Factors Associated with Survival to Discharge of Newborns in a Middle-Income Country

Clinical and mortality audit is an essential part of quality improvement in health care; information obtained in this process is used to develop targeted interventions to improve outcome. This study aimed to determine predictors of short-term survival in neonates. An existing neonatal database was reviewed. A total of 5018 neonates > 400 g admitted to a tertiary hospital (Johannesburg South Africa) between 1 January 2013 and 31 December 2015 were analysed. Mean birth weight was 2148 g (standard deviation [SD]: 972) and mean gestational age was 34.2 weeks (SD: 4.8). Overall survival was 85.6% (4294/5018). The most common causes of death were prematurity (46.2%), hypoxia (19.5%) and infection (17.2). The strongest predictors of survival were birth weight (OR 1.0; 95% confidence intervals (CI): 1.0–1.01) and gestational age (OR = 1.1, 95% CI: 1.05–1.17). Other predictors of survival included metabolic acidosis (OR = 0.14, 95% CI: 0.09–0.20), hyperglycemia (OR = 0.31, 95% CI: 0.23–0.41), mechanical ventilation (OR = 0.35, 95% CI: 0.28–0.46), major birth defect (OR = 0.12, 95% CI: 0.08–0.18), resuscitation at birth (OR = 0.39, 95% CI: 0.31–0.49) and Caesarean section (OR = 1.8, 95% CI: 1.44–2.25). In conclusion, resources need to be focused on improved care of VLBW infants

Serum 1,3-βD-Glucan assay in the diagnosis of invasive fungal disease in neonates

Invasive fungal disease is a significant cause of morbidity and mortality in the neonate. The current study aims to assess the 1, 3-βD-Glucan (BG) assay in a prospective analysis in neonates with suspected fungaemia. A multicentre, prospective cohort study was conducted in Johannesburg, South Africa. The study included 72 neonates with clinically suspected late onset sepsis who were at high risk of fungaemia. A BG assay was performed on each patient and correlated with a sepsis classification based on the full blood count, C-reactive protein and blood culture results as no fungaemia, possible fungaemia, probable fungaemia or definite fungaemia. Sensitivity and specificity of the BG assay at levels of 60 pg/mL are 73.2% and 71.0% respectively and at levels of 80 pg/mL are 70.7% and 77.4% respectively. Positive and negative predictive values at 60 pg/mL are 76.9% and 66.7% respectively and at 80 pg/mL are 80.6% and 66.7% respectively. The area under the receiver operating curve is 0.753. The BG assay is a useful adjunct to the diagnosis of invasive fungal disease in neonates. It does, however, need to be considered in the context of the clinical picture and supplementary laboratory investigations

Serum procalcitonin as an early marker of neonatal sepsis

Background. It has recently been suggested that procalcitonin (PCT) is of value in the diagnosis of neonatal sepsis, with varying results. This study was to evaluate the role of PCT as a single early marker of neonatal sepsis. Setting. Neonatal Unit, Johannesburg Hospital, and Microbiology Laboratory, National Health Laboratory Service (NHLS), South Africa. Subjects and methods. Neonates undergoing evaluation for sepsis between April and August 2002 were eligible for inclusion. Patients were categorised into ‘no infection', ‘possible infection' and ‘definite infection' on the basis of C-reactive protein (CRP), white cell count (WCC), platelet count and blood culture results. PCT was correlated with infection categories. Results. One hundred and eighty-three neonates were enrolled. One hundred and eighteen had no infection, 52 possible infection and 13 definite infection. PCT differed significantly among infection categories (p < 0.0001) and correlated significantly with CRP at presentation (correlation coefficient 0.404, p < 0.001) and CRP at 24 hours (correlation coefficient 0.343, p < 0.001). PCT predicted 89.5% of definite infection. Receiver operating characteristic (ROC) analysis for PCT to predict definite infection showed odds ratio (OR) 1.145 (95% confidence interval (CI): 1.05 - 1.25) with an area under the curve of 0.778. PCT had a negative predictive value of 0.95 (95% CI: 0.915 - 0.988) for definite infection. Conclusions. Although PCT was significantly related to the category of infection, it is not sufficiently reliable to be the sole marker of neonatal sepsis. PCT would be useful as part of a full sepsis evaluation, but is relatively expensive. A negative PCT on presentation may rule out sepsis, but this needs to be evaluated further. S Afr Med J 2004; 94: 851-854

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

Cardiovascular risk factors and mortality in children with chronic kidney disease

Background. Cardiovascular disease (CVD) begins early in children with chronic kidney disease (CKD), and its progression is determined by the presence of single or multiple cardiovascular risk factors (CVRFs).Objective. To determine the prevalence of CVRFs in children with CKD and their association with mortality in children on chronic dialysis.Methods. This comparative cross-sectional study recruited children aged 5 - 18 years with all stages of CKD. All patients had a short history taken along with a physical examination, and their blood samples were assessed for serum creatinine, urea, albumin, calcium, phosphorus, parathyroid hormone, alkaline phosphatase, total cholesterol (TC), haemoglobin and C-reactive protein. Urine samples were also assessed for proteinuria.Results. One hundred and six children who met the study criteria were recruited, 34 with CKD I, 36 with CKD II - IV and 36 with CKD V (dialysis). The overall median age was 11 years (range 8 - 14), and the male/female ratio was 2.1:1. The most common CVRF was anaemia (39.6%). The rate of anaemia was higher in the dialysis group than in the CKD II - IV and CKD I groups (77.8%, 33.3% and 5.9%, respectively). Other CVRFs detected were hypertension, proteinuria, hypercholesterolaemia and dysregulated mineral bone metabolism. Seven deaths were recorded in the dialysis group during the study period. Severe hypertension and intracranial bleeding were the most common causes of death. Modifiable risk factors such as increased TC and decreased albumin levels were more common than other CVRFs in the dialysis patients who died.Conclusions. CVRFs may be present in early CKD, even before the decline in GFR. Routine screening for CVRFs, along with timely intervention, may prevent the progression of CVD and mortality later in life.

Appropriateness of admissions of children with cancer to intensive care facilities in a resource-limited setting

Background: The increasing intensity of treatment of paediatric malignancies has led to improved survival rates, but often necessitates intensive supportive care. The decision to admit a child to the paediatric intensive care unit (PICU) is based on the probability of both short-term and long-term survival in the context of severe resource constraints. Resource constraints in South Africa result in limited access of children with cancer to PICU facilities. Objectives: The aim of this study was to determine whether referrals by paediatric oncologists to a PICU in Johannesburg were appropriate by analysing indications for admission, underlying diagnoses, duration and costs of admissions, and overall outcomes. Methods: A retrospective review of consecutive PICU admissions over a 12-year period was performed. Data from all patients with histologically proven malignant conditions were included and analysed using descriptive statistical methods, Kaplan–Meier curves, log-rank analysis and Fisher’s exact test. Results: There were 5704 recorded admissions to PICU in the study period. Of these admissions, 120 (2.1%) were for patients with malignancies. The majority of PICU oncology admissions were for post-operative care, and the median duration of stay was 1 day (interquartile range: 1–3 days). The short-term mortality rate of oncology patients in PICU was 13.3% in comparison with 16.2% in the overall PICU population. The 4-year overall survival rate post PICU discharge was 54%. Conclusion: The documented short-term mortality rate indicates that referrals by paediatric oncologists are consistent with current PICU admission policies. Oncologists should assess the prognosis for survival before requesting admission to PICU, and, resources permitting, these patients should be accepted to PICU

Parental perception of neonatal intensive care in public sector hospitals in South Africa

Background. Little is known about parental experience and decision making with regard to premature  infants requiring intensive care in developing countries. We undertook this study to characterise parents' experience of physician counselling and their role in making life-support decisions for very low-birth-weight (VLBW) (birth weight &lt; 1 501 g) infants born in South Africa's public-sector neonatal intensive care units (NICUs).Methods. Parents of surviving VLBW infants treated in three Johannesburg-area public hospitals and  attending follow-up clinics in August 2001 were interviewed regarding their experience of perinatal  counselling on outcomes (pain, survival, disability), perception of actual and optimal decision making, and satisfaction with NICU communication.Results. Parents of 51 infants were interviewed. Seventy-five per cent of parents reported antenatal counselling by physicians on at least one perinatal topic (severe disability,pain, death, finances or  religious/moral considerations). The majority of parents(&gt; 60%) who received counselling thought that these topics had been discussed adequately. Most parents reported that doctors had the primary  decisionmaking role, either without consulting them (41 %) or after consulting them (37%). Joint decision making was rare (14%). Parents wanted more input in life-support decisions than they reported being given.Conclusion. Counselling is not consistently provided in publicsector hospitals in Johannesburg. Parents  of premature infants want a larger share in NICU decision making than they currently experience. Most parents were satisfied with communication later during their infant's hospitalisation. South Africa presents a unique opportunity to study the use of advanced medical technologies in a nation with marked disparities in access to care.

Improved survival of children and adolescents with classical Hodgkin lymphoma treated on a harmonised protocol in South Africa

Funding: CANSA, Wits Faculty Research Committee Individual Research Grant, Carnegie Corporation Research Funding, Crowdfunding through Doit4Charity Backabuddy and the Ride Joburg Cycle Race.Background Historic South African 5-year overall survival (OS) rates for Hodgkin lymphoma (HL) from 2000 to 2010 were 46% and 84% for human immunodeficiency virus (HIV)-positive and HIV-negative children, respectively. We investigated whether a harmonised treatment protocol using risk stratification and response-adapted therapy could increase the OS of childhood and adolescent HL. Methods Seventeen units prospectively enrolled patients less than 18 years, newly diagnosed with classical HL onto a risk-stratified, response-adapted treatment protocol from July 2016 to December 2022. Low- and intermediate-risk patients received four and six courses of adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD), respectively. High-risk patients received two courses of ABVD, followed by four courses of cyclophosphamide, vincristine, prednisone, and dacarbazine (COPDac). Those with a slow early response and bulky disease received consolidation radiotherapy. HIV-positive patients could receive granulocyte colony-stimulating factor and less intensive therapy if stratified as high risk, at the treating clinician's discretion. Kaplan–Meier survival analysis was performed to determine 2-year OS and Cox regression to elucidate prognostic factors. Results  The cohort comprised 132 patients (19 HIV-positive, 113 HIV-negative), median age of 9.7 years, with a median follow-up of 2.2 years. Risk grouping comprised nine (7%) low risk, 36 (27%) intermediate risk and 87 (66%) high risk, with 71 (54%) rapid early responders and 45 (34%) slow early responders, and 16 (12%) undocumented. Two-year OS was 100% for low-risk, 93% for intermediate-risk, and 91% for high-risk patients. OS for HIV-negative (93%) and HIV-positive (89%) patients were similar (p = .53). Absolute lymphocyte count greater than 0.6 × 109 predicted survival (94% vs. 83%, p = .02). Conclusion In the first South African harmonised HL treatment protocol, risk stratification correlated with prognosis. Two-year OS of HIV-positive and HIV-negative patients improved since 2010, partially ascribed to standardised treatment and increased supportive care. This improved survival strengthens the harmonisation movement and gives hope that South Africa will achieve the WHO Global Initiative for Childhood Cancer goals.Publisher PDFPeer reviewe