Blood counts, hemoglobin (Hb) high performance liquid chromatography (HPLC), and DNA analyses were performed on 260 children, aged 5 months to 16 years, at Siem Reap to assess the prevalence of thalassemia and other hemoglobinopathies in regional Cambodia. Hemoglobinopathies were present in 134 children (51.5%) with 20 abnormal genotypes identified. alpha-Thalassemia (thal) (35.4%) was the most prevalent disorder and the -alpha3.7 gene deletion was the most common alpha-globin gene abnormality. The - -SEA deletion and nondeletional forms of alpha-thal, Hb Constant Spring [Hb CS, alpha142, Term-->Gln, TAA-->CAA (alpha2)], Hb Paksé [alpha142, Term-->Tyr, TAA-->TAT (alpha2)] and triplicated alpha genes, were also present but at low frequencies. Hb E [beta26(B8)Glu-->Lys, GAG-->AAG] (28.8%) was the most common beta-globin gene abnormality, whilst beta-thal was only detected in two children (0.8% of cases). Although hemoglobinopathies were common, the majority of abnormalities detected (heterozygous -alpha3.7 and Hb E) were not clinically significant. On the basis of these findings, and with the majority of abnormalities being mild, it seems improbable that thalassemia represents a major health burden in this region of Cambodia.

Objectives: Following surgery, it is difficult to distinguish a postoperative inflammatory reaction from infection. This study examined the predictive value of the biomarkers; procalcitonin, C-reactive protein, lactate, neutrophils, lymphocytes, platelets, and the biphasic activated partial thromboplastin time waveform in diagnosing bacterial infection following cardiac surgery. Design: Prospective, observational study. Setting: A regional, PICU in the United Kingdom. Patients: Three-hundred sixty-eight children under the age of 16 admitted to the PICU for elective cardiac surgery were enrolled in the study. Interventions: All biomarker measurements were determined daily until postoperative day 7. Children were assessed for postoperative infection until day 28 and divided into four groups: bacterial infection, culture-negative sepsis, viral infection, and no infection. We used the Kruskal-Wallis test, chi-square test, analysis of variance, and area under the curve in our analysis. Measurements and Main Results: In total, 71 of 368 children (19%) developed bacterial infection postoperatively, the majority being surgical site infections. In those with bacterial infection, procalcitonin was elevated on postoperative days 1–3 and the last measurement prior to event compared with those without bacterial infection. The most significant difference was the last measurement prior to event; 0.72 ng/mL in the bacterial infection group versus 0.13 ng/mL in the no infection group (for all groups; p < 0.001). Longitudinal profiles of all biomarkers were indistinct in the bacterial infection and nonbacterial infection groups except in those with culture-negative infections who had distinct procalcitonin kinetics on postoperative days 1–4. Children with culture-negative sepsis required longer ventilatory support and PICU stay and were more likely to develop complications than the other groups. Conclusions: None of the biomarkers studied within 3 days of infection distinguished between infection and postoperative inflammatory reaction. However, procalcitonin kinetics peaked on postoperative day 2 and fell more sharply than C-reactive protein kinetics, which peaked at postoperative day 3. The monitoring of procalcitonin kinetics following cardiac surgery may help guide rational antimicrobial use.

ObjectivesHospital-acquired infections (HAI) are associated with significant mortality and morbidity and prolongation of hospital stay, adding strain on limited hospital resources. Despite stringent infection control practices some children remain at high risk of developing HAI. The development of biomarkers which could identify these patients would be useful. In this study our objective was to evaluate mRNA candidate biomarkers for HAI prediction in a pediatric intensive care unit.DesignSerial blood samples were collected from patients admitted to pediatric intensive care unit between March and June 2012. Candidate gene expression (IL1B, TNF, IL10, CD3D, BCL2, BID) was quantified using RT-qPCR. Comparisons of relative gene expression between those that did not develop HAI versus those that did were performed using Mann Whitney U-test.PatientsExclusion criteria were: age <28 days or ≥16 years, expected length of stay < 24 hours, expected survival < 28 days, end-stage renal disease and end-stage liver disease. Finally, 45 children were included in this study.Main ResultsThe overall HAI rate was 30% of which 62% were respiratory infections. Children who developed HAI had a three-fold increase in hospital stay compared to those who did not (27 days versus 9 days, p<0.001). An increased expression of cytokine genes (IL1B and IL10) was observed in patients who developed HAI, as well as a pro-apoptosis pattern (higher expression of BID and lower expression of BCL2). CD3D, a key TCR co-factor was also significantly down-modulated in patients who developed HAI.ConclusionsTo our knowledge, this is the first study of mRNA biomarkers of HAI in the paediatric population. Increased mRNA expressions of anti-inflammatory cytokine and modulation of apoptotic genes suggest the development of immunosuppression in critically ill children. Immune monitoring using a panel of genes may offer a novel stratification tool to identify HAI risk.

Cambodia is an extremely underdeveloped country in Southeast Asia with a childhood mortality rate of 105/1000 live births. Angkor Hospital for Children is a paediatric teaching hospital in Siem Reap, northwest Cambodia, which serves as the provincial paediatric department but also sees children from provinces throughout northern Cambodia, and with training provided for health workers from all parts of the country. The impact of genetic disease on this paediatric population is discussed, addressing the areas of haematology (including thalassaemia and other haemoglobinopathies, glucose-6-phosphate deficiency and bleeding disorders), multifactorial disorders (cleft palate, congenital heart disease and neural tube defects), and uncommon genetic disorders and chromosomal syndromes. In the future, as low-income countries develop and their burden of infectious disease begins to subside, the contribution of these disorders to paediatric morbidity and mortality will become increasingly apparent. This transition needs to be considered in the allocation of health resources and in the structuring of undergraduate and postgraduate medical education.

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AimsThe Systemic Inflammatory Response Syndrome (SIRS) is common after cardiac surgery and cardiopulmonary bypass (CPB), leading to difficulty in distinguishing between a bacterial infection or SIRS. Early diagnosis of post-operative infection is of fundamental importance in order to improve outcomes and reduce antibiotic over use. This study examined the predictive value of the biomarkers procalcitonin (PCT), lactate, neutrophil gelatinase associated lipocalin (NGAL) and the biphasic APTT waveform (bAPTT).MethodsConsecutive children admitted for cardiac surgery at a tertiary paediatric intensive care unit (PICU) were enrolled in the study. None of our patients had a bacterial infection (BI) at admission. Receiver operating curves (ROC) were created to determine the predictive value of the biomarkers to diagnose BI.ResultsIn total, 88/368 children (24%) developed BI. Median PCT in children with BI was 0.16 ng/ml (IQR 0.06–0.98) compared with 0.10 ng/ml (IQR 0.–0.36) in the non-infected group (p=0.03). Median lactate in children with BI was 1.42 mmol/L (IQR 0.93–2.37) compared with 1.20 mmol/L (0.93–1.79) in the non-infected group (p=0.03). The other biomarkers were not significantly different between BI and non-BI groups. The median inotrope score in first 12 hours was 10 (IQR 5–15) in those with BI compared with 7 (5–12) in the non-infected group (p=0.002). Prolonged hospital stay (p=0.001) and increased duration of mechanical ventilation (p=0.001) were more common in children with BI. CPB time was increased in children with BI (median 133 min, IQR 75–183) compared with those without BI (median 101 min, IQR 60–147) (p=0.005).Using ROC curves to predict BI, the AUC for PCT was 0.58, lactate 0.46, inotrope score in the first 12 hours 0.60, CPB 0.60, and circulatory arrest time 0.55 respectively.ConclusionNone of the biomarkers studied demonstrated strong predictive value for BI. The increased health utilisation of postoperative infection is highlighted by increased PICU and hospital stay. Children at higher risk of developing post-operative infection can be identified as those with prolonged bypass and crossclamp times, and those with high inotrope scores in the first 12 hours of admission.

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