Prevalence of Poverty and Hunger at Cancer Diagnosis and Its Association with Malnutrition and Overall Survival in South Africa

Many South African children live in poverty and food insecurity; therefore, malnutrition within the context of childhood cancer should be examined. Parents/caregivers completed the Poverty-Assessment Tool (divided into poverty risk groups) and the Household Hunger Scale questionnaire in five pediatric oncology units. Height, weight, and mid-upper arm circumference assessments classified malnutrition. Regression analysis evaluated the association of poverty and food insecurity with nutritional status, abandonment of treatment, and one-year overall survival (OS). Nearly a third (27.8%) of 320 patients had a high poverty risk, associated significantly with stunting (p = 0.009), food insecurity (p < 0.001) and residential province (p < 0.001) (multinomial regression). Stunting was independently and significantly associated with one-year OS on univariate analysis. The hunger scale was significant predictor of OS, as patients living with hunger at home had an increased odds ratio for treatment abandonment (OR 4.5; 95% CI 1.0; 19.4; p = 0.045) and hazard for death (HR 3.2; 95% CI 1.02, 9.9; p = 0.046) compared to those with food security. Evaluating sociodemographic factors such as poverty and food insecurity at diagnosis is essential among South African children to identify at-risk children and implement adequate nutritional support during cancer treatment.

Changes in anthropometrical status and body composition in children with cancer during initial chemotherapy

Children with cancer require adequate nutritional support to prevent malnutrition. This study investigated the impact of chemotherapy on anthropometrical status and body composition during the first six months of treatment. Anthropometrical status and body composition were measured at diagnosis, utilizing standardized protocols and validated S10 InBody bio-electrical impedance (BIA) measurements and compared to subsequent consecutive monthly follow-up measurements to plot changes over time during the first six months. Statistical significance was defined as p < 0.05. Forty-three newly diagnosed children (median age 4 years, IQR: 2.0-7.6; male-female ratio 1:0.9; 53% haematological malignancies and 47% solid tumors) were included. Prevalence of malnutrition varied, with under-nutrition 14% (mid-upper arm circumference (MUAC)/body mass index (BMI)), over-nutrition 9.3% (BMI) and stunting 7% at diagnosis. MUAC (14%) identified fewer participants with underlying muscle store depletion than BIA (41.8%). Chemotherapy exposure acutely exacerbated existing nutritional depletion during the first two months after diagnosis for all variables except fat mass (FM), with contrary effects on cancer type. Haematological malignancies had rapid increases in weight, BMI and FM. All patients had an acute loss of skeletal muscle mass. Nutritional improvement experienced by all cancer types during month two to three of treatment resulted in catch-up growth, with a significant increase in weight (chi2=40.43, p < 0.001), height (chi2=53.79, p < 0.001), BMI (chi2=16.32, p < 0.005), fat free mass (chi2=23.69, p < 0.003) and skeletal muscle mass (chi2=24.19, p < 0.001) after six months. Monthly nutritional assessments, including advanced body composition measurements, are essential to provide timely nutritional interventions to overcome the acute decline in nutritional reserves observed during the first two months of chemotherapy exposure.

Current status of African pediatric oncology education efforts aligned with the Global Initiative for Childhood Cancer

Education of the pediatric oncology workforce is an important pillar of the World Health Organization CureAll technical package. This is not only limited to healthcare workers, but all stakeholders in the childhood cancer management process. It includes governmental structures, academic institutions, parents and communities. This review evaluated the current educational and advocacy training resources available to the childhood cancer community, the contribution of SIOP Africa in the continental educational needs and evaluated future needs to improve the management of pediatric malignancies in reaching the Global Initiative for Childhood Cancer goals. Childhood cancer, unlike adult cancers, has not been prioritized in African cancer control plans nor the teaching and advocacy surrounding pediatric oncology. The availability of formal training programs for pediatric oncologists, pediatric surgeons and radiotherapy specialists are limited to particular countries. In pharmacy and nutritional services, the exposure to pediatric oncology is limited while training in advocacy doesn't exist. Many nonacademic stakeholders are creating the opportunities in Africa to gain experience and train in these various fields, but formal training programs should still be advocated for. LEARNING POINTSThe African continent has various resources to increase the capacity of childhood cancer care stakeholders to increase their knowledge.African pediatric oncology teams rely on a multitude of international sources for training while developing their own.There is a greater need for formal, standardized cancer training especially for pediatric surgeons, radio-oncologists and nurses.Greater inclusion of pathologists, pediatric oncology pharmacists and dieticians into multidisciplinary care and childhood cancer training should be facilitated and resourced.Successful advocacy programs and tool kits exist in parts of Africa, but the training in advocacy is still underdeveloped.

Prevalence of vitamin and iron deficiencies at cancer diagnosis at two pediatric oncology units in South Africa

This study investigates the prevalence of vitamin and iron deficiencies at cancer diagnosis. Newly diagnosed children between October 2018 and December 2020 at two South African pediatric oncology units (POUs) were assessed for nutritional and micronutrient status (Vit A, Vit B12, Vit D, folate, and iron). A structured interview with caregivers provided information regarding hunger and poverty risks. There were 261 patients enrolled with a median age of 5.5 years and a male-to-female ratio of 1:0.8. Nearly half had iron deficiency (47.6%), while a third had either Vit A (30.6%), Vit D (32.6%), or folate (29.7%) deficiencies. Significant associations existed between moderate acute malnutrition (MAM) and low levels of Vit A (48.4%; p = .005), Vit B12 (29.6%; p < .001), and folate (47.3%; p = .003), while Vit D deficiency was associated with wasting (63.6%) (p < .001). Males had significantly lower Vit D levels (respectively, 40.9%; p = .004). Folate deficiency was significantly associated with patients born at full term (33.5%; p = .017), age older than five years (39.8%; p = .002), residing in provinces Mpumalanga (40.9%) and Gauteng (31.5%) (P = .032); as well as having food insecurity (46.3%; p < .001), or hematological malignancies (41.3%; p = .004). This study documents the high prevalence of Vit A, Vit D, Vit B12, folate, and iron deficiency in South African pediatric cancer patients, demonstrating the need to include micronutrient assessment at diagnosis to ensure optimal nutritional support for macro-and micronutrients.

Conference report on the 14th International Society of Paediatric Oncology African Continental Meeting, 16–18 March 2022, Kampala, Uganda

Together with the Africa Continental Branch of the International Society of Paediatric Oncology (SIOP Africa), the Uganda Cancer Institute, a tertiary governmental institution for specialised cancer care services, research and training, hosted the 14th continental meeting of SIOP Africa from the 16–18 March 2022. Under the conference theme, ‘Innovate for Africa’, the hybrid conference brought together close to 400 international delegates to discuss innovations and experiences, as well as share the latest research in the field of paediatric oncology. The World Health Organisation 2030 Global Initiative for Childhood Cancer provided the main starting point for the conference with a comprehensive pre-conference workshop programme, from multiple stakeholders and organisations and the themes for the plenaries towards improving survival to the main breakout sessions. Delegates discussed various ways of improving outcomes in Africa, despite the challenges faced individually and collectively ranging from education, management systems and treatment guidelines to future governmental and NGO involvement in African cancer care. The main achievements of the conference were various commitments for collaboration, investing in junior investigators, development of registries and systems for improved childhood care on the African continent, while working towards greater access to advanced management options such as targeted therapies and bone marrow transplant services.

Reporting Incidences of Neuroblastoma in Various Resource Settings

The incidences of neuroblastoma (NB) differ significantly between various resource settings because of varying quality of cancer registries and underdiagnoses. This study aimed to evaluate current regional variations as reported by international cancer registries and the theoretical and reported differences in international NB incidences and to evaluate South Africa (SA) as a case for variable reporting.

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries

BACKGROUND

The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe.

METHODS

A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries.

RESULTS

Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease.

CONCLUSIONS

Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral.

Assessment of nutritional status in children with cancer: A narrative review

A child's appropriate development stems in large part from proper nutrition. Malnutrition is an adverse prognostic factor in children with cancer, and its prevalence is highly variable. Currently, there is no standardized definition and assessment method of nutritional status in pediatric oncology. A complete nutritional assessment includes anthropometry, biochemical, clinical, and dietary assessments. In this article, we explore these methods and suggest practical approaches for pediatric cancer units depending on the levels of care that these can provide. We also advise on the monitoring and follow-up of children with cancer during and after treatment, and discuss potential areas for future research.

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance

Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives

To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, and Participants

A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes and Measures

Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results

The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions and Relevance

This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.

Exploring the Multiple Meanings of Adaptive Management: A Case Study of the Lachlan Catchment in the Murray-Darling Basin

Managing rivers and sharing their benefits is largely dependent on stakeholder values and knowledge, expressed through policy, governance and institutions. Adaptive management is essentially a social learning process, which can provide a tool to navigate the 'wickedness' of contemporary social-ecological challenges. This research applied an interpretive, qualitative approach to examine government intentions for adaptive management, as expressed in water policy documents, and practitioner experiences of learning through adaptive management in a case study of water management in the Lachlan catchment, Murray-Darling Basin, Australia. Data were created from content analysis of government water policy documents and interviews with key water managing and policy stakeholders. Interview participants attached divergent meanings to the concept of adaptive management. Five different 'styles' of adaptive management were found to coexist in the Lachlan catchment, which were associated with different levels of learning. While some learning was ad hoc, there was also promising evidence of more active adaptive management of environmental flows, which was resulting in higher-level learning. The findings highlight a disconnect between how adaptive management is understood in the academic literature, by practitioners, and how it is portrayed in Australian water policy, which is restricting opportunities for higher-level learning. Transformative learning was found to occur in response to crisis, rather than being linked to an intentional learning process.

Unmet Needs in Nutritional Care in African Paediatric Oncology Units

BACKGROUND

Up to 50% of children diagnosed with cancer in low- and middle-income countries are malnourished, which likely affects survival.

SUBJECTS AND METHODS

An online survey to paediatric oncology units (POUs) in Africa was done regarding nutritional assessment and care.

RESULTS

Sixty-six surveys were received from POUs in 31 countries. Only 44.4% had a dedicated dietician for nutritional assessment and support; 29.6% undertook routine nutritional assessment during treatment. None reported defined criteria for nutritional intervention. Total parenteral nutrition was not available for 42.6% of POUs, while 51.8% did not have access to commercial enteral nutrition for inpatients, and 25.9% of the hospitals could not supply any home-based nutritional supplements.

CONCLUSION

Nutritional assessment in POUs in Africa is neither routinely undertaken nor are there defined criteria to initiate nutritional interventions. Standardized guidelines for nutritional assessment and interventions are needed for African POUs to enable improved outcome.

Highlights from the 13th African Continental Meeting of the International Society of Paediatric Oncology (SIOP), 6-9 March 2019, Cairo, Egypt

The 13th African continental meeting of the international society of paediatric oncology, held on 6-9 March 2019 in Cairo, was organised in collaboration with the Children Cancer Hospital (57357) in Egypt and the global parents' organisation (Childhood Cancer International) and supported by a large international faculty. With 629 delegates from 37 countries (24 African), this was the largest forum of healthcare professionals focused on children and young people with cancer in Africa to showcase advances and discuss further improvements. Three targeted workshops, on nursing care, pharmacy and nutrition, attracted large numbers and catalysed new collaborative initiatives in supportive care studies, extended roles for pharmacists in quality control and care delivery and addressed malnutrition concurrently with cancer treatment. The Collaborative Wilms Tumour Africa Project, open in seven sub-Saharan countries, and the trials in Burkitt's lymphoma reported encouraging outcomes with further initiatives in supportive care (the supportive care for children with cancer in Africa project). While acknowledging deficits in radiotherapy provision, available in only 23 of 52 African countries, centres with facilities reported their technical advances that benefit patients. Of great importance for children with brain tumours, who are underdiagnosed in Africa, was the first announcement of African paediatric neuro-oncology society, whose 63 current members aim to tackle the shortage of neurosurgeons through training fellowships, workshops and a dedicated conference. The congress provided the opportunity to discuss how African countries will work with the WHO global initiative aiming to improve childhood cancer survival to 60% in all countries by 2030. This conference report is dedicated to the three Kenyan delegates who died tragically on the Ethiopian Airlines flight ET302 on their way home, full of new ideas and pride in what they had achieved so far. All those who heard their presentations are determined to continue their excellent work to improve cancer care for children in Africa.

Ventriculoperitoneal shunting in childhood tuberculous meningitis

Hydrocephalus is a common complication of tuberculous meningitis (TBM) in children. In this study, 217 patients with stage II and III TBM and hydrocephalus (TBMH) were reviewed. Ventriculoperitoneal shunting (VPS) was performed in the acute stage if the hydrocephalus was non-communicating or following failed medical therapy if the hydrocephalus was communicating. Following this protocol only 65 of 217 (29.9%) patients eventually required VPS. Non-communicating hydrocephalus was present in 38 of 65 (58.5%) and communicating hydrocephalus in 27 of 65 (41.5%) of the shunted cases. These 65 cases were followed for 6 months and their outcome assessed. Good outcome or moderate disability was seen in 55.4% and 12.3% died. Different factors relating to outcome are discussed. The shunted patients in this study had a high complication rate of 32.3%, with shunt infection and shunt obstruction each occurring in 9 of 65 (13.5%) of cases. TBM complicated by hydrocephalus remains a devastating condition and VPS in these patients has a high complication rate. Identifying those patients who may be managed without shunting will save costs and reduce complications, however early VPS in patients with non-communicating hydrocephalus is still indicated.

Bacterial vaginosis diagnosed at the first antenatal visit better predicts preterm labour than diagnosis later in pregnancy

This study was conducted as part of a double-blind randomised placebo-controlled trial, the aim of which was to determine whether vitamin C could reduce the recurrence risk of pre-term labour. In this study, women with a history of pre-term labour in a preceding pregnancy were randomised to receive either 250 mg vitamin C or a matching placebo twice daily until 34 weeks' gestation. They attended a dedicated pre-term labour clinic every 2 weeks. All women were screened for bacterial vaginosis (BV) at each visit. It was first determined that vitamin C did not have any effect on the presence of BV. Women who were diagnosed with BV before 20 weeks' gestation were at higher risk of delivering pre-term than those who developed BV after 20 weeks.

A randomised, double-blind placebo-controlled trial of ascorbic acid supplementation for the prevention of preterm labour

In a previous study from this institution, patients at high risk for preterm labour were screened for the presence of bacterial vaginosis (BV). When BV was present, they were randomised to receive either treatment (metronidazole) or placebo (vitamin C). There were significantly more patients with preterm labour in the metronidazole group. The aim of this double-blind randomised placebo-controlled trial study was to determine whether vitamin C could indeed reduce the recurrence risk of preterm labour. Patients with a history of preterm labour in a preceding pregnancy were randomised to receive 250 mg vitamin C or a matching placebo twice daily until 34 weeks' gestation. They attended a dedicated premature labour clinic. Significantly more women delivered before term in the group that received vitamin C, but there was no difference in the outcome of the babies between the two groups. Supplementation with vitamin C did not prevent premature labour.

Long-term follow up of childhood tuberculous meningitis

The purpose of the present study was to determine the long-term outcome of 76 children (40 females and 36 males) diagnosed and treated with modern antituberculosis drugs. The median age of the children on admission was 29.5 months and on follow-up 9 years. Antituberculosis therapy consisted of daily isoniazid (20 mg/kg), rifampicin (20 mg/kg), ethionamide (20 mg/kg), and pyrazinamide (40 mg/kg) for 6 months. Twenty-three children received daily prednisone (2-4 mg/kg) for the first month of treatment. Raised intracranial pressure was actively monitored and treated. Patients with non-communicating hydrocephalus received ventriculo-peritoneal shunts shortly after admission while communicating hydrocephalus was treated with oral acetazolamide (100 mg/kg/day) and furosemide (1 mg/kg/day) in 3-4 divided doses. Communicating hydrocephalus that did not respond to this regimen within the first month of treatment also underwent ventriculo-peritoneal shunting. Only 20% of children were functionally completely normal at follow-up. Main areas of functional deficit were cognitive impairment (80%), poor scholastic progress (43%), and emotional disturbance (40%). Twenty-five per cent of children had evidence of motor impairment, but all could walk and only 5 of 76 children (6% of total) were unable to run. One child was blind but no child had sensori-neural deafness. It was concluded that these disabilities in children from mainly deprived socioeconomic backgrounds have serious implications for their future social, academic, and career prospects. A high index of suspicion of TBM in high tuberculosis incidence communities will help prevent the morbidity documented in this study.

Preterm labour--is Mycoplasma hominis involved?

OBJECTIVE

To assess whether Mycoplasma hominis is associated with preterm labour in primigravidae and multigravidae with previous midtrimester abortion or preterm labour.

DESIGN

Cohort analytical study.

SETTING

Tygerberg Hospital, a tertiary academic hospital in the Western Cape.

METHODS

Gram's stains were done on smears taken from the posterior vaginal fornix, at the first antenatal visit, between 16 and 26 weeks' gestation, in primigravidae and multigravidae at risk for preterm labour. Cultures for M. hominis and other commonly occurring organisms were done from endocervical swabs taken at the same visit. The outcome of pregnancy in mothers with positive cultures for M. hominis was then compared with outcome in women with negative cultures.

OUTCOME MEASURES

Prevalence of Chlamydia trachomatis, Ureaplasma urealyticum, bacterial vaginosis and preterm delivery, birth weight and perinatal deaths.

RESULTS

Cultures for M. hominis were positive in 83 patients (21%) and negative in 312 (79%). Significantly more mothers in the positive group (40%) delivered before 37 weeks' gestation than in the negative group (28%, P = 0.0313). Their babies weighed significantly less (2,669 g v. 2,864 g, P = 0.0141). The positive group was also associated with more alcohol use in pregnancy and fewer of them were married. C. trachomatis was found in 18% of mothers in the positive group but in 8% of the negative group (P = 0.0082). U. urealyticum was cultured in 96% of mothers in the positive group in contrast to 81% in the negative group (P = 0.001). Bacterial vaginosis was observed on 75% of mothers with positive cultures for M. hominis but in 22% with negative cultures (P = 0.00001, odds ratio 10.21, 95% confidence interval: 5.63-18.65).

CONCLUSION

Positive culture for M. hominis was associated with more preterm deliveries and also with a higher frequency of C. trachomatis, U. urealyticum and bacterial vaginosis.

Preterm labour--is bacterial vaginosis involved?

OBJECTIVE

To assess the efficacy of treatment of bacterial vaginosis (BV) using metronidazole to reduce preterm labour in primigravidae and multigravidae with previous midtrimester abortion or preterm labour.

DESIGN

Randomised controlled trial.

SETTING

Tertiary academic hospital.

METHOD

Two different groups of patients were screened for BV at the first antenatal visit, namely primigravidae and high-risk multigravidae who had had a previous midtrimester abortion or preterm delivery. Patients where BV was diagnosed clinically or on Gram's stain of a smear taken from the posterior vaginal fornix, received either 400 mg metronidazole, or 100 mg vitamin C orally twice daily for 2 days. The Gram's stain was repeated after 4 weeks. If BV was found again, treatment with the same drug was repeated.

OUTCOME MEASURES

Preterm delivery, birth weight and perinatal deaths.

RESULTS

One thousand and five patients entered the study, but 40 were excluded for various reasons and 10 were lost to follow-up. There were 464 primigravidae, of whom 150 (32%) had BV. Except for the 5-minute Apgar score, no significant differences were found between primigravidae negative for BV and those who received either metronidazole or vitamin C. There were 491 high-risk multigravidae, of whom 127 (26%) had BV. The mean gestational age in the BV-negative group was 37 weeks, in contrast to 37.4 weeks in the vitamin C group and 35.6 weeks in the metronidazole group. Birth weights in these three groups were 2,752 g, 2,759 g and 2,475 g respectively, significantly less (P = 0.0109) in the metronidazole group in comparison with the BV-negative group. Delivery before 37 weeks occurred in 29% of high-risk multigravidae with no BV but in 24% of those who took vitamin C and in 43% who took metronidazole. Differences were significant between the BV-negative and metronidazole groups (P = 0.0231) and also between the metronidazole and vitamin C groups (P = 0.0274). Delivery before 28 weeks occurred in 4% of the high-risk multigravidae with no BV but in 10% of those with BV who took metronidazole. The difference was significant (P = 0.0430). Analysis for maximum likelihood estimates for preterm labour identified only previous preterm labour or midtrimester abortion as risk factors.

CONCLUSION

Metronidazole does not seem to reduce the prevalence of preterm labour when given for BV before 26 weeks' gestation.

Tuberculous hydrocephalus: comparison of different treatments with regard to ICP, ventricular size and clinical outcome

The effect of different treatment regimes on intracranial pressure (ICP), degree of hydrocephalus and clinical outcome was evaluated in 81 children with tuberculous meningitis. 24 children underwent CSF shunting, while 57 with communicating hydrocephalus were randomly assigned to three treatment groups: antituberculous drugs only; or additional intrathecal hyaluronidase or oral acetazolamide and furosemide in addition to antituberculous treatment. The addition of acetazolamide and furosemide was significantly more effective in achieving normal ICP than antituberculous drugs alone. No difference was found in mortality or number of disabled survivors between groups. Of those surviving, nearly two-thirds with stage II tuberculous meningitis were mildly disabled and nearly one-half with stage III were severely disabled at follow-up, emphasising the need for early diagnosis of tuberculous meningitis in the young child.

MR of childhood tuberculous meningitis

MR imaging was performed on 27 children with stage II-III tuberculous meningitis for the specific purpose of examining the brainstem, as well as comparison with other CT features of the disease. In addition to defining the ischemic disturbances of basal ganglia and diencephalon more clearly, MR also demonstrates the frequent occurrence of parenchymal signal abnormalities in the brainstem and adjacent temporal lobes, which are invisible or uncertain on CT. Although the presence of brainstem abnormalities on MR correlated well with clinical findings of brainstem dysfunction, clinical staging on admission remains the best prognostic indicator in advanced TBM. We also review the MR features of basal exudation, hydrocephalus and tuberculoma.