The development of a screening tool to evaluate infants who are HIV positive

HIV/AIDS continues to be one of the greatest health challenges which South Africa faces. The epidemic in children is closely linked to that in women, the prevalence of which continues to grow according to antenatal statistics from the South African Department of Health (DOH). HIV is known to invade the central nervous system at the time of infection, and causes widespead damage. In children, this leads to a well-researched condition known as HIV encephalopathy, which affects all areas of neurodevelopment. The effects of timely initiation of antiretroviral therapy on alleviating the impact of encephalopathy have been well described. Neurodevelopmental delay is a stage four disease indicator according to the World Health Organisation (WHO), and therefore is a criterion for initiation of Highly Active Antiretroviral Therapy (HAART). HAART is often only administered according to the virologic and immunologic status of a child, as standardised neurodevelopmental assessment tools are not widely available in South African clinics. When HAART initiation is dependent on immunologic status, it is often too late to prevent encephalopathy. To date, the only means of prevention of this condition is early initiation of HAART, which has not been widely available in South Africa. Stringent guidelines for the commencement of this therapy according to the WHO, and the South African Department of Health (DOH) have had to be followed, leading to late initiation of HAART, and widespread central nervous system encephalopathy. Studies which have been carried out in South African clinics have demonstrated the high prevalence of this condition. Once there is evidence of encephalopathy, children should be referred for assessments in all facets of development, and where necessary, for rehabilitation. A standardised developmental screening tool which is suitable for use in a developing country is therefore necessary in order to screen for neurodevelopmental delays to allow for further assessment and referral to rehabilitation services, as well as providing an additional assessment criterion for initiation of HAART. Paediatric HIV clinics in developing countries are understaffed, and children may be seen by junior staff or screened by nurses due to the high numbers of clinic attendees. This often results in neurodevelopment being inadequately assessed and children are therefore not referred for intervention services. A standardised screening tool, could be administered by clinic staff in order to ensure correct and timely referral of children for further assessment and intervention is therefore necessary. This is of importance both locally and internationally where a screening tool, which has been developed specifically for this purpose, does not exist. The aim of this study was therefore to evaluate the agreement between the Bayley-III Screening Test and the Bayley Scales of Infant Development (3rd version) in a population of HIV positive infants in order to evaluate its appropriateness for use in South Africa. The Bayley Scales of Infant Development have long been considered the ‘gold standard’ in infant developmental assessment, which is why this tool was chosen to evaluate the Bayley-III Screening Test against. The developmental scores in each facet (cognitive, motor or language) were evaluated to determine which should be included in an assessment tool for this population. Further objectives for the study were to adapt the screening tool to the needs of the population, or to develop a new screening tool shouldthe Bayley-III Screening Test not prove suitable for use in this population. In order to meet the aims and objectives, a cross-sectional study was conducted where 112 HIV positive infants between the ages of six and eighteen months were assessed using the Bayley-III Screening Test and the Bayley Scales of Infant Development (3rd version) (BSID III). The infants were stratified into four age groups namely 6-8 months, 9-12 months, 13-16 months, and 17-18 months. Children were recruited from Harriet Shezi Children’s Clinic at Chris Hani Baragwanath Hospital in Soweto. The agreement between the Bayley-III Screening Test and the Bayley Scales of Infant Development (3rd version) was analysed using Kappa, for the overall group, and for each age group. Overall agreement between the tools was as follows: K=0.58 for the Cognitive facet, K=0.82 for the Expressive Communication facet, K=0.76 for the Receptive Communication facet, K=0.44 for the Fine Motor facet and K=0.57 for the Gross Motor facet. These values indicate that the Bayley-III Screening Test is therefore not acceptable for clinical use, as excellent agreement (k≥0.75) in all facets would be necessary for this purpose. A new screening tool therefore had to be developed. The infant’s developmental scores from the BSID III were analysed to determine which facets of development were most severely affected, and therefore which facets should be included in a new screening tool. Gross motor function was demonstrated to be the area which was most severely affected, followed by cognitive function. A gross motor screening tool would therefore be suitable for use in this population, as no equipment would be necessary. Gross motor development is the most universally similar aspect of development, which is not completely dependent on cultural or socioeconomic factors which often have an influence on language and cognitive development. Item selection from the BSID III was undertaken to determine which items should be included in a brief screening tool. In each of the four age groups, item selection occurred as follows: Two items which discriminated the At-Risk, from Emerging and Competent groups (less than 20% in the At-Risk group, and 100% in the other groups) were selected. Two items, which discriminated between children in the ‘Emerging’ and ‘Competent’ categories on the BSID III were selected (0-5% of children who were At-Risk obtained credit, 30-50% of the Emerging group obtained credit, and 100% of the Competent group obtained credit). Lastly, two items were selected which discriminated the Competent group from the other two groups (100% or as high as possible in the Competent group, and 0% in the other groups). The new gross motor screening tool was assembled using the selected items, scoring was allocated, and it was tested against the scores obtained on the Gross Motor facet of the BSID III for the initial 112 infants. Agreement between the tools was analysed using Kappa, and refinements were made according to the discrepancies. This was done three times, until the Kappa value revealed excellent agreement between the tools (k = 0.87). A panel of experts was then invited to examine the new gross motor screening tool, and to comment on it, and further adjustments were made accordingly. Preliminary concurrent validity testing of the new gross motor screening tool was then carried out against the Gross Motor facet of the BSID III on 60 children, who were recruited from the Harriet Shezi Children’s Clinic at Chris Hani Baragwanath Hospital in Soweto. Statistical analysis revealed that the agreement between the BSID III and the new screening tool was excellent (k=0.85). The diagnostic properties of the new gross motor screening tool were as follows: sensitivity 97.4%, specificity 85.7%, positive predictive value 92.7%, and negative predictive value 94.7%. These values indicate that the statistical properties of the tool are excellent, and the tool will not be predisposed to underreferrals or over-referrals. Preliminary reliability testing was carried out on 15 children for test-retest/intrarater reliability and 15 children for interrater reliability. Interrater, test-retest and intrarater reliability were excellent (r=1, r=0.98, r=0.98 respectively). Further testing of reliablity and validity should be undertaken in order to establish these properties, and standardisation should also be carried out on healthy children. Given the need for an assessment tool of this nature in South Africa and other developing countries, and the statistical properties thus far, the tool may be used clinically for the purposes for which it was developed

The extent of delay of language, motor and cognitive development in HIV posititive infants

In South Africa, a total number of 5.7 – 6.2 million individuals had acquired HIV infection by 2004 (Department of Health, 2004). It is estimated that 3.3 million females, 2.8 million males, and 104 963 babies had been infected with HIV in South Africa by 2004 (Department of Health, 2004). It has been found that HIV-positive children have significantly greater neurological dysfunction in eight domains (activity, language, cranial nerve, fine motor, gross motor, cerebellar, sensory and primitive reflexes) than their HIV negative counterparts (Belman et al, 1996). There has been very little research conducted in Africa regarding the extent of delay of language, motor, and cognitive development in HIV positive infants. The main aim of this study is to determine the extent of delay in acquisition of language, cognitive and motor skills of HIV positive children. The Bayley Scales of Infant Development II (BSID II) were used to determine performance in each section of the child’s age group. These results were transferred to the facet scoring section, which analyse in greater detail, with respect to cognitive, language and motor development. Baseline BSID II assessments of HIV infected children currently enrolled in a longitudinal study of neurodevelopmental delay were analysed to determine which facets of development are most delayed. The Mental and Psychomotor Developmental Indices (MDI and PDI) of the BSID II were used to determine the extent of mental and motor delays in this sample. Mean cognitive development was 7.63 months delayed, which was statistically significant (p<0.01) and 97.5% of the sample were functioning below the expected cognitive age. Mean motor development was 9.65 months delayed (p<0.01), and 97.5% of the sample were functioning below expected motor age. Gross motor skills were more affected than fine motor skills, and 85% of the sample demonstrated gross motor delays on descriptive analysis. Language was descriptively analysed, revealing language delays in 82.5% of the sample. The infants in this study demonstrated significant mental and motor delays, as well as delays in language. It is postulated that motor delays may be attributed to decreased strength, as the most adversely affected skill in this sample was gross motor development. The cognitive delays noted may be due to disease progression and structural damage to the brain, as well as socio-economic factors. The language delays noted could be due to neurological impairment, cognitive delay or environmental deprivation. Children with HIV have significant delays in mental and motor development, and language is delayed in most children with HIV. The results of this study are similar to findings in other parts of the world, which indicates a global trend in HIV and neurodevelopmental delay. The results of this study are important, particularly for those involved in motor and language rehabilitation, as an awareness of potential problems in these infants is needed in order to provide them with the best management and care possible

Treatment of type 2B and 2C hip dysplasia: monitoring vs Pavlik harness treatment

This was an address given at a South East teaching day for Allied Health Professionals across the South East

Paediatric HIV - Looking beyond CD4 counts

Paediatric HIV remains a significant health and social challenge in sub-Saharan Africa despite many countries gaining improved access to antiretroviral treatment. Paediatric HIV affects multiple body systems and has the potential to cause wide ranging impairments as well as activity and participation limitations. The aim of this paper is to highlight some of the impairments that remain, despite the children having access to better medical care, in order to establish a possible role for physiotherapists. Nine studies conducted through the department of physiotherapy at the University of the Witwatersrand, South Africa are presented. The results of these studies demonstrate the neurodevelopmental, musculoskeletal, respiratory and quality of life challenges which children infected with HIV as well as their caregivers continue to face. The need for long term, multidisciplinary follow up of children infected with HIV is emphasized

Developmental outcome of very low birth weight infants in a developing country

Background: Advances in neonatal care allow survival of extremely premature infants, who are at risk of handicap. Neurodevelopmental follow up of these infants is an essential part of ongoing evaluation of neonatal care. The neonatal care in resource limited developing countries is very different to that in first world settings. Follow up data from developing countries is essential; it is not appropriate to extrapolate data from units in developed countries. This study provides follow up data on a population of very low birth weight (VLBW) infants in Johannesburg, South Africa. Methods: The study sample included all VLBW infants born between 01/06/2006 and 28/02/2007 and discharged from the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Bayley Scales of Infant and Toddler Development Version 111 (BSID) 111 were done to assess development. Regression analysis was done to determine factors associated with poor outcome. Results: 178 infants were discharged, 26 were not available for follow up, 9 of the remaining 152 (5.9%) died before an assessment was done; 106 of the remaining 143 (74.1%) had a BSID 111 assessment. These 106 patients form the study sample; mean birth weight and mean gestational age was 1182 grams (SD: 197.78) and 30.81 weeks (SD: 2.67) respectively. The BSID (111) was done at a median age of 16.48 months. The mean cognitive subscale was 88.6 (95% CI: 85.69-91.59), 9 (8.5%) were < 70, mean language subscale was 87.71 (95% CI: 84.85-90.56), 10 (9.4%) < 70, and mean motor subscale was 90.05 (95% CI: 87.0-93.11), 8 (7.6%) < 70. Approximately one third of infants were identified as being at risk (score between 70 and 85) on each subscale. Cerebral palsy was diagnosed in 4 (3.7%) of babies. Factors associated with poor outcome included cystic periventricular leukomalacia (PVL), resuscitation at birth, maternal parity, prolonged hospitalisation and duration of supplemental oxygen. PVL was associated with poor outcome on all three subscales. Birth weight and gestational age were not predictive of neurodevelopmental outcome. Conclusion: Although the neurodevelopmental outcome of this group of VLBW infants was within the normal range, with a low incidence of cerebral palsy, these results may reflect the low survival of babies with a birth weight below 900 grams. In addition, mean subscale scores were low and one third of the babies were identified as "at risk", indicating that this group of babies warrants long-term follow up into school going age

Transduction of the Geomagnetic Field as Evidenced from Alpha-band Activity in the Human Brain

Magnetoreception, the perception of the geomagnetic field, is a sensory modality well-established across all major groups of vertebrates and some invertebrates, but its presence in humans has been tested rarely, yielding inconclusive results. We report here a strong, specific human brain response to ecologically-relevant rotations of Earth-strength magnetic fields. Following geomagnetic stimulation, a drop in amplitude of EEG alpha oscillations (8-13 Hz) occurred in a repeatable manner. Termed alpha event-related desynchronization (alpha-ERD), such a response has been associated previously with sensory and cognitive processing of external stimuli including vision, auditory and somatosensory cues. Alpha-ERD in response to the geomagnetic field was triggered only by horizontal rotations when the static vertical magnetic field was directed downwards, as it is in the Northern Hemisphere; no brain responses were elicited by the same horizontal rotations when the static vertical component was directed upwards. This implicates a biological response tuned to the ecology of the local human population, rather than a generic physical effect. Biophysical tests showed that the neural response was sensitive to static components of the magnetic field. This rules out all forms of electrical induction (including artifacts from the electrodes) which are determined solely on dynamic components of the field. The neural response was also sensitive to the polarity of the magnetic field. This rules out free-radical 'quantum compass' mechanisms like the cryptochrome hypothesis, which can detect only axial alignment. Ferromagnetism remains a viable biophysical mechanism for sensory transduction and provides a basis to start the behavioral exploration of human magnetoreception

The state of the Martian climate

60°N was +2.0°C, relative to the 1981–2010 average value (Fig. 5.1). This marks a new high for the record. The average annual surface air temperature (SAT) anomaly for 2016 for land stations north of starting in 1900, and is a significant increase over the previous highest value of +1.2°C, which was observed in 2007, 2011, and 2015. Average global annual temperatures also showed record values in 2015 and 2016. Currently, the Arctic is warming at more than twice the rate of lower latitudes

Perceived stressors of climate vulnerability across scales in the Savannah zone of Ghana: a participatory approach

Smallholder farmers in sub-Saharan Africa are confronted with climatic and non-climatic stressors. Research attention has focused on climatic stressors, such as rainfall variability, with few empirical studies exploring non-climatic stressors and how these interact with climatic stressors at multiple scales to affect food security and livelihoods. This focus on climatic factors restricts understanding of the combinations of stressors that exacerbate the vulnerability of farming households and hampers the development of holistic climate change adaptation policies. This study addresses this particular research gap by adopting a multi-scale approach to understand how climatic and non-climatic stressors vary, and interact, across three spatial scales (household, community and district levels) to influence livelihood vulnerability of smallholder farming households in the Savannah zone of northern Ghana. This study across three case study villages utilises a series of participatory tools including semi-structured interviews, key informant interviews and focus group discussions. The incidence, importance, severity and overall risk indices for stressors are calculated at the household, community, and district levels. Results show that climatic and non-climatic stressors were perceived differently; yet, there were a number of common stressors including lack of money, high cost of farm inputs, erratic rainfall, cattle destruction of crops, limited access to markets and lack of agricultural equipment that crossed all scales. Results indicate that the gender of respondents influenced the perception and severity assessment of stressors on rural livelihoods at the community level. Findings suggest a mismatch between local and district level priorities that have implications for policy and development of agricultural and related livelihoods in rural communities. Ghana’s climate change adaptation policies need to take a more holistic approach that integrates both climatic and non-climatic factors to ensure policy coherence between national climate adaptation plans and District development plans

State of the climate in 2013

In 2013, the vast majority of the monitored climate variables reported here maintained trends established in recent decades. ENSO was in a neutral state during the entire year, remaining mostly on the cool side of neutral with modest impacts on regional weather patterns around the world. This follows several years dominated by the effects of either La Niña or El Niño events. According to several independent analyses, 2013 was again among the 10 warmest years on record at the global scale, both at the Earths surface and through the troposphere. Some regions in the Southern Hemisphere had record or near-record high temperatures for the year. Australia observed its hottest year on record, while Argentina and New Zealand reported their second and third hottest years, respectively. In Antarctica, Amundsen-Scott South Pole Station reported its highest annual temperature since records began in 1957. At the opposite pole, the Arctic observed its seventh warmest year since records began in the early 20th century. At 20-m depth, record high temperatures were measured at some permafrost stations on the North Slope of Alaska and in the Brooks Range. In the Northern Hemisphere extratropics, anomalous meridional atmospheric circulation occurred throughout much of the year, leading to marked regional extremes of both temperature and precipitation. Cold temperature anomalies during winter across Eurasia were followed by warm spring temperature anomalies, which were linked to a new record low Eurasian snow cover extent in May. Minimum sea ice extent in the Arctic was the sixth lowest since satellite observations began in 1979. Including 2013, all seven lowest extents on record have occurred in the past seven years. Antarctica, on the other hand, had above-average sea ice extent throughout 2013, with 116 days of new daily high extent records, including a new daily maximum sea ice area of 19.57 million km2 reached on 1 October. ENSO-neutral conditions in the eastern central Pacific Ocean and a negative Pacific decadal oscillation pattern in the North Pacific had the largest impacts on the global sea surface temperature in 2013. The North Pacific reached a historic high temperature in 2013 and on balance the globally-averaged sea surface temperature was among the 10 highest on record. Overall, the salt content in nearsurface ocean waters increased while in intermediate waters it decreased. Global mean sea level continued to rise during 2013, on pace with a trend of 3.2 mm yr-1 over the past two decades. A portion of this trend (0.5 mm yr-1) has been attributed to natural variability associated with the Pacific decadal oscillation as well as to ongoing contributions from the melting of glaciers and ice sheets and ocean warming. Global tropical cyclone frequency during 2013 was slightly above average with a total of 94 storms, although the North Atlantic Basin had its quietest hurricane season since 1994. In the Western North Pacific Basin, Super Typhoon Haiyan, the deadliest tropical cyclone of 2013, had 1-minute sustained winds estimated to be 170 kt (87.5 m s-1) on 7 November, the highest wind speed ever assigned to a tropical cyclone. High storm surge was also associated with Haiyan as it made landfall over the central Philippines, an area where sea level is currently at historic highs, increasing by 200 mm since 1970. In the atmosphere, carbon dioxide, methane, and nitrous oxide all continued to increase in 2013. As in previous years, each of these major greenhouse gases once again reached historic high concentrations. In the Arctic, carbon dioxide and methane increased at the same rate as the global increase. These increases are likely due to export from lower latitudes rather than a consequence of increases in Arctic sources, such as thawing permafrost. At Mauna Loa, Hawaii, for the first time since measurements began in 1958, the daily average mixing ratio of carbon dioxide exceeded 400 ppm on 9 May. The state of these variables, along with dozens of others, and the 2013 climate conditions of regions around the world are discussed in further detail in this 24th edition of the State of the Climate series. © 2014, American Meteorological Society. All rights reserved