Biomedical subjects
Publications and source records attributed to J D Vince.
An interesting case of a multifocal Langerhans cell granulomatosis in an 18-mo-old female child is described. The diagnosis was confirmed by fine-needle aspiration cytology. The unusual findings at the initial stage of the disease and its possible etiopathogenesis are discussed.
Anthropometrical indices of 66 school children aged between 7 and 9 years from a community with a very high prevalence of non-insulin dependent diabetes mellitus (NIDDM) were compared with those of age and sex matched school children from two low prevalence communities. Two way analysis of variance indicated that case children of both sexes were significantly lighter (P < 0.001), shorter (P < 0.001) and had lower body mass indices (BMI) (P < 0.001) than their comparisons but had greater triceps skinfold thickness (TSFT) (P = 0.01). These differences may be a reflection of subtle changes in metabolism in children destined, without intervention, to develop NIDDM. Anthropometrical indices may therefore have a role to play in the prediction of future disease. Although not the prime objective of the study, an analysis of available birth weights indicated a lower mean birth weight for the cases than the controls (difference of means, 0.35 kg; 95% confidence intervals (CI95%). 0.13-0.57). This finding is consistent with the theory that impaired intrauterine growth may predispose to NIDDM.
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National data for diarrhoeal disease in children can only be used as a very rough guide to morbidity and mortality, since they are based on incomplete reporting. Furthermore, when only one diagnosis per attendance, admission or cause of death is recorded, the true importance of diarrhoea as a cause of morbidity and mortality may be obscured. This may in part explain discrepancies between figures recorded in national and hospital statistics and those recorded in detailed studies of diarrhoeal admissions. While there appear to be quite marked differences in the relative importance of diarrhoea in different parts of the country, and while diarrhoeal disease is less of a scourge than in some other parts of the world, it is nevertheless a major cause of attendance at health facilities, the second or third most common cause of admission to many of the hospitals in the country, and a significant and often preventable cause of death. Limited studies of diarrhoeal aetiology indicate the major importance of rotavirus, Shigella and enteropathogenic and enterotoxigenic Escherichia coli. The control of diarrhoeal diseases in children is based not only on early and appropriate treatment, but also on preventive strategies. These include breastfeeding (which has saved the lives of many thousands of Papua New Guinean children and which is once again under threat), ensuring good host defence by good nutrition, immunization and early treatment of childhood illness, and ensuring satisfactory sanitation and hygiene. Increasing fluid intake to prevent dehydration remains the most important part of the early management of acute diarrhoeal disease. In the management of children with dehydration, UNICEF glucose-based oral rehydration therapy is widely available but not used as well as it should be. There are significant advantages in cereal-based oral rehydration solutions, and the use of such solutions, locally prepared, should be encouraged. Breastfeeding should be continued during episodes of diarrhoea, unless there is the specific contraindication of lactose intolerance. In all events the child's nutritional intake should be maintained and if possible increased during episodes of diarrhoea. There are specific indications for the use of antibiotics in the management of children with diarrhoea. They should not be used, and may be harmful, in the absence of these indications. Persistent diarrhoea--lasting more than 14 days--is associated with a high mortality and severe malnutrition. It is therefore important that children whose diarrhoea is prolonged for more than 7 days are managed appropriately, using the standard guidelines.
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A cross-sectional analysis of the prevalence of hepatitis B surface antigenaemia in cord blood from 50 newborn babies and in blood from 415 children admitted to the children's ward of Port Moresby General Hospital indicates that perinatal vertical transmission is likely to be important and that there is a high rate of horizontal transmission in the 1st few years of life. Thirteen per cent of infants aged 3-5 months and 29-30% of those over 2 years of age were strongly positive for hepatitis B surface antigen. Open sores and poor hygiene are likely to play a significant role in the high level of horizontal transmission of hepatitis B virus (HBV) in our context. Our findings give support and urgency to the current active immunization policy against HBV, beginning as soon as possible after birth.
We report a case of snake bite complicated by tourniquet induced ischaemic damage and rhabdomyolysis causing acute renal failure. The case highlights the dangers of tourniquet use and of sudden release. We outline measures which can be taken to minimize morbidity in such patients.
We report a prospective study of 108 children aged from 2 weeks to 10 years with purulent meningitis admitted to the children's wards of Port Moresby General Hospital, 105 of whom were treated with a standard management regimen using chloramphenicol (given intramuscularly initially) as the only antibiotic. The case fatality rate of 16.7% and the apparently low morbidity rate were felt to be very satisfactory in a high risk population. The medical officers' compliance with the standard antibiotic regimen was good, but was disappointing for the use of anticonvulsants. The presence of convulsions before admission or at any time in the illness, coma on admission, and a history of illness of more than 3 days duration prior to admission were strongly associated with death. We believe phenobarbitone should be given prophylactically to children less than 2 years of age who have meningitis. Further improvements in outcome are likely to be achieved not by changes in antibiotic policy but by improving early diagnosis and basic supportive care, and by preventing convulsions.
Malaria is a major problem in children in many parts of Papua New Guinea; it has a high mortality and, if observations from other countries are applicable, significant long-term morbidity. Standard treatment regimens are the backbone of management of malaria throughout the country, but these must continue to be reviewed and updated in the face of changing patterns of parasite drug sensitivity. Diagnosis of malaria will for practical purposes remain primarily clinical for the foreseeable future. There is a need for uniform reporting of malaria statistics using the established definitions of uncomplicated, treatment failure and severe malaria, in order to assess incidence and outcome throughout the country, and to compare malaria patterns and outcome in Papua New Guinea with those in other parts of the world. Congenital malaria should always be considered in a febrile or ill neonate. Awareness of the complications of severe malaria, particularly hypoglycaemia, needs to be increased. Methods for the diagnosis and facilities for treatment of hypoglycaemia should be widely available. The characteristics of those children most at risk from hypoglycaemia need elucidation, and the current standard management regimen for severe malaria needs to be assessed for its propensity both to cause and to prevent hypoglycaemia. It would be reasonable to incorporate phenobarbitone prophylaxis of convulsions into the standard management regimen for cerebral malaria.
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Analysis of 100 unselected paired maternal and cord blood samples showed 11 mothers to be HBsAg positive and 6 of these to be also HBeAg positive. 5 cord blood samples were HBsAg positive and 3 were HBeAg positive. Assuming a protective efficacy rate of 75%, the present plasma-derived hepatitis B virus vaccine control program is likely to prevent the perinatal acquisition of the hepatitis B virus carrier state in 27 per 1000 children. The addition of immunoglobulin prophylaxis would be likely to reduce this by another 5 per 1000, but its use does not appear practicable at the present time.
We report on two sisters and their brother, all of whom are affected by McKusick-Kaufman syndrome. This sibship confirms autosomal recessive inheritance and the occurrence of the syndrome in Melanesians. It also demonstrates multisystem involvement in both sexes and illustrates difficulties in the diagnosis and management of hydrocolpos.
Data from the Papua New Guinea Tumour Registry and the Central Pathology Department were reviewed in order to document the incidence and pattern of malignancies in children in Papua New Guinea. Altogether, 680 cases of histologically defined childhood malignancies were recorded during the 14.5 years from 1971 to 1985. The frequencies of the various tumours were compared with past data and with published data from other countries. The incidence of malignancies in Papua New Guinean children appeared to be low, 36.5/1,000,000/year, with a male:female ratio of 1.6:1. Lymphoma was the most commonly occurring tumour and Burkitt's tumour accounted for 53% in this group. The relative frequency of leukaemia compared with lymphoma appeared to have increased since a previous report. A relatively high incidence of retinoblastoma (6.9%) and of other embryonal tumours (4.8%) was recorded, whilst the recorded incidences of tumours of the central nervous system (3.8%) and neuroblastoma (3.7%) were low. Ewing's sarcoma accounted for almost half of the bone tumours, whilst Kaposi's sarcoma was a relatively frequent soft tissue tumour. Differences and similarities between the Papua New Guinea data and those from other countries are discussed.
The case reports of 54 patients from 2 to 16 years of age admitted with snake bite to Port Moresby General Hospital, Papua New Guinea, over a period of 38 months were reviewed. The case fatality rate was 7.7%. The commonest pattern of toxicity was a combination of neurological deficit and coagulation disturbance, but other patterns were recorded. Treatment included antivenom in 49 patients and endotracheal intubation in 16. The response to treatment was analysed to discover factors associated with a complicated course or a fatal outcome. Early administration of antivenom reduced the need for intubation. Reactions to antivenom were reduced by the use of hydrocortisone and promethazine together. Children 5 years of age or less formed a high risk group. Recommendations are made concerning the use of antivenom, hydrocortisone plus promethazine, and intubation, which may result in the saving of both lives and money.
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The pattern of early neonatal serum bilirubin levels in a population of normal fullterm healthy Melanesian babies was determined. The mean (and standard deviation) of cord blood serum bilirubin from 98 babies was 1.2 (1.4) mg/dl (20.5 (23.9) mumol/l). Between 24 and 60 h of age the mean serum bilirubin from 99 babies was 8 (3.5) mg/dl (136.8 (59.85) mumol/l). Seventeen babies excluded from the main study group because of factors known to predispose to neonatal jaundice had a mean serum bilirubin of 10.7 mg/dl (183 mumol/l). In the early neonatal period, Melanesian babies have a mean serum bilirubin level higher than that reported for Caucasian but lower than that reported for Asian babies. Genetic factors are the most likely explanation for these differences.