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Bangirana P, Boehme AK, Birabwa A, Opoka RO, Munube D, Mupere E, Kasirye P, Muwanguzi G, Musiimenta M, Ru G, Green NS, Idro R. Neurocognitive Impairment in Ugandan Children with Sickle Cell Anemia Compared to Sibling Controls: A cross-sectional study. medRxiv 2024:2023.11.09.23298329. [PMID: 38014206 PMCID: PMC10680894 DOI: 10.1101/2023.11.09.23298329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Introduction Neurocognitive function in Ugandan children aged 1-12 years with sickle cell anemia (SCA) were compared to their non-SCA siblings to identify risk factors for disease-associated impairment. Methods This cross-sectional neurocognitive function study of children with SCA (N=242) and non-SCA siblings (N=127) used age- and linguistically-appropriate standardized tests of cognition, executive function and attention for children ages 1-4 and 5-12 years. Test scores were converted to locally derived age-normalized z-scores. The SCA group underwent standardized stroke examination for prior stroke and transcranial doppler ultrasound (TCD) to determine stroke risk by arterial flow velocity. Results The SCA group was younger than siblings (mean ages 5.46±3.0 versus 7.11±3.51 years, respectively; p <.001), with lower hemoglobin concentration (7.32±1.02 vs. 12.06±1.42, p <.001). Overall cognitive SCA z-scores were lower: -0.73 ±0.98 vs. siblings -0.25 ±1.12 (p<.001), with comparable findings for executive function of -1.09±0.94 versus -0.84±1.26 (p=0.045), respectively. Attention z-scores for ages 5-12 for the SCA group and controls were similar: -0.37±1.4 vs. -0.11±0.17 (p=.09). Overall differences by SCA status were largely driven by the older age group, as z-scores in the younger sub-sample did not differ from controls. Analyses revealed the strongest predictors of poor neurocognitive outcomes among the SCA sample to be the disease, age and prior stroke (each p<.001). Impact from anemia and SCA were indistinguishable. Discussion Neurocognitive testing in children with SCA compared to non-SCA siblings revealed poorer SCA-associated functioning in children older than age 4. Results indicate need for trials assessing impact from disease modification for children with SCA.
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Affiliation(s)
- Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Amelia K. Boehme
- Department of Neurology, Columbia University Vagelos Medical Center, New York, United States
| | - Annet Birabwa
- Department of Mental Health and Community Psychology, Makerere University College of Social Sciences, Kampala, Uganda
| | - Robert O. Opoka
- Global Health Uganda, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Deogratias Munube
- Global Health Uganda, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Phillip Kasirye
- Directorate of Paediatrics and Child Health, Mulago National Referral Hospital
| | | | | | - George Ru
- Department of Pediatrics, Columbia University Vagelos Medical Center, New York, United States
| | - Nancy S. Green
- Department of Pediatrics, Columbia University Vagelos Medical Center, New York, United States
| | - Richard Idro
- Global Health Uganda, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
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Datta D, Gopinadhan A, Soto A, Bangirana P, Opoka RO, Conroy AL, Saykin AJ, Kawata K, John CC. Blood biomarkers of neuronal injury in paediatric cerebral malaria and severe malarial anaemia. Brain Commun 2023; 5:fcad323. [PMID: 38075948 PMCID: PMC10710298 DOI: 10.1093/braincomms/fcad323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/04/2023] [Accepted: 11/25/2023] [Indexed: 02/12/2024] Open
Abstract
Persistent neurodisability is a known complication in paediatric survivors of cerebral malaria and severe malarial anaemia. Tau, ubiquitin C-terminal hydrolase-L1, neurofilament-light chain, and glial fibrillary acidic protein have proven utility as biomarkers that predict adverse neurologic outcomes in adult and paediatric disorders. In paediatric severe malaria, elevated tau is associated with mortality and neurocognitive complications. We aimed to investigate whether a multi-analyte panel including ubiquitin C-terminal hydrolase-L1, neurofilament-light chain, and glial fibrillary acidic protein can serve as biomarkers of brain injury associated with mortality and neurodisability in cerebral malaria and severe malarial anaemia. In a prospective cohort study of Ugandan children, 18 months to 12 years of age with cerebral malaria (n = 182), severe malarial anaemia (n = 158), and asymptomatic community children (n = 118), we measured admission blood levels of ubiquitin C-terminal hydrolase-L1, neurofilament-light chain, and glial fibrillary acidic protein. We investigated differences in biomarker levels, associations with mortality, blood-brain barrier integrity, neurodeficits and cognitive Z-scores in survivors up to 24-month follow-up. Admission ubiquitin C-terminal hydrolase-L1 levels were elevated >95th percentile of community children in 71 and 51%, and neurofilament-light chain levels were elevated >95th percentile of community children in 40 and 37% of children with cerebral malaria and severe malarial anaemia, respectively. Glial fibrillary acidic protein was not elevated in disease groups compared with controls. In cerebral malaria, elevated neurofilament-light chain was observed in 16 children who died in hospital compared with 166 survivors (P = 0.01); elevations in ubiquitin C-terminal hydrolase-L1 levels were associated with degree of blood-brain barrier disruption (P = 0.01); and the % predictive value for neurodeficits over follow-up (discharge, 6-, 12-, and 24 months) increased for ubiquitin C-terminal hydrolase-L1 (60, 67, 72, and 83), but not neurofilament-light chain (65, 68, 60, and 67). In cerebral malaria, elevated ubiquitin C-terminal hydrolase-L1 was associated with worse memory scores in children <5 years at malaria episode who crossed to over 5 years old during follow-up cognitive testing [β -1.13 (95% confidence interval -2.05, -0.21), P = 0.02], and elevated neurofilament-light chain was associated with worse attention in children ≥5 years at malaria episode and cognitive testing [β -1.08 (95% confidence interval -2.05, -1.05), P = 0.03]. In severe malarial anaemia, elevated ubiquitin C-terminal hydrolase-L1 was associated with worse attention in children <5 years at malaria episode and cognitive testing [β -0.42 (95% confidence interval -0.76, -0.07), P = 0.02]. Ubiquitin C-terminal hydrolase-L1 and neurofilament-light chain levels are elevated in paediatric cerebral malaria and severe malarial anaemia. In cerebral malaria, elevated neurofilament-light chain is associated with mortality whereas elevated ubiquitin C-terminal hydrolase-L1 is associated with blood-brain barrier dysfunction and neurodeficits over follow-up. In cerebral malaria, both markers are associated with worse cognition, while in severe malarial anaemia, only ubiquitin C-terminal hydrolase-L1 is associated with worse cognition.
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Affiliation(s)
- Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Adnan Gopinadhan
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Alejandro Soto
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Global Health Uganda, P.O. Box 33842, Kampala, Uganda
| | - Robert O Opoka
- Global Health Uganda, P.O. Box 33842, Kampala, Uganda
- Aga Khan University Medical College, P.O. Box 30270, Nairobi, Kenya
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Andrew J Saykin
- Indiana Alzheimer’s Disease Research Center and Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Keisuke Kawata
- Department of Kinesiology, Indiana University School of Public Health-Bloomington, Bloomington, IN 47405, USA
- Program in Neuroscience, The College of Arts and Sciences, Indiana University, Bloomington, IN 47405, USA
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Lima-Cooper G, Ouma BJ, Datta D, Bond C, Soto AA, Conroy AL, Park GS, Bangirana P, Joloba ML, Opoka RO, Idro R, John CC. Apolipoprotein-E4: risk of severe malaria and mortality and cognitive impairment in pediatric cerebral malaria. Pediatr Res 2023:10.1038/s41390-023-02912-8. [PMID: 38007518 DOI: 10.1038/s41390-023-02912-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/21/2023] [Accepted: 11/02/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND The relationship of apolipoprotein-E4 (APOE4) to mortality and cognition after severe malaria in children is unknown. METHODS APOE genotyping was performed in children with cerebral malaria (CM, n = 261), severe malarial anemia (SMA, n = 224) and community children (CC, n = 213). Cognition was assessed over 2-year follow-up. RESULTS A greater proportion of children with CM or SMA than CC had APOE4 (n = 162, 31.0%; n = 142, 31.7%; n = 103, 24.2%, respectively, p = 0.02), but no difference was seen in APOE3 (n = 310, 59.4%; n = 267, 59.6%; n = 282, 66.2%, respectively, p = 0.06), or APOE2 (n = 50, 9.6%; n = 39, 8.7%; and n = 41, 9.6%, respectively, p = 0.87). APOE4 was associated with increased mortality in CM (odds ratio, 2.28; 95% CI, 1.01, 5.11). However, APOE4 was associated with better long-term cognition (ß, 0.55; 95% CI, 0.04, 1.07, p = 0.04) and attention (ß 0.78; 95% CI, 0.26, 1.30, p = 0.004) in children with CM < 5 years old, but worse attention (ß, -0.90; 95% CI, -1.69, -0.10, p = 0.03) in children with CM ≥ 5 years old. Among children with CM, risk of post-discharge malaria was increased with APOE4 and decreased with APOE3. CONCLUSIONS APOE4 is associated with higher risk of CM or SMA and mortality in children with CM, but better long-term cognition in CM survivors <5 years of age.
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Affiliation(s)
- Giselle Lima-Cooper
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Benson J Ouma
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Dibyadyuti Datta
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Caitlin Bond
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alejandro A Soto
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gregory S Park
- Office of the Vice President for Research, University of Minnesota, Minneapolis, MN, USA
| | - Paul Bangirana
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Moses L Joloba
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Robert O Opoka
- Department of Pediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Richard Idro
- Department of Pediatrics and Child Health, Makerere University, Kampala, Uganda
- Nuffield Department of Medicine, Centre of Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Chandy C John
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA.
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Green NS, Rosano C, Bangirana P, Opoka R, Munube D, Kasirye P, Kawooya M, Lubowa SK, Mupere E, Conroy A, Minja FJ, Boehme AK, Kang MS, Honig LS, Idro R. Neurofilament light chain: A potential biomarker for cerebrovascular disease in children with sickle cell anaemia. Br J Haematol 2023; 203:460-467. [PMID: 37581299 PMCID: PMC10615726 DOI: 10.1111/bjh.19036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/23/2023] [Accepted: 08/01/2023] [Indexed: 08/16/2023]
Abstract
Cerebrovascular injury frequently occurs in children with sickle cell anaemia (SCA). Limited access to magnetic resonance imaging and angiography (MRI-MRA) in sub-Saharan Africa impedes detection of clinically unapparent cerebrovascular injury. Blood-based brain biomarkers of cerebral infarcts have been identified in non-SCA adults. Using plasma samples from a well-characterized cross-sectional sample of Ugandan children with SCA, we explored relationships between biomarker levels and MRI-detected cerebral infarcts and transcranial Doppler (TCD) arterial velocity. Testing was performed using a 4-plex panel of brain injury biomarkers, including neurofilament light chain (NfL), a central nervous system neuron-specific protein. Mean biomarker levels from the SCA group (n = 81) were similar to those from non-SCA sibling controls (n = 54). Within the SCA group, NfL levels were significantly higher in those with MRI-detected infarcts compared to no infarcts, and higher with elevated TCD velocity versus normal velocity. Elevated NfL remained strongly associated with MRI-detected infarcts after adjusting for sex and age. All non-SCA controls and SCA participants lacking MRI-detected infarcts had low NfL levels. These data suggest potential utility of plasma-based NfL levels to identify children with SCA cerebrovascular injury. Replication and prospective studies are needed to confirm these novel findings and the clinical utility of NfL versus MRI imaging.
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Affiliation(s)
- Nancy S Green
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Caterina Rosano
- Department of Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Robert Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Deogratias Munube
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Philip Kasirye
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Michael Kawooya
- Department of Radiology, Makerere University College of Health Sciences, Kampala, Uganda
- Ernest Cook Ultrasound Research and Education Institute (ECUREI), Mengo Hospital, Kampala, Uganda
| | - Samson K Lubowa
- Department of Radiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrea Conroy
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Frank J Minja
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amelia K Boehme
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Min Suk Kang
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Lawrence S Honig
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
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Nalugya JS, Skylstad V, Babirye JN, Ssemata AS, Ndeezi G, Bangirana P, Engebretsen IMS, Nakasujja N. "She gives it to her child who doesn't even talk": a qualitative exploration of alcohol and drug use among primary school-age children in Uganda. BMC Public Health 2023; 23:2114. [PMID: 37891544 PMCID: PMC10605311 DOI: 10.1186/s12889-023-17016-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND There is little research on alcohol and other drugs (AOD) use by school-age children in low-resource settings like Uganda. Including the voices of children in research can inform prevention and early intervention efforts for those at risk of AOD use. The aim of this study was to understand the perspectives of children aged 6 to 13 years regarding AOD in Uganda. METHODS This qualitative study was conducted in Mbale district, Uganda from February to March 2020. Eight focus group discussions (FGDs) were conducted with 56 primary school-age children, stratified by age (6-9 and 10-13 years), sex (male and female), and school status (in school and out of school). All FGDs were conducted in either Lumasaaba or Luganda. The FGDs were audio-recorded, transcribed verbatim, and translated into English. Data were coded, and overarching themes were identified using thematic framework analysis. RESULTS Two themes identified were (1) Children's perceptions and experiences with AODs. The participants understood alcohol by its consistency, colour, odour, and by brand/logo. They described the types and quantities of AOD consumed by school-age children, brewing processes for homemade alcoholic drinks, and short and long-term consequences of the use of alcohol. (2) Contributing factors to childhood drinking included: Stress relief for children who experienced multiple adversities (orphaned, poverty-stricken, and hailing from broken homes), fitting in with friends, influence from families, and media exposure that made alcohol look cool. Children would start drinking at an early age) or were given alcohol by their parents, sometimes before they could start talking. In the community, alcohol and other drugs were cheap and available and children could drink from anywhere, including in the classroom. CONCLUSIONS Children eligible for primary education in Uganda can easily access and use AOD. Several factors were identified as contributing to alcohol and other drug use among children, including availability and accessibility, advertising, lack of parental awareness and supervision, peer influence, adverse childhood experiences, socioeconomic factors, and cultural norms. There is a need for multi-sectoral action for awareness of childhood AOD use and deliberate consideration of children in the planning, design, and implementation of research, policies, and programs for prevention and early intervention.
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Affiliation(s)
- Joyce Sserunjogi Nalugya
- Department of Psychiatry, Mulago National Referral and Teaching Hospital, Ministry of Health, Kampala, Uganda.
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.
- Centre for International Health, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway.
| | - Vilde Skylstad
- Centre for International Health, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Juliet N Babirye
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew Sentoogo Ssemata
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Grace Ndeezi
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ingunn M S Engebretsen
- Centre for International Health, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Noeline Nakasujja
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Clark DJ, Bond C, Andrews A, Muller DJ, Sarkisian A, Opoka RO, Idro R, Bangirana P, Witten A, Sausen NJ, Birbeck GL, John CC, Postels DG. Admission Clinical and EEG Features Associated With Mortality and Long-term Neurologic and Cognitive Outcomes in Pediatric Cerebral Malaria. Neurology 2023; 101:e1307-e1318. [PMID: 37541845 PMCID: PMC10558167 DOI: 10.1212/wnl.0000000000207657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 06/02/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES For children with cerebral malaria, mortality is high, and in survivors, long-term neurologic and cognitive dysfunctions are common. While specific clinical factors are associated with death or long-term neurocognitive morbidity in cerebral malaria, the association of EEG features with these outcomes, particularly neurocognitive outcomes, is less well characterized. METHODS In this prospective cohort study of 149 children age 6 months to 12 years who survived cerebral malaria in Kampala, Uganda, we evaluated whether depth of coma, number of clinical seizures, or EEG features during hospitalization were associated with mortality during hospitalization, short-term and long-term neurologic deficits, or long-term cognitive outcomes (overall cognition, attention, memory) over the 2-year follow-up. RESULTS Higher Blantyre or Glasgow Coma Scores (BCS and GCS, respectively), higher background voltage, and presence of normal reactivity on EEG were each associated with lower mortality. Among clinical and EEG features, the presence of >4 seizures on admission had the best combination of negative and positive predictive values for neurologic deficits in follow-up. In multivariable modeling of cognitive outcomes, the number of seizures and specific EEG features showed independent association with better outcomes. In children younger than 5 years throughout the study, seizure number and presence of vertex sharp waves were independently associated with better posthospitalization cognitive performance, faster dominant frequency with better attention, and higher average background voltage and faster dominant background frequency with better associative memory. In children younger than 5 years at CM episode but 5 years or older at cognitive testing, seizure number, background dominant frequency, and the presence of vertex sharp waves were each associated with changes in cognition, seizure number and variability with attention, and seizure number with working memory. DISCUSSION In children with cerebral malaria, seizure number is strongly associated with the risk of long-term neurologic deficits, while seizure number and specific EEG features (average background voltage, dominant rhythm frequency, presence of vertex sharp waves, presence of variability) are independently associated with cognitive outcomes. Future studies should evaluate the predictive value of these findings.
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Affiliation(s)
- Daniel J Clark
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi.
| | - Caitlin Bond
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Alexander Andrews
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Daniel J Muller
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Angela Sarkisian
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Robert O Opoka
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Richard Idro
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Paul Bangirana
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Andy Witten
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nicholas J Sausen
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Gretchen L Birbeck
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Chandy C John
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Douglas G Postels
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
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7
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Ssemata AS, Nakitende AJ, Kizito S, Thomas MR, Islam S, Bangirana P, Nakasujja N, Yang Z, Yu Y, Tran TM, John CC, McHenry MS. Association of severe malaria with cognitive and behavioural outcomes in low- and middle-income countries: a meta-analysis and systematic review. Malar J 2023; 22:227. [PMID: 37537555 PMCID: PMC10401769 DOI: 10.1186/s12936-023-04653-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 07/22/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Malaria affects 24 million children globally, resulting in nearly 500,000 child deaths annually in low- and middle-income countries (LMICs). Recent studies have provided evidence that severe malaria infection results in sustained impairment in cognition and behaviour among young children; however, a formal meta-analysis has not been published. The objective was to assess the association between severe malaria infection with cognitive and behavioural outcomes among children living in LMICs. METHODS Six online bibliographic databases were searched and reviewed in November 2022. Studies included involved children < 18 years of age living in LMICs with active or past severe malaria infection and measured cognitive and/or behaviour outcomes. The quality of studies was assessed. Definitions of severe malaria included cerebral malaria, severe malarial anaemia, and author-defined severe malaria. Results from all studies were qualitatively summarized. For studies with relevant data on attention, learning, memory, language, internalizing behaviour and externalizing behaviour, results were pooled and a meta-analysis was performed. A random-effects model was used across included cohorts, yielding a standardized mean difference between the severe malaria group and control group. RESULTS Out of 3,803 initial records meeting the search criteria, 24 studies were included in the review, with data from 14 studies eligible for meta-analysis inclusion. Studies across sub-Saharan Africa assessed 11 cohorts of children from pre-school to school age. Of all the studies, composite measures of cognition were the most affected areas of development. Overall, attention, memory, and behavioural problems were domains most commonly found to have lower scores in children with severe malaria. Meta-analysis revealed that children with severe malaria had worse scores compared to children without malaria in attention (standardized mean difference (SMD) -0.68, 95% CI -1.26 to -0.10), memory (SMD -0.52, 95% CI -0.99 to -0.06), and externalizing behavioural problems (SMD 0.45, 95% CI 0.13-0.78). CONCLUSION Severe malaria is associated with worse neuropsychological outcomes for children living in LMICs, specifically in attention, memory, and externalizing behaviours. More research is needed to identify the long-term implications of these findings. Further interventions are needed to prevent cognitive and behavioural problems after severe malaria infection. TRIAL REGISTRATION This systematic review was registered under PROSPERO: CRD42020154777.
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Affiliation(s)
- Andrew Sentoogo Ssemata
- Department of Psychiatry, School of Medicine, Makerere University, P. O. Box 7072, Kampala, Uganda.
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Simon Kizito
- Department of Mental Health and Community Psychology, School of Psychology, Makerere University, Kampala, Uganda
| | - Melissa R Thomas
- Richard M. Fairbanks School of Public Health, Indiana University-Purdue University, Indianapolis, USA
| | - Sumaiya Islam
- School of Medicine, City University of New York (CUNY), New York City, USA
- Mailman School of Public Health, Columbia University, New York City, USA
| | - Paul Bangirana
- Department of Psychiatry, School of Medicine, Makerere University, P. O. Box 7072, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Noeline Nakasujja
- Department of Psychiatry, School of Medicine, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Ziyi Yang
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, USA
| | - Yunpeng Yu
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, USA
| | - Tuan M Tran
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Megan S McHenry
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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8
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Conroy AL, Datta D, Opoka RO, Batte A, Bangirana P, Gopinadhan A, Mellencamp KA, Akcan-Arikan A, Idro R, John CC. Cerebrospinal fluid biomarkers provide evidence for kidney-brain axis involvement in cerebral malaria pathogenesis. Front Hum Neurosci 2023; 17:1177242. [PMID: 37200952 PMCID: PMC10185839 DOI: 10.3389/fnhum.2023.1177242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
Introduction Cerebral malaria is one of the most severe manifestations of malaria and is a leading cause of acquired neurodisability in African children. Recent studies suggest acute kidney injury (AKI) is a risk factor for brain injury in cerebral malaria. The present study evaluates potential mechanisms of brain injury in cerebral malaria by evaluating changes in cerebrospinal fluid measures of brain injury with respect to severe malaria complications. Specifically, we attempt to delineate mechanisms of injury focusing on blood-brain-barrier integrity and acute metabolic changes that may underlie kidney-brain crosstalk in severe malaria. Methods We evaluated 30 cerebrospinal fluid (CSF) markers of inflammation, oxidative stress, and brain injury in 168 Ugandan children aged 18 months to 12 years hospitalized with cerebral malaria. Eligible children were infected with Plasmodium falciparum and had unexplained coma. Acute kidney injury (AKI) on admission was defined using the Kidney Disease: Improving Global Outcomes criteria. We further evaluated blood-brain-barrier integrity and malaria retinopathy, and electrolyte and metabolic complications in serum. Results The mean age of children was 3.8 years (SD, 1.9) and 40.5% were female. The prevalence of AKI was 46.3% and multi-organ dysfunction was common with 76.2% of children having at least one organ system affected in addition to coma. AKI and elevated blood urea nitrogen, but not other measures of disease severity (severe coma, seizures, jaundice, acidosis), were associated with increases in CSF markers of impaired blood-brain-barrier function, neuronal injury (neuron-specific enolase, tau), excitatory neurotransmission (kynurenine), as well as altered nitric oxide bioavailability and oxidative stress (p < 0.05 after adjustment for multiple testing). Further evaluation of potential mechanisms suggested that AKI may mediate or be associated with CSF changes through blood-brain-barrier disruption (p = 0.0014), ischemic injury seen by indirect ophthalmoscopy (p < 0.05), altered osmolality (p = 0.0006) and through alterations in the amino acids transported into the brain. Conclusion In children with cerebral malaria, there is evidence of kidney-brain injury with multiple potential pathways identified. These changes were specific to the kidney and not observed in the context of other clinical complications.
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Affiliation(s)
- Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
- Undergraduate Medical Education, The Aga Khan University, Nairobi, Kenya
| | - Anthony Batte
- Global Health Uganda, Kampala, Uganda
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Global Health Uganda, Kampala, Uganda
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Adnan Gopinadhan
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Kagan A. Mellencamp
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
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Benki-Nugent S, Tamasha N, Mueni A, Laboso T, Wamalwa D, Njuguna I, Gómez L, Tapia K, Bangirana P, Maleche-Obimbo E, Boivin MJ, John-Stewart G. Early Antiretroviral Therapy Reduces Severity but Does Not Eliminate Neurodevelopmental Compromise in Children With HIV. J Acquir Immune Defic Syndr 2023; 93:7-14. [PMID: 36693138 PMCID: PMC10079595 DOI: 10.1097/qai.0000000000003165] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/13/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Early antiretroviral therapy (ART) during infancy reduces cognitive impairment due to HIV, but the extent of benefit is unclear. SETTING Children were recruited from hospital and health centers providing HIV care and treatment in Nairobi, Kenya. METHODS Cognitive, behavioral, and motor outcomes were assessed in children with HIV and early ART (<1 year), children with HIV and late ART (1.5-6 years), and children HIV-unexposed uninfected (CHUU). Domain z scores and odds neurobehavioral impairment (≤15th percentile in CHUU) were compared in adjusted analyses. RESULTS Children with HIV initiated ART at median ages 0.4 (early ART) and 3.5 years (late ART). Children were assessed at median ages 6.9 (CHUU, N = 61), 6.9 (early ART, N = 54), and 13.5 (late ART; N = 27) years. Children with late ART vs. children with early ART had significantly lower z scores in 7 domains, specifically global cognition, short-term memory, visuospatial processing, learning, nonverbal test performance, executive function, and motor skills (adjusted mean differences, -0.42 to -0.62, P values ≤ 0.05), and had higher odds impairment in 7 domains (adjusted odds ratios [aORs], 2.87 to 16.22, P values ≤ 0.05). Children with early ART vs. CHUU had lower z scores in 5 domains (global cognition, short-term memory, delayed memory, processing speed, and behavioral regulation [adjusted mean differences, -0.32 to -0.88, P values < 0.05]) and higher impairment for 2 domains (short-term memory [aOR, 3.88] and behavioral regulation [aOR 3.46], P values < 0.05). Children with late ART vs. CHUU had lower z scores in 8 domains (adjusted mean differences, -0.57 to -1.05, P values ≤ 0.05), and higher impairment in 7 domains (aORs 1.98 to 2.32, P values ≤ 0.05). CONCLUSION Early ART in the first year of life attenuates but does not eliminate the neurodevelopmental compromise of HIV.
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Affiliation(s)
| | - Nancy Tamasha
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Alice Mueni
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Tony Laboso
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Dalton Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Irene Njuguna
- Department of Global Health, University of Washington, Seattle, USA
- Kenyatta National Hospital, Nairobi Kenya
| | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, USA
| | - Kenneth Tapia
- Department of Global Health, University of Washington, Seattle, USA
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Michael J Boivin
- Departments of Psychiatry and of Neurology & Ophthalmology, Michigan State University, East Lansing and Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
- Department of Pediatrics, University of Washington, Seattle, USA
- Department of Epidemiology University of Washington, Seattle, USA
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10
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Nakitende AJ, Bangirana P, Nakasujja N, Ssenkusu JM, Bond C, Idro R, Zhao Y, Semrud-Clikeman M, John CC. Severe Malaria and Academic Achievement. Pediatrics 2023; 151:190792. [PMID: 36861307 DOI: 10.1542/peds.2022-058310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Cerebral malaria (CM) and severe malarial anemia (SMA) are associated with neurocognitive impairment in childhood but their effects on long-term academic achievement are not known. METHODS Ugandan children 5 to 12 years old who participated in a previous study evaluating cognitive outcomes after CM (n = 73) or SMA (n = 56), along with community children (CC, n = 100) from the same household or neighborhood, were on average enrolled 67.1 months (range, 19-101 months) after the severe malaria episode or previous study enrollment. Academic achievement in word reading, sentence comprehension, spelling, and math computation was evaluated using the Wide Range Achievement Test, Fourth Edition. Age-adjusted z-scores for academic achievement outcomes were calculated from CC scores. RESULTS After adjustment for age and time from enrollment, reading scores were lower (mean difference from CC [95% confidence interval]) in children with CM (-0.15 [-0.27 to -0.03], P = .02) or SMA (-0.15 [-0.28 to -0.02], P = .02) than CC. Postdischarge malaria episodes were associated with worse spelling and reading scores in CM and worse spelling scores only in SMA. Pathway analysis showed that incidence of postdischarge uncomplicated malaria contributed significantly to the association of CM or SMA with poorer reading scores. CONCLUSION Children with CM or SMA have poorer long-term reading skills. Postdischarge malaria episodes contribute significantly to this association. Postdischarge malaria chemoprevention should be assessed as an intervention to improve long-term academic achievement in children with severe malaria.
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Affiliation(s)
| | - Paul Bangirana
- Department of Psychiatry.,Global Health Uganda, Kampala, Uganda
| | | | | | | | - Richard Idro
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda.,Centre of Tropical Medicine and Global Health, University of Oxford, United Kingdom and
| | - Yi Zhao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
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11
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Bangirana P, Conroy AL, Opoka RO, Semrud-Clikeman M, Jang JH, Apayi C, Kakuru A, Muhindo MK, Georgieff MK, Dorsey GM, Kamya MR, Havlir D, John CC. Effect of Malaria and Malaria Chemoprevention Regimens in Pregnancy and Childhood on Neurodevelopmental and Behavioral Outcomes in Children at 12, 24, and 36 Months: A Randomized Clinical Trial. Clin Infect Dis 2023; 76:600-608. [PMID: 36219705 PMCID: PMC10169410 DOI: 10.1093/cid/ciac815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/23/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malaria in pregnancy has been associated with worse cognitive outcomes in children, but its association with behavioral outcomes and the effectiveness of malaria chemoprevention on child neurodevelopment are not well characterized. METHODS To determine if more effective malaria chemoprevention in mothers and their children results in better neurodevelopment, 305 pregnant women were randomly assigned to 3 doses of sulfadoxine-pyrimethamine, 3 doses of dihydroartemisinin-piperaquine (DP), or monthly DP during pregnancy, and their 293 children were assigned to DP every 3 months or monthly DP from 2 to 24 months of age. Cognition, language, and motor function were assessed at 12, 24. and 36 months of age, and attention, memory, behavior, and executive function were assessed at 24 and 36 months of age. RESULTS Children of mothers with versus without malaria in pregnancy had worse scores on cognitive, behavioral, and executive function outcomes at 24 months. Clinical malaria in children within the first 12 months was similarly associated with poorer scores in behavior and executive function at 24 months, language at 24 and 36 months, and motor function scores at 36 months. However, more effective malaria chemoprevention in the mothers and children was not associated with better outcomes. CONCLUSIONS Malaria in pregnancy was associated with worse cognitive, behavioral, and executive function scores in affected children, but more effective malaria chemoprevention measures did not result in better outcomes. Malaria chemoprevention prior to and early in gestation and with even higher efficacy in mothers and children may be required to prevent neurodevelopmental impairment in children. Clinical Trials Registration. NCT02557425.
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Affiliation(s)
- Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis
| | - Robert O Opoka
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Jeong H Jang
- Underwood International College and Department of Applied Statistics, Yonsei University, Seoul, Korea
| | - Claire Apayi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Mary K Muhindo
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Grant M Dorsey
- Department of Medicine, University of California, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane Havlir
- Department of Medicine, University of California, California, USA
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis
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12
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Conroy AL, Tran TM, Bond C, Opoka RO, Datta D, Liechty EA, Bangirana P, Namazzi R, Idro R, Cusick S, Ssenkusu JM, John CC. Plasma Amino Acid Concentrations in Children With Severe Malaria Are Associated With Mortality and Worse Long-term Kidney and Cognitive Outcomes. J Infect Dis 2022; 226:2215-2225. [PMID: 36179241 DOI: 10.1093/infdis/jiac392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/14/2022] [Accepted: 09/20/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Global changes in amino acid levels have been described in severe malaria (SM), but the relationship between amino acids and long-term outcomes in SM has not been evaluated. METHODS We measured enrollment plasma concentrations of 20 amino acids using high-performance liquid chromatography in 500 Ugandan children aged 18 months to 12 years, including 122 community children and 378 children with SM. The Kidney Disease: Improving Global Outcomes criteria were used to define acute kidney injury (AKI) at enrollment and chronic kidney disease (CKD) at 1-year follow-up. Cognition was assessed over 2 years of follow-up. RESULTS Compared to laboratory-defined, age-specific reference ranges, there were deficiencies in sulfur-containing amino acids (methionine, cysteine) in both community children and children with SM. Among children with SM, global changes in amino acid concentrations were observed in the context of metabolic complications including acidosis and AKI. Increases in threonine, leucine, and valine were associated with in-hospital mortality, while increases in methionine, tyrosine, lysine, and phenylalanine were associated with postdischarge mortality and CKD. Increases in glycine and asparagine were associated with worse attention in children <5 years of age. CONCLUSIONS Among children with SM, unique amino acid profiles are associated with mortality, CKD, and worse attention.
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Affiliation(s)
- Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tuan M Tran
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Global Health Uganda, Kampala, Uganda
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Edward A Liechty
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Global Health Uganda, Kampala, Uganda
| | - Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Global Health Uganda, Kampala, Uganda
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Global Health Uganda, Kampala, Uganda
| | - Sarah Cusick
- Division of Pediatric Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Fernander EM, Adogamhe P, Datta D, Bond C, Zhao Y, Bangirana P, Conroy AL, Opoka RO, John CC. Elevated Plasma Soluble ST2 Levels are Associated With Neuronal Injury and Neurocognitive Impairment in Children With Cerebral Malaria. Pathog Immun 2022; 7:60-80. [PMID: 35800259 PMCID: PMC9254869 DOI: 10.20411/pai.v7i1.499] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background Murine experimental cerebral malaria studies suggest both protective and deleterious central nervous system effects from alterations in the interleukin-33 (IL-33)/ST2 pathway. Methods We assessed whether soluble ST2 (sST2) was associated with neuronal injury or cognitive impairment in a cohort of Ugandan children with cerebral malaria (CM, n=224) or severe malarial anemia (SMA, n=193). Results Plasma concentrations of sST2 were higher in children with CM than in children with SMA or in asymptomatic community children. Cerebrospinal fluid (CSF) sST2 levels were elevated in children with CM compared with North American children. Elevated plasma and CSF ST2 levels in children with CM correlated with increased endothelial activation and increased plasma and CSF levels of tau, a marker of neuronal injury. In children with CM who were ≥5 years of age at the time of their malaria episode, but not in children <5 years of age, elevated risk factor-adjusted plasma levels of sST2 were associated with worse scores for overall cognitive ability and attention over a 2-year follow-up. Conclusions The study findings suggest that sST2 may contribute to neuronal injury and long-term neurocognitive impairment in older children with CM.
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Affiliation(s)
- Elizabeth M. Fernander
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Pontian Adogamhe
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yi Zhao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - Paul Bangirana
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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Musindo O, Krabbendam L, Mutahi J, García MP, Bangirana P, Kumar M. Neurocognitive deficits and socioeconomic risk factors among children and adolescents living with HIV in sub-Saharan Africa: a systematic review. Child Adolesc Psychiatry Ment Health 2022; 16:31. [PMID: 35477577 PMCID: PMC9047261 DOI: 10.1186/s13034-022-00465-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/02/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Children and adolescents living with HIV (C/ALHIV) are at a risk for significant neurocognitive deficits. There is limited literature that addresses the role of socioeconomic factors in neurocognitive deficits among CALHIV in Sub Saharan Africa (SSA), as it is very difficult to establish this causal relationship. Our systematic review was guided by the biodevelopmental framework that assumes that foundations of health and adversity affect later development and life outcomes. This systematic review aims to assess available evidence on the relationship between neurocognitive deficits and socioeconomic factors among HIV children and adolescents in SSA region. METHOD Using a pre-determined search strategy, we searched electronic databases including PubMed, web of Science and EBSCOhost (CINAHL and MEDLINE). Peer-reviewed publications that address neurocognitive deficits, psychosocial and socioeconomic risk factors among children and adolescents living with HIV in SSA were included in review. RESULTS Out of 640 articles, 17 studies from SSA met the inclusion criteria. Four studies reported no significant differences in the neurocognitive measures comparing children and adolescents with HIV infection to those uninfected. However, 10 studies suggest that C/ALHIV scored significantly low in general intellectual functions as compared to their uninfected peers. C/ALHIV were found to have substantial deficits in specific cognitive domains such as sequential processing, simultaneous processing, and learning. In addition, deficits in visuo-spatial processing, visual memory and semantic fluency were mentioned. Socioeconomic factors such as lower socioeconomic status (income, education and occupation), child orphanhood status and under-nutrition were linked with neurocognitive deficits. CONCLUSION Our findings suggest that CALHIV presented with poorer neurocognitive outcomes when compared to other populations which were associated with specific socioeconomic factors.
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Affiliation(s)
- Otsetswe Musindo
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Lydiah Krabbendam
- grid.12380.380000 0004 1754 9227Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Joan Mutahi
- grid.10604.330000 0001 2019 0495Department of Psychiatry, University of Nairobi, Nairobi, Kenya
| | - Miguel Pérez García
- grid.4489.10000000121678994Facultad de Psicología, Universidad de Granada, Granada, Spain
| | - Paul Bangirana
- grid.11194.3c0000 0004 0620 0548Department of Psychiatry, Makerere University, Kampala, Uganda
| | - Manasi Kumar
- grid.10604.330000 0001 2019 0495Department of Psychiatry , University of Nairobi to Brain and Mind Institute Aga Khan University , Nairobi, Kenya
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Kasujja R, Bangirana P, Chiumento A, Hasan T, Jansen S, Kagabo DM, Popa M, Ventevogel P, White RG. Translating, contextually adapting, and pilot testing of psychosocial and mental health assessment instruments for Congolese refugees in Rwanda and Uganda. Confl Health 2022; 16:17. [PMID: 35428341 PMCID: PMC9013053 DOI: 10.1186/s13031-022-00447-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 04/02/2022] [Indexed: 11/18/2022] Open
Abstract
Background Forcibly displaced people are at elevated risk of experiencing circumstances that can adversely impact on mental health. Culturally and contextually relevant tools to assess their mental health and psychosocial needs are essential to inform the development of appropriate interventions and investigate the effectiveness of such interventions. Methods We conducted two related studies: (1) to translate and contextually adapt the Patient Health Questionnaire (PHQ-9), a measure of depressive symptomatology, along with assessment instruments measuring levels of daily stress (Checklist for Daily & Environmental Stressors; CDES), social capital (Shortened and Adapted Social Capital Assessment Tool; SASCAT) and perceived social support (Multidimensional Scale of Perceived Social Support; MSPSS) for use with Congolese refugees; (2) to conduct pilot testing of the assessment instruments (including cognitive interviewing about participants’ views of completing them) and a validation of the adapted PHQ-9 using a ‘known group’ approach by recruiting Congolese refugees from refugee settings in Rwanda (n = 100) and Uganda (n = 100). Results Study 1 resulted in the translation and adaptation of the assessment instruments. No substantive adaptations were made to the SASCAT or MSPSS, while notable linguistic and contextual adaptations were made in both sites to the CDES and the PHQ-9. The cognitive interviewing conducted in Study 2 indicated that the adapted assessment instruments were generally well received by members of the refugee communities. Participants recruited on the basis that local informants adjudged them to have high levels of depressive symptoms had significantly higher PHQ-9 scores (M = 11.02; SD = 5.84) compared to those in the group adjudged to have low levels of depressive symptoms (M = 5.66; SD = 5.04). In both sites, the adapted versions of the PHQ-9 demonstrated concurrent validity via significant positive correlations with levels of daily stressors. Each of the four adapted assessment instruments demonstrated at least adequate levels of internal consistency in both sites. Conclusions The adapted versions of the PHQ-9, CDES, SASCAT and MSPSS are appropriate for use amongst Congolese refugees in Rwanda and Uganda. We recommend further application of the approaches used in the current studies for contextually adapting other assessment instruments in humanitarian settings.
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Benki-Nugent SF, Yunusa R, Mueni A, Laboso T, Tamasha N, Njuguna I, Gómez L, Wamalwa DC, Tapia K, Maleche-Obimbo E, Bangirana P, Boivin MJ, John-Stewart GC. Lower Neurocognitive Functioning in HIV-Exposed Uninfected Children Compared With That in HIV-Unexposed Children. J Acquir Immune Defic Syndr 2022; 89:441-447. [PMID: 35202050 PMCID: PMC8873990 DOI: 10.1097/qai.0000000000002881] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Perinatal HIV and antiretroviral therapy exposure may influence neurocognitive outcomes, although evidence is mixed and most studies are limited to outcomes in the first 24 months. We compared neurocognitive outcomes in school-aged children who were HIV exposed uninfected (CHEU) with those in children who were HIV unexposed uninfected (CHUU). SETTING Children were recruited from a health center in Nairobi, Kenya. METHODS Key inclusion criteria were children aged 5-12 years and confirmed child and maternal HIV status; for CHEU, mothers reported knowing HIV-positive status before or at delivery of the index child. Children underwent a detailed battery of neuropsychological tests and behavioral assessment, and comparisons of scores between CHEU and CHUU were conducted using linear regression. RESULTS Among 56 CHEU and 65 CHUU, the median age and sex distributions were 6.8 and 7.0 years (P = 0.8) and 48% and 60% girls (P = 0.2), respectively. In analyses adjusted for child's age and sex and caregiver's age, education, and household rent, CHEU had significantly lower mean z scores for global cognitive ability than CHUU [-0.35, 95% confidence interval (CI): -0.64 to -0.05; P = 0.02], short-term memory (-0.44, 95% CI: -0.76 to -0.12; P = 0.008), delayed memory (-0.43, 95% CI: -0.79 to -0.08; P = 0.02), attention (-0.41, 95% CI: -0.78 to -0.05; P = 0.03), and processing speed (-0.76, 95% CI: -1.37 to -0.16; P = 0.01). Models adjusted for child nutritional status, household food security, and orphanhood yielded similar results. CONCLUSIONS Children exposed to HIV had poorer long-term neurocognitive outcomes than CHUU. These data suggest that long-term studies of neurocognitive and educational attainment in CHEU are warranted.
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Affiliation(s)
| | - Rabi Yunusa
- Department of Global Health, University of Washington, Seattle, WA
| | - Alice Mueni
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Tony Laboso
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Nancy Tamasha
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Irene Njuguna
- Department of Global Health, University of Washington, Seattle, WA
| | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, WA
| | - Dalton C Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Kenneth Tapia
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Paul Bangirana
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | - Michael J Boivin
- Departments of Psychiatry and of Neurology & Ophthalmology, Michigan State University, East Lansing
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, WA
- Departments of Pediatrics
- Epidemiology; and
- Medicine, University of Washington, Seattle, WA
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Namazzi R, Opoka R, Datta D, Bangirana P, Batte A, Berrens Z, Goings MJ, Schwaderer AL, Conroy AL, John CC. Acute Kidney Injury Interacts With Coma, Acidosis, and Impaired Perfusion to Significantly Increase Risk of Death in Children With Severe Malaria. Clin Infect Dis 2022; 75:1511-1519. [PMID: 35349633 PMCID: PMC9617576 DOI: 10.1093/cid/ciac229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Mortality in severe malaria remains high in children treated with intravenous artesunate. Acute kidney injury (AKI) is a common complication of severe malaria, but the interactions between AKI and other complications on the risk of mortality in severe malaria are not well characterized. METHODS Between 2014 and 2017, 600 children aged 6-48 months to 4 years hospitalized with severe malaria were enrolled in a prospective clinical cohort study evaluating clinical predictors of mortality in children with severe malaria. RESULTS The mean age of children in this cohort was 2.1 years (standard deviation, 0.9 years) and 338 children (56.3%) were male. Mortality was 7.3%, and 52.3% of deaths occurred within 12 hours of admission. Coma, acidosis, impaired perfusion, AKI, elevated blood urea nitrogen (BUN), and hyperkalemia were associated with increased mortality (all P < .001). AKI interacted with each risk factor to increase mortality (P < .001 for interaction). Children with clinical indications for dialysis (14.4% of all children) had an increased risk of death compared with those with no indications for dialysis (odds ratio, 6.56; 95% confidence interval, 3.41-12.59). CONCLUSIONS AKI interacts with coma, acidosis, or impaired perfusion to significantly increase the risk of death in severe malaria. Among children with AKI, those who have hyperkalemia or elevated BUN have a higher risk of death. A better understanding of the causes of these complications of severe malaria, and development and implementation of measures to prevent and treat them, such as dialysis, are needed to reduce mortality in severe malaria.
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Affiliation(s)
- Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda,Global Health Uganda, Kampala, Uganda
| | - Robert Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda,Global Health Uganda, Kampala, Uganda
| | - Dibyadyuti Datta
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Paul Bangirana
- Global Health Uganda, Kampala, Uganda,Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Anthony Batte
- Child Development Centre, Makerere University, Kampala, Uganda
| | - Zachary Berrens
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael J Goings
- Indiana University Center for Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew L Schwaderer
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrea L Conroy
- Correspondence: A. L. Conroy, Department of Pediatrics, Indiana University School of Medicine, 1044 W Walnut St, Indianapolis, IN 46202 ()
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Idro R, Boehme AK, Kawooya M, Lubowa SK, Munube D, Bangirana P, Opoka R, Mupere E, Lignelli A, Kasirye P, Green NS, Minja FJ. Brain Magnetic Resonance Imaging and Angiography in Children with Sickle Cell Anaemia in Uganda in a Cross-Sectional Sample. J Stroke Cerebrovasc Dis 2022; 31:106343. [PMID: 35158150 PMCID: PMC9004405 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/11/2022] [Accepted: 01/19/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Children with sickle cell anaemia (SCA) are highly susceptible to cerebrovascular injury. We performed brain magnetic resonance imaging and angiography (MRI-MRA) in Ugandan children with SCA to identify structural cerebrovascular abnormalities and examine their relationship to standardized clinical assessments. METHODS A sub-sample (n=81) was selected from a cross-sectional study of children attending SCA clinic, including 52 (64.2%) with and 29 (35.8%) without clinically detected abnormalities. Clinical evaluation included assessment for prior stroke, cognitive testing and cerebral arterial transcranial doppler (TCD) flow velocity. MRI-MRA scans were interpreted by at least two neuroradiologists. RESULTS Mean age was 6.5±2.7 years, with 39 (48.1%) female. Mean haemoglobin was 7.3±0.9 g/dl. Overall, 13 (16.0%) were malnourished. Infarcts and/or stenoses were detected in 55 (67.9%) participants, with stenoses primarily in the anterior circulation. Infarcts were seen in those with normal 17/29 (58.6%) or abnormal 34/52 (65.4%) clinical testing (p=0.181). Neither abnormal MRI nor MRA was associated with age, sex, haemoglobin, or malnutrition. Abnormal MRA was highly associated with infarcts (p<0.0001). Participants with abnormal imaging had two-fold higher proportion of stroke on exam and/or impaired cognition. Stroke on exam was strongly associated with an imaging abnormality after adjusting for age, sex, malnutrition, and haemoglobin (OR 11.8, 95%CI 1.87-74.2). CONCLUSION Over half of these SCA children had cerebrovascular infarcts and/or arterial stenoses. Cerebrovascular disease was frequently undetectable by clinical assessments. While rarely available in under-resourced settings, MRI-MRA brain imaging is an important tool for defining SCA cerebrovascular disease and for assessing impact of clinical intervention trials.
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Affiliation(s)
| | | | - Michael Kawooya
- Radiology, Makerere University College of Health Sciences, Kampala, Uganda; Ernest Cook Ultrasound Research and Education Institute (ECUREI) Mengo Hospital, Kampala, Uganda
| | - Samson K Lubowa
- Radiology, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | | | | | - Angela Lignelli
- Radiology, Columbia University Irving Medical Center, NY, USA
| | | | | | - Frank J Minja
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Namazzi R, Batte A, Opoka RO, Bangirana P, Schwaderer AL, Berrens Z, Datta D, Goings M, Ssenkusu JM, Goldstein SL, John CC, Conroy AL. Acute kidney injury, persistent kidney disease, and post-discharge morbidity and mortality in severe malaria in children: A prospective cohort study. EClinicalMedicine 2022; 44:101292. [PMID: 35198918 PMCID: PMC8850340 DOI: 10.1016/j.eclinm.2022.101292] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/15/2022] [Accepted: 01/20/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Globally, 85% of acute kidney injury (AKI) cases occur in low-and-middle-income countries. There is limited information on persistent kidney disease (acute kidney disease [AKD]) following severe malaria-associated AKI. METHODS Between March 28, 2014, and April 18, 2017, 598 children with severe malaria and 118 community children were enrolled in a two-site prospective cohort study in Uganda and followed up for 12 months. The Kidney Disease: Improving Global Outcomes (KDIGO) criteria were used to define AKI (primary exposure) and AKD at 1-month follow-up (primary outcome). Plasma neutrophil gelatinase-associated lipocalin (NGAL) was assessed as a structural biomarker of AKI. FINDINGS The prevalence of AKI was 45·3% with 21·5% of children having unresolved AKI at 24 h. AKI was more common in Eastern Uganda. In-hospital mortality increased across AKI stages from 1·8% in children without AKI to 26·5% with Stage 3 AKI (p < 0·0001). Children with a high-risk plasma NGAL test were more likely to have unresolved AKI (OR, 7·00 95% CI 4·16 to 11·76) and die in hospital (OR, 6·02 95% CI 2·83 to 12·81). AKD prevalence was 15·6% at 1-month follow-up with most AKD occurring in Eastern Uganda. Risk factors for AKD included severe/unresolved AKI, blackwater fever, and a high-risk NGAL test (adjusted p < 0·05). Paracetamol use during hospitalization was associated with reduced AKD (p < 0·0001). Survivors with AKD post-AKI had higher post-discharge mortality (17·5%) compared with children without AKD (3·7%). INTERPRETATION Children with severe malaria-associated AKI are at risk of AKD and post-discharge mortality. FUNDING This work was supported by the National Institutes of Health National Institute of Neurological Disorders and Stroke (R01NS055349 to CCJ) and the Fogarty International Center (D43 TW010928 to CCJ), and a Ralph W. and Grace M. Showalter Young Investigator Award to ALC.
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Affiliation(s)
- Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Anthony Batte
- Child Health and Development Center, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Paul Bangirana
- Global Health Uganda, Kampala, Uganda
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew L. Schwaderer
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Zachary Berrens
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN, USA
| | - Michael Goings
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN, USA
| | - John M. Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | | | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN, USA
- Center for Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN, USA
- Center for Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
- Corresponding author at: Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN 46202, USA.
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Datta D, Bangirana P, Opoka RO, Conroy AL, Co K, Bond C, Zhao Y, Kawata K, Saykin AJ, John CC. Association of Plasma Tau With Mortality and Long-term Neurocognitive Impairment in Survivors of Pediatric Cerebral Malaria and Severe Malarial Anemia. JAMA Netw Open 2021; 4:e2138515. [PMID: 34889945 PMCID: PMC8665370 DOI: 10.1001/jamanetworkopen.2021.38515] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Cerebral malaria (CM) and severe malarial anemia (SMA) are associated with persistent neurocognitive impairment (NCI) among children in Africa. Identifying blood biomarkers of acute brain injury that are associated with future NCI could allow early interventions to prevent or reduce NCI in survivors of severe malaria. OBJECTIVE To investigate whether acutely elevated tau levels are associated with future NCI in children after CM or SMA. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted at Mulago National Referral Hospital in Kampala, Uganda, from March 2008 to October 2015. Children aged 1.5 to 12 years with CM (n = 182) or SMA (n = 162) as well as community children (CC; n = 123) were enrolled in the study. Data analysis was conducted from January 2020 to May 2021. EXPOSURE CM or SMA. MAIN OUTCOMES AND MEASURES Enrollment plasma tau levels were measured using single-molecule array detection technology. Overall cognition (primary) and attention and memory (secondary) z scores were measured at 1 week and 6, 12, and 24 months after discharge using tools validated in Ugandan children younger than 5 years or 5 years and older. RESULTS A total of 467 children were enrolled. In the CM group, 75 (41%) were girls, and the mean (SD) age was 4.02 (1.92) years. In the SMA group, 59 (36%) were girls, and the mean (SD) age was 3.45 (1.60) years. In the CC group, 65 (53%) were girls, and the mean (SD) age was 3.94 (1.92) years. Elevated plasma tau levels (>95th percentile in CC group; >6.43 pg/mL) were observed in 100 children (55%) with CM and 69 children (43%) with SMA (P < .001). In children with CM who were younger than 5 years, elevated plasma tau levels were associated with increased mortality (odds ratio [OR], 3.06; 95% CI, 1.01-9.26; P = .048). In children with CM who were younger than 5 years at both CM episode and follow-up neurocognitive testing, plasma tau levels (log10 transformed) were associated with worse overall cognition scores over 24-month follow-up (β = -0.80; 95% CI, -1.32 to -0.27; P = .003). In children with CM who were younger than 5 years at CM episode and 5 years or older at follow-up neurocognitive testing, plasma tau was associated with worse scores in attention (β = -1.08; 95% CI, -1.79 to -0.38; P = .003) and working memory (β = -1.39; 95% CI, -2.18 to -0.60; P = .001). CONCLUSIONS AND RELEVANCE In this study, plasma tau, a marker of injury to neuronal axons, was elevated in children with CM or SMA and was associated with mortality and persistent NCI in children with CM younger than 5 years.
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Affiliation(s)
- Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis
| | - Katrina Co
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis
| | - Yi Zhao
- Department of Biostatistics and Health Sciences, Indiana University School of Medicine, Indianapolis
| | - Keisuke Kawata
- Department of Kinesiology, Indiana University School of Public Health-Bloomington, Bloomington
- Program in Neuroscience, The College of Arts and Sciences, Indiana University, Bloomington
| | - Andrew J Saykin
- Indiana Alzheimer's Disease Research Center and Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis
- Division of Global Pediatrics, University of Minnesota Medical School, Minneapolis
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Mburu W, Conroy AL, Cusick SE, Bangirana P, Bond C, Zhao Y, Opoka RO, John CC. The Impact of Undernutrition on Cognition in Children with Severe Malaria and Community Children: A Prospective 2-Year Cohort Study. J Trop Pediatr 2021; 67:6424536. [PMID: 34755192 PMCID: PMC8578678 DOI: 10.1093/tropej/fmab091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The frequency of recovery from undernutrition after an episode of severe malaria, and the relationship between undernutrition during severe malaria and clinical and cognitive outcomes are not well characterized. METHODS We evaluated undernutrition and cognition in children in Kampala, Uganda 18 months to 5 years of age with cerebral malaria (CM), severe malarial anemia (SMA) or community children (CC). The Mullen Scales of Early Learning was used to measure cognition. Undernutrition, defined as 2 SDs below median for weight-for-age (underweight), height-for-age (stunting) or weight-for-height (wasting), was compared with mortality, hospital readmission and cognition over 24-month follow-up. RESULTS At enrollment, wasting was more common in CM (16.7%) or SMA (15.9%) than CC (4.7%) (both p < 0.0001), and being underweight was more common in SMA (27.0%) than CC (12.8%; p = 0.001), while prevalence of stunting was similar in all three groups. By 6-month follow-up, prevalence of wasting or being underweight did not differ significantly between children with severe malaria and CC. Undernutrition at enrollment was not associated with mortality or hospital readmission, but children who were underweight or stunted at baseline had lower cognitive z-scores than those who were not {underweight, mean difference [95% confidence interval (CI)] -0.98 (-1.66, -0.31), -0.72 (-1.16, -0.27) and -0.61 (-1.08, -0.13); and stunted, -0.70 (-1.25, -0.15), -0.73 (-1.16, -0.31) and -0.61 (-0.96, -0.27), for CM, SMA and CC, respectively}. CONCLUSION In children with severe malaria, wasting and being underweight return to population levels after treatment. However, being stunted or underweight at enrollment was associated with worse long-term cognition in both CC and children with severe malaria.
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Affiliation(s)
- Waruiru Mburu
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55454, USA,Correspondence: Waruiru Mburu, Division of Epidemiology and Community Health, University of Minnesota, 1300 S 2nd St, Unit 300, Minneapolis, MN 55454, USA. Tel: 612-624-6368. E-mail: <> and Chandy C. John, Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, 1044 W Walnut Street, R4 402D, Indianapolis, IN 46202, USA. Tel: 317-274-8940. E-mail: <>
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Sarah E Cusick
- Division of Global Pediatrics, Department of Pediatrics, and Center for Neurobehavioral Development, University of Minnesota, Minneapolis, MN 55455, USA
| | - Paul Bangirana
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Caitlin Bond
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Yi Zhao
- Department of Biostatistics, Fairbanks School of Public Health, Indiana University—Purdue University at Indianapolis, Indianapolis, IN 46202, USA
| | - Robert O Opoka
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Chandy C John
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA,Department of Biostatistics, Fairbanks School of Public Health, Indiana University—Purdue University at Indianapolis, Indianapolis, IN 46202, USA,Correspondence: Waruiru Mburu, Division of Epidemiology and Community Health, University of Minnesota, 1300 S 2nd St, Unit 300, Minneapolis, MN 55454, USA. Tel: 612-624-6368. E-mail: <> and Chandy C. John, Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, 1044 W Walnut Street, R4 402D, Indianapolis, IN 46202, USA. Tel: 317-274-8940. E-mail: <>
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22
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Alinaitwe R, Birungi C, Bangirana P, Nakasujja N. Prevalence and factors associated with depressive illness in patients with tuberculosis in Mulago hospital, Kampala- Uganda: A cross sectional study. J Psychosom Res 2021; 149:110591. [PMID: 34390942 DOI: 10.1016/j.jpsychores.2021.110591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/29/2021] [Accepted: 07/29/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Depression is a major cause of the global disease burden and globally affects 350-400 million persons making it the largest contributor to years lived with disability. Among of patients with chronic physical illnesses like tuberculosis, depression affects up to 25-33% of individuals. There are limited studies on the comorbidity of depressive illness and tuberculosis in the Ugandan setting. Our aim was to determine the prevalence and factors associated with depressive illness in patients with tuberculosis in Mulago Hospital, Uganda. METHODS This was a cross sectional study involving 308 consecutively sampled participants aged 18 years and above diagnosed with tuberculosis attending the tuberculosis clinic in Mulago Hospital, Uganda. Consecutive sampling was done for a sample size of 308 participants. Participants had the following instruments administered to them; the Socio-demographic questionnaire, the Mini Neuropsychiatric Interview (MINI) to diagnose depressive illness and the Patient Health Questionnaire- 9 to rate the severity of depression. Data was entered using Epi-Data. Descriptive, bivariate and multivariate analyses were done with the Statistical Package for Social Sciences (SPSS). RESULTS the prevalence of depressive illness was 23.7% (95% confidence interval 19.3-28.9). Depressive illness was independently associated with low education level (AOR = 0.39, 95%CI = 0.21-0.72, p = 0.003), being in the intensive phase of TB treatment (AOR = 2.34, 95%CI = (1.27-4.33), p = 0.007) and family history of depressive illness (AOR = 5.42, 95%CI = 2.02-14.54, p = 0.001). On the PHQ, 60.3% had moderate to severe depression. CONCLUSION Depressive illnesses should be screened and managed among patients with TB. RECOMMENDATION Depression should be routinely screened and managed among patients with Tuberculosis.
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Affiliation(s)
- Racheal Alinaitwe
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Caroline Birungi
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Noeline Nakasujja
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
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23
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Conroy AL, Opoka RO, Bangirana P, Namazzi R, Okullo AE, Georgieff MK, Cusick S, Idro R, Ssenkusu JM, John CC. Parenteral artemisinins are associated with reduced mortality and neurologic deficits and improved long-term behavioral outcomes in children with severe malaria. BMC Med 2021; 19:168. [PMID: 34315456 PMCID: PMC8317420 DOI: 10.1186/s12916-021-02033-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/11/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In 2011, the World Health Organization recommended injectable artesunate as the first-line therapy for severe malaria (SM) due to its superiority in reducing mortality compared to quinine. There are limited data on long-term clinical and neurobehavioral outcomes after artemisinin use for treatment of SM. METHODS From 2008 to 2013, 502 Ugandan children with two common forms of SM, cerebral malaria and severe malarial anemia, were enrolled in a prospective observational study assessing long-term neurobehavioral and cognitive outcomes following SM. Children were evaluated a week after hospital discharge, and 6, 12, and 24 months of follow-up, and returned to hospital for any illness. In this study, we evaluated the impact of artemisinin derivatives on survival, post-discharge hospital readmission or death, and neurocognitive and behavioral outcomes over 2 years of follow-up. RESULTS 346 children received quinine and 156 received parenteral artemisinin therapy (artemether or artesunate). After adjustment for disease severity, artemisinin derivatives were associated with a 78% reduction in in-hospital mortality (adjusted odds ratio, 0.22; 95% CI, 0.07-0.67). Among cerebral malaria survivors, children treated with artemisinin derivatives also had reduced neurologic deficits at discharge (quinine, 41.7%; artemisinin derivatives, 23.7%, p=0.007). Over a 2-year follow-up, artemisinin derivatives as compared to quinine were associated with better adjusted scores (negative scores better) in internalizing behavior and executive function in children irrespective of the age at severe malaria episode. After adjusting for multiple comparisons, artemisinin derivatives were associated with better adjusted scores in behavior and executive function in children <6 years of age at severe malaria exposure following adjustment for child age, sex, socioeconomic status, enrichment in the home environment, and the incidence of hospitalizations over follow-up. Children receiving artesunate had the greatest reduction in mortality and benefit in behavioral outcomes and had reduced inflammation at 1-month follow-up compared to children treated with quinine. CONCLUSIONS Treatment of severe malaria with artemisinin derivatives, particularly artesunate, results in reduced in-hospital mortality and neurologic deficits in children of all ages, reduced inflammation following recovery, and better long-term behavioral outcomes. These findings suggest artesunate has long-term beneficial effects in children surviving severe malaria.
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Affiliation(s)
- Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, R4 402C 1044 West Walnut St, Indianapolis, IN, 46202, USA.
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Allen E Okullo
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Sarah Cusick
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, R4 402C 1044 West Walnut St, Indianapolis, IN, 46202, USA.,Division of Global Pediatrics, University of Minnesota Medical School, Minneapolis, USA
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24
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Bangirana P, Birabwa A, Nyakato M, Nakitende AJ, Kroupina M, Ssenkusu JM, Nakasujja N, Musisi S, John CC, Idro R. Use of the creating opportunities for parent empowerment programme to decrease mental health problems in Ugandan children surviving severe malaria: a randomized controlled trial. Malar J 2021; 20:267. [PMID: 34120616 PMCID: PMC8201864 DOI: 10.1186/s12936-021-03795-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 06/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severe malaria is associated with long-term mental health problems in Ugandan children. This study investigated the effect of a behavioural intervention for caregivers of children admitted with severe malaria, on the children's mental health outcomes 6 months after discharge. METHODS This randomized controlled trial was conducted at Naguru Hospital in Kampala, Uganda from January 2018 to July 2019. Caregiver and child dyads were randomly assigned to either a psycho-educational arm providing information about hospital procedures during admission (control group), or to a behavioural arm providing information about the child's possible emotions and behaviour during and after admission, and providing age appropriate games for the caregiver and child (intervention group). Pre- and post-intervention assessments for caregiver anxiety and depression (Hopkins Symptom Checklist) and child mental health problems (Strength and Difficulties Questionnaire and the Child Behaviour Checklist) were done during admission and 6 months after discharge, respectively. T-tests, analysis of covariance, Chi-Square, and generalized estimating equations were used to compare outcomes between the two treatment arms. RESULTS There were 120 caregiver-child dyads recruited at baseline with children aged 1.45 to 4.89 years (mean age 2.85 years, SD = 1.01). The intervention and control groups had similar sociodemographic, clinical and behavioural characteristics at baseline. Caregiver depression at baseline, mother's education and female child were associated with behavioural problems in the child at baseline (p < 0.05). At 6 months follow-up, there was no difference in the frequency of behavioural problems between the groups (6.8% vs. 10% in intervention vs control groups, respectively, p = 0.72). Caregiver depression and anxiety scores between the treatment arms did not differ at 6 months follow-up. CONCLUSION This behavioural intervention for caregivers and their children admitted with severe malaria had no effect on the child's mental health outcomes at 6 months. Further studies need to develop interventions for mental health problems after severe malaria in children with longer follow-up time. Trail registration ClinicalTrials.gov Identifier: NCT03432039.
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Affiliation(s)
- Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Annet Birabwa
- Department of Mental Health and Community Psychology, Makerere University College of Humanities and Social Sciences, Kampala, Uganda
| | - Mary Nyakato
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ann J Nakitende
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maria Kroupina
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Noeline Nakasujja
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Seggane Musisi
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University, Indianapolis, IN, USA
| | - Richard Idro
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
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25
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Ogwang R, Ningwa A, Akun P, Bangirana P, Anguzu R, Mazumder R, Salamon N, Henning OJ, Newton CR, Abbo C, Mwaka AD, Marsh K, Idro R. Epilepsy in Onchocerca volvulus Sero-Positive Patients From Northern Uganda-Clinical, EEG and Brain Imaging Features. Front Neurol 2021; 12:687281. [PMID: 34149607 PMCID: PMC8209377 DOI: 10.3389/fneur.2021.687281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/12/2021] [Indexed: 01/08/2023] Open
Abstract
Globally, epilepsy is the most common chronic neurological disorder. The incidence in sub-Saharan Africa is 2-3 times higher than that in high income countries. Infection by Onchocerca volvulus may be an underlying risk factor for the high burden and based upon epidemiological associations, has been proposed to cause a group of disorders—Onchocerca associated epilepsies (OAE) like nodding syndrome (NS). To improve our understanding of the disease spectrum, we described the clinical, electroencephalographic (EEG) and magnetic resonance imaging (MRI) features of children with epilepsy and sero-positive for Onchocerca volvulus (possible OAEs other than nodding syndrome). Twenty-nine children and adolescents with non-nodding syndrome OAE in northern Uganda were enrolled. A diagnosis of OAE was made in patients with epilepsy and seizure onset after age 3 years, no reported exposure to perinatal severe febrile illness or traumatic brain injury, no syndromic epilepsy diagnosis and a positive Ov-16 ELISA test. Detailed clinical evaluation including psychiatric, diagnostic EEG, a diagnostic brain MRI (in 10 patients) and laboratory testing were performed. Twenty participants (69%) were male. The mean age was 15.9 (standard deviation [SD] 1.9) years while the mean age at seizure onset was 9.8 (SD 2.9) years. All reported normal early childhood development. The most common clinical presentation was a tonic-clonic seizure. The median number of seizures was 2 (IQR 1–4) in the previous month. No specific musculoskeletal changes, or cranial nerve palsies were reported, neither were any vision, hearing and speech difficulties observed. The interictal EEG was abnormal in the majority with slow wave background activity in 52% (15/29) while 41% (12/29) had focal epileptiform activity. The brain MRI showed mild to moderate cerebellar atrophy and varying degrees of atrophy of the frontal, parietal and occipital lobes. The clinical spectrum of epilepsies associated with Onchocerca may be broader than previously described. In addition, focal onset tonic-clonic seizures, cortical and cerebellar atrophy may be important brain imaging and clinical features.
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Affiliation(s)
- Rodney Ogwang
- College of Health Sciences, Makerere University, Kampala, Uganda.,KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Coast, Kilifi, Kenya.,Centre of Tropical Neuroscience, Kitgum, Uganda
| | - Albert Ningwa
- College of Health Sciences, Makerere University, Kampala, Uganda.,Centre of Tropical Neuroscience, Kitgum, Uganda
| | - Pamela Akun
- College of Health Sciences, Makerere University, Kampala, Uganda.,Centre of Tropical Neuroscience, Kitgum, Uganda
| | - Paul Bangirana
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ronald Anguzu
- College of Health Sciences, Makerere University, Kampala, Uganda.,Centre of Tropical Neuroscience, Kitgum, Uganda.,Division of Epidemiology, Medical College of Wisconsin, Institute for Health and Equity, Milwaukee, WI, United States
| | - Rajarshi Mazumder
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Noriko Salamon
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Oliver Johannes Henning
- Division of Clinical Neuroscience, The National Centre for Epilepsy, Oslo University Hospital, Oslo, Norway
| | - Charles R Newton
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Coast, Kilifi, Kenya.,Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Catherine Abbo
- College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Kevin Marsh
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Richard Idro
- College of Health Sciences, Makerere University, Kampala, Uganda.,Centre of Tropical Neuroscience, Kitgum, Uganda.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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26
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Josias KS, Bangirana P, Rujumba J, Kakooza-Mwesige A. Prevalence and factors associated with behavioural problems in children with epilepsy attending Mulago hospital, Uganda: A cross-sectional study. Seizure 2021; 88:109-115. [PMID: 33848789 DOI: 10.1016/j.seizure.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/28/2021] [Accepted: 04/03/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To determine the prevalence of behavioural problems and the associated factors in children with epilepsy (CWE). METHODS This was a cross-sectional study conducted at Mulago National Referral Hospital, Kampala, Uganda, from December 2019 to May 2020. A total of 300 CWE aged 6 to 17 years were consecutively enrolled and assessed for behavioural problems using the Strengths and Difficulties Questionnaire. We obtained data on the associated factors by using pretested structured questionnaires, the Rosenberg Self-Esteem Scale, the Kilifi Stigma Scale of Epilepsy, the Morisky medication adherence scale and the Tumaini Child Health Screener for childhood disabilities. Simple logistic regression and multivariate analysis was done to determine the associated factors while adjusting for the presence of neurodevelopmental disorders and childhood disabilities. RESULTS Behavioural problems were detected in 108/300 CWE (36%) with more internalizing (28%) than externalizing (21%) behaviour scores noted. The odds of behavioural problems increased with the presence of co-morbid neurodevelopmental disorders or childhood disabilities (cOR: 5.42, p-value < 0.001). Factors associated with occurrence of behavioural problems were high stigma perception (aOR: 4.06, p-value < 0.001) and being seizure-free in the last six months (aOR: 3.43, p-value =0.031) while being an adolescent (aOR: 0.33, p=0.001) lessened the risk. CONCLUSIONS Behavioural problems occur in more than a third of CWE. They are more in the internalizing domain than in the externalizing domain. Their odds increase with high perceived stigma and in the first six months of seizure control.
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Affiliation(s)
- Kasereka Songya Josias
- Paediatric Resident, Department of Paediatrics and Child Health, College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda..
| | - Paul Bangirana
- Senior lecturer, Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda..
| | - Joseph Rujumba
- Senior lecturer, Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda..
| | - Angelina Kakooza-Mwesige
- Senior lecturer, Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda..
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27
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Nagot N, Singata-Madliki M, Cournil A, Nalugya J, Tassembedo S, Quillet C, Tonga MW, Tumwine J, Meda N, Kankasa C, Mwiya M, Bangirana P, Peries M, Batting J, Engebretsen IMS, Tylleskär T, Perre PV, Ndeezi G, Molès JP. Growth, clinical and neurodevelopmental outcomes at school age are similar for children who received 1-year lamivudine or lopinavir/ritonavir HIV prophylaxis in early life. Sci Rep 2021; 11:3173. [PMID: 33542437 PMCID: PMC7862474 DOI: 10.1038/s41598-021-82762-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 01/20/2021] [Indexed: 11/29/2022] Open
Abstract
In the ANRS 12174 trial, HIV-exposed uninfected African neonates who received lopinavir-ritonavir (LPV/r) prophylaxis for 1 year exhibited slower growth from birth to week 50 compared with those receiving lamivudine (3TC). We assessed whether this difference in growth persisted over time, and was accompanied by differences in neuropsychological and clinical outcomes. Between February 2017 and February 2018, we conducted a cross-sectional clinical evaluation among former trial participants who completed the 50-week follow-up and who were not HIV-infected. In addition to clinical examination, neuropsychological outcomes were assessed using the tests Kaufman-ABCII, Test of Variables of Attention, Movement Assessment Battery for Children and the Strengths and Difficulties questionnaire, parent version. Of 1101 eligible children, aged 5–7 years, 553 could be traced and analysed (274 in the LPV/r and 279 in the 3TC groups). Growth, clinical and neuropsychological outcomes did not differ between treatment groups. At school age, children exposed to LPV/r and 3TC at birth for 1 year had comparable growth and neuropsychological outcomes without evidence of long-term side-effects of LPV/r. It provides reassuring data on clinical outcomes for all HIV-infected children treated with this antiretroviral drug in early life.
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Affiliation(s)
- Nicolas Nagot
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM U1058, Université de Montpellier, Etablissement Français du Sang, Université des Antilles, 60, rue de Navacelles, 34394, Montpellier Cedex, France.
| | | | - Amandine Cournil
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM U1058, Université de Montpellier, Etablissement Français du Sang, Université des Antilles, 60, rue de Navacelles, 34394, Montpellier Cedex, France
| | - Joyce Nalugya
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Catherine Quillet
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM U1058, Université de Montpellier, Etablissement Français du Sang, Université des Antilles, 60, rue de Navacelles, 34394, Montpellier Cedex, France
| | - Melany W Tonga
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - James Tumwine
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Chipepo Kankasa
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Mwiya Mwiya
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Paul Bangirana
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Marianne Peries
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM U1058, Université de Montpellier, Etablissement Français du Sang, Université des Antilles, 60, rue de Navacelles, 34394, Montpellier Cedex, France
| | | | | | | | - Philippe Vande Perre
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM U1058, Université de Montpellier, Etablissement Français du Sang, Université des Antilles, 60, rue de Navacelles, 34394, Montpellier Cedex, France
| | - Grace Ndeezi
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jean-Pierre Molès
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM U1058, Université de Montpellier, Etablissement Français du Sang, Université des Antilles, 60, rue de Navacelles, 34394, Montpellier Cedex, France
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Ouma BJ, Bangirana P, Ssenkusu JM, Datta D, Opoka RO, Idro R, Kain KC, John CC, Conroy AL. Plasma angiopoietin-2 is associated with age-related deficits in cognitive sub-scales in Ugandan children following severe malaria. Malar J 2021; 20:17. [PMID: 33407493 PMCID: PMC7789657 DOI: 10.1186/s12936-020-03545-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/11/2020] [Indexed: 12/27/2022] Open
Abstract
Background Elevated angiopoietin-2 (Angpt-2) concentrations are associated with worse overall neurocognitive function in severe malaria survivors, but the specific domains affected have not been elucidated. Methods Ugandan children with severe malaria underwent neurocognitive evaluation a week after hospital discharge and at 6, 12 and 24 months follow-up. The relationship between Angpt-2 concentrations and age-adjusted, cognitive sub-scale z-scores over time were evaluated using linear mixed effects models, adjusting for disease severity (coma, acute kidney injury, number of seizures in hospital) and sociodemographic factors (age, gender, height-for-age z-score, socio-economic status, enrichment in the home environment, parental education, and any preschool education of the child). The Mullen Scales of Early Learning was used in children < 5 years and the Kaufman Assessment Battery for Children 2nd edition was used in children ≥ 5 years of age. Angpt-2 levels were measured on admission plasma samples by enzyme-linked immunosorbent assay. Adjustment for multiple comparisons was conducted using the Benjamini–Hochberg Procedure of False Discovery Rate. Results Increased admission Angpt-2 concentration was associated with worse outcomes in all domains (fine and gross motor, visual reception, receptive and expressive language) in children < 5 years of age at the time of severe malaria episode, and worse simultaneous processing and learning in children < 5 years of age at the time of severe malaria who were tested when ≥ 5 years of age. No association was seen between Angpt-2 levels and cognitive outcomes in children ≥ 5 years at the time of severe malaria episode, but numbers of children and testing time points were lower for children ≥ 5 years at the time of severe malaria episode. Conclusion Elevated Angpt-2 concentration in children with severe malaria is associated with worse outcomes in multiple neurocognitive domains. The relationship between Angpt-2 and worse cognition is evident in children < 5 years of age at the time of severe malaria presentation and in selected domains in older years.
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Affiliation(s)
- Benson J Ouma
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda.,Centre of Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Kevin C Kain
- Department of Medicine, University of Toronto and University Health Network, Toronto, Canada
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA.
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Datta D, Conroy AL, Castelluccio PF, Ssenkusu JM, Park GS, Opoka RO, Bangirana P, Idro R, Saykin AJ, John CC. Elevated Cerebrospinal Fluid Tau Protein Concentrations on Admission Are Associated With Long-term Neurologic and Cognitive Impairment in Ugandan Children With Cerebral Malaria. Clin Infect Dis 2021; 70:1161-1168. [PMID: 31044219 DOI: 10.1093/cid/ciz325] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/18/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Elevated concentrations of cerebrospinal fluid (CSF) tau, a marker of axonal injury, have been associated with coma in severe malaria (cerebral malaria [CM]). However, it is unknown whether axonal injury is related to long-term neurologic deficits and cognitive impairment in children with CM. METHODS Admission CSF tau concentrations were measured in 145 Ugandan children with CM and compared to clinical and laboratory factors and acute and chronic neurologic and cognitive outcomes. RESULTS Elevated CSF tau concentrations were associated with younger age, increased disease severity (lower glucose and hemoglobin concentrations, malaria retinopathy, acute kidney injury, and prolonged coma duration, all P < .05), and an increased CSF:plasma albumin ratio, a marker of blood-brain barrier breakdown (P < .001). Admission CSF tau concentrations were associated with the presence of neurologic deficits at hospital discharge, and at 6, 12, and 24 months postdischarge (all P ≤ .02). After adjustment for potential confounding factors, elevated log10-transformed CSF tau concentrations correlated with worse cognitive outcome z scores over 2-year follow-up for associative memory (β coefficient, -0.31 [95% confidence interval [CI], -.53 to -.10]) in children <5 years of age, and for overall cognition (-0.69 [95% CI, -1.19 to -.21]), attention (-0.78 [95% CI, -1.34 to -.23]), and working memory (-1.0 [95% CI, -1.68 to -.31]) in children ≥5 years of age (all P < .006). CONCLUSIONS Acute axonal injury in children with CM is associated with long-term neurologic deficits and cognitive impairment. CSF tau concentrations at the time of the CM episode may identify children at high risk of long-term neurocognitive impairment.
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Affiliation(s)
- Dibyadyuti Datta
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indianapolis
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indianapolis
| | - Peter F Castelluccio
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University, Kampala, Uganda
| | | | - Robert O Opoka
- Departments of Paediatrics and Child Health, Kampala, Uganda
| | - Paul Bangirana
- Departments of Psychiatry, Makerere University, Kampala, Uganda
| | - Richard Idro
- Departments of Paediatrics and Child Health, Kampala, Uganda
| | - Andrew J Saykin
- Indiana Alzheimer Disease Center and Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis
| | - Chandy C John
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indianapolis.,University of Minnesota Medical School, Minneapolis
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Namuli JD, Nalugya JS, Bangirana P, Nakimuli-Mpungu E. Prevalence and Factors Associated With Suicidal Ideation Among Children and Adolescents Attending a Pediatric HIV Clinic in Uganda. Front Sociol 2021; 6:656739. [PMID: 34212027 PMCID: PMC8239397 DOI: 10.3389/fsoc.2021.656739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/25/2021] [Indexed: 05/15/2023]
Abstract
Background: Suicidal behavior and HIV/AIDS are vital public health challenges especially in low and middle-income countries. As suicide in adults is perturbing for those closest to them, this sentiment is much more intense and generalized in the case of a child or adolescent. Knowledge of factors associated with suicidal ideation in HIV infected children and adolescents may inform suicide prevention strategies needed to improve their quality of life. This study aimed to assess the prevalence and factors associated with suicidal ideation among HIV infected children and adolescents attending a pediatric HIV clinic in Uganda. Methods: Data from a sample of 271 children and adolescents aged 6-18 years living with HIV/AIDS attending a pediatric HIV clinic was analyzed. Child characteristics and clinical variables were assessed using a socio-demographic questionnaire and medical records respectively. Suicidal ideation and depression were assessed using the Child Depression Inventory. The types of behavioral problems and the parent-child relationship were assessed using Child Behavioral Check List (6-18 years) and the Parent Child Relationship Scale respectively. Child exposure to different stressful life events was assessed with a series of standardized questions. Logistic regression models were used to explore factors independently associated with suicidal ideation. Results: The prevalence of suicidal ideation was 17%. In the multivariate analysis; Child exposure to family or friend's death (prevalence rate ratio (PRR = 2.02; 95% CI, 1.01-4.03), p = 0.046), HIV wasting syndrome (PRR = 0.39; 95% CI, 0.21-0.75, p = 0.04), Depression (PRR = 1.08; 95% CI, 1.03-1.12, p = 0.001), Anxiety symptoms (PRR = 1.10; 95% CI, 1.01-1.20, p = 0.024) and Rule breaking behavior (PRR = 1.06; 95% CI, 0.99-1.13, p = 0.051) were independently associated with suicidal ideations. Conclusion: The prevalence of suicidal ideation among children and adolescents living with HIV/AIDS is substantial. Children and adolescents with exposure to family or friend's death, those with higher depression scores, anxiety symptoms and rule breaking behavior are more likely to report suicidal ideation. Those with HIV wasting syndrome were less likely to report suicidal ideation. There is urgent need for HIV care providers to screen for suicide and link to mental health services.
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Affiliation(s)
- Justine Diana Namuli
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
- *Correspondence: Justine Diana Namuli,
| | | | - Paul Bangirana
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
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Ssemata AS, Opoka RO, Ssenkusu JM, Nakasujja N, John CC, Bangirana P. Socio-emotional and adaptive behaviour in children treated for severe anaemia at Lira Regional Referral Hospital, Uganda: a prospective cohort study. Child Adolesc Psychiatry Ment Health 2020; 14:45. [PMID: 33292468 PMCID: PMC7694894 DOI: 10.1186/s13034-020-00352-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 11/21/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Severe anaemia is a global public health challenge commonly associated with morbidity and mortality among children < 5 years of age in Sub-Saharan Africa. However, less is known about the behavioural performance of children < 5 years surviving severe anaemia in low resource settings. We investigated social-emotional and adaptive behaviour in children < 5 years diagnosed with severe anaemia in Northern Uganda. METHODS We conducted a hospital based prospective cohort study among children 6-42 months who were treated for severe anaemia (n = 171) at Lira Regional Referral Hospital, Uganda. Socio-emotional and adaptive behaviour were assessed 14 days post discharge using the Bayley Scales of Infant and Toddler Development, 3rd edition. Age-adjusted z-scores for each domain were calculated using scores from healthy community children (n = 88) from the same environment for each age category. Multiple linear regression was used to compare z-scores in the social-emotional and adaptive behaviour scales between the two groups after adjusting for weight-for-age z-score, social economic status, mother's education, father's education and father's employment on all the scales. RESULTS Compared with healthy community controls, children with severe anaemia had poorer [adjusted mean scores (standard error)], socio-emotional [- 0.29, (0.05) vs. 0.01, (0.08), P = 0.002]; but not overall/ composite adaptive behaviour [- 0.10, (0.05) vs. - 0.01, (0.07), P = 0.343]. Within the adaptive behaviour subscales, children with SA displayed significantly poorer scores on the community use [adjusted mean score (standard error)], [- 0.63, (0.10) vs. - 0.01, (0.13), P < 0.001]; and leisure [- 0.35, (0.07) vs. - 0.02, (0.07), P = 0.036] skills. CONCLUSION This study suggests that severe anaemia in children < 5 years is associated with poor social-emotional scores in the short-term post clinical recovery in Northern Uganda. We recommend long-term follow-up to determine the course of these problems and appropriate interventions to reduce the behavioural burden among children < 5 years surviving severe anaemia in Uganda.
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Affiliation(s)
- Andrew Sentoogo Ssemata
- Department of Psychiatry, Makerere University, College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
| | - Robert Opika Opoka
- Department of Paediatrics and Child Health, Makerere University, College of Health Sciences, Kampala, Uganda
| | - John Mbaziira Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Noeline Nakasujja
- Department of Psychiatry, Makerere University, College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease & Global Health, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Paul Bangirana
- Department of Psychiatry, Makerere University, College of Health Sciences, P.O. Box 7072, Kampala, Uganda
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Chiumento A, Rutayisire T, Sarabwe E, Hasan MT, Kasujja R, Nabirinde R, Mugarura J, Kagabo DM, Bangirana P, Jansen S, Ventevogel P, Robinson J, White RG. Exploring the mental health and psychosocial problems of Congolese refugees living in refugee settings in Rwanda and Uganda: a rapid qualitative study. Confl Health 2020; 14:77. [PMID: 33292363 PMCID: PMC7670672 DOI: 10.1186/s13031-020-00323-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Refugees fleeing conflict often experience poor mental health due to experiences in their country of origin, during displacement, and in new host environments. Conditions in refugee camps and settlements, and the wider socio-political and economic context of refugees' lives, create structural conditions that compound the effects of previous adversity. Mental health and psychosocial support services must address the daily stressors and adversities refugees face by being grounded in the lived reality of refugee's lives and addressing issues relevant to them. METHODS We undertook a rapid qualitative study between March and May 2019 to understand the local prioritisation of problems facing Congolese refugees living in two refugee settings in Uganda and Rwanda. Thirty free list interviews were conducted in each setting, followed by 11 key informant interviews in Uganda and 12 in Rwanda. RESULTS Results from all interviews were thematically analysed following a deductive process by the in-country research teams. Free list interview findings highlight priority problems of basic needs such as food, shelter, and healthcare access; alongside contextual social problems including discrimination/inequity and a lack of gender equality. Priority problems relating to mental and psychosocial health explored in key informant interviews include discrimination and inequity; alcohol and substance abuse; and violence and gender-based violence. CONCLUSIONS Our findings strongly resonate with models of mental health and psychosocial wellbeing that emphasise their socially determined and contextually embedded nature. Specifically, findings foreground the structural conditions of refugees' lives such as the physical organisation of camp spaces or refugee policies that are stigmatising through restricting the right to work or pursue education. This structural environment can lead to disruptions in social relationships at the familial and community levels, giving rise to discrimination/inequity and gender-based violence. Therefore, our findings foreground that one consequence of living in situations of pervasive adversity caused by experiences of discrimination, inequity, and violence is poor mental health and psychosocial wellbeing. This understanding reinforces the relevance of feasible and acceptable intervention approaches that aim to strengthening familial and community-level social relationships, building upon existing community resources to promote positive mental health and psychosocial wellbeing among Congolese refugees in these settings.
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Affiliation(s)
- Anna Chiumento
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, England.
| | - Theoneste Rutayisire
- Mental Health and Behaviour Research Group, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - M Tasdik Hasan
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, England
| | - Rosco Kasujja
- Department of Mental Health and Community Psychology, Makerere University, Kampala, Uganda
| | - Rachel Nabirinde
- Department of Mental Health and Community Psychology, Makerere University, Kampala, Uganda
| | - Joseph Mugarura
- Department of Mental Health and Community Psychology, Makerere University, Kampala, Uganda
| | - Daniel M Kagabo
- Mental Health & Community Psychology and Behaviour Research Group, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Paul Bangirana
- Department of Psychiatry, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Stefan Jansen
- Center for Mental Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Peter Ventevogel
- Public Health Section, Division of Resilience and Solutions, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Jude Robinson
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Ross G White
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, England
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Ssemata AS, Opoka RO, Ssenkusu JM, Nakasujja N, John CC, Bangirana P. Neurodevelopmental performance among pre-schoolers treated for severe anaemia at Lira Regional Referral Hospital, Uganda. PLoS One 2020; 15:e0240694. [PMID: 33147287 PMCID: PMC7641407 DOI: 10.1371/journal.pone.0240694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/01/2020] [Indexed: 12/20/2022] Open
Abstract
Background Severe anaemia is a common clinical problem among young children in sub-Saharan Africa. However, the effect of severe anaemia on neurodevelopment of these children is not well described. Therefore, we assessed the neurodevelopmental performance of preschool children diagnosed with severe anaemia in Northern Uganda. Methods We conducted a prospective cohort study among children < 5 years of age 14 days post discharge after an episode of severe anaemia (Hb < 5.0 g/dl; n = 171; mean Hb = 3.9g/dl) at Lira Regional Referral Hospital, Uganda. Neurodevelopmental outcomes (cognitive, language and motor) were assessed using Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III). Age-adjusted z-scores for each domain were calculated using scores from healthy community control children (n = 88) recruited from the same environment for each age category. Multiple linear regression was used to compare z-scores in the cognitive, language and motor scales between the two groups after adjusting for weight-for-age z-score, socioeconomic status, mother’s education, and father’s employment on all the scales. Results The prevalence of neurodevelopmental impairment was 2.3% (95% CI: 0.8–6.1) for cognition, 1.7% (95%: 0.6–5.3) for language and 3.5% (95% CI: 1.6–7.6) for motor scales and 4.6% (95% CI: 2.3–9.1) for deficits in ≥1 area of neurodevelopment. Significant differences were observed between the two groups with the SA group performing worse on cognition [adjusted mean score, (Standard error, SE), P-value] [-0.20, (0.01) vs. 0.00, (0.01), P = 0.02]; language [-0.25, (0.01) vs. 0.00, (0.01), P< 0.001]; and motor [-0.17, (0.01) vs. 0.00, (0.01), P = 0.05] scales. Conclusion In children < 5 years of age, severe anaemia was associated with neurocognitive (cognition, language and motor) deficits in the immediate period post treatment. Further research is needed to identify risk factors and determine the long-term effects of poor neurodevelopment in young children with severe anaemia.
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Affiliation(s)
- Andrew S. Ssemata
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
- * E-mail:
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - John M. Ssenkusu
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Noeline Nakasujja
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Diseases & Global Health, School of Medicine, Indianapolis, Indiana, United States of America
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
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Namuli JD, Joyce NS, Bangirana P, Nakimuli-Mpungu E. Complementary Alternative Medicine (CAM) Use and Associated Factors among HIV Infected Children and Adolescents Seeking Mental Health Services in Uganda. EC Psychol Psychiatr 2020; 9:1-8. [PMID: 34557877 PMCID: PMC8457676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Given the limited integration of mental health services into pediatric HIV care in sub-Saharan Africa, there is limited information on the nature of mental health service use sought by caregivers of children and adolescents living with HIV/AIDS. METHODS We analyzed data from a sample of 135 children and adolescents living with HIV/AIDS and attending a pediatric HIV care service whose parents or caregivers had sought for mental health care for their emotional or behavior problems in the past year. We assessed complementary alternative medicine use, socio-demographic characteristics and types of behavioral problems using a SOCIO-DEMOGRAPHIC questionnaire and the child behavioral checklist (6 - 18) respectively. Logistic regression models were used to explore factors independently associated with specific patterns of mental health service use. RESULTS Of 135 parents/caregivers interviewed, 38 (28.15%) sought mental health care from only complementary and alternative medicine (CAM) providers (traditional or faith healers), 38 (28.15%) from only conventional medical providers (general physicians, general nurses, psychiatrists or HIV counselors) and 59 (43.70%) sought care from both). Severe HIV disease in the young children [PRR = 2.09, 95%CI = 1.36 to 3.2, p-value = 0.001] and thought problems [PRR 1.26, 95%CI = 0.81 to 1.72, p-value = 0.04] in adolescents were independently associated with complementary and alternative medicine use. CONCLUSION Caregivers of children and adolescents with progressive HIV disease and thought problems were more likely to seek mental health services from complementary and alternative medicine providers.
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Affiliation(s)
- Justine Diana Namuli
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nalugya S Joyce
- Mulago National Referral and Teaching Hospital, Ministry of Health, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
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Ssemata AS, Nakitende JA, Kizito S, Whipple EC, Bangirana P, Nakasujja N, John CC, McHenry MS. Associations of childhood exposure to malaria with cognition and behavior outcomes: a systematic review protocol. Syst Rev 2020; 9:174. [PMID: 32772929 PMCID: PMC7416398 DOI: 10.1186/s13643-020-01434-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/29/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Malaria is one of the major contributing risk factors for poor development of children living in low- and middle-income countries (LMICs). However, little is known about the specific domains of cognition and behavior that are impacted by malaria, the extent of these deficits, and the different types of the malaria spectrum that are associated with these deficits. The objective of this systematic review is to determine the association of the different types of malaria infection on cognition and behavioral outcomes among children living in LMICs. METHODS AND ANALYSIS We will systematically search online bibliographic databases including MEDLINE (via PubMed), CINAHL (via EBSCO), PsycINFO (via EBSCO), Embase, and The Cochrane Central Register of Controlled Trials (CENTRAL) as well as Google Scholar and bibliographies of pertinent articles. We will include studies with a comparison group (e.g., clinical trials, cohort, observational, cross-sectional case-control, and controlled before and after or interrupted-time-series studies) involving children under 18 years of age living in LMICs, as determined by the World Bank criteria, with either an active malaria infection or history of malaria. Included articles must also measure cognitive and/or behavior outcomes determined by standardized psychological assessments (questionnaire-based scales and or neurocognitive assessments). Studies will be excluded if they are not in English, lack a control group, take place in a high-income country, or if a standardized instrument was not used. Two reviewers will independently review all articles to determine if they meet eligibility criteria. Any conflicts will be resolved after discussion with a third reviewer. When a list of included articles is finalized, two reviewers will extract data to populate and then cross check within an electronic table. Risk of bias and the strength of evidence and recommendations will be assessed independently using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, and a final score will be given upon consensus. For sufficiently homogeneous data on measured outcomes in multiple studies, we will investigate the possibility of pooling data to perform a meta-analysis. DISCUSSION This systematic review will evaluate the evidence of the association of malaria on the cognitive and behavioral outcomes. Findings from this planned review will generate insight on the domains affected by the different forms of malaria infection and may inform subsequent malaria interventions and future research in pediatric care. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020154777.
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Affiliation(s)
- Andrew Sentoogo Ssemata
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda.
| | - Jacquelline Ann Nakitende
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Simon Kizito
- Department of Mental Health and Community Psychology, School of Psychology, Makerere University, Kampala, Uganda
| | - Elizabeth C Whipple
- Ruth Lilly Medical Library, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Paul Bangirana
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Noeline Nakasujja
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Chandy C John
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Megan S McHenry
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana, USA
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Mwesiga EK, Nakasujja N, Nakku J, Nanyonga A, Gumikiriza JL, Bangirana P, Akena D, Musisi S. One year prevalence of psychotic disorders among first treatment contact patients at the National Psychiatric Referral and Teaching Hospital in Uganda. PLoS One 2020; 15:e0218843. [PMID: 31995567 PMCID: PMC6988969 DOI: 10.1371/journal.pone.0218843] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 01/07/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction Hospital based studies for psychotic disorders are scarce in low and middle income countries. This may impact on development of intervention programs. Objective We aimed to determine the burden of psychotic disorders among first treatment contact patients at the national psychiatric referral hospital in Uganda. Methods A retrospective patient chart-file review was carried out in March 2019 for all patients presenting to the hospital for the first time in the previous year. Patients were categorised into those with and without psychotic disorders. We collected sociodemographic data on age, gender, occupation, level of education, ethnicity, religion and home district. We determined the one year prevalence of psychotic disorders among first treatment contact patients. Using logistic regression models, we also determined the association between psychotic disorders and various exposure variables among first treatment contact patients. Results In 2018, 63% (95% CI: 60.2–65.1) of all first time contact patients had a psychosis related diagnosis. Among the patients with psychotic disorders, the median age was 29 years (IQR 24–36). Most of the patients were male (62.8%) and unemployed (63.1%). After adjusting for patients’ residence, psychotic disorders were found to be more prevalent among the female gender [OR 1.58 (CI1.46–1.72)] and those of Pentecostal faith [OR 1.25 (CI 1.10–1.42)]. Conclusion Among first treatment contact patients in Uganda, there is a large burden of psychotic disorders. The burden was more prevalent among females as well as people of Pentecostal faith who seemed to use their church for faith-based healing. Incidence studies are warranted to determine if this phenomenon is replicated at illness onset.
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Affiliation(s)
- Emmanuel Kiiza Mwesiga
- Department of Psychiatry, College of Health Sciences, Makerere University, Mulago, Uganda
- NURTURE Mental Health subgroup, College of Health Sciences, Makerere University, Mulago, Uganda
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Noeline Nakasujja
- Department of Psychiatry, College of Health Sciences, Makerere University, Mulago, Uganda
- NURTURE Mental Health subgroup, College of Health Sciences, Makerere University, Mulago, Uganda
| | - Juliet Nakku
- National Psychiatric Teaching and Referral Hospital of Uganda, Kampala, Uganda
| | - Annet Nanyonga
- National Psychiatric Teaching and Referral Hospital of Uganda, Kampala, Uganda
| | - Joy Louise Gumikiriza
- Department of Psychiatry, College of Health Sciences, Makerere University, Mulago, Uganda
- NURTURE Mental Health subgroup, College of Health Sciences, Makerere University, Mulago, Uganda
| | - Paul Bangirana
- Department of Psychiatry, College of Health Sciences, Makerere University, Mulago, Uganda
- NURTURE Mental Health subgroup, College of Health Sciences, Makerere University, Mulago, Uganda
| | - Dickens Akena
- Department of Psychiatry, College of Health Sciences, Makerere University, Mulago, Uganda
- NURTURE Mental Health subgroup, College of Health Sciences, Makerere University, Mulago, Uganda
| | - Seggane Musisi
- Department of Psychiatry, College of Health Sciences, Makerere University, Mulago, Uganda
- NURTURE Mental Health subgroup, College of Health Sciences, Makerere University, Mulago, Uganda
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Conroy AL, Bangirana P, Muhindo MK, Kakuru A, Jagannathan P, Opoka RO, Liechty EA, Nakalembe M, Kamya MR, Dorsey G, John CC. Case Report: Birth Outcome and Neurodevelopment in Placental Malaria Discordant Twins. Am J Trop Med Hyg 2020; 100:552-555. [PMID: 30628574 DOI: 10.4269/ajtmh.18-0659] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Maternal infection during pregnancy can have lasting effects on neurodevelopment, but the impact of malaria in pregnancy on child neurodevelopment is unknown. We present a case of a 24-year-old gravida three woman enrolled at 14 weeks 6 days of gestation in a clinical trial evaluating malaria prevention strategies in pregnancy. She had two blood samples test positive for Plasmodium falciparum using loop-mediated isothermal amplification before 20 weeks of gestation. At 31 weeks 4 days of gestation, the woman presented with preterm premature rupture of membranes, and the twins were delivered by cesarean section. Twin A was 1,920 g and Twin B was 1,320 g. Both placentas tested negative for malaria by microscopy, but the placenta of Twin B had evidence of past malaria by histology. The twins' development was assessed using the Bayley Scales of Infant and Toddler Development-Third Edition. At 1 year chronologic age, Twin B had lower scores across all domains (composite scores: cognitive, Twin A [100], Twin B [70]; motor, Twin A [88], Twin B [73]; language, Twin A [109], Twin B [86]). This effect persisted at 2 years chronologic age (composite scores: cognitive, Twin A [80], Twin B [60]; motor, Twin A [76], Twin B [67]; language, Twin A [77], Twin B [59]). Infant health was similar over the first 2 years of life. We report differences in neurodevelopmental outcomes in placental malaria-discordant dizygotic twins. Additional research is needed to evaluate the impact of placental malaria on neurodevelopmental complications. Trial registration number: ClinicalTrials.gov number, NCT02163447. Registered: June 2014, https://clinicaltrials.gov/ct2/show/NCT02163447.
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Affiliation(s)
- Andrea L Conroy
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mary K Muhindo
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Prasanna Jagannathan
- Division of Infectious Diseases and Geographical Medicine, Stanford University, Stanford, California
| | - Robert O Opoka
- Department of Paediatrics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Edward A Liechty
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Miriam Nakalembe
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Moses R Kamya
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Grant Dorsey
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Chandy C John
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
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Hickson MR, Conroy AL, Bangirana P, Opoka RO, Idro R, Ssenkusu JM, John CC. Acute kidney injury in Ugandan children with severe malaria is associated with long-term behavioral problems. PLoS One 2019; 14:e0226405. [PMID: 31846479 PMCID: PMC6917349 DOI: 10.1371/journal.pone.0226405] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/26/2019] [Indexed: 11/25/2022] Open
Abstract
Background Acute kidney injury (AKI) is a risk factor for neurocognitive impairment in severe malaria (SM), but the impact of AKI on long-term behavioral outcomes following SM is unknown. Methods We conducted a prospective study on behavioral outcomes of Ugandan children 1.5 to 12 years of age with two forms of severe malaria, cerebral malaria (CM, n = 226) or severe malarial anemia (SMA, n = 214), and healthy community children (CC, n = 173). AKI was defined as a 50% increase in creatinine from estimated baseline. Behavior and executive function were assessed at baseline and 6, 12, and 24 months later using the Child Behavior Checklist and Behavior Rating Inventory of Executive Function, respectively. Age-adjusted z-scores were computed for each domain based on CC scores. The association between AKI and behavioral outcomes was evaluated across all time points using linear mixed effect models, adjusting for sociodemographic variables and disease severity. Results AKI was present in 33.2% of children with CM or SMA at baseline. Children ≥6 years of age with CM or SMA who had AKI on admission had worse scores in socio-emotional function in externalizing behaviors (Beta (95% CI), 0.52 (0.20, 0.85), p = 0.001), global executive function (0.48 (0.15, 0.82), p = 0.005) and behavioral regulation (0.66 (0.32, 1.01), p = 0.0002) than children without AKI. There were no behavioral differences associated with AKI in children <6 years of age. Conclusions AKI is associated with long-term behavioral problems in children ≥6 years of age with CM or SMA, irrespective of age at study enrollment.
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Affiliation(s)
- Meredith R. Hickson
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indiana, United States of America
- * E-mail:
| | - Paul Bangirana
- Department of Psychiatry, Makerere University of School of Medicine, Kampala, Uganda
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University School of Medicine, Kampala, Uganda
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University School of Medicine, Kampala, Uganda
- Centre of Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - John M. Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indiana, United States of America
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Green NS, Munube D, Bangirana P, Buluma LR, Kebirungi B, Opoka R, Mupere E, Kasirye P, Kiguli S, Birabwa A, Kawooya MS, Lubowa SK, Sekibira R, Kayongo E, Hume H, Elkind M, Peng W, Li G, Rosano C, LaRussa P, Minja FJ, Boehme A, Idro R. Burden of neurological and neurocognitive impairment in pediatric sickle cell anemia in Uganda (BRAIN SAFE): a cross-sectional study. BMC Pediatr 2019; 19:381. [PMID: 31651270 PMCID: PMC6814102 DOI: 10.1186/s12887-019-1758-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 10/09/2019] [Indexed: 01/01/2023] Open
Abstract
Background Children with sickle cell anemia (SCA) are highly susceptible to stroke and other manifestations of pediatric cerebral vasculopathy. Detailed evaluations in sub-Saharan Africa are limited. Methods We aimed to establish the frequency and types of pediatric brain injury in a cross-sectional study at a large SCA clinic in Kampala, Uganda in a randomly selected sample of 265 patients with HbSS ages 1–12 years. Brain injury was defined as one or more abnormality on standardized testing: neurocognitive impairment using an age-appropriate test battery, prior stroke by examination or transcranial Doppler (TCD) velocities associated with stroke risk in children with SCA (cerebral arterial time averaged mean maximum velocity ≥ 170 cm/second). Results Mean age was 5.5 ± 2.9 years; 52.3% were male. Mean hemoglobin was 7.3 ± 1.01 g/dl; 76.4% had hemoglobin < 8.0 g/dl. Using established international standards, 14.7% were malnourished, and was more common in children ages 5–12. Overall, 57 (21.5%) subjects had one to three abnormal primary testing. Neurocognitive dysfunction was found in 27, while prior stroke was detected in 15 (5.7%). The most frequent abnormality was elevated TCD velocity 43 (18.1%), of which five (2.1%) were in the highest velocity range of abnormal. Only impaired neurocognitive dysfunction increased with age (OR 1.44, 95%CI 1.23–1.68), p < 0.001). In univariate models, malnutrition defined as wasting (weight-for-height ≤ −2SD), but not sex or hemoglobin, was modestly related to elevated TCD (OR 1.37, 95%CI 1.01–1.86, p = 0.04). In adjusted models, neurocognitive dysfunction was strongly related to prior stroke (OR 6.88, 95%CI 1.95–24.3, p = .003) and to abnormal TCD (OR 4.37, 95%CI 1.30, p = 0.02). In a subset of 81 subjects who were enriched for other abnormal results, magnetic resonance imaging and angiography (MRI/MRA) detected infarcts and/or arterial stenosis in 52%. Thirteen subjects (25%) with abnormal imaging had no other abnormalities detected. Conclusions The high frequency of neurocognitive impairment or other abnormal results describes a large burden of pediatric SCA brain disease in Uganda. Evaluation by any single modality would have underestimated the impact of SCA. Testing the impact of hydroxyurea or other available disease-modifying interventions for reducing or preventing SCA brain effects is warranted.
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Affiliation(s)
- Nancy S Green
- Department of Pediatrics, Columbia University Vagelos Medical Center, 630 West 168 St., Black Building 2-241, Box 168, New York, NY, USA.
| | - Deogratias Munube
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Linda Rosset Buluma
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Bridget Kebirungi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Philip Kasirye
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Sarah Kiguli
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Annet Birabwa
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Michael S Kawooya
- Department Radiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Samson K Lubowa
- Department Radiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rogers Sekibira
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Edwards Kayongo
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Heather Hume
- Department of Paediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Canada
| | - Mitchell Elkind
- Departments of Neurology, Epidemiology and Biostatistics, Columbia University Vagelos Medical Center, New York, NY, USA
| | - Weixin Peng
- Department of Biostatistics, Mailman School of Public Health, Columbia University Vagelos Medical Center, New York, NY, USA
| | - Gen Li
- Department of Biostatistics, Mailman School of Public Health, Columbia University Vagelos Medical Center, New York, NY, USA
| | - Caterina Rosano
- Epidemiology and of Clinical and Translation Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Philip LaRussa
- Department of Pediatrics, Columbia University Vagelos Medical Center, New York, NY, USA
| | - Frank J Minja
- Department of Radiology, Yale University, New Haven, CT, USA
| | - Amelia Boehme
- Department of Neurology, Columbia University Vagelos Medical Center, New York, NY, USA
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
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Akellot J, Bangirana P. Association between parental involvement and academic achievement of deaf children at Mulago school for the deaf, Kampala, Uganda. Afr Health Sci 2019; 19:2270-2281. [PMID: 31656513 PMCID: PMC6794534 DOI: 10.4314/ahs.v19i2.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Deaf children face many challenges in dealing with educational opportunities and ensuring attainment of academic skills. A parent's involvement in the child's education has the potential to enhance academic performance. We sought to study the association between parental involvement and academic achievement among deaf children in Uganda. Methods Using purposive consecutive sampling, one hundred and eight parents of deaf children (Primary 1 to 7) were recruited from Mulago School for the Deaf in Kampala, Uganda. The Parental Involvement Questionnaire was used to measure parents' involvement in school activities while the Wide Range Assessment Test, third edition, was used to measure academic achievement (reading, spelling and arithmetic). Linear regression was used to test the association between parental involvement and academic achievement. Results One hundred and five children with mean age 11.09 years (SD = 2.89) were enrolled of whom 56 (35.3%) were female. With a Beta coefficient of 0.07, a 7% unit increase of summed parental involvement showed no significant association between parental involvement and academic achievement (p = 0.46) of the deaf children. Conclusion Parental involvement was not associated with academic achievement among deaf children in Kampala. Other factors associated with academic achievement need to be identified to enhance deaf children's performance at school.
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Affiliation(s)
- Josephine Akellot
- Department of Mental Health and Community Psychology, Makerere University, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, Makerere University, Kampala, Uganda
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Conroy AL, Opoka RO, Bangirana P, Idro R, Ssenkusu JM, Datta D, Hodges JS, Morgan C, John CC. Acute kidney injury is associated with impaired cognition and chronic kidney disease in a prospective cohort of children with severe malaria. BMC Med 2019; 17:98. [PMID: 31109328 PMCID: PMC6528242 DOI: 10.1186/s12916-019-1332-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/29/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a recognized complication of pediatric severe malaria, but its long-term consequences are unknown. METHODS Ugandan children with cerebral malaria (CM, n = 260) and severe malaria anemia (SMA, n = 219) or community children (CC, n = 173) between 1.5 and 12 years of age were enrolled in a prospective cohort study. Kidney Disease: Improving Global Outcomes (KDIGO) criteria were used to retrospectively define AKI and chronic kidney disease (CKD). Cognitive testing was conducted using the Mullen Scales of Early Learning in children < 5 and Kaufman Assessment Battery for Children (K-ABC) second edition in children ≥ 5 years of age. RESULTS The prevalence of AKI was 35.1%, ranging from 25.1% in SMA to 43.5% in CM. In-hospital mortality was 11.9% in AKI compared to 4.2% in children without AKI (p = 0.001), and post-discharge mortality was 4.7% in AKI compared to 1.3% in children without AKI (p = 0.030) corresponding to an all-cause adjusted hazard ratio of 2.30 (95% CI 1.21, 4.35). AKI was a risk factor for short- and long-term neurocognitive impairment. At 1 week post-discharge, the frequency of neurocognitive impairment was 37.3% in AKI compared to 13.5% in children without AKI (adjusted odds ratio (aOR) 2.31 [95% CI 1.32, 4.04]); at 1-year follow-up, it was 13.3% in AKI compared to 3.4% in children without AKI (aOR 2.48 [95% CI 1.01, 6.10]), and at 2-year follow-up, it was 13.0% in AKI compared to 3.4% in children without AKI (aOR 3.03 [95% CI 1.22, 7.58]). AKI was a risk factor for CKD at 1-year follow-up: 7.6% of children with severe malaria-associated AKI had CKD at follow-up compared to 2.8% of children without AKI (p = 0.038) corresponding to an OR of 2.81 (95% CI 1.02, 7.73). The presenting etiology of AKI was consistent with prerenal azotemia, and lactate dehydrogenase as a marker of intravascular hemolysis was an independent risk factor for AKI in CM and SMA (p < 0.0001). In CM, AKI was associated with the presence and severity of retinopathy (p < 0.05) and increased cerebrospinal fluid albumin suggestive of blood-brain barrier disruption. CONCLUSIONS AKI is a risk factor for long-term neurocognitive impairment and CKD in pediatric severe malaria.
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Affiliation(s)
- Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN 46202 USA
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - John M. Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN 46202 USA
| | - James S. Hodges
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, USA
| | - Catherine Morgan
- Division of Pediatric Nephrology, University of Alberta, Edmonton, Canada
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN 46202 USA
- Division of Global Pediatrics, University of Minnesota Medical School, Minneapolis, USA
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Bangirana P, Giordani B, Kobusingye O, Murungyi L, Mock C, John CC, Idro R. Patterns of traumatic brain injury and six-month neuropsychological outcomes in Uganda. BMC Neurol 2019; 19:18. [PMID: 30717695 PMCID: PMC6360708 DOI: 10.1186/s12883-019-1246-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 01/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic brain injuries in Uganda are on the increase, however little is known about the neuropsychological outcomes in survivors. This study characterized patients with traumatic brain injury (TBI) and the associated six-month neuropsychological outcomes in a Ugandan tertiary hospital. METHODS Patients admitted at Mulago Hospital with head injury from November 2015 to April 2016 were prospectively enrolled during admission and followed up at six months after discharge to assess cognition, posttraumatic stress symptoms (PTSS), depression symptoms and physical disability. The outcomes were compared to a non-head-injury group recruited from among the caretakers, siblings and neighbours of the patients with age and sex entered as covariates. RESULTS One hundred and seventy-one patients and 145 non-head injury participants were enrolled. The age range for the whole sample was 1 to 69 years with the non-head injury group being older (mean age (SD) 33.34 (13.35) vs 29.34 (14.13) years of age, p = 0.01). Overall, motorcycle crashes (36/171, 38.6%) and being hit by an object (58/171, 33.9%) were the leading causes of TBI. Head injury from falls occurred more frequently in children < 18 years (13.8% vs 2.8%, p = 0.03). In adults 18 years and older, patients had higher rates of neurocognitive impairment (28.4% vs 6.6%, p < 0.0001), PTSS (43.9% vs 7.9%, p < 0.0001), depression symptoms (55.4% vs 10%, p < 0.0001) and physical disability (7.2% vs 0%, p = 0.002). Lower Glasgow Coma Score (GCS) on admission was associated with neurocognitive impairment (11.6 vs 13.1, p = 0.04) and physical disability (10 vs 12.9, p = 0.01) six months later. CONCLUSION This first such study in the East-African region shows that depth of coma on admission in TBI is associated with neurocognitive impairment and physical disability.
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Affiliation(s)
- Paul Bangirana
- Department of Psychiatry, Makerere University, Kampala, Uganda.
| | - Bruno Giordani
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Olive Kobusingye
- Trauma, Injury, and Disability Track, School of Public Health, Makerere University, Kampala, Uganda
| | | | - Charles Mock
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
| | - Chandy C John
- Department of Paediatrics, Indiana University, Indianapolis, IN, USA
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
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Nakitende AJ, Bangirana P, Nakasujja N, Semrud-Clikeman M, Ssemata AS, John CC, Idro R. "I feel so bad but have nothing to do." Exploring Ugandan caregivers' experiences of parenting a child with severe malaria and subsequent repeated uncomplicated malaria. Malar J 2018; 17:360. [PMID: 30314439 PMCID: PMC6186059 DOI: 10.1186/s12936-018-2514-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 10/08/2018] [Indexed: 11/17/2022] Open
Abstract
Background Severe malaria in children is often associated with long-term behavioural and cognitive problems. A sizeable minority of children go on to experience repeated malaria due to the high transmission and infection rates in the region. The purpose of this study was to explore caregivers’ experiences of parenting a child with a history of severe malaria followed by repeated episodes of uncomplicated malaria in comparison to healthy community children. Methods Thirty-one caregivers were enrolled in the study. These included caregivers of children previously exposed to severe malaria and who had experienced repeated uncomplicated malaria attacks (SM with RMA, n = 15), caregivers of children exposed to severe malaria who did not experience repeated episodes (SM, n = 10), and caregivers of healthy community children (CC, n = 6) were purposively selected. Results Thematic-content analysis generated eight areas of concern, six of which were noted only by caregivers of children with SM or SM with RMA: (1) a sense of helplessness; (2) challenges with changes in behaviour; (3) responses to a child’s behaviour; (4) family life disruptions, including breakdown of relationships and inadequate male-spouse involvement in child care; (5) disagreements in seeking healthcare; (6) societal burden; and two by caregivers of children with SM, SM with RMA and also CC; (7) concern about academic achievement; and, (8) balancing work and family life. Conclusions The study findings suggest that severe malaria, especially when followed by repeated malaria episodes, affects not only children who have the illness but also their caregivers. The effects on caregivers can decrease their social functioning and isolate them from other parents and may disrupt families. Interventions to support caregivers by counselling the ongoing problems that might be expected in children who have had severe malaria and repeated episodes of malaria, and how to manage these problems, may provide a way to improve behavioural and mental health outcomes for those children and their caregivers.
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Affiliation(s)
- Ann J Nakitende
- Department of Psychiatry, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
| | - Paul Bangirana
- Department of Psychiatry, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Noeline Nakasujja
- Department of Psychiatry, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | | | - Andrew S Ssemata
- Department of Psychiatry, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Chandy C John
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.,Department of Pediatrics, Indiana University, Indianapolis, IN, USA
| | - Richard Idro
- Department of Pediatrics and Child Health, Makerere University, Kampala, Uganda.,Centre of Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Bangirana P, Ruel TD, Boivin MJ, Pillai SK, Giron LB, Sikorskii A, Banik A, Achan J. Absence of neurocognitive disadvantage associated with paediatric HIV subtype A infection in children on antiretroviral therapy. J Int AIDS Soc 2018; 20. [PMID: 29052340 PMCID: PMC5810341 DOI: 10.1002/jia2.25015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 09/28/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction Infection with HIV subtype A has been associated with poorer neurocognitive outcomes compared to HIV subtype D in Ugandan children not eligible for antiretroviral therapy (ART). In this study, we sought to determine whether subtype‐specific differences are also observed among children receiving ART. Materials and Methods Children were recruited from a clinical trial in which they were randomized to receive either lopinavir (LPV)‐ or non‐nucleoside reverse transcriptase inhibitor (NNRTI)‐ based ART (NCT00978068). Age at initiation of ART ranged from six months to six years. HIV subtype was determined by PCR amplification and population sequencing of the pol region derived from peripheral blood mononuclear cell DNA, followed by application of the REGA and Recombinant Identification Programme algorithms. General cognition was assessed using the Kaufman Assessment Battery for Children (Second Edition), attention using the Test of Variables of Attention, and motor skills using the Bruininks‐Oseretsky Test of Motor Proficiency (Second Edition). Home environment was assessed using the Home Observation for the Measurement of the Environment (HOME). Age‐adjusted test z‐scores were entered into a regression model that adjusted for sex, socio‐economic status score, HOME score, years of schooling, and ART treatment type. Results One hundred and five children were tested; median (interquartile range) age was 7.05 years (6.30 to 8.44), CD4 count was 867.7 cells/mm3 (416.0 to 1203.5), and duration on ART was 4.03 years (3.55 to 4.23). Seventy‐eight children had HIV subtype A and 27 had subtype D; the groups had comparable home and socio‐economic status, except that there were more males among children infected with subtype A than D (64.7% vs. 35.3%, p = 0.02). There were no differences between the subtypes in general cognition (estimated mean difference: 0.20; 95% CI: −0.11 to 0.50); p = 0.21), attention (−0.18, 95% CI: −0.60 to 0.24, p = 0.41) and motor skills (1.60, 95% CI: −0.84 to 4.04, p = 0.20). Conclusions Our results imply that ART may diminish the neurocognitive disadvantage seen in treatment‐naïve HIV‐infected children with subtype A.
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Affiliation(s)
- Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Theodore D Ruel
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Michael J Boivin
- Department of Psychiatry, Michigan State University, East Lansing, MI, USA
| | - Satish K Pillai
- Blood Systems Research Institute, San Francisco, CA, USA.,Department of Laboratory Medicine, University of California, San Francisco, CA, USA
| | | | - Alla Sikorskii
- Department of Psychiatry, Michigan State University, East Lansing, MI, USA.,Department of Statistics and Probability, Michigan State University, East Lansing, MI, USA
| | - Asish Banik
- Department of Statistics and Probability, Michigan State University, East Lansing, MI, USA
| | - Jane Achan
- Disease Control and Elimination Theme, Medical Research Council Unit, Banjul, The Gambia
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Bangirana P, Conroy AL, Opoka RO, Hawkes MT, Hermann L, Miller C, Namasopo S, Liles WC, John CC, Kain KC. Inhaled nitric oxide and cognition in pediatric severe malaria: A randomized double-blind placebo controlled trial. PLoS One 2018; 13:e0191550. [PMID: 29370261 PMCID: PMC5784958 DOI: 10.1371/journal.pone.0191550] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/04/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Severe malaria is a leading cause of acquired neurodisability in Africa and is associated with reduced nitric oxide (NO) bioavailability. A neuroprotective role for inhaled NO has been reported in animal studies, and administration of inhaled NO in preterm neonates with respiratory distress syndrome is associated with a 47% reduced risk of cognitive impairment at two years of age. METHODS A randomized double-blind placebo-controlled trial of inhaled NO versus placebo as an adjunctive therapy for severe malaria was conducted in Uganda between 2011 and 2013. Children received study gas for a maximum 72 hours (inhaled NO, 80 parts per million; room air placebo). Neurocognitive testing was performed on children<5 years at 6 month follow-up. The neurocognitive outcomes assessed were overall cognition (a composite of fine motor, visual reception, receptive language, and expressive language), attention, associative memory, and the global executive composite. Main outcomes were attention, associative memory, and overall cognitive ability. RESULTS Sixty-one children receiving iNO and 59 children receiving placebo were evaluated. Forty-two children (35.0%) were impaired in at least one neurocognitive domain. By intention-to-treat analysis, there were no differences in unadjusted or unadjusted age-adjusted z-scores for overall cognition (β (95% CI): 0.26 (-0.19, 0.72), p = 0.260), attention (0.18 (-0.14, 0.51), p = 0.267), or memory (0.14 (-0.02, 0.30), p = 0.094) between groups by linear regression. Children receiving inhaled NO had a 64% reduced relative risk of fine motor impairment than children receiving placebo (relative risk, 95% CI: 0.36, 0.14-0.96) by log binomial regression following adjustment for anticonvulsant use. CONCLUSIONS Severe malaria is associated with high rates of neurocognitive impairment. Treatment with inhaled NO was associated with reduced risk of fine motor impairment. These results need to be prospectively validated in a larger study powered to assess cognitive outcomes in order to evaluate whether strategies to increase bioavailable NO are neuroprotective in children with severe malaria. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01255215.
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Affiliation(s)
- Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrea L Conroy
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Michael T Hawkes
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada.,Division of Pediatric Infectious Diseases, University of Alberta, Edmonton, Canada
| | - Laura Hermann
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Christopher Miller
- Department of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Sophie Namasopo
- Department of Paediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - W Conrad Liles
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Kevin C Kain
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada
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Musindo O, Bangirana P, Kigamwa P, Okoth R, Kumar M. Neurocognitive functioning of HIV positive children attending the comprehensive care clinic at Kenyatta national hospital: exploring neurocognitive deficits and psychosocial risk factors. AIDS Care 2018; 30:618-622. [PMID: 29353495 DOI: 10.1080/09540121.2018.1426829] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Children and adolescents are affected in different ways by HIV/AIDS. Neurocognitive deficits are one of the most significant long term effects on HIV infected children and adolescents. Several factors are thought to influence cognitive outcomes and this include immune status, Highly Active Antiretroviral Therapy (HAART), education and social support. The aim of the study was to assess the neurocognitive function of HIV infected children and adolescents and correlate it with psychosocial factors. A cross sectional study was carried out involving a sample of 90 children living with HIV between 8 and 15 years (M = 11.38, SD = 2.06) attending Comprehensive Care Clinic (CCC) at Kenyatta National Hospital (KNH). Samples were selected by using purposive sample technique. Kaufman Assessment Battery for Children-Second Edition was used to assess cognitive function and psychosocial issues were assessed using HEADS-ED. Data was analyzed using SPSS v23 and independent T-tests, Pearson's correlation and linear regression were used. The prevalence of neurocognitive deficits among HIV positive children attending CCC at KNH was 60% with neurocognitive performance of 54 children being at least 2SD below the mean based on the KABC-II scores. There was no significant correlation between mental processing index and CD4 count (Pearson's rho = -0.01, p = 0.39). There was no significant association between Mental Processing Index and viral load (p = 0.056) and early ARV initiation (0.27). Using the HEADS-ED, risks factors related to education (β = -5.67, p = 0.02) and activities and peer support (β = -9.1, p = 0.002) were significantly associated with poor neurocognitive performance. Neurocognitive deficits are prevalent among HIV positive children attending CCC-KNH. This extent of the deficits was not associated with low CD4 count, high viral load or early initiation in HIV care. However, poor school performance and problem with peers was associated with poor neurocognitive performance.
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Affiliation(s)
- Otsetswe Musindo
- a Department of Psychiatry , College of Health Sciences, University of Nairobi , Nairobi , Kenya
| | - Paul Bangirana
- b Department of Psychiatry , College of Health Sciences, Makerere University , Kampala , Uganda
| | - Pius Kigamwa
- a Department of Psychiatry , College of Health Sciences, University of Nairobi , Nairobi , Kenya
| | - Roselyne Okoth
- a Department of Psychiatry , College of Health Sciences, University of Nairobi , Nairobi , Kenya
| | - Manasi Kumar
- a Department of Psychiatry , College of Health Sciences, University of Nairobi , Nairobi , Kenya
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Opoka RO, Bangirana P, Idro R, Shabani E, Namazzi R, John CC. Lack of mortality in 22 children with sickle cell anemia and severe malarial anemia. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26745. [PMID: 28834130 PMCID: PMC6072279 DOI: 10.1002/pbc.26745] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/20/2017] [Accepted: 07/15/2017] [Indexed: 11/07/2022]
Abstract
Retrospective studies suggest that there is high mortality in children with sickle cell anemia (SCA) and severe malaria. We assessed mortality in Ugandan children with severe malarial anemia (SMA, n = 232) or cerebral malaria (CM, n = 267) by sickle cell hemoglobin genotype. Admission and 2-year follow-up mortality did not differ among children with SMA who had homozygous form of sickle cell hemoglobin (HbSS) versus normal form of adult hemoglobin (admission, 0/22, 0%, vs. 1/208, 0.5%; follow-up, 1/22, 4.5%; 7/207, 3.4%, respectively; all P > 0.6). The single child with CM and HbSS survived. The study findings highlight the need for large prospective studies of malaria-related mortality in children with SCA.
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Affiliation(s)
- Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Estela Shabani
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indiana
- Department of Pediatrics, University of Minnesota, Minnesota
| | - Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indiana
- Department of Pediatrics, University of Minnesota, Minnesota
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Semrud-Clikeman M, Romero RAA, Prado EL, Shapiro EG, Bangirana P, John CC. [Formula: see text]Selecting measures for the neurodevelopmental assessment of children in low- and middle-income countries. Child Neuropsychol 2017; 23:761-802. [PMID: 27609060 PMCID: PMC5690490 DOI: 10.1080/09297049.2016.1216536] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Diseases affecting millions of children in low- and middle-income countries (LMICs), such as malnutrition, micronutrient deficiency, malaria, and HIV, can lead to adverse neurodevelopmental outcomes. Thus, a key health outcome in children is neurodevelopmental status. In this paper, the neurodevelopmental screening and testing measures most commonly utilized in LMICs are reviewed, and a matrix is presented to help researchers and clinicians determine which measures may be most useful for various LMIC inquiries. The matrix is based on an Internet literature review of 114 publications for the period January 1998 to February 2016, reporting the psychometric properties of instruments tested in LMIC children. The measures are classified as screening tests or more detailed tests that include both comprehensive batteries of general development and tests of specific domains. For completeness, two experts have reviewed this paper, as well as the authors. An overview of the tests used to date is presented, including the benefits and drawbacks of each test, in order to provide researchers and developmental clinicians with a way to decide which tests may be best suited to their developmental assessment goals. Remarkable progress has been made in neurodevelopmental testing in children in LMICs over the past two decades but there remains a need for additional research in this area to develop new tests, better evaluate and adapt current tests, and assess test validity and reliability across cultures.
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Affiliation(s)
| | | | | | - Elsa G Shapiro
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Paul Bangirana
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | - Chandy C John
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
- Department of Pediatrics, Indiana University, Indianapolis, IN
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Opoka RO, Hamre KES, Brand N, Bangirana P, Idro R, John CC. High Postdischarge Morbidity in Ugandan Children With Severe Malarial Anemia or Cerebral Malaria. J Pediatric Infect Dis Soc 2017; 6:e41-e48. [PMID: 28339598 PMCID: PMC5907851 DOI: 10.1093/jpids/piw060] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 09/12/2016] [Indexed: 11/14/2022]
Abstract
BACKGROUND Cerebral malaria (CM) and severe malarial anemia (SMA) account for a substantial proportion of malaria-related deaths in sub-Saharan Africa. However, postdischarge morbidity in children with CM or SMA has not been well established. METHODS Children 18 months to 12 years of age, enrolled on admission to Mulago National Referral Hospital in Kampala, Uganda (CM, n = 162; SMA, n = 138), and healthy children recruited from the community (CC) (n = 133) were followed up for 6 months. The incidences of hospitalizations and outpatient clinic visits for illness during the follow-up period were compared between children with CM or SMA and the CC. RESULTS After adjustment for age, sex, and nutritional status, children with SMA had a higher incidence rate ratio (IRR) than CC for hospitalization (95% confidence interval [CI], 20.81 [2.48-174.68]), hospitalization with malaria (17.29 [95% CI, 2.02-148.35]), and clinic visits for any illness (95% CI, 2.35 [1.22-4.51]). Adjusted IRRs for children with CM were also increased for all measures compared with those for CC, but they achieved statistical significance only for clinic visits for any illness (2.24 [95% CI, 1.20-4.15]). In both groups, the primary reason for the clinic visits and hospitalizations was malaria. CONCLUSIONS In the 6 months after initial hospitalization, children with SMA have an increased risk of repeated hospitalization, and children with CM or SMA have an increased risk of outpatient illness. Malaria is the main cause of inpatient and outpatient morbidity. Malaria prophylaxis has the potential to decrease postdischarge morbidity rates in children with SMA or CM.
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Affiliation(s)
| | - Karen E S Hamre
- Division of Global Pediatrics, University of Minnesota, Minneapolis
| | - Nathan Brand
- Columbia College of Physicians and Surgeons, New York; and
| | | | | | - Chandy C John
- Division of Global Pediatrics, University of Minnesota, Minneapolis;,Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University, Indianapolis,Corresponding Author: C. C. John, MD, MS, Ryan White Center for Pediatric Infectious Disease and Global Health, 1044 W. Walnut St, R4 402D, Indianapolis, IN 44202. E-mail:
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50
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Holmberg D, Franzén-Röhl E, Idro R, Opoka RO, Bangirana P, Sellgren CM, Wickström R, Färnert A, Schwieler L, Engberg G, John CC. Cerebrospinal fluid kynurenine and kynurenic acid concentrations are associated with coma duration and long-term neurocognitive impairment in Ugandan children with cerebral malaria. Malar J 2017; 16:303. [PMID: 28754152 PMCID: PMC5534063 DOI: 10.1186/s12936-017-1954-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/22/2017] [Indexed: 01/26/2023] Open
Abstract
Background One-fourth of children with cerebral malaria (CM) retain cognitive sequelae up to 2 years after acute disease. The kynurenine pathway of the brain, forming neuroactive metabolites, e.g. the NMDA-receptor antagonist kynurenic acid (KYNA), has been implicated in long-term cognitive dysfunction in other CNS infections. In the present study, the association between the kynurenine pathway and neurologic/cognitive complications in children with CM was investigated. Methods Cerebrospinal fluid (CSF) concentrations of KYNA and its precursor kynurenine in 69 Ugandan children admitted for CM to Mulago Hospital, Kampala, Uganda, between 2008 and 2013 were assessed. CSF kynurenine and KYNA were compared to CSF cytokine levels, acute and long-term neurologic complications, and long-term cognitive impairments. CSF kynurenine and KYNA from eight Swedish children without neurological or infectious disease admitted to Astrid Lindgren’s Children’s Hospital were quantified and used for comparison. Results Children with CM had significantly higher CSF concentration of kynurenine and KYNA than Swedish children (P < 0.0001 for both), and CSF kynurenine and KYNA were positively correlated. In children with CM, CSF kynurenine and KYNA concentrations were associated with coma duration in children of all ages (P = 0.003 and 0.04, respectively), and CSF kynurenine concentrations were associated with worse overall cognition (P = 0.056) and attention (P = 0.003) at 12-month follow-up in children ≥5 years old. Conclusions CSF KYNA and kynurenine are elevated in children with CM, indicating an inhibition of glutamatergic and cholinergic signaling. This inhibition may lead acutely to prolonged coma and long-term to impairment of attention and cognition.
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Affiliation(s)
- Dag Holmberg
- Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine Solna, Unit of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden
| | - Elisabeth Franzén-Röhl
- Department of Medicine Solna, Unit of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | - Carl M Sellgren
- Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Färnert
- Department of Medicine Solna, Unit of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Lilly Schwieler
- Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Göran Engberg
- Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden.
| | - Chandy C John
- Department of Pediatrics, Indiana University, Indianapolis, IN, USA.,Department of Pediatrics, University of Minnesota, Minnesota, USA
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