An analysis of neonates with surgical diagnoses admitted to the neonatal intensive care unit at Charlotte Maxeke Johannesburg Academic Hospital, South Africa

Background. The burden of neonatal surgical conditions is not well documented in low- to middle-income countries (LMICs). These conditions are thought to be relatively common, with a considerable proportion of neonates admitted to the neonatal intensive care unit (NICU) requiring surgical intervention.Objectives. To review neonates with surgical conditions admitted to the NICU in our hospital setting.Methods. This was a retrospective, descriptive study of neonates with surgical conditions admitted to the NICU at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), South Africa, between 1 January 2013 and 31 December 2015. The characteristics and survival of these neonates were described using univariate analysis. The NICU at CMJAH is combined with a paediatric intensive care unit, to a total of 15 beds, and serves as a referral unit.Results. Of 923 neonates admitted to the NICU, 319 (34.6%) had primarily surgical conditions. Of these 319 neonates, 205 survived (64.3%). There were 125/319 neonates (39.2%) with necrotising enterocolitis (NEC), 55 of whom survived (55/125; 44.0%), making the presence of NEC significantly associated with poor outcome (p<0.001). Other significant predictors of poor outcome were the patient being outborn (p=0.029); the presence of late-onset sepsis (p<0.001), with Gram-negative organisms (p=0.005); and lesser gestational age (p=0.001) and lower birth weight (p<0.001). Major birth defects were present in 166/319 neonates (52.0%). The abdomen was the most prevalent site of surgery, with 216/258 procedures (83.7%) being abdominal, resulting in a mortality rate of 76/216 (35.2%).Conclusions. Neonates with major surgical conditions accounted for one-third of NICU admissions in the present study. The study highlights the considerable burden placed on paediatric surgical services at a large referral hospital in SA. Paediatric surgical services, with early referral and improvement of neonatal transport systems, must be a priority in planned healthcare interventions to reduce neonatal mortality in LMICs

Developing young people's sense of self and place through sport

Previous research has recognized positive health implications, both physical and mental, as an outcome of participation in leisure pursuits. They provide opportunities for self-expression and stress reduction, as well as an environment in which people can socialize. Leisure activities, specifically sport activities, can play a significant role in young people's identity development. This paper explores the leisure activities in which young people in Adelaide, Australia participate. It examines the role of leisure activities in terms of young people's identity and feelings towards their hometown. This study consisted of semi-structured focus groups conducted with 24 senior high school students, followed by a survey resulting in 226 useable responses. Respondents were aged between 16 and 18 years of age. From the range of activities identified and explored, the results revealed sports activities to have the greatest impact on young people's lives. The results demonstrated that frequency of participation has a significant effect on young people's involvement levels and how they identify with the activity

Socioeconomic disparities in physical health among Aboriginal and Torres Strait Islander children in Western Australia

Objective. Few empirical studies have specifically examined the relationship between socio-economic status (SES) and health in Indigenous populations of Australia. We sought to provide insights into the nature of this relationship by examining socio-economic disparities in physical health outcomes among Aboriginal and Torres Strait Islander children in Western Australia. Design. We used a diverse set of health and SES indicators from a representative survey conducted in 20002002 on the health and development of 5289 Indigenous children aged 017 years in Western Australia. Analysis was conducted using multivariate logistic regression within a multilevel framework. Results. After controlling for age and sex, we found statistically significant socio- economic disparities in health in almost half of the associations that were investigated, although the direction, shape and magnitude of associations differed. For ear infections, recurring chest infections and sensory function problems, the patterns were generally consistent with a positive socio-economic gradient where better health was associated with higher SES. The reverse pattern was found for asthma, accidents and injuries, and oral health problems, although this was primarily observed for area-level SES indicators. Conclusion. Conventional notions of social position and class have some influence on the physical health of Indigenous children, although the diversity of results implies that there are other ways of conceptualising and measuring SES that are important for Indigenous populations. We need to consider factors that relate specifically to Indigenous circumstances and culture in the past and present day, and give more thought to how we measure social position in the Indigenous community, to gain a better understanding of the pathways from SES to Indigenous child health

Exploring undergraduate midwifery students' readiness to deliver culturally secure care for pregnant and birthing Aboriginal women

Background: Culturally secure health care settings enhance accessibility by Aboriginal Australians and improve their satisfaction with service delivery. A culturally secure health service recognises and responds to the legitimate cultural rights of the recipients of care. Focus is upon the health care system as well as the practice and behaviours of the individuals within it. In an attempt to produce culturally secure practitioners, the inclusion of Aboriginal content in health professional programs at Australian universities is now widespread. Studies of medical students have identified the positive impact of this content on knowledge and attitudes towards Aboriginal people but relatively little is known about the responses of students in other health professional education programs. This study explored undergraduate midwifery students' knowledge and attitudes towards Aboriginal people, and the impact of Aboriginal content in their program. Methods: The study surveyed 44 students who were in their first, second and third years of a direct entry, undergraduate midwifery program at a Western Australian (WA) university. The first year students were surveyed before and after completion of a compulsory Aboriginal health unit. Second and third year students who had already completed the unit were surveyed at the end of their academic year. Results: Pre- and post-unit responses revealed a positive shift in first year students' knowledge and attitudes towards Aboriginal people and evidence that teaching in the unit was largely responsible for this shift. A comparison of post-unit responses with those from students in subsequent years of their program revealed a significant decline in knowledge about Aboriginal issues, attitudes towards Aboriginal people and the influence of the unit on their views. Despite this, all students indicated a strong interest in more clinical exposure to Aboriginal settings. Conclusions: The inclusion of a unit on Aboriginal health in an undergraduate midwifery program has been shown to enhance knowledge and shift attitudes towards Aboriginal people in a positive direction. These gains may not be sustained, however, without vertical integration of content and reinforcement throughout the program. Additional midwifery-specific Aboriginal content related to pregnancy and birthing, and recognition of strong student interest in clinical placements in Aboriginal settings provide opportunities for future curriculum development

Global research priorities for COVID-19 in maternal, reproductive and child health: Results of an international survey.

BACKGROUND: The World Health Organization's "Coordinated Global Research Roadmap: 2019 Novel Coronavirus" outlined the need for research that focuses on the impact of COVID-19 on pregnant women and children. More than one year after the first reported case significant knowledge gaps remain, highlighting the need for a coordinated approach. To address this need, the Maternal, Newborn and Child Health Working Group (MNCH WG) of the COVID-19 Clinical Research Coalition conducted an international survey to identify global research priorities for COVID-19 in maternal, reproductive and child health. METHOD: This project was undertaken using a modified Delphi method. An electronic questionnaire was disseminated to clinicians and researchers in three different languages (English, French and Spanish) via MNCH WG affiliated networks. Respondents were asked to select the five most urgent research priorities among a list of 17 identified by the MNCH WG. Analysis of questionnaire data was undertaken to identify key similarities and differences among respondents according to questionnaire language, location and specialty. Following elimination of the seven lowest ranking priorities, the questionnaire was recirculated to the original pool of respondents. Thematic analysis of final questionnaire data was undertaken by the MNCH WG from which four priority research themes emerged. RESULTS: Questionnaire 1 was completed by 225 respondents from 29 countries. Questionnaire 2 was returned by 49 respondents. The four priority research themes which emerged from the analysis were 1) access to healthcare during the COVID-19 pandemic, 2) the direct and 3) indirect effects of COVID-19 on pregnant and breastfeeding women and children and 4) the transmission of COVID-19 and protection from infection. CONCLUSION: The results of these questionnaires indicated a high level of concordance among continents and specialties regarding priority research themes. This prioritized list of research uncertainties, developed to specifically highlight the most urgent clinical needs as perceived by healthcare professionals and researchers, could help funding organizations and researchers to answer the most pressing questions for clinicians and public health professionals during the pandemic. It is hoped that these identified priority research themes can help focus the discussion regarding the allocation of limited resources to enhance COVID-19 research in MNCH globally

Conservation of Salmonella Infection Mechanisms in Plants and Animals

Salmonella virulence in animals depends on effectors injected by Type III Secretion Systems (T3SSs). In this report we demonstrate that Salmonella mutants that are unable to deliver effectors are also compromised in infection of Arabidopsis thaliana plants. Transcriptome analysis revealed that in contrast to wild type bacteria, T3SS mutants of Salmonella are compromised in suppressing highly conserved Arabidopsis genes that play a prominent role during Salmonella infection of animals. We also found that Salmonella originating from infected plants are equally virulent for human cells and mice. These results indicate a high degree of conservation in the defense and infection mechanism of animal and plant hosts during Salmonella infection

Patterns of antibiotic use, pathogens, and prediction of mortality in hospitalized neonates and young infants with sepsis: A global neonatal sepsis observational cohort study (NeoOBS)

BACKGROUND: There is limited data on antibiotic treatment in hospitalized neonates in low- and middle-income countries (LMICs). We aimed to describe patterns of antibiotic use, pathogens, and clinical outcomes, and to develop a severity score predicting mortality in neonatal sepsis to inform future clinical trial design. METHODS AND FINDINGS: Hospitalized infants <60 days with clinical sepsis were enrolled during 2018 to 2020 by 19 sites in 11 countries (mainly Asia and Africa). Prospective daily observational data was collected on clinical signs, supportive care, antibiotic treatment, microbiology, and 28-day mortality. Two prediction models were developed for (1) 28-day mortality from baseline variables (baseline NeoSep Severity Score); and (2) daily risk of death on IV antibiotics from daily updated assessments (NeoSep Recovery Score). Multivariable Cox regression models included a randomly selected 85% of infants, with 15% for validation. A total of 3,204 infants were enrolled, with median birth weight of 2,500 g (IQR 1,400 to 3,000) and postnatal age of 5 days (IQR 1 to 15). 206 different empiric antibiotic combinations were started in 3,141 infants, which were structured into 5 groups based on the World Health Organization (WHO) AWaRe classification. Approximately 25.9% (n = 814) of infants started WHO first line regimens (Group 1-Access) and 13.8% (n = 432) started WHO second-line cephalosporins (cefotaxime/ceftriaxone) (Group 2-"Low" Watch). The largest group (34.0%, n = 1,068) started a regimen providing partial extended-spectrum beta-lactamase (ESBL)/pseudomonal coverage (piperacillin-tazobactam, ceftazidime, or fluoroquinolone-based) (Group 3-"Medium" Watch), 18.0% (n = 566) started a carbapenem (Group 4-"High" Watch), and 1.8% (n = 57) a Reserve antibiotic (Group 5, largely colistin-based), and 728/2,880 (25.3%) of initial regimens in Groups 1 to 4 were escalated, mainly to carbapenems, usually for clinical deterioration (n = 480; 65.9%). A total of 564/3,195 infants (17.7%) were blood culture pathogen positive, of whom 62.9% (n = 355) had a gram-negative organism, predominantly Klebsiella pneumoniae (n = 132) or Acinetobacter spp. (n = 72). Both were commonly resistant to WHO-recommended regimens and to carbapenems in 43 (32.6%) and 50 (71.4%) of cases, respectively. MRSA accounted for 33 (61.1%) of 54 Staphylococcus aureus isolates. Overall, 350/3,204 infants died (11.3%; 95% CI 10.2% to 12.5%), 17.7% if blood cultures were positive for pathogens (95% CI 14.7% to 21.1%, n = 99/564). A baseline NeoSep Severity Score had a C-index of 0.76 (0.69 to 0.82) in the validation sample, with mortality of 1.6% (3/189; 95% CI: 0.5% to 4.6%), 11.0% (27/245; 7.7% to 15.6%), and 27.3% (12/44; 16.3% to 41.8%) in low (score 0 to 4), medium (5 to 8), and high (9 to 16) risk groups, respectively, with similar performance across subgroups. A related NeoSep Recovery Score had an area under the receiver operating curve for predicting death the next day between 0.8 and 0.9 over the first week. There was significant variation in outcomes between sites and external validation would strengthen score applicability. CONCLUSION: Antibiotic regimens used in neonatal sepsis commonly diverge from WHO guidelines, and trials of novel empiric regimens are urgently needed in the context of increasing antimicrobial resistance (AMR). The baseline NeoSep Severity Score identifies high mortality risk criteria for trial entry, while the NeoSep Recovery Score can help guide decisions on regimen change. NeoOBS data informed the NeoSep1 antibiotic trial (ISRCTN48721236), which aims to identify novel first- and second-line empiric antibiotic regimens for neonatal sepsis. TRIAL REGISTRATION: ClinicalTrials.gov, (NCT03721302)

Patterns of antibiotic use, pathogens, and prediction of mortality in hospitalized neonates and young infants with sepsis: A global neonatal sepsis observational cohort study (NeoOBS).

BACKGROUND: There is limited data on antibiotic treatment in hospitalized neonates in low- and middle-income countries (LMICs). We aimed to describe patterns of antibiotic use, pathogens, and clinical outcomes, and to develop a severity score predicting mortality in neonatal sepsis to inform future clinical trial design. METHODS AND FINDINGS: Hospitalized infants <60 days with clinical sepsis were enrolled during 2018 to 2020 by 19 sites in 11 countries (mainly Asia and Africa). Prospective daily observational data was collected on clinical signs, supportive care, antibiotic treatment, microbiology, and 28-day mortality. Two prediction models were developed for (1) 28-day mortality from baseline variables (baseline NeoSep Severity Score); and (2) daily risk of death on IV antibiotics from daily updated assessments (NeoSep Recovery Score). Multivariable Cox regression models included a randomly selected 85% of infants, with 15% for validation. A total of 3,204 infants were enrolled, with median birth weight of 2,500 g (IQR 1,400 to 3,000) and postnatal age of 5 days (IQR 1 to 15). 206 different empiric antibiotic combinations were started in 3,141 infants, which were structured into 5 groups based on the World Health Organization (WHO) AWaRe classification. Approximately 25.9% (n = 814) of infants started WHO first line regimens (Group 1-Access) and 13.8% (n = 432) started WHO second-line cephalosporins (cefotaxime/ceftriaxone) (Group 2-"Low" Watch). The largest group (34.0%, n = 1,068) started a regimen providing partial extended-spectrum beta-lactamase (ESBL)/pseudomonal coverage (piperacillin-tazobactam, ceftazidime, or fluoroquinolone-based) (Group 3-"Medium" Watch), 18.0% (n = 566) started a carbapenem (Group 4-"High" Watch), and 1.8% (n = 57) a Reserve antibiotic (Group 5, largely colistin-based), and 728/2,880 (25.3%) of initial regimens in Groups 1 to 4 were escalated, mainly to carbapenems, usually for clinical deterioration (n = 480; 65.9%). A total of 564/3,195 infants (17.7%) were blood culture pathogen positive, of whom 62.9% (n = 355) had a gram-negative organism, predominantly Klebsiella pneumoniae (n = 132) or Acinetobacter spp. (n = 72). Both were commonly resistant to WHO-recommended regimens and to carbapenems in 43 (32.6%) and 50 (71.4%) of cases, respectively. MRSA accounted for 33 (61.1%) of 54 Staphylococcus aureus isolates. Overall, 350/3,204 infants died (11.3%; 95% CI 10.2% to 12.5%), 17.7% if blood cultures were positive for pathogens (95% CI 14.7% to 21.1%, n = 99/564). A baseline NeoSep Severity Score had a C-index of 0.76 (0.69 to 0.82) in the validation sample, with mortality of 1.6% (3/189; 95% CI: 0.5% to 4.6%), 11.0% (27/245; 7.7% to 15.6%), and 27.3% (12/44; 16.3% to 41.8%) in low (score 0 to 4), medium (5 to 8), and high (9 to 16) risk groups, respectively, with similar performance across subgroups. A related NeoSep Recovery Score had an area under the receiver operating curve for predicting death the next day between 0.8 and 0.9 over the first week. There was significant variation in outcomes between sites and external validation would strengthen score applicability. CONCLUSION: Antibiotic regimens used in neonatal sepsis commonly diverge from WHO guidelines, and trials of novel empiric regimens are urgently needed in the context of increasing antimicrobial resistance (AMR). The baseline NeoSep Severity Score identifies high mortality risk criteria for trial entry, while the NeoSep Recovery Score can help guide decisions on regimen change. NeoOBS data informed the NeoSep1 antibiotic trial (ISRCTN48721236), which aims to identify novel first- and second-line empiric antibiotic regimens for neonatal sepsis. TRIAL REGISTRATION: ClinicalTrials.gov, (NCT03721302)