Transfusion and Treatment of severe anaemia in African children (TRACT): a study protocol for a randomised controlled trial

BACKGROUND: In sub-Saharan Africa, where infectious diseases and nutritional deficiencies are common, severe anaemia is a common cause of paediatric hospital admission, yet the evidence to support current treatment recommendations is limited. To avert overuse of blood products, the World Health Organisation advocates a conservative transfusion policy and recommends iron, folate and anti-helminthics at discharge. Outcomes are unsatisfactory with high rates of in-hospital mortality (9-10 %), 6-month mortality and relapse (6 %). A definitive trial to establish best transfusion and treatment strategies to prevent both early and delayed mortality and relapse is warranted.

METHODS/DESIGN: TRACT is a multicentre randomised controlled trial of 3954 children aged 2 months to 12 years admitted to hospital with severe anaemia (haemoglobin < 6 g/dl). Children will be enrolled over 2 years in 4 centres in Uganda and Malawi and followed for 6 months. The trial will simultaneously evaluate (in a factorial trial with a 3 x 2 x 2 design) 3 ways to reduce short-term and longer-term mortality and morbidity following admission to hospital with severe anaemia in African children. The trial will compare: (i) R1: liberal transfusion (30 ml/kg whole blood) versus conservative transfusion (20 ml/kg) versus no transfusion (control). The control is only for children with uncomplicated severe anaemia (haemoglobin 4-6 g/dl); (ii) R2: post-discharge multi-vitamin multi-mineral supplementation (including folate and iron) versus routine care (folate and iron) for 3 months; (iii) R3: post-discharge cotrimoxazole prophylaxis for 3 months versus no prophylaxis. All randomisations are open. Enrolment to the trial started September 2014 and is currently ongoing. Primary outcome is cumulative mortality to 4 weeks for the transfusion strategy comparisons, and to 6 months for the nutritional support/antibiotic prophylaxis comparisons. Secondary outcomes include mortality, morbidity (haematological correction, nutritional and infectious), safety and cost-effectiveness.

DISCUSSION: If confirmed by the trial, a cheap and widely available 'bundle' of effective interventions, directed at immediate and downstream consequences of severe anaemia, could lead to substantial reductions in mortality in a substantial number of African children hospitalised with severe anaemia every year, if widely implemented.

Psychological distress in mothers of children admitted to a nutritional rehabilitation unit in Malawi - a comparison with other paediatric wards

In a previous study we found a very high prevalence of psychological distress in mothers of children admitted to a nutritional rehabilitation unit (NRU) in Malawi, Africa. The objective of this study was to compare the prevalence and severity of maternal distress within the NRU with that in other paediatric wards. Given the known association between poor maternal psychological well-being and child undernutrition in low- and middle-income countries, we hypothesised that distress would be higher among NRU mothers. Mothers of consecutive paediatric inpatients in a NRU, a high-dependency (and research) unit and an oncology ward were assessed for psychological distress using the Self-Reporting Questionnaire (SRQ). Two hundred sixty-eight mothers were interviewed (90.3% of eligible). The prevalence of SRQ score ≥8 was 35/150 {23.3% [95% confidence interval (CI) 16.8- 30.9%]} on the NRU, 13/84 [15.5% (95% CI 8.5-25.0%)] on the high-dependency unit and 7/34 [20.6% (95% CI 8.7-37.9%)] on the oncology ward (χ(2)  = 2.04, P = 0.36). In linear regression analysis, the correlates of higher SRQ score were child diarrhoea on admission, child diagnosed with tuberculosis, and maternal experience of abuse by partner; child height-for-age z-score fell only just outside significance (P = 0.05). In summary, we found no evidence of greater maternal distress among the mothers of severely malnourished children within the NRU compared with mothers of paediatric inpatients with other severe illnesses. However, in support of previous research findings, we found some evidence that poor maternal psychological well-being is associated with child stunting and diarrhoea.

Persistent endothelial activation and inflammation after Plasmodium falciparum Infection in Malawian children

Endothelial dysregulation is central to the pathogenesis of acute Plasmodium falciparum infection. It has been assumed that this dysregulation resolves rapidly after treatment, but this return to normality has been neither demonstrated nor quantified. We therefore measured a panel of plasma endothelial markers acutely and in convalescence in Malawian children with uncomplicated or cerebral malaria. Evidence of persistent endothelial activation and inflammation, indicated by increased plasma levels of soluble intracellular adhesion molecule 1, angiopoetin 2, and C-reactive protein, were observed at 1 month follow-up visits. These vascular changes may represent a previously unrecognized contributor to ongoing malaria-associated morbidity and mortality.

Human melioidosis, Malawi, 2011

A case of human melioidosis caused by a novel sequence type of Burkholderia pseudomallei occurred in a child in Malawi, southern Africa. A literature review showed that human cases reported from the continent have been increasing.

A high-value, low-cost bubble continuous positive airway pressure system for low-resource settings:technical assessment and initial case reports

Acute respiratory infections are the leading cause of global child mortality. In the developing world, nasal oxygen therapy is often the only treatment option for babies who are suffering from respiratory distress. Without the added pressure of bubble Continuous Positive Airway Pressure (bCPAP) which helps maintain alveoli open, babies struggle to breathe and can suffer serious complications, and frequently death. A stand-alone bCPAP device can cost $6,000, too expensive for most developing world hospitals. Here, we describe the design and technical evaluation of a new, rugged bCPAP system that can be made in small volume for a cost-of-goods of approximately $350. Moreover, because of its simple design--consumer-grade pumps, medical tubing, and regulators--it requires only the simple replacement of a <$1 diaphragm approximately every 2 years for maintenance. The low-cost bCPAP device delivers pressure and flow equivalent to those of a reference bCPAP system used in the developed world. We describe the initial clinical cases of a child with bronchiolitis and a neonate with respiratory distress who were treated successfully with the new bCPAP device.

Dissenting Exhibitions by Artists (1968-1998). Reframing Marxist Exhibition Legacy.

The goal of this thesis is to look at the critical and dissenting value of exhibitions through the examination of four cases studies, based on six exhibitions taking place between 1968 and 1998 in Latin and North America. The exhibitions belong to the history of modern and contemporary exhibitions and curating, a field of research and study that has only started to be written about in the last two decades. This investigation contributes to it, in its creation of new genealogies by connecting previously overlooked antecedents, or by proposing new relations within established lineages, at the intersection of a specific historiography; to address exhibitions, a tradition of artists acting as curators and an emerging history of curating. The examined exhibitions were put together by artists or artist collectives and were placed in a liminal position between artistic and curatorial practice. All the cases presented a distinct proposal in relation to art and social change, a fact that connects them, in their aims and modus operandi, to a Marxist and neo-Marxist critical and transformative legacy. The cases address the following connections: exhibition as political site (Tucumán Arde, 1968); exhibition as social space (The People’s Choice (Arroz con Mango), 1981); exhibition as encounter (Rooms with a view, We the People, Art/Artifact, 1987-88); and exhibition as an exchange situation (El Museo de la Calle, 1998-2001). Key to their analysis is the concept of dissensus, as put forward by Jacques Rancière. Within this theoretical framework, these exhibitions put into practice particular cases of dissensus in a given distribution of the sensible. All of them tried to deal with their thematic concerns by performing them as a praxis. They dissent with the way in which reality was formatted in their historical moment and challenge the exhibition medium itself opening new ways of doing and making in the exhibition field. Therefore, in this thesis the dissenting value of exhibitions is closely related to its main features as a medium, namely their temporality, heterogeneity and flexibility, which contribute to their potential for creative analysis and propositioning. In the case of these exhibitions, this capability is brought into play for institutional interrogation, for offering alternative cultural narratives and also for inspiring new imaginary realms.

The Structure of Design Processes: ideal and reality in Bruce Archer’s 1968 doctoral thesis

The paper centres on a single document, the 1968 doctoral thesis of L Bruce Archer. It traces the author’s earlier publications and the sources that informed and inspired his thinking, as a way of understanding the trajectory of his ideas and the motivations for his work at the Royal College of Art from 1962. Analysis of the thesis suggests that Archer’s ambition for a rigorous ‘science of design’ inspired by algorithmic approaches was increasingly threatened with disruption by his experience of large, complex design projects. His attempts to deal with this problem are shown to involve a particular interpretation of cybernetics. The paper ends with Archer’s own retrospective view and a brief account of his dramatically changed opinions. Archer is located as both a theorist and someone intensely interested in the commercial world of industrial design.

Le traitement définitoire des noms de plantes herbacées dans le Petit Robert

La présente étude, de type métalexicographique, s'insère dans une perspective de recherche visant à dresser le bilan de la pratique lexicographique réservée aux noms d'espèces naturelles dans les dictionnaires usuels du français. Elle porte sur le traitement définitoire de tous les noms de plantes herbacées répertoriés dans le Petit Robert (édition électronique 1996). Son objectif principal est de décrire très précisément la pratique définitoire en cause. Nous commençons par passer rapidement en revue les différents procédés définitoires illustrés par notre corpus, avant de procéder à l'analyse détaillée du procédé le plus exploité, celui de la définition par inclusion. Notre méthode d'analyse est basée sur la segmentation et l'examen comparatif des différentes composantes sémantiques et formelles présentes dans les définitions par inclusion de notre corpus. Elle permet non seulement de mieux connaître la pratique du Petit Robert , mais aussi d'en extraire un certain savoir-faire. Nous étudions quatre grandes catégories d'éléments descriptifs bien représentées dans notre corpus: les éléments de classification, les éléments de localisation, les éléments de valorisation ainsi que les éléments de morphologie en lien avec ces derniers. Nous donnons, de la métalangue utilisée et des principaux modèles de description exploités, un portrait relativement précis qui pourra alimenter la réflexion des lexicographes et autres linguistes qui s'intéressent à la description des noms d'espèces naturelles en général et des noms de plantes en particulier.