War Memorial Children's Hospital Research Articles

Common Arterial Trunk Repair at the Red Cross War Memorial Hospital, Cape Town: A 20-Year Review of Surgical Practice and Outcomes.

This study describes the 20-year experience of managing common arterial trunk (CAT) in a low-and-middle-income country and compares the early and medium-term outcomes following the transition from conduit to nonconduit repair at the Red Cross War Memorial Children's Hospital. Single-center retrospective study of consecutive patients aged less than 18 years who underwent repair of CAT from January 1999 to December 2018 at the Red Cross War Memorial Children's Hospital. Patients with interrupted aortic arch or previous pulmonary artery banding were excluded. Fifty-four patients had CAT repair during the study period. Thirty-four (63.0%) patients had a conduit repair, and 20 (37.0%) patients had a nonconduit repair. There were two intraoperative deaths. Thirty-day in-hospital mortality was 22.2% (12/54). Overall, in-hospital mortality was 29.6% (16/54). Eight (21.1%) late mortalities were observed. The actuarial survival for the conduit group was 77.5%, 53.4%, and 44.5% at 6, 12, and 27 months, respectively, and the nonconduit group was 58.6% at six months. The overall freedom from reoperation between the conduit group and nonconduit group was 66.2% versus 86.5%, 66.2% versus 76.9%, and 29.8% versus 64.1% at 1, 2, and 8 years, respectively. The outcomes following the transition to nonconduit repair for CAT in a low- and middle-income setting appear to be encouraging. There was no difference in mortality between conduit and nonconduit repairs, and importantly the results suggest a trend toward lower reintervention rates.

The state of paediatric deceased-organ donation at a South African tertiary public- sector hospital: A 14-year analysis.

Solid-organ transplantation (SOT) has been proven to be a highly effective and life-saving treatment modality for adults and children suffering from end-stage organ failure. However, high paediatric waiting-list mortality has been reported, and children may suffer irreversible physical and deleterious psychological effects if not transplanted timeously. To identify in-hospital barriers to organ donation and gain a better understanding of the paediatric donor landscape. A retrospective descriptive study of consecutive deceased-donor referrals at Red Cross War Memorial Children's Hospital over a 14-year period, from 1 January 2007 to 31 December 2020. During the study period, 156 in-hospital deaths were recorded in the trauma unit and 1 425 in the paediatric intensive care unit. Ninety-three of the 1 581 patients (5.9%) were referred to the on-call transplant co-ordinator as potential organ donors, of whom 69% had been involved in a traumatic accident, including 52% in road traffic collisions. The mean age of the potential donors was 7 years with 60.2% being boys. On initial assessment, 67 of the 93 potential donors (72%) were assessed as eligible for donation of at least one solid organ. The transplant co-ordinator attempted to approach all families for consent; however, five families/next of kin could not be located despite multiple attempts. Among the remaining 62 eligible donors, 44 families/next-of-kin declined consent for solid-organ donation, resulting in a consent rate of 29% (n=18). Several families refused consent for religious reasons. One of the consented donors did not proceed to procurement as there were no suitable recipients. Seventeen donors proceeded to theatre, the intention being solid-organ procurement, but in 2 donors the organs were assessed as being unsuitable for transplant. From the remaining 15 donors, a total of 46 organs were procured and successfully transplanted: 14 livers, 30 kidneys and 2 hearts. During the 14-year study period, only 15 deceased donors could be utilised for SOT, as a result of low in-hospital referral (5.9%) and consent rates (29%). The reasons for low referral and consent rates are complex and often multifactorial, which the current study was not designed to investigate in sufficient detail. Future studies should be designed to further interrogate our findings, while accommodating for nuances specific to the paediatric deceased-donor population and their families.

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.

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.

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.

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

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.

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.

Ten years' experience with bone conduction hearing aids in the Western Cape, South Africa.

Untreated conductive and mixed hearing losses as a result of middle ear pathology or congenital ear malformations can lead to poor speech, language and academic outcomes in children. Lack of access to centralised hearing healthcare in resource-constrained environments limits opportunities for children with hearing loss. Red Cross War Memorial Children's Hospital (RCWMCH) is one of only two dedicated paediatric hospitals in sub-Saharan Africa. Between 2016 and 2021, 29 children received implanted bone conduction hearing devices, and 104 children were fitted with bone conduction devices on softbands. The authors' experience at RCWMCH suggests that bone-anchored hearing devices, either fitted on softbands or on implanted abutments, can provide solutions in settings where patients have limited access to hearing healthcare and optimal classroom environments. Hearing healthcare should be accessible and delivered at the appropriate level of care to mitigate the adverse effects of hearing loss in children.Contribution:This article describes strategies employed at RCWMCH such as fitting bone conduction hearing devices on a softband immediately after hearing loss diagnosis and conducting follow-up via remote technology to make hearing healthcare more accessible to vulnerable populations.

Streamlining referral decisions for childhood poisoning: a cross-sectional study from a tertiary children's hospital in Cape Town, South Africa.

The study objectives were to report on current paediatric poisoning figures from South Africa, and to better understand this patient population to contribute suggestions for streamlining local triage and referral criteria. A retrospective review of children presenting to Red Cross War Memorial Children's Hospital (RCWMCH) with poisoning between January 2009 and December 2019 was performed. Data were extracted from the Poisons Information Centre's Clinical Poisonings Database. There were 3699 incidents, involving 3662 patients; 3011 (81%) patients were under 5 years (median 29 months, IQR 19 to 49 months). There was a slight decline in numbers over the 11-year period.Most patients were referred (n=2542, 69%), which included a greater proportion that were symptomatic (p < 0.001). There were 8 deaths (case fatality rate 0.2%).Medications were the most common single toxin group (n=1270, 38%), followed by handyman and industrial (HI) products (n=889, 27%), household products (n=451, 14%), and pesticides (n=445, 13%). There was a significant relationship between toxin type and referral patterns (p < 0.001) as well as clinical severity (p < 0.001): pesticides and HI products (paraffin, n=486/568, 86%) had a greater proportion of referrals, and pesticides more moderate to fatal poisonings (n=132/445, 30%), all due to cholinergic (organophosphates and carbamates) and formamidine pesticides.The medication subgroups anticonvulsants (n=21/78, 27%), anti-infectives (n=4/34, 12%), multi-vitamin/mineral (MVM) supplements (n=17/84, 20%), neuropsychiatric medications (n=50/350, 14%) and substances of abuse (n=13/47, 28%) had larger proportions of moderate to severe poisonings (p < 0.001), as did the small group of biological toxins (n=17/55, 31%; p < 0.001). Certain medication, pesticide, and biological toxin subgroups, should be flagged for early referral. The goal is to improve patient outcomes as well as optimize the use of limited resources.

More than 25 years after selective dorsal rhizotomy: physical status, quality of life, and levels of anxiety and depression in adults with cerebral palsy.

The primary purpose of selective dorsal rhizotomy (SDR) is to ameliorate spasticity in the lower extremities of children with cerebral palsy (CP). In correctly selected patients, this neurosurgical procedure has been shown to have a beneficial effect on many aspects of the child's life. However, given the challenges faced by adults with CP, it would be valuable to document the status of this population compared to their peers later in adulthood. Therefore, the aim of this study was to determine the physical status, mental health, and health-related quality of life (HRQoL) of adults with CP who underwent SDR at least 25 years ago, compared to matched typically developing (TD) individuals. The second aim was to investigate relationships between physical status and the other outcome measures. Adults with CP were recruited from a database of children who had undergone SDR performed using the technique introduced by Professor Warwick Peacock at Red Cross War Memorial Children's Hospital in Cape Town, South Africa, between 1981 and 1991. These individuals were matched for age, sex, body mass index, and socioeconomic status to a TD adult cohort from a similar background. The parameters assessed were lower-extremity muscle tone, passive range of motion, muscle strength, selectivity, functional mobility and dynamic balance (Timed Up and Go [TUG] test), HRQoL (SF-36), and anxiety and depression levels. Twenty-six adults with CP who had a median age of 35.8 years (interquartile range 34.2-41.4 years) (female/male: n = 10/16; Gross Motor Function Classification System level I/II/III: n = 13/10/3), were compared to 26 TD adults. Muscle tone was similar, whereas passive range of motion, muscle strength, selectivity, TUG, and SF-36 physical functioning (concept and summary) scores differed between the cohorts. Other SF-36 parameters, anxiety levels, and depression levels were not different. Strong correlations were found between the muscle strength and TUG scores. Normalized lower-extremity muscle tone was sustained 25-35 years after SDR. Whereas the lower scores for physical assessments are in line with findings in other CP populations, remarkably, relatively good mental health and HRQoL scores were reported in this CP group despite their physical limitations. The strong correlation between muscle strength and TUG suggests that strength training after SDR may have value in improving functional mobility and balance.

Outcomes After Bidirectional Glenn Shunt in a Tertiary-Care Pediatric Hospital in South Africa

Large data sets have been published on short- and long-term outcomes following bidirectional Glenn surgery (BDG), or partial cavopulmonary connection, in high-income countries. Data from low-income and middle-income countries are few and often limited to the immediate postoperative period. The primary outcome was any in-hospital postoperative complication, assessed according to predefined criteria, in children who underwent BDG surgery at Red Cross War Memorial Children's Hospital. A retrospective cohort study. A tertiary teaching hospital. The study authors identified 61 children (<18 years of age) who underwent BDG over 8 years. The median age of patients undergoing BDG was 2.5 years (interquartile range, 1.4-5.5 years). BDG surgery. Thirty-five patients (57.4%) had a postoperative complication, with some patients (17 of 61, 27.9%) having more than 1 complication. The most frequent complications were infective (29.5%). Univariate analysis found that postoperative complications were associated with the use of nitric oxide (p=0.004) and a longer duration of anesthesia (p=0.045) and surgery (p=0.004). Patients with complications spent longer in the pediatric intensive care unit (ICU) (p < 0.001) and in the hospital (p < 0.012). On multivariate analysis, a priori risk factors based on previous studies were not found to be statistically significant. A total of 37.3% of patients completed their single-ventricle palliation, and 30.5% of patients were lost to follow-up. Important findings were the older age at which the BDG was performed compared to high-income countries, an acceptable mortality rate of 3.3%, infection being the most common complication, the association of a complication with increased ICU and hospital lengths of stay, and the high rate of patients lost to follow-up.

Profile of paediatric tuberculosis mastoiditis -a case series

Tuberculosis (TB) otitis media is an uncommon site of extrapulmonary TB and can primarily present as a complicated TB mastoiditis (TBM). This complication is rare in children, even in TB endemic areas but necessitates early identification as delays can lead to severe morbidities. We describe the clinical characteristics as a case series to raise awareness of the condition, and highlight fundamentals related to diagnosis and management.A retrospective chart review of clinical and radiological information of five children with TBM seen at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa, over the last 5 years. Variables collected included symptomatology, duration of disease, investigations and management.All were under 5 years of age and presented with typical features of acute bacterial mastoiditis. Mean duration of symptoms was 12 days (range 3-30 days). Two children had known TB contacts. Two children had pulmonary involvement, one with miliary TB. CT of the temporal bone demonstrated extensive bony destruction of the petromastoid and demineralised ossicles in all cases. Three children had intracranial extension. Four children demonstrated hearing loss between 30 dB and 83 dB. Necrotising granulomatous inflammation was present in the mastoid specimens in all cases. Confirmatory diagnosis was made via GeneXpert polymerase chain reaction (PCR) (2), Ziehl-Nielson (ZN) stain (1) or a positive TB culture (2). Postoperatively, one patient had normal hearing, two patients had mild conductive hearing loss (CHL), one had mild-moderate CHL and one had profound hearing loss.Delays in identification and management result in marked bony destruction and hearing loss. Radiological and surgical findings typical of TBM, therefore, require tissue sampling from the ear for urgent microscopic, PCR and histologic testing, allowing the avoidance of a mastoidectom. In a TB endemic setting, children with typical findings and necrotising granulomatous inflammation on histology should be considered for prompt commencement of anti-TB therapy while awaiting a definitive diagnosis.

Clinical correlations to distinguish severe from milder forms of obstructive sleep apnoea syndrome using overnight oximetry for prioritising adenotonsillectomy in a limited-resource setting

BackgroundIn resource-poor settings with limited surgical services, it is essential to identify and prioritise children with severe and very severe obstructive sleep apnoea syndrome (OSAS) to expedite surgery. McGill's Oximetry Score (MOS) has been validated against polysomnography for OSAS and is affordable and easy to use. AimsThe aim of this study was to assess the correlation of tonsillar size and clinical symptoms with MOS grade 3 or 4, to identify who requires overnight oximetry and who to prioritise for adenotonsillectomy. MethodsChildren with suspected OSAS were recruited from the otolaryngology clinic at the Red Cross War Memorial Children's Hospital. Demographics, symptom screening scores (SSS), patient characteristics, overnight oximetry (OO), echocardiography and MOS scores (graded 1–4) were recorded. Multivariate modified-Poisson regression models were used to examine correlations of patient characteristics ‘with grade 3 or 4 MOS. ResultsOne-hundred-and-three children were analysed, 38% were female, and median (IQR) age was 3.8 (2.5–5.3) years. Increased tonsil size was associated with a 60% increased risk of grade 3 or 4 MOS, risk ratio (RR) 1.59, 95% CI 1.10–2.29 (p = 0.014). Children with witnessed apnoeic events during sleep had 1.3 times increased risk of MOS Grade 3 or 4, RR 1.31, 95% CI (p = 0.033). A significant correlation was shown with grade 3 or 4 MOS, RR 1.15, 95% CI 1.03–1.27 (p = 0.010) by combining tonsillar size with the following symptoms: apnoeic events; struggling to breathe during sleep and needing to stimulate the child to breathe. ConclusionIdentifying children with suspected OSAS who require overnight oximetry can be performed using a simple 3-question screening tool: witnessed apnoeic events, struggling to breathe and the need to shake them awake to breathe. This is more precise with an additional clinical finding of grade 3 or 4 tonsils. These children should have surgery expedited. Any child with a MOS 3 or 4 score on OO needs to have expedited surgery.

Outcomes of children with sensorineural hearing loss fitted with binaural hearing aids at a pediatric public hospital in South Africa

ObjectiveTo describe hearing aid outcomes for children with bilateral sensorineural hearing loss (SNHL) at a pediatric public hospital in South Africa in terms of daily use and oral/aural performance. Materials and methodsRetrospective review of clinical data and caregiver reported outcomes of children aged 0–13 years with bilateral SNHL at one-month and three-months post-fitting. Oral/aural performance was measured by the Parents’ Evaluation of Aural/Oral Performance of Children (PEACH) questionnaire. Multiple linear regression was used to evaluate factors associated with hearing aid use. Thematic analysis was applied for qualitative caregiver-reported outcomes. Study sampleSixty-eight children with confirmed bilateral SNHL who were fitted with binaural air-conduction hearing aids at Red Cross War Memorial Children's Hospital in Cape Town, South Africa, between January 2017 and December 2019. ResultsAverage daily hearing aid use increased significantly (p < 0.05) from one-month (5.0; 3.0 SD; range 0.3–14.0) to three-months post-fitting (5.9; 3.4 SD; range 1.1–16.8). Average PEACH scores were higher in Quiet (73.4%) than in Noise (69.6%). More than half (52.2%) of children required review based on their overall percentage PEACH scores. Higher average daily hearing aid use was significantly associated with higher overall PEACH scores (p < 0.05). Neuro-typically developing children had significantly higher hearing aid use than children with additional disabilities (p < 0.001). Qualitative caregiver feedback revealed themes pertaining to advantages and barriers to hearing aid use. ConclusionOutcomes of children with SNHL fitted with binaural hearing aids at a pediatric public hospital in South Africa demonstrated increased average daily hearing aid use from one-month to three-months post-fitting. Aural/oral performance was typical for one in two children. Children with additional disabilities had significantly poorer hearing aid use and aural/oral performance requiring more support for this vulnerable group to realize sufficient benefit from hearing aid use.

Global leadership in paediatric and congenital cardiac care: "global health advocacy, lift as you rise - an interview with Liesl J. Zühlke, MBChB, MPH, PhD".

Professor Liesl Zühlke is the focus of our fifth in a series of interviews in Cardiology in the Young entitled, "Global Leadership in Paediatric and Congenital Cardiac Care". Professor Zühlke (nee Hendricks) was born in Cape Town, South Africa. She would attend medical school in her hometown at University of Cape Town, graduating in 1991. Professor Zühlke then went on to complete a Diploma in Child Health at College of Medicine in Cape Town followed by completion of her Paediatric and Paediatric Cardiology training in 1999 and 2007, respectively. She would subsequently complete her Masters of Public Health (Clinical Research Methods) at the University of Cape Town, completing her dissertation in 2011 on computer-assisted auscultation as a screening tool for cardiovascular disease, under the supervision of Professors Landon Myer and Bongani Mayosi.Professor Zühlke began her clinical position as a paediatric cardiologist in the Department of Paediatrics and Child Health at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa in 2007. In this role, she has been instrumental in developing a transitional clinic at the paediatric hospital, is a team member of the combined cardio-obstetric and grown-up congenital heart disease clinics, each of which are rare in South Africa, with very few similar clinics in Africa. Professor Zühlke would continue her research training, completing her Doctorate at the University of Cape Town in 2015, with her dissertation on the outcomes of asymptomatic and symptomatic rheumatic heart disease under the supervision of Professor Bongani Mayosi and Associate Professor Mark Engel. In 2015, in affiliation with the University of Cape Town and the Department of Paediatrics and the Institute of Child Health, she established The Children's Heart Disease Research Unit, with the goals to conduct, promote and support paediatric cardiac research on the African continent, facilitate Implementation Science and provide postgraduate supervision and training in paediatric cardiac research. In 2018, she would subsequently complete her Master of Science at the London School of Economics in Health Economics, Outcomes and Management of cardiovascular sciences. Professor Zühlke currently serves as the acting Deputy-Dean of Research at the Faculty of Health Sciences, University of Cape Town.Professor Zühlke has achieved the highest leadership positions within cardiology in South Africa, including President of the Paediatric Cardiac Society of South Africa and President of the South African Heart Association. She is internationally regarded as a leader in research related to rheumatic heart disease. Professor Zühlke's work includes patient, family and health advocacy on a global scale, being involved in the development of policies that have been adopted by major global organisations such as the World Health Organization. In addition to her clinical and research efforts, she is highly regarded by students, colleagues and graduates as an effective teacher, mentor and advisor. This article presents our interview with Professor Zühlke, an interview that covers her experience as a thought leader in the field of Paediatric Cardiology, specifically in her work related to rheumatic heart disease, Global Health and paediatric and congenital cardiac care in resource-limited settings.

Engaging nurses in research awareness using a new style of hospital journal club - a descriptive evaluation

BackgroundNurses, especially nurses in Africa, face barriers when trying to access and apply literature. These challenges include paywalls; complex academic language; and journal content which is hard to translate to local realities. ObjectivesTo investigate nurses' self-reported experiences of participating in a monthly hospital wide journal club at the Red Cross War Memorial Children's Hospital (RCWMCH). DesignThis descriptive study used a researcher-designed quantitative questionnaire design. The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guideline were used. SettingRed Cross War Memorial Children's Hospital (RCWMCH) in Cape Town, South Africa. ParticipantsAll cadres of nurses working at the Red Cross War Memorial Children's Hospital (RCWMCH) who had attended six or more hospital journal club sessions at RCWMCH over the previous two years. MethodsA descriptive study using a researcher-designed quantitative questionnaire. Results155 participants completed the survey (96.87% response rate). Participants self-reported an improved knowledge of the main sections of a journal article (p < 0.001) and a significant increase in talking to colleagues about evidence-based nursing practice after attending journal club (p < 0.001). ConclusionsAttendance at a journal club appears to contribute to increased access to scientific literature, personal and organisational habits of reading, and collaborative exploration of clinical practice for nurses of all cadres. Innovative facilitation methods (including large-scale graphic facilitation) may contribute to efficacy and popularity of sessions.

A review of the use of inhaled nitric oxide in the PICU at Red Cross War Memorial Children's Hospital, 2011-2015: A retrospective cohort study.

Background Inhaled nitric oxide (iNO) functions as a selective pulmonary vasodilator. It is an expensive treatment that is often employed as rescue therapy for refractory hypoxaemia in acute respiratory distress syndrome (ARDS) and pulmonary hypertension (PHT) following cardiac surgery. Objectives To describe the use of iNO and the cost of treatment in our paediatric intensive care unit (PICU). Methods A retrospective descriptive study of all patients treated with iNO in the PICU at Red Cross War Memorial Children’s Hospital (RCWMCH) from 2011 - 2015. Results We treated 140 patients with iNO, 82 for PHT following cardiac surgery, 53 for ARDS and 5 for persistent pulmonary hypertension of the newborn (PPHN). A response to treatment was observed in 64% of the cohort as a whole, 80% of those with PPHN, 67% of those with PHT post-cardiac surgery, and 64% of those with ARDS. A longer duration of PICU and hospital admission, and higher in-hospital mortality (53%), was seen in the group with ARDS, in particular those with adenoviral infection (63%), when compared with patients treated for PHT post-cardiac surgery (18%) and for PPHN (20%). The total cost of treatment with iNO was ZAR1 441 376 for the 5-year period studied. There are no protocols guiding the use of iNO in our unit, and it was found that response to treatment was not being objectively measured and documented, and that practice varied between clinicians. Conclusion Considering the cost of treatment and lack of evidence showing improved outcomes with iNO therapy, its continued use in our resource-limited setting should be guided by protocol. Contributions of the studyThere is a paucity of data regarding the indications for use, and outcomes of patients treated with iNO in resource-limited settings. We did not find evidence of improved outcomes in patients treated with iNO despite the high costs of the therapy. Protocols should be developed to guide the use of iNO in resource-limited settings.