Background Review of data from multiple sources is often necessary to determine cause of death for stillbirths and neonatal deaths, especially in low- to middle-income countries (LMICs) where available data may vary. The minimally invasive tissue sampling (MITS) procedure provides granular histologic and microbiologic data that clinical reports and verbal autopsies cannot provide. Expert panel evaluation of data from individual deaths can be resource-intensive but remains essential to accurately infer causes of death. Methods The Project to Understand and Research Preterms and Stillbirths in South Asia (PURPOSe) study uses review panels to evaluate causes of death in 2 LMICs. To make the process manageable, a subset of the study variables was selected with professional input and organized into case reports. Case reports include clinical information, laboratory results, fetal or neonatal organ histology and polymerase chain reaction results from tissue obtained by MITS. Panelists evaluated the complete case report forms and then determined the cause of death based on available data. Results Computerized case reports averaged 2 to 3 pages. Approximately 6 to 8 cases were reviewed and discussed per 1-hour panel meeting. All panelists were provided the same information; missing data were noted. This limited bias between panelists and across meetings. Study teams notably took ownership of data quality. Conclusions Standardized case reports for cause-of-death determination panel evaluation improve the efficiency of the review process, clarify available information, and limit bias across panelists, time, and location.
Objective: To examine internal organ tissues and placentas of stillbirths for various pathogens. Design: Prospective, observational study. Settings: Three study hospitals in India and a large maternity hospital in Pakistan. Population: Stillborn infants delivered in a study hospital. Methods: A prospective observational study. Main outcome measures: Organisms identified by pathogen polymerase chain reaction (PCR) in internal organs and placental tissues of stillbirths.Results: Of 2437 stillbirth internal tissues, 8.3% (95% CI 7.2-9.4) were positive. Organisms were most commonly detected in brain (12.3%), cerebrospinal fluid (CSF) (9.5%) and whole blood (8.4%). Ureaplasma urealyticum/parvum was the organism most frequently detected in at least one internal organ (6.4% of stillbirths and 2% of all tissues). Escherichia coli/Shigella was the next most common (4.1% one or more internal organ tissue sample and 1.3% of tissue samples), followed by Staphylococcus aureus in at least one internal organ tissue (1.9% and 0.9% of all tissues). None of the other organisms was found in more than 1.4% of the tissue samples in stillbirths or more than 0.6% of the internal tissues examined. In the placenta tissue, membrane or cord blood combined, 42.8% (95% CI 40.2-45.3) had at least one organism identified, with U. urealyticum/parvum representing the most commonly identified (27.8%). Conclusions: In about 8% of stillbirths, there was evidence of a pathogen in an internal organ. Ureaplasma urealyticum/parvum was the most common organism found in the placenta and in the internal tissues, especially in the fetal brain.
Introduction: Central nervous system (CNS) manifestations in children with rickettsial diseases are increasingly being reported from various parts of India but still rickettsial disease, as a cause of central nervous system (CNS) infections are underdiagnosed because of lack of freely available rapid and cheap diagnostic tests and varied clinical spectrum of rickettsial fever. Objective: To report CNS manifestations in probable cases of rickettsial diseases so as to increase awareness amongst pediatricians. Materials and Methods: A retrospective analysis of children (birth to 18 years) hospitalized in Bapuji Child Health Institute, which is secondary referral centre catering to children from five districts of Karnataka, with diagnosis of rickettsial disease from January 2016 to December 2018. The diagnosis of rickettsial infections was made by scoring system proposed by Rathi Goodman Aghai (RGA), weil felix test, prompt response to doxycycline within 48 hours and exclusion of differential diagnoses. Results: Out of 278 patients, who were diagnosed as probable case of rickettsia, 172 patients had neurological involvement. Out of 172 patients with diagnosis of rickettsial disease having symptomatic neurological involvement, 148 (86%) had neurological manifestation as the main presenting feature while remaining presented with non-neurological manifestations of rickettsial diseases too, along with neurological manifestations. The youngest patient was 3 month old infant. The various neurological manifestations seen were altered mental status (76%), irritability (61%), headache (48%), meningeal signs (32%), seizures (31%), papilloedema (26%), focal neurological deficits (18%), cerebrospinal fluid (CSF) abnormalities (76%) and neuroimaging abnormalities (28%). Conclusions: The myriads of neurological manifestations were seen with varying range of severity. Pediatricians should be aware of neurological manifestations seen in rickettsial infections and should have high index of suspicion for rickettsial diseases in febrile patients having neurological features specially in endemic areas.
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