomes following chemotherapy-induced FN are likely in children with AML, severe neutropenia and with CVAD placement.Contribution: Adverse outcomes from paediatric febrile neutropenia is high. There is need for clinical decision making aimed at prevention and early identification of individuals at risk.

Normal values of respiratory oscillometry in South African children and adolescents.

Noninvasive measurement of respiratory impedance by oscillometry can be used in young children aged from 3 years and those unable to perform forced respiratory manoeuvres. It can discriminate between healthy children and those with respiratory disease. However, its clinical application is limited by the lack of reference data for African paediatric populations. The aim of the present study was to develop reference equations for oscillometry outcomes in South African children and adolescents. Healthy subjects, enrolled in the Drakenstein Child Health Study, HIV-uninfected adolescents in the Cape Town Adolescent Antiretroviral Cohort and healthy children attending surgical outpatient clinics at Red Cross War Memorial Children's Hospital were measured with conventional spectral (6-32 Hz) and intra-breath (10 Hz) oscillometry. Stepwise linear regression was used to assess the relationship between respiratory variables and anthropometric predictors (height, sex, ancestry) to generate reference equations. A total of 692 subjects, 48.4% female, median age of 5.2 years (range: 3-17 years) were included. The median (interquartile range (IQR)) for weight for age z-score and height for age z-score was -0.42 (-1.11-0.35) and -0.65 (-1.43-0.35), respectively. Stepwise regression demonstrated that all the variables were significantly dependent on height only. Comparison to previous reference data indicated slightly higher resistance and lower compliance values in the smallest children. We established the first respiratory oscillometry reference equations for African children and adolescents, which will facilitate use in early identification and management of respiratory disease. Our results suggest differences in oscillometry measures by ancestry but also highlight the lack of standardisation in methodology.

123I]-metaiodobenzylguanidine imaging findings and outcome in patients with metastatic neuroblastoma

Background: 123I-Metaiodobenzylguanidine ([123I]mIBG) is the agent of choice to assess for presence of metastases and therapy response in patients with neuroblastoma.Aim: To assess [123I]mIBG scan results and outcome in patients with stage 4 neuroblastoma at our institution.Setting: Red Cross War Memorial Children’s Hospital.Methods: A retrospective review of baseline and follow-up [123I]mIBG scans of patients who presented between January 2001 and May 2015. The clinical follow up extended until October 2019. The association between the baseline and post-induction Curie score (CS) and overall survival (OS) were assessed.Results: Thirty-four patients with stage 4 disease were included. Twenty-two (65%) patients died. The median age at diagnosis for survivors was 15.5 months vs 39 months for those who died (Kruskal Wallis c2 = 4.63, p = 0.03). Neither the baseline CS nor the post-induction CS predict the outcome or duration of survival. The median OS for a baseline CS ≤ 12 and CS 12 was 19 and 26 months, p = 0.13. The median OS for a post-induction CS 2 and CS ≤ 2 was 28 and 26 months, p = 0.66.Conclusion: In this study, baseline, post-induction and reduction in CS did not predict OS in stage 4 neuroblastoma. Factors such as small patient numbers, less intensive treatment regimes, and possible poorly dedifferentiated disease have been identified for this finding.Contribution: In contrast to international studies the Curie score did not predict treatment outcome in the South African setting where the vast majority of patients are treated with OPEC/OJEC OPEC/OJEC (vincristine [O], cisplatin [P], etoposide [E], cyclophosphamide [C] and carboplatin [J]) chemotherapy.

Doing more with less: The use of non-invasive ventilatory support in a resource-limited setting.

Bubble CPAP (bCPAP), a non-invasive ventilation modality, has emerged as an intervention that is able to reduce pneumonia-related mortality in children in low resourced settings. Our study primarily aimed to describe a cohort of children who were started on CPAP in the Medical Emergency Unit (MEU) of Red Cross War Memorial Children's Hospital 2016-2018. A retrospective review of a randomly selected sample of paper-based folders was conducted. Children started on bCPAP at MEU were eligible for inclusion. Demographic and clinical data, management, and outcomes regarding admission to PICU, need for invasive ventilation and mortality were documented. Descriptive statistical data were generated for all relevant variables. Percentages depicted frequencies of categorical data while medians with interquartile ranges (IQR) were used to summarise continuous data. Of 500 children started on bCPAP, 266 (53%) were male; their median age was 3.7 (IQR 1.7-11.3) months and 169 (34%) were moderately to severely underweight-for-age. There were 12 (2%) HIV-infected children; 403 (81%) had received appropriate immunisations for their age; and 119 (24%) were exposed to tobacco smoke at home. The five most common primary reasons for admission were acute respiratory illness, acute gastroenteritis, congestive cardiac failure, sepsis and seizures. Most children, 409 (82%), had no underlying medical condition. Most children, 411 (82%), were managed in high care areas of the general medical wards while 126 (25%) went to PICU. The median time on CPAP was 1.7 (IQR 0.9-2.8) days. The median hospitalisation time was 6 (IQR 4-9) days. Overall, 38 (8%) children required invasive ventilatory support. Overall, 12 (2%) children with a median age of 7.5 (IQR 0.7-14.5) months died, six of whom had an underlying medical condition. Seventy-five percent of children initiated on bCPAP did not require PICU admission. This form of non-invasive ventilatory support should be considered more widely in the context of limited access to paediatric intensive care units in other African settings.

Surgical management of extrahepatic portal vein obstruction in children: advantages of MesoRex shunt compared with distal splenorenal shunt

PurposeTo review surgical management of extrahepatic portal vein obstruction (EHPVO) at Red Cross War Memorial Children’s Hospital and compare MesoRex shunt (MRS) with distal splenorenal shunt (DSRS).MethodsThis is a single-centre retrospective review documenting pre- and post-operative data in 21 children. Twenty-two shunts were performed, 15 MRS and 7 DSRS, over an 18-year period. Patients were followed up for a mean of 11 years (range 2–18). Data analysis included demographics, albumin, prothrombin time (PT), partial thromboplastin time (PTT), International normalised ratio (INR), fibrinogen, total bilirubin, liver enzymes and platelets before the operation and 2 years after shunt surgery.ResultsOne MRS thrombosed immediately post-surgery and the child was salvaged with DSRS. Variceal bleeding was controlled in both groups. Significant improvements were seen amongst MRS cohort in serum albumin, PT, PTT, and platelets and there was a mild improvement in serum fibrinogen. The DSRS cohort showed only a significant improvement in the platelet count. Neonatal umbilic vein catheterization (UVC) was a major risk for Rex vein obliteration.ConclusionIn EHPVO, MRS is superior to DSRS and improves liver synthetic function. DSRS does control variceal bleeding but should only be considered when MRS is not technically feasible or as a salvage procedure when MRS fails.

Cerebrovascular Pressure Reactivity Has a Strong and Independent Association With Outcome in Children With Severe Traumatic Brain Injury.

To examine cerebrovascular pressure reactivity index (PRx) in a large cohort of children with severe traumatic brain injury (sTBI) in association with physiologic variables and outcome. Retrospective observational cohort study. Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Pediatric (≤ 14 yr old) sTBI patients with intracranial pressure (ICP) monitoring (postresuscitation Glasgow Coma Score [Glasgow Coma Scale (GCS)] of ≤ 8). Data were analyzed from ICM+ files sampled at 100Hz. PRx (a mathematical indicator of pressure reactivity) was calculated as a moving correlation coefficient between ICP and mean arterial pressure (MAP) as previously described. Associations between PRx, age, GCS, ICP, MAP, and cerebral perfusion pressure (CPP) were examined with summary measures and correlation analysis using high-frequency data. Associations between PRx and mortality/outcome were examined with multivariable logistic regression analysis and the prognostic ability of PRx with receiver operating characteristic (ROCs) curves. The dataset included over 1.7 million minutes (28,634 hr) of MAP and ICP data in 196 children. The series mortality was 10.7% (21/196), and unfavorable outcome 29.6% (58/196). PRx had a moderate positive correlation with ICP ( r = 0.44; p < 0.001), a moderate negative correlation with CPP ( r = -0.43; p < 0.001), and a weak negative correlation with MAP ( r = -0.21; p = 0.004). PRx was consistently higher in patients with poor outcome and had a strong, independent association with mortality (ROC area under the curve = 0.91). A PRx threshold of 0.25 showed the best predictive ability for mortality. This is the largest cohort of children with PRx analysis of cerebrovascular reactivity to date. PRx had a strong association with outcome that was independent of ICP, CPP, GCS, and age. The data suggest that impaired autoregulation is an independent factor associated with poor outcome and may be useful in directing clinical care.

Candida bloodstream infection among children hospitalised in three public-sector hospitals in the Metro West region of Cape Town, South Africa

BackgroundCandida bloodstream infection (BSI) causes appreciable mortality in neonates and children. There are few studies describing the epidemiology of Candida BSI in children living in sub-Saharan Africa.MethodsA retrospective descriptive study was conducted at three public sector hospitals in Cape Town, South Africa. Demographic and clinical details, antifungal management and patient outcome data were obtained by medical record review. Candida species distribution and antifungal susceptibility testing results were obtained from the National Health Laboratory Service database.ResultsOf the 97 Candida BSI episodes identified during a five-year period, 48/97 (49%) were Candida albicans (C. albicans), and 49/97 (51%) were non-C. albicans species. The overall incidence risk was 0.8 Candida BSI episodes per 1000 admissions at Red Cross War Memorial Children’s Hospital. Of the 77/97 (79%) Candida BSI episodes with available clinical information, the median age (interquartile range) at the time of BSI was 7 (1–25) months, 36/77 (47%) were associated with moderate or severe underweight-for-age and vasopressor therapy was administered to 22/77 (29%) study participants. Most of the Candida BSI episodes were healthcare-associated infections, 63/77 (82%). Fluconazole resistance was documented among 17%, 0% and 0% of C. parapsilosis, C. tropicalis and C. albicans isolates, respectively. All Candida isolates tested were susceptible to amphotericin B and the echinocandins. The mortality rate within 30 days of Candida BSI diagnosis was 13/75 (17%). On multivariable analysis, factors associated with mortality within 30 days of Candida BSI diagnosis included vasopressor therapy requirement during Candida BSI, adjusted Odds ratio (aOR) 53 (95% confidence interval 2–1029); hepatic dysfunction, aOR 13 (95% CI 1–146); and concomitant bacterial BSI, aOR 10 (95% CI 2–60).ConclusionThe study adds to the limited number of studies describing paediatric Candida BSI in sub-Saharan Africa. Non-C. Albicans BSI episodes occurred more frequently than C. albicans episodes, and vasopressor therapy requirement, hepatic dysfunction and concomitant bacterial BSI were associated with an increase in 30-day mortality.