Acute bacterial meningitis in children admitted to the Queen Elizabeth Central Hospital Blantyre, Malawi in 1996-97.

In order to design appropriate interventioos, we collected clinical and demographic data prospectively on all children aged one day to 14 years admitted with a diagnosis of bacterial meningitis (BM) from April 1st 1996 to March 31st 1997 to the Queen Elizabeth Central Hospital (QECH), Blantyre Malawi. During the study period 267 children (2.7% of all paediatric admissions) were found to have BM; 83% were under 5 years of age, 61 % under one year and 23% under one month. The most common causative organisms in the post neonatal period (n = 206) were Streptococcus pneumoniae (27%), Haemophilus influenzae type b (Hib) 21 %, and Salmonella typhimurium (6%). In the neonatal group «I month, n = 61) the most common causes were Streptococcus agalactiae (23%), S. typhimurium (15%), S. pneumoniae (11. 5%) and other gram negative rods (11.5%). Nineteen of 21 salmonella infections were in children under one year of age and all S. agalactiae were in infants under three months. There was delay on presentation: the average length of fever was 4.6 days, 39.5% had convulsed prior to arrival and 57% had an altered level of consciousness. An initial diagnosis of malaria had probably contributed to the delay in 22.5% , (42 of 186 tested). Forty eight percent were < 80% weight for age, with 18% < 60 % weight for age. The overall mortality was 40%. The outcome was worst in salmonella infections, particularly neonatal salmonella BM with a case fatality rate (CFR) of 89% (8 of 9 cases). Coma on presentation worsened prognosis (mortality 64% if Blantyre Coma Score <3, 26% if > 3). Fifteen percent of survivors had sequelae on discharge. Twenty percent of Hib isolates were resistant to chloramphenicol, but all salmonellae were sensitive. Five percent of S. pneumoniae were resistant to penicillin and 8% to chloramphenicol. Earlier access to adequate health care and awareness of BM in a malaria endemic area would reduce mortality and morbidity. Vaccination against Hib infection would have reduced death by 18 (17%) and prevented sequelae in 7

Effect of transmission setting and mixed species infections on clinical measures of malaria in Malawi

<p>Background: In malaria endemic regions people are commonly infected with multiple species of malaria parasites but the clinical impact of these Plasmodium co-infections is unclear. Differences in transmission seasonality and transmission intensity between endemic regions have been suggested as important factors in determining the effect of multiple species co-infections.</p> <p>Principal Findings: In order to investigate the impact of multiple-species infections on clinical measures of malaria we carried out a cross-sectional community survey in Malawi, in 2002. We collected clinical and parasitological data from 2918 participants aged >6 months, and applied a questionnaire to measure malaria morbidity. We examined the effect of transmission seasonality and intensity on fever, history of fever, haemoglobin concentration ([Hb]) and parasite density, by comparing three regions: perennial transmission (PT), high intensity seasonal transmission (HIST) and low intensity seasonal transmission (LIST). These regions were defined using multi-level modelling of PCR prevalence data and spatial and geo-climatic measures. The three Plasmodium species (P. falciparum, P. malariae and P. ovale) were randomly distributed amongst all children but not adults in the LIST and PT regions. Mean parasite density in children was lower in the HIST compared with the other two regions. Mixed species infections had lower mean parasite density compared with single species infections in the PT region. Fever rates were similar between transmission regions and were unaffected by mixed species infections. A history of fever was associated with single species infections but only in the HIST region. Reduced mean [Hb] and increased anaemia was associated with perennial transmission compared to seasonal transmission. Children with mixed species infections had higher [Hb] in the HIST region.</p> <p>Conclusions: Our study suggests that the interaction of Plasmodium co-infecting species can have protective effects against some clinical outcomes of malaria but that this is dependent on the seasonality and intensity of malaria transmission.</p&gt

Public policy and financial stability: the impact of PCA and TARP on U.S. bank non-performing loans

This study explores the implications of Prompt Corrective Action (PCA) and the Troubled Asset Relief Program (TARP) on the behavior of non-performing loans (NPLs) and real estate non-performing loans (RELs) in the U.S. over 1984-2015 using a Markov switching framework. We find that NPLs and RELs exhibit pronounced episodic behavior switching between non-stationary and stationary regimes. PCA and TARP have a significant impact on banking sector stability by influencing the probability of switching from non-stationary regimes to stationary regimes and by reducing the level of NPLs and RELs. These results are robust to various model specifications and have important implications for bank regulation as well as for the formulation of macro stress-testing

Case Report - A 6 year-old boy was referred from a district hospital with congestive cardiac failure

No Abstract

Findings of the International Subarachnoid Aneurysm Trial and the National Study of Subarachnoid Haemorrhage in context.

Concern has been expressed about the applicability of the findings of the International Subarachnoid Aneurysm Trial (ISAT) with respect to the relative effects on outcome of coiling and clipping. It has been suggested that the findings of the National Study of Subarachnoid Haemorrhage may have greater relevance for neurosurgical practice. The objective of this paper was to interpret the findings of these two studies in the context of differences in their study populations, design, execution and analysis. Because of differences in design and analysis, the findings of the two studies are not directly comparable. The ISAT analysed all randomized patients by intention-to-treat, including some who did not undergo a repair, and obtained the primary outcome for 99% of participants. The National Study only analysed participants who underwent clipping or coiling, according to the method of repair, and obtained the primary outcome for 91% of participants. Time to repair was also considered differently in the two studies. The comparison between coiling and clipping was susceptible to confounding in the National Study, but not in the ISAT. The two study populations differed to some extent, but inspection of these differences does not support the view that coiling was applied inappropriately in the National Study. Therefore, there are many reasons why the two studies estimated different sizes of effect. The possibility that there were real, systematic differences in practice between the ISAT and the National Study cannot be ruled out, but such explanations must be seen in the context of other explanations relating to chance, differences in design or analysis, or confounding

The Implementation and Effects of Direct Facility Funding in Kenya’s Health Centres and Dispensaries

Direct facility funding (DFF) is an initiative that was developed in response to concern that Ministry of Health funds allocated to districts rarely filter down to the health centres and dispensaries, and that these facilities have also lost revenue due to the reduction in official user fees in 2004. Piloted in Coast Province from late 2005, DFF involved facilities receiving funds for recurrent expenditure directly into their bank accounts. This report presents an evaluation of the implementation and effects of DFF in health centres and dispensaries. The findings in this report are based on data collected between October 2007 and March 2008, about 2 to 3 years after DFF implementation. A structured survey that included an interview with facility in-charges, records review, and outpatient exit interviews was conducted at a random sample of 15 facilities in each of the two purposively selected districts (Kwale and Tana River). In addition, focus group discussions with health facility committee (HFC) members and key informant interviews with in-charges and DHMTs were conducted in a subset of 6 facilities in each district

Ward Round – A patient with multi-organ failure

No Abstract

Pharmacokinetics of Antituberculosis Drugs in HIV-Positive and HIV-Negative Adults in Malawi

Limited data address the impact of HIV co-infection on the pharmacokinetics of anti-tuberculosis drugs in Sub-Saharan Africa. 47 Malawian adults underwent rich pharmacokinetic sampling at 0-0.5-1-2-3-4-6-8 and 24 hours post-dose. 51% were male; mean age was 34 years. 65% were HIV-positive with a mean CD4 count of 268 cells/μL. Anti-tuberculosis drugs were administered as fixed-dose combinations (rifampicin150mg/isoniazid75mg/pyrazinamide400mg/ethambutol275mg) according to recommended weight bands. Plasma drug concentrations were determined by high-performance liquid chromatography (rifampicin and pyrazinamide) or liquid chromatography-mass spectrometry (isoniazid and ethambutol). Data were analysed by non-compartmental methods and analysis of variance of log-transformed summary parameters. Pharmacokinetic parameters were: rifampicin Cmax 4.129 (2.474-5.596)μg/mL, AUC0-24 21.32 (13.57-28.60)μg/mL*h, half-life 2.45 (1.86-3.08)h; isoniazid Cmax 3.97 (2.979-4.544)μg/mL, AUC0-24 22.5 (14.75-34.59)μg/mL*h, half-life 3.93 (3.18-4.73)h.; pyrazinamide Cmax 34.21 (30.00-41.60)μg/mL, AUC0-24 386.6 (320.0-463.7)μg/mL*h, half-life 6.821 (5.71-8.042)h; ethambutol Cmax 2.278 (1.694-3.098)μg/mL, AUC0-24 20.41 (16.18-26.27)μg/mL*h, half-life 7.507 (6.517-8.696)h. Isoniazid PK data analysis suggested that around two-thirds were slow acetylators. Dose, weight and weight-adjusted dose were not significant predictors of PK exposure probably due to weight-banded dosing. In this first pharmacokinetic study of tuberculosis drugs in Malawian adults, measures of pharmacokinetic exposure were comparable with other studies for all first line drugs except for rifampicin, for which Cmax and AUC0-24 were notably lower. Contrary to some earlier observations, HIV status did not significantly affect AUC of any of the drugs. Increasing the dose of rifampicin could be beneficial in African adults, irrespective of HIV status. Current co-trimoxazole prophylaxis was associated with an increase in half-life of isoniazid of 41% (p=0.022). Possible competitive interactions between isoniazid and sulphamethoxazole mediated by the N-acetyltransferase pathway should therefore be explored further

Late Ordovician to early Silurian acritarchs from the Qusaiba-1 shallow core hole, central Saudi Arabia

Well-preserved acritarchs are documented from Upper Ordovician and lower Silurian sections in the Qusaiba-1 shallow core hole of central Saudi Arabia. Sixty-nine genera comprising 68 named species and 62 forms under open nomenclature were recorded from forty core samples. At the base of the Upper Ordovician and lower Silurian succession in Qusaiba-1 is the Quwarah Member of the Qasim Formation. This is overlain by glacio-marine deposits of the Sarah Formation, which are overlain in turn by the Qusaiba Member of the Qalibah Formation. Four distinct acritarch assemblages are informally numbered 1 to 4 from the base of the core upwards. Assemblage 1 is from the Quwarah Member, and is independently dated by Chitinozoa as being late Katian to early Hirnantian in age (Late Ordovician). The assemblage contains a number of new species, plus species reported from low-latitude Late Ordovician Laurentia and Baltica as well as the Gondwanan margin. Assemblage 2 is from a glacitectonite at the base of the Sarah Formation and is early Hirnantian in age. Assemblage 3, from the Baq'a Shale Member of the Sarah Formation, is also Hirnantian in age and is characterized by a stratigraphically admixed Ordovician palynoflora. Assemblage 4 is restricted to three samples from the Qusaiba Member in the lowermost part of the Qalibah Formation and is dated as Rhuddanian (earliest Silurian). The highest of the three samples that comprise Assemblage 4 is from the same level as a gamma ray peak at 254.8 ft. Reworking of Middle Ordovician forms is evident in Assemblage 3 and is attributed to processes of glacial erosion and resedimentation during glacial melting. Reworked specimens are probably from the Hanadir Member and possibly also the Kahfah Member of the Qasim Formation. The extent of later Ordovician reworking in Assemblage 3, for example reworking from the Quwarah Member, is unclear. However, given that glacial erosion extended to levels below the Quwarah Member, Late Ordovician palynomorphs present in Assemblage 3 might also be reworked. The extent of any reworking in assemblages 1 and 2 is uncertain. There is no evidence for reworking in Assemblage 4. Two new acritarch genera, five new species and one new combination are proposed: Dorsennidium polorum (Miller and Eames, 1982) comb. nov., Falavia magniretifera gen. et sp. nov., Inflatarium trilobatum gen. et sp. nov., Nexosarium mansouri sp. nov., Orthosphaeridium orthogonium sp. nov. and Tunisphaeridium bicaudatum sp. nov. Samples from the same set were used for chitinozoan, scolecodont and miospore studies (this volume). Eurypterid and graptolite remains are also presen