Anthony Westwood

Improvements in lung function of a pediatric cystic fibrosis population in a developing country

OBJECTIVE To document the change in pulmonary function of a pediatric cystic fibrosis population managed at the Red Cross War Memorial Childrens Hospital, Cape Town, South Africa, between January 1999 and December 2006. METHODS Retrospective review of the medical records and best spirometry results within 3-monthly intervals. RESULTS A total of 1,139 pulmonary function tests from 79 patients showed a significant improvement over the 8 years studied. When comparing the first quarter of 1999 with the last quarter of 2006, 78 pulmonary function tests were performed on 65 patients with equal patient numbers in both groups and similar in terms of gender, age, age at diagnosis, ethnicity, cystic fibrosis genotype and number of patients colonized with either Staphylococcus aureus or Pseudomonas aeruginosa. In 2006, 15 patients (38.5%) were on azithromycin treatment compared to one (2.6%) patient in 1999 (p = 0.0003). Median (interquartile range) forced expiratory volume in 1 second, forced vital capacity, and average expiratory flow between 25 and 75% of forced vital capacity increased from 61% (51-73), 63% (52-89), and 40% (27-57), predicted in the first quarter of 1999, to 81% (69-100, p = 0.004), 82% (70-98, p = 0.007), and 62% (41-87, p = 0.01), predicted during the last quarter of 2006, respectively. CONCLUSIONS Pulmonary function tests increased by 20% over 8 years in comparable patient groups. This likely reflects improved care of South African children with cystic fibrosis.

Transition from child- to adult-orientated care for children with long-term health conditions: A process, not an event

Long-term health conditions in childhood include both congenital conditions and acquired diseases. Children with long-term health conditions face issues and potential secondary problems that are different from those of adults with chronic diseases. Transition to adult-orientated care for such children and adolescents is a major challenge. Transition needs to be prepared for and planned. A variety of possible transition models exists, depending on circumstances.

The prognosis of cystic fibrosis in the Western Cape region of South Africa

Objective: To study the prognosis of cystic fibrosis (CF) in South Africa.

Rate of pulmonary function decline in South African children with cystic fibrosis

Background . Pulmonary function tests (PFTs) objectively measure the extent and progression of cystic fibrosis (CF) lung disease. The rate of lung function decline in developing countries has not previously been studied. Aim . To investigate the average annual rates of pulmonary function decline in South African children with CF from 1999 to 2006. Methodology : The medical records and best PFT over 3-monthly intervals of children attending the CF clinic at Red Cross War Memorial Children’s Hospital, Cape Town, were retrospectively reviewed and analysed using the mixed model regression method. Results . A total of 1 139 PFT were recorded on 79 patients, with a median (interquartile range) of 14 (6 - 21) PFTs per patient. The mean (standard error) forced expiratory volume in 1 second (FEV1) at age 6 years was estimated at 73.83 (3.34) per cent predicted with an FEV1 decline of 0.23 (0.43)% per annum. FEV1 at age 6 was affected by age at CF diagnosis, genotype, and year of birth. Rate of FEV1 decline was significantly affected by Pseudomonas aeruginosa colonisation and genotype. Conclusions . Although FEV1 at age 6 years was low compared with developed countries, the annual rate of FEV1 decline in South African children with CF was minimal, setting the scene for improved survival in this population.

Climate change is catchy – but when will it really hurt?

Concern and general awareness about the impacts of climate change in all sectors of the social-ecological-economic system is growing as a result of improved climate science products and information, as well as increased media coverage of the apparent manifestations of the phenomenon in our society. However, scales of climate variability and change, in space and time, are often confused and so attribution of impacts on various sectors, including the health sector, can be misunderstood and misrepresented. In this review, we assess the mechanistic links between climate and infectious diseases in particular, and consider how this relationship varies, and may vary according to different time scales, especially for aetiologically climate-linked diseases. While climate varies in the medium (inter-annual) time frame, this variability itself may be oscillating and/or trending on cyclical and long-term (climate change) scales because of regional and global scale climate phenomena such as the El-Nino southern oscillation coupled with global-warming drivers of climate change. As several studies have shown, quantifying and modelling these linkages and associations at appropriate time and space scales is both necessary and increasingly feasible with improved climate science products and better epidemiological data. The application of this approach is considered for South Africa, and the need for a more concerted effort in this regard is supported.

Childhood in-hospital mortality from acute gastro-enteritis in Cape Town

Since 2004, there has been a progressively more active system-wide approach to tackling the AGE incidence, morbidity and mortality. This involves the media, community and hospital services and progressive provision of basic amenities to the city’s over 200 informal settlements. Though covering the whole metropolitan area, this plan focuses on areas with the highest child mortality from AGE. In 2009, a data collection system was set up to monitor the scale and impact of the annual AGE peak from February to April that involved all 11 public hospitals (5 district, 3 regional and 3 central) in the city. All incident cases were counted on admission to a ward; inter-hospital transfers were not counted to avoid double counting. Deaths were counted, and information on co-morbid diseases such as HIV and malnutrition was collected on each death using the Child Healthcare Problem Identification Programme. 2 In all, 3 568 children were admitted during the 3-month period, approximately 1% of the city’s estimated 333 700 children under 5 years of age (Department of Health, unpublished data). The largest concentration of patients (1 476 patients, 41.4% of the total) was admitted to the Red Cross War Memorial Children’s Hospital, which drains three sub-districts (under-5 population 137 000) that contain areas with high social deprivation indices.

The utility of computed tomography for recent-onset partial seizures in childhood

OBJECTIVES To determine the diagnostic yield of computed tomography (CT) of the head in children presenting for the first time with partial seizures in a region with a high prevalence of tuberculosis and neurocysticercosis. DESIGN Prospective cohort study. SETTING The secondary-level ambulatory service of Red Cross Childrens Hospital, Cape Town. SUBJECTS Children aged 6 months-12 years with a first partial seizure. Outcome measures. Abnormal CT findings; clinically unsuspected abnormal CT findings. RESULTS Of 118 enrolled children, CT findings were available for 94 (80%). Sixteen (33%) of 49 children scheduled to return later for an initial CT scan failed to do so. Thirty-two scans (34%) were reported normal, 45 (48%) showed single or multiple granulomas, and 17 (18%) showed other findings. All 8 children with persistent specific CT findings were suspected of having the condition before CT scan. Of 68 cases with prospectively recorded clinically expected CT findings, normal scans were expected in 2 cases (3%) and occurred in 33 cases (49%). CONCLUSIONS Routine CT scan for children presenting with a first partial seizure in an area with a high prevalence of neurocysticercosis failed to identify findings other than neurocysticercosis that meaningfully altered clinical management. Assuming a 70% relative reduction of seizures with albendazole treatment for neurocysticercosis, routine CT scanning in the study population would require 11 scans and 5 courses of albendazole to prevent 1 child from having seizures, compared with no CT scans and 11 courses of albendazole with blanket use of albendazole.

Paediatric triage in South Africa

Reducing child mortality is a high priority in sub-Saharan Africa, and swift, appropriate triage can make an important contribution to this goal. There has been a lot of interest and work in the field of triage of sick children in South Africa over the past few years. Despite this, in many parts of South Africa no formal system for triage of children in acute and emergency settings is used. This article aims to explain some of the key paediatric triage tools being considered and developed in South Africa. The triage tools discussed are the World Health Organization Emergency Triage Assessment and Treatment (ETAT), the South African adaptation of this tool known as ETAT-SA, the South African Triage Scale (SATS), and the Revised Paediatric SATS (P-SATS). The article describes how they were developed and their relevance to the country.

Rehydration in acute gastro-enteritis - the value of going rapid and enteral

Acute gastro-enteritis (AGE) is a leading post-neonatal cause of death among South Africa’s children. Almost all these deaths are caused by the consequences of dehydration. Many of these deaths occur in hospitals. AGE is also a significant nutritional insult at a critical time of growth. When the literature on therapy for AGE is reviewed, only four interventions recommend themselves for universal application for uncomplicated disease: rapid rehydration within 4 - 6 hours with hypotonic solutions, preferably via the gut; continuation of breastfeeding throughout the episode; early re-introduction of full-strength feeds; and zinc therapy. This article explores the first of these, but will show how its application enhances the positive effects of feeding on the diarrhoea as well as the child’s nutritional status.

Children with disabling chronic conditions in the Western health subdistrict of Cape Town, South Africa: Estimating numbers and service gaps.

BACKGROUND Children with disabling chronic conditions often have extensive, complex and unmet healthcare and educational needs. They can be defined as a subset of the group of children with chronic health conditions whose condition results in some degree of functional or activity limitation. There is limited information in South Africa and other low- and middle-income countries with regard to the percentage of such children that access specialist health and special educational services, particularly in an urban setting, and what services exist for them. OBJECTIVES To count the number of children with disabling chronic conditions who were accessing specialist health and special educational services in the Western health subdistrict of Cape Town, and to briefly describe the access to services outside of hospital-based specialist services. METHODS A cross-sectional observational study was conducted between January 2010 and December 2011. The target population included all children <19 years of age with disabling chronic conditions, living in the Western subdistrict of Cape Town, who were accessing specialist health and special educational services. Such children were identified from the relevant referral hospitals, educational institutions, and private and non-profit organisations in the area. RESULTS A total of 1 138 children with disabling chronic conditions were identified. In the context of an under-19 population of 112 249, this corresponds to a rate of 10 per 1 000, whereas the expected rate of children with disabling chronic conditions would be about 50 per 1 000. Only 14% of children in special educational institutions attended specialist paediatric services during a 2-year period. Allied health and medical services for children outside of hospitals were very limited. CONCLUSIONS There are a significant number of children with disabling chronic conditions who do not access health and special educational services in the Western health subdistrict of Cape Town. Medical and allied health support for children in institutions is very limited. Current information systems are inadequate to describe the need.