Medicine Digest
Donnez J et al. Ulipristal acetate versus placebo for fibroid treatment before surgery. NEJM 2012; 366: 409–20; Donnez J et al.
Ulipristal acetate versus
leuprolide acetate for uterine fibroids. Ibid: 421–32; Stewart EA. Uterine fibroids and evidence-based- medicine - not an oxymoron. Ibid: 471–3 (editorial).
Neurodevelopmental outcomes
after intrauterine or neonatal insult Although the millennium development goals have concentrated attention on neonatal and early childhood mortal- ity there has been less attention paid to morbidity resulting from intrauterine or neonatal insult. A total of 153 studies has been included in a systematic review of the global effects of such insults on child neurodevelopment. The studies included 22161 survivors
of intrauterine or neonatal insults (sep- sis, meningitis, hypoxia, ischaemic en- cephalopathy, preterm birth, jaundice, tetanus, and infections with cytomegalo- virus, herpes virus, rubella, toxoplasma, or syphilis. The outcomes assessed were cognition, motor ability, hearing, vision, seizures, behaviour, and multidomain. With at least one of any of these insults the risk of at least one neurodevelop- mental sequel was 39%. The risk of se- vere impairment was 19%, of at least one moderate impairment 5%, and of at least one mild impairment 10%. Al- most 60% of children with sequelae had learning difficulties, cognitive defects, and developmental delay. Cerebral palsy occurred in 21%, hearing impairment in 20%, and visual impairment in 18%. Multiple impairments were present in 32% of impaired survivors. There were few studies from developing countries
and more studies are needed. Mwaniki MK et al. Long-term neurodevelopmental outcomes after intrauterine and neonatal insults: a systematic review. Lancet 2012; 379: 445–52; Thompson LC, Gillberg C. Behavioural problems from perinatal and neonatal insults. Ibid: 392–3 (comment).
ply vertical transmission from the mother and late onset, maternally or environ- mentally acquired infection. Intrapartum antibiotic prophylaxis given to high-risk or known carrier mothers is effective but the disease is still an important cause of infant morbidity and mortality. A sys- tematic review and meta-analysis has included 74 studies, only five from low- income countries. The mean incidence of group B strep-
tococcal infection in infants up to 89 days of age was 0.53 cases per 1000 livebirths and the mean case fatality ratio was 9.6% (0.43 per 1000 and 12.1% for early onset disease, 0.24 per 1000 and 6.8% for late onset disease). Case fatality was 4.6% in high-income countries and 12.6% in low-income countries. There were no serotype data from low-income countries but in high-income countries the most common serotypes were III, Ia, Ib, II, and V. A vaccine including these serotypes should be effective. Where intrapartum antibiotic prophylaxis was common the average incidence of group B streptococcal disease was 0.23 per 1000 live births but where such prophy- laxis was not commonly used the inci- dence was 0.75 per 1000 livebirths. Group B streptococcal infection in
early infancy remains important. A vac- cine is in preparation. More data from
developing countries are needed. Edmond KM et al. Group B streptococcal disease in infants aged younger than 3 months: systematic re- view and meta-analysis. Lancet 2012; 379: 547–56; Cotton MF. Rabie H. Group B streptococcal disease in infants. Ibid: 502–3 (comment).
Prevention of sexually transmitted infections
Community-based interventions to pre- vent sexually transmitted infection (STIs) in Africa and elsewhere have had mixed results. A trial in Peru has shown possible benefits. Twenty Peruvian cities were ran-
Infection
Group B streptococcal infection in early infancy
In developed countries the most com- mon cause of sepsis in early infancy is the group B streptococcus (Streptococ- cus agalactiae). Affecting infants in the first 3 months of life, group B streptococ- cal infection may be early onset (in the first 6 days of life) or late onset (at age 7–89 days). Early onset is taken to im-
July 2012
domised to intervention (an S-PLUS pro- gramme of four components: (strength- ened STI management by pharmacy workers and clinicians, mobile-team out- reach to female sex workers (FSWs), pre- sumptive treatment of FSWs for trichmo- niasis, and condom promotion for FSWs and the general public) or standard care. STI screening was performed at baseline and random sample follow-up surveys were performed after 2 or 3 years. Full follow-up data were obtained for 12930 people aged 18–29 years. Testing was for
infection with Chlamydia tracho- matis, Trichomonas vaginalis, Neisseria
gonorrhoeae, or positive syphilis serol- ogy. During the course of the trial there was a non-significant reduction in the four STIs together from 8.4% to 8.1% in control cities and from 7.6% to 6.3% in intervention cities. Significant reductions were noted in young women and FSWs overall, and for T vaginalis among young women and T vaginalis and N gonor- rhoeae among FSWs. The intervention was followed by sig- nificant reductions in some STIs in young
women and FSWs. Garcia PJ et al. Prevention of sexually transmitted infections in urban communities (Peru PREVEN): a multicomponent community-randomised controlled trial. Lancet 2012; 379: 1120–8; Donovan B, Guy R. Developments in research for STI prevention in Peru. Ibid: 1081–2 (comment).
Paediatrics
Oral amoxicillin for severe early childhood pneumonia in rural Pakistan
In 2008, pneumonia accounted for 18% of all deaths in children under the age of 5 years. Almost half of all deaths in young children occur in Pakistan, India, China, Nigeria, and the Democratic Re- public of the Congo. Delayed treatment is responsible for many child pneumonia deaths and in 2004 WHO and UNICEF recommended antibiotic treatment at home given by trained health workers, in- stead of hospital referral, for non-severe pneumonia in rural areas. Meta-analyses have confirmed the effectiveness of this policy. Now a trial in rural Pakistan has shown that the policy is effective for chil- dren with severe pneumonia. A cluster-randomised trial in rural
Sindh province, Pakistan included 4410 children aged 2–59 months with WHO- defined severe pneumonia. The children were screened by lady health workers (LHWs). Those with severe pneumonia were prescribed oral amoxicillin syrup (45mg/kg twice daily) for 5 days at home (intervention clusters) or given a single dose of oral co-trimoxazole and referred to the nearest health facility for i.v. an- tibiotic treatment (control clusters). The children were followed up at 2, 3, 6, and 14 days. Treatment failure by day 6 occurred in 8% (intervention) and 13% (control), a non-significant difference. There were three deaths, two in the in- tervention group and one in the control group.
Home treatment with oral amoxicillin Africa Health 57
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