Characteristics of HIV-infected children seen in Western Kenya

Objectives: To describe the characteristics and outcomes of children registered for care in a large HIV care programme in Western Kenya. Design: A retrospective descriptive study. Setting: USAID-AMPATH HIV clinics in health centres; district and sub-district hospitals; Moi Teaching and Referral Hospital in Western Kenya. Subjects: HIV-infected children below age of 15 years seen in a network of 18 clinics in Western Kenya. Interventions: Paediatric HIV diagnosis and care including treatment and prevention of opportunistic infections and provision of combination antiretroviral therapy (CART). Main outcome measures: Diagnosis, clinical stage and immune status at enrollment and follow-up; hospitalisation and death. Descriptive statistical analyses and chi square tests were performed. Results: Four thousand and seventeen HIV-infected children seen between June 2002 and April 2008. Median age at enrollment was four years (0-14.2 years), 51% girls, 25% paternal orphans, 10% total orphans and 13% maternal orphans. At enrollment, 25% had weight-for-Age Z scores (WAZ)\u3e -1 and 21% had WAZ scores \u3c 3. Orphaned children had worse WAZ scores (p=0.0001). Twenty five per cent of children were classified as WHO clinical stage 3 and 4, 56% were WHO clinical stages 1 and 2 with 19% missing clinical staging at enrollment. Cough (25%), gastroenteritis (21%), fever (15%), pneumonia (10%) were the commonest presenting features. Twenty six per cent had been diagnosed with tuberculosis and only 25% started on cotrimoxazole preventive therapy (CPT). Median CD4% at enrollment was 16% (0-64%); latest recorded values were 22% (0-64). Sixty four per cent were on cART (cART+), median age at start was 5.4 (014.4 years).The median initial CD4% among cART+ was 13 (0-62) compared to 24 (0-64) for those not on ART (cART-). Median CD4% for cART+ improved to 22% (0-59); whereas cART- was 23% (0- 64) at last appointment. During the period of follow-up, one fifth (19%) of children on cART were lost to follow-up compared to slightly over one third (37%) for those not on cART. Thirty four percent were hospitalised; 41% diagnosed with pneumonia. Six per cent of 4017 were confirmed dead. Conclusions: HIV -infected children were enrolled in care early in childhood. Orphanhood was prevalent in these children as were gastroenteritis, fever, pneumonia and advanced immuno-suppression. Orphans were more likely to be severely malnourished. Only a quarter of children were put on cotrimoxazole preventive therapy. Children commenced on cART late but responded well to treatment. Loss to follow-up was less prevalent among those on cART

Morbidity and mortality in HIV - infected children admitted at Moi Teaching and Referral Hospital in Western Kenya

Background: HIV-infected children are at higher risk of opportunistic infections that could result in hospitalisation. The outcomes of hospitalisation are variable and depend on the admission diagnosis, the patients’ immune status and whether or not the patient is on anti-retroviral drugs.Objective: To describe the characteristics and causes of hospitalisation and mortality for HIV infected children admitted to Moi Teaching and Referral hospital in western Kenya.Design: a retrospective study of prospectively collected data.Setting: The paediatric wards of Moi Teaching and Referral Hospital (MTRH). A Kenyan National Referral Hospital.Subjects: HIV-infected children admitted the paediatric wards.Interventions: Treatment with combination anti-retroviral therapy (cART), treatment of common opportunistic infections.Main outcome measures: Demographic and clinical data, including diagnosis, immune status, and treatment with combination anti-retroviral therapy (cART), were extracted from hospital admission records of HIV-infected children registered with the USAIDAcademic Model Providing Access to Healthcare (AMPATH) partnership. We conducted descriptive statistical analyses and used chi-square and fisher’s exact tests to assess for associations between categorical variables and each of the independent variables.Results: Between December 2006 and May 2009, 396 HIV-infected children were admitted to MTRH. Median age at admission was 2.0 years (range 0-15); 236 (59%) were male; 36 (15%) of available 236 orphan status entries were orphaned; 198 (73%) were in CDC categories B and C and 61 (16%) of available 386 had been on ART. Among 108 patients with documented immunologic status, the mean CD4 cell percentage was 16% (SD 10.8). Among the 396 children, 104 (15%) were diagnosed with pneumonia, 92 (14%) with gastroenteritis, 36 (9%) with tuberculosis and 37 (9%) with malaria. Deaths occurred in 28(7%) of the patients. The median duration of hospitalisation was seven days (range 1- 516) for discharged patients and six days (range 0-72) for those who died. A significantly higher percentage of the children who were not previously enrolled in AMPATH died, signifying 14 (15%) mortality among this population of admitted patients, p = 0.0017. Of those who died, (17%) were diagnosed with pneumonia and 22 (79%) of them were not on cART.Conclusion: The common diagnoses at hospitalisation included pneumonia, gastroenteritis, malaria and tuberculosis. Higher mortality occurred among those diagnosed with pneumonia and those not previously enrolled in the HIV care programme. Aggressive treatment and prevention of the most prevalent diseases and early enrollment into HIV care are recommended for HIV-infected children. A follow-up study to investigate the pathological causes of death in this population is recommended

Clinical disorders affecting mesopic vision

Vision in the mesopic range is affected by a number of inherited and acquired clinical disorders. We review these conditions and summarize the historical background, describing the clinical characteristics alongside the genetic basis and molecular biological mechanisms giving rise to rod and cone dysfunction relevant to twilight vision. The current diagnostic gold standards for each disease are discussed and curative and symptomatic treatment strategies are summarized

Factors that precipitate heart failure among children with rheumatic heart disease

Objective: To identify factors that precipitates heart failure in children with rheumatic heart disease.Design: a descriptive cross-sectional study.Setting: Paediatric wards at the Moi Teaching and Referral Hospital.Subjects: Children with Rheumatic heart disease admitted for in-patient care due to decompensated heart failure.Results: A total of 33 patients were studied, thirty two of whom were in the New York Heart Association (NYHA) class IV and one in class III. Non-compliance to antifailure therapy was the most common precipitating factor occurring in 87.9% cases.Arrhythmia, recurrent rheumatic fever, pneumonia, infective endocarditis, anaemia and overexertion were identified as other precipitating factors. Seventy percent of the patients did not adhere to secondary prophylaxis against rheumatic fever.Conclusion: Non compliance to anti-failure therapy was the most common precipitating factor

Prevalence of pain and adequacy of analgesic prescription among children admitted at Trans Nzoia County Referral Hospital, Kenya

Objective: To determine the prevalence and severity of pain and adequacy of analgesic prescription among children admitted at Trans-Nzoia County Referral Hospital (TCRH) pediatric wards.Design: A sequential explanatory mixed method study.Setting: TCRH pediatric wards.Participants: Children aged 5-14 years admitted over a period of 6 months. Healthcare providers and managers at TCRH.Interventions: Pain assessment using the Faces Pain Scale-Revised (FPS-R).Outcome measures: Prevalence computed by those who reported pain versus the total screened population. Severity computed by levels of pain reported by the sampled population. Adequacy assessed by the dosing and choice of analgesic versus the WHO analgesic ladder.Results: Out of the 928 children screened, 764 (82.33%) had pain. Among the 384 sampled, severity reported at 35.7% mild, 49.7% moderate and 14.6% severe. Adequacy of prescription in dosing determined at 16.7% with 34.2% of prescriptions being under dose and 49.1% overdose. Adequacy in choice of analgesia as per WHO analgesic ladder was at 42.45%. Pain score was statistically significant in association with prescription adequacy (P-value < 0.001, AOR= 32 moderate pain and 69.8 severe pain, CI=5.175-183.07). Drug  availability and knowledge on pediatric pain management were some of the factors determining drug prescription in the facility.Conclusion: Prevalence of pain among children admitted at TCRH is very high, occurring in 4 out of 5 children. There is low adequacy of analgesic prescription. Pain score, drug availability, staffing and pediatric pain management knowledge were the major factors associated with analgesic prescription and administration