Acute bacterial meningitis among children, in Manhiça, a rural area in Southern Mozambique

INTRODUCTION: Acute bacterial meningitis (ABM) is one of the most severe diseases in Sub-Saharan Africa. Although data for the continent is very limited, more than one million cases are estimated per year, with mortality and life-long sequelae occurring in 50% of these cases. METHODS: As part of the clinical management of children admitted to the Manhi?a District Hospital, information on cases of ABM was recorded. We analysed data from June 1998 to November 2003. RESULTS: During the study period, 475 cerebrospinal-fluid (CSF) samples were collected from 20,173 children <15 years of age admitted to hospital. Culture results confirmed 71 (15%) cases of ABM. The most prevalent bacterial aetiologies were Streptotoccus pneumoniae (pneumococcus, n=31), Haemophilus influenzae (n=13) and Neisseria meningitis (n=8). Other important bacteria were Streptococcus sp. (n=7), Salmonella sp. (n=4) and Staphylococcus aureus (n=3). Crude incidence rates of ABM and pneumococcal meningitis were 20/100,000 and 10/100,000 children-year-at-risk, respectively. Incidences were more than three times higher in the <1 year age group. Overall case fatality rate was 36%, and was highest for H. influenzae and pneumococcal meningitis (55% and 45%, respectively, p=0.044). Pneumococcal susceptibility was 81% for oxacillin and 93% for chloramphenicol. For H. influenzae isolates, susceptibility was 54% for ampicillin and 62% for chloramphenicol. CONCLUSIONS: S. pneumoniae and H. influenzae are the main aetiologies responsible for the high burden of morbidity and mortality associated with ABM in rural Mozambique. These findings are important to evaluate treatment guidelines and potential impact of control measures.     

Community incidences of respiratory infections in an actively followed cohort of children <1 year of age in Manhiça, a rural area of southern Mozambique

Objective To estimate the community incidence‐rates of respiratory infections among infants in Manhiça, southern Mozambique, and to determine risk factors associated with these infections. Methods A cohort of children <1 year of age were visited at home every week until they turned one. During the visits, field workers recorded signs/symptoms of respiratory infections and tested the children for malaria parasites when they had fever. Results Between 1 July 1998 and 30 June 1999, 1044 children contributed with 23 726 weeks at risk. Children met the criteria for acute respiratory infection in 19.2% of the visits, for lower respiratory infection in 0.9% and for severe lower respiratory infection in 0.2%. The crude incidence rate measured for acute respiratory infections was 23.0, that for lower respiratory infection was 0.9 and that for severe lower respiratory infection was 0.2 per 100‐person‐week‐at‐risk. The risk of acute and lower respiratory infection was inversely related to age. Females were at significantly lower risk for all three conditions than males. A trend of increased risk of severe lower respiratory infection was noted among children born during the rainy season (adjusted rate ratio = 1.95, P = 0.122 in only 47 episodes). Malaria was strongly associated with an increased risk of all three respiratory infections [rate ratio of 2.35, 10.90 and 13.82 (P < 0.001) in the adjusted analysis, respectively]. Thirty‐five children died during the follow‐up period; 20% of them from lower respiratory infection. Conclusions Respiratory infections are a major cause of morbidity and mortality among infants in rural Mozambique. Our study provides a better understanding of the associated determinants.     

Behçet's disease in Moroccan children: a report of 12 cases

We report 12 cases of Beh?et's disease (BD) in children. The mean age of symptom onset was 12.4 years. Four patients (33.3%) had a past familial history of BD. Clinical manifestations were: oral aphtosis (n = 12), genital aphtosis (n = 9), ocular involvement (n = 9), neuro-Beh?et (n = 6), venous thrombosis (n = 4), articular involvement (n = 3), and entero-Beh?et (n = 1). All patients but one were initially treated with steroids; three cases with ocular involvement were treated with chlorambucil; and three other cases of neuro-Beh?et were treated with cyclophosphamide. After a mean follow-up of 4 years, four patients with neurological involvement developed steroid-dependence with recurrence of symptoms. Four patients had optic atrophy with blindness.     

Community response to intermittent preventive treatment delivered to infants (IPTi) through the EPI system in Manhiça, Mozambique

OBJECTIVE: To describe attitudes to the expanded programme on immunization (EPI) and intermittent preventive treatment in infants (IPTi), and perceptions of the relationship between them. In particular, whether the introduction of IPTi negatively affects community attitudes to, or use of, EPI; or, conversely, whether and if so how, the concurrent delivery of IPTi and immunization influences perceptions of IPTi. METHODS: Anthropological study carried out in the context of a trial of IPTi with sulphadoxine-pyrimethamine delivered alongside routine EPI vaccinations. We used open in-depth interviews, semi-structured interviews and participant observation, conducted in both community and clinic settings. RESULTS: IPTi was generally acceptable, in spite of initial resistance. Perceived negative aspects of IPTi did not affect perceptions of EPI, and IPTi was not misinterpreted as immunization against malaria, leading to a reduction of other preventive measures or delay in treatment seeking. Initial resistance was related more to the trial than to IPTi per se, but both rejection and acceptance were embedded in a complex constellation of local and wider contextual factors. CONCLUSIONS: IPTi delivered together with EPI was generally accepted after initial rejection. The factors that led to this rejection were largely local and trial related, but they did resonate with much wider cultural themes (rumours about research and health interventions, gender inequality and health-related decision making). The prior acceptance and routine administration of EPI played a key role in the acceptance of IPTi in this community. However, more studies, in different social and cultural settings and using different drugs and regimens, are needed before generalizations can be made. Although trial settings are different from actual implementation, it is necessary to study acceptability before implementation in order to anticipate problems and design information campaigns to ensure maximum community acceptance.     

Epidemiologic and clinical aspects of Behçet's disease in a defined area of Northwestern Spain, 1988-1997

OBJECTIVE: To assess the frequency and clinical manifestations of Beh?et's disease (BD) during the past 10 years in a defined area of Northwestern Spain. METHODS: The charts of all the patients diagnosed as having BD at the Hospital Xeral-Calde from 1988 through 1997 were reviewed. All the patients were residents of Lugo. Patients were followed from the time of diagnosis until either the patient's death or July 1, 1998. By that time patients were classified as having complete BD if they fulfilled the International Study Group Criteria (ISG) for BD. Patients with recurrent oral ulcerations plus one of the remaining 4 criteria of the ISG were classified as having an incomplete form of BD. RESULTS: Sixteen patients (9 men/7 women) were diagnosed as having complete BD and 7 (3 men) as having incomplete BD. The average annual incidence rate of complete BD in the Lugo region of Northwestern Spain was 0.66/100,000. Oral ulcerations with or without genital ulcerations were the most common initial manifestations. Neurological involvement was relatively frequent in men with complete BD. In contrast, a positive pathergy test was less common. Two patients with neurological involvement and 3 with uveitis had severe sequelae. However, there was a single death, apparently not related to BD. CONCLUSION: In Northwestern Spain, BD is more common than was expected and is a nonfatal disease. However, central nervous system involvement and severe ocular complications overshadow the good prognosis observed in the majority of patients.     

Microsatellite instability screening should be done for right-sided colon cancer patients less than 60 years of age

Background and aims  

Microsatellite analysis is a screening tool used for the identification of Lynch syndrome. We evaluated the occurrence of high-frequency microsatellite instability (MSI-H) in 160 patients with colorectal cancer ≤60 years old to determine if these individuals should be routinely tested for microsatellite instability.     

The occurrence of occult malignancy in patients less than 50 years of age with venous thromboembolism: which diagnostic screening methods to use?

Trousseau was the first who describe an association of venous thromboembolism (VTE) with malignancy. The prevalence of occult cancer in patients with secondary VTE is comparable with the prevalence of cancer in general population (2-3%), while the prevalence of occult cancer in patients with idiopathic VTE is 4-10%. It has been demonstrated that the frequency of malignancy is higher in the first 6 to 12 months after diagnosis of VTE. 113 consecutive patients (50 males, 63 females) with first or recurrent VTE before the age 50, mean age (mean age 34.1 at time of VTE diagnosis) were followed retrospectively. Patients with known cancer were excluded for follow-up. The presence of known malignancy and concomitant cancer at the time of diagnosis of VTE and during follow-up (average 29 months) was investigated. The use of routine or extensive screening detection of occult cancer was also assessed. Extensive screening was performed in 61% of patients and compared with 39 % of routine screening. Overall of occult cancer was 1.8 %. The incidence of occult cancer was 1.2% during one year follow-up, and the prevalence at the time of diagnosis of VTE was 0.9%. The authors confirmed the low prevalence of occult cancer in cohort of consecutive young patients with VTE under the age of 50. It seems that only routine investigation with careful history taking, physical examination and simple laboratory tests are sufficient to detect of occult cancer in this age population. The authors recommend the follow-up of these patients, mainly those with idiopathic VTE. Inherited thrombophilia much more prevails in this young thrombophilia patients but risk of occult malignancy exists as well.     

Prevalence of asthma and allergic disorders in regional,rural, and indigenous children aged 6–8 years in Tasmania

Objective: Asthma and allergic diseases are poorly described in rural areas. The objective of this study was, therefore, to determine the prevalence of wheezing, asthma, and other allergic disorders among children living in regional and rural Tasmania. Methodology: Data from a cross-sectional survey using standardized questionnaires of asthma, allergic conditions and food allergies were collected from 39 primary schools across North West Tasmania. We enrolled 1075 children between 6 and 8?years. The main outcomes were prevalences of wheezing, asthma, and other allergic disorders further stratified by sex and indigenous status. Results: Baseline characteristics were as follows: median age 8.1?years (IQR: 7.6, 8.7) with equal sex distribution, most (80.1%) attended public schools and 11.0% identified as indigenous. We report prevalences of current wheezing (22.7%), allergic rhinoconjunctivitis (16.3%) and atopic eczema (16.6%), with higher prevalences among boys (except eczema). Food allergies were reported in 8.6% and food-related anaphylaxis in 1.6% of the sample. Indigenous children had significantly higher prevalence of current wheezing (indigenous 31.1% versus non-indigenous 21.6%; p?=?0.02). Further, children with current wheezing and no asthma diagnosis, had similar prevalence of other atopic diseases (hayfever 31.4%, eczema 44.0%, and food reaction 23.2%) compared with diagnosed asthmatics, although likely shared the illness. Conclusions: Childhood asthma is more prevalent in regional Tasmania compared with national estimates, especially among indigenous children. This appears not to be driven by an allergic response. Also, a significant proportion of children are likely to have undiagnosed asthma which has implications for rural health service delivery.     

High prevalence of Helicobacter heilmannii-associated gastritis in a small, predominantly rural area: further evidence in support of a zoonosis?

BACKGROUND: Primary hosts of Helicobacter heilmannii are domestic animals--cats, dogs and pigs, but rarely is it detected in gastric biopsies from humans. We found H. heilmannii in gastric biopsies obtained from patients living in a predominantly rural area. METHODS: We evaluated geographic and demographic data from the area and calculated both the total prevalence and the prevalence in each community in this area. Chi-squared test and exploratory data analysis were used for statistical evaluation. Histologic and clinical data were recorded. RESULTS: Forty-three communities, mostly rural, were identified in the area, the size of which is about 200 km2. H. heilmannii was detected in 33 patients (prevalence 2%) living in 20 communities. The prevalence of H. heilmannii statistically significantly varied in those communities from 0.06%-1.1%. It was possible to infer that there is a negative correlation between prevalence and community size. Chronic active gastritis was diagnosed in all patients. The active inflammation became inactive after eradication of H. heilmannii via common anti-Helicobacter therapy. CONCLUSION: A high prevalence of H. heilmannii-associated gastritis in a small, predominantly rural area and statistically significant differences in prevalence from one community to the next, i.e. highest in the smallest village and lowest in a small town with a rather urban lifestyle, were found. In our opinion, these prevalence rates may be a consequence of transmission of the infection from domestic animals, because animal-human contact is generally more common in villages than in towns.     

Clinical features of Kashin–Beck disease in adults younger than 50 years of age during a low incidence period: severe elbow and knee lesions

More than one million people are affected by Kashin–Beck disease (KBD) in a limited endemic area. However, few studies focused on the clinical features of adult KBD patients. The aim of this study was to investigate the clinical features of adult KBD patients who were younger than 50 years of age during a low incidence period. A special questionnaire was designed that surveyed general data, clinical symptoms, and signs and included the Visual Analogue Scale (VAS). Anthropometrics, the joint VAS, the range of joint motion (ROM), and joint function were measured. The VAS and joint dysfunction were compared among the different joints of extremities, and the relationship among the VAS, ROM, age, course of KBD, and number of enlarged knee and elbow joints elbow was analyzed. Two hundred forty-nine adult Tibetan KBD patients, matched with 249 healthy control subjects, have been surveyed. The VAS results show that the knee is the joint associated with the most pain, followed by the elbow. The elbow shows a higher percentage of limited ROM (47.0 %). The number of enlarged joints has a significant correlation with the VAS or elbow and knee ROM compared with the age or course of disease (P?<?0.05). Severe elbow and knee lesions are important clinical features of KBD in adults younger than 50 years of age during a low incidence period. The number of enlarged joints can partially predict the VAS or ROM of elbow and knee and may be used for evaluating the patient’s condition and function.     

Invasive ductal adenocarcinoma of the pancreas may originate from the larger pancreatic duct: a study of 13 tumors less than 2 cm in diameter

Background/Purpose

We aimed to elucidate the origin/primary site of invasive ductal adenocarcinoma of the pancreas, based on the distribution of intraductal carcinoma components. These components were identified by a mural elastic fiber cuff.

Methods

Thirteen specimens from patients with invasive ductal adenocarcinoma (microscopically, less than 2?cm in diameter) of the pancreas were studied histopathologically. Variants of invasive ductal adenocarcinoma and intraductal papillary-mucinous carcinoma were excluded.

Results

Intraductal carcinoma components of invasive ductal adenocarcinoma were found in 12 of the specimens 13 (92%), and were observed within the tumor mass and/or on its boundary, or outside the tumor mass. Intraductal components were characterized by low papillary projections lacking a fibrovascular core, with/without surrounding tubular structures, or by irregular stratification and pleomorphism of the epithelial cells. Invasive components mostly showed a tubular pattern with desmoplasia. The distribution of the intraductal components in the 12 specimens was as follows: in 9 (75%), they were in both the main pancreatic duct and large branch ducts; and in 3, they were in the smaller branch ducts only.

Conclusions

Invasive ductal adenocarcinomas of the pancreas may originate most frequently from the main pancreatic duct or larger branch ducts, while the smaller ducts are less often the site of cancer origin.

     

Clustering of noncommunicable disease risk factors among adults (18–69 years) in rural population,South-India

Background and aimsNon-communicable diseases (NCDs) and its risk factors are increasing worldwide and in India. Controlling the rise in risk factors at present is crucial to prevent NCD surge in future. Current study was conducted to estimate the burden of clustering of NCD risk factors among adult population (18–69 years) residing in selected villages of rural Bengaluru, KarnatakaMethodsPopulation based screening for NCD risk factors were carried out among adults in rural Bengaluru during May to October 2019. NCD risk factors were screened using WHO STEPwise approach to chronic disease risk factor surveillance (STEPs) instrument and Integrated Disease Surveillance Project (IDSP) NCD risk factor tool. Presence of three or more risk factors in same individual was considered as presence of clustering of NCD risk factors. Additional analysis was done for clustering of NCD risk factors with different number of risk factors.ResultsPrevalence of clustering of NCD risk factors in rural adult population was as follows; ≥2 risk factors 81.0%, ≥3 risk factors 56.3%, ≥4 risk factors 33.6%, ≥5 risk factors 14.5% and ≥6 risk factors 4.8%. The most common NCD risk factors were inadequate intake of fruits and vegetables (82.3%), physical inactivity (46.8%) and central obesity (46.4%). Clustering NCD risk factors were significantly associated with increased age, males and lower levels of education.ConclusionsHigh burden of clustering of risk factor indicates the need for health policies with integrated NCD risk factors prevention strategies than targeted approach. Awareness regarding the effect of clustering needs to be increased among the primary care physicians practising in rural areas.     

Contrasting the clinical care and outcomes of 2,622 children with type 1 diabetes less than 6 years of age in the United States T1D Exchange and German/Austrian DPV registries

Aims/hypothesis

The study aimed to compare participant characteristics, treatment modalities and clinical outcomes in registry participants less than 6 years old.

Methods

Participant characteristics, treatment modalities and clinical outcomes (HbA_1c, severe hypoglycaemia [SH] and diabetic ketoacidosis [DKA]) as well as frequencies of attaining HbA_1c goals in line with the International Society for Pediatric and Adolescent Diabetes (<7.5% [<58 mmol/mol]) and ADA (<8.5% [<69 mmol/mol]) were compared.

Results

Insulin pump use was more frequent (74% vs 50%, p?<?0.001) and HbA_1c levels lower in the Prospective Diabetes Follow-up Registry (DPV) than in the T1D Exchange (T1DX) (mean 7.4% vs 8.2%, p?<?0.001). A lower HbA_1c level was seen in the DPV compared with the T1DX for both pump users (p?<?0.001) and injection users (p?<?0.001). More children from DPV were meeting the recommended HbA_1c goals, compared with children from T1DX (HbA_1c <7.5%: 56% vs 22%, p?<?0.001; HbA_1c <8.5%: 90% vs 66%, p?<?0.001). The adjusted odds of having an HbA_1c level <7.5% or <8.5% were 4.2 (p?<?0.001) and 3.6 (p?<?0.001) higher for the DPV than the T1DX, respectively. The frequency of SH did not differ between registries or by HbA_1c, whereas the frequency of DKA was higher for the T1DX and greater in those with higher HbA_1c levels.

Conclusions/interpretation

DPV data indicate that an HbA_1c of <7.5% can frequently be achieved in children with type 1 diabetes who are under 6 years old. An improved metabolic control of type 1 diabetes in young patients appears to decrease the risk of DKA without increasing SH. The greater frequency of suboptimal control in young patients in the T1DX compared with the DPV is not fully explained by a less frequent use of insulin pumps and may relate to the higher HbA_1c targets that are recommended for this age group in the USA.     

Longitudinal development of cognitive,visuomotor and adaptive behavior skills in HIV uninfected children,aged 3–5 years of age,exposed pre- and perinatally to anti-retroviral medications

Little is known about the neurodevelopmental outcomes of children older than 3 years of age born to HIV infected mother but who are HIV-uninfected (HEU), and who have been exposed in utero and early in life to HIV and to antiretroviral medications (ARVs). We conducted a longitudinal study of cognitive, visuomotor and adaptive function of HEU children, who were assessed at two ages, 3.5 and 5.5 years. Sixty-four children (33 female) were assessed. In comparison with population norms for their age, at 3.5 years of age they had scores significantly below age expectations on aspects of adaptive behavior, but at age 5.5 years, their scores did not significantly diverge from the population norms on any of the measures. Verbal intelligence was lower at age 5.5 than at age 3.5 years, although there were also improvements in some features of adaptive behavior. Exposure to PI-based ARVs (compared to NNRTIs) was associated with higher Performance IQ, visuomotor and communication scores at age 5.5 years. Birth, early growth, and sociodemographic variables were predictive of outcomes. This study is important in tracking the trajectory of neurocognitive development across the pre-school and early school age years. The findings suggest that the full impact of early ARV exposure may not be evident until a considerable period of development has occurred. The results raise the possibility of negative effects of early ARV exposure on neurodevelopment that emerge over time, and reiterate the importance of sociodemographic and early health variables for optimal development.