Background. The rate of complete remission after induction therapy for steroid-resistant nephrotic syndrome (SRNS) due to either focal segmental glomerulosclerosis (FSGS) or minimal change nephrotic syndrome (MCNS) has been reported to be <50%. The present retrospective study investigated 86 children with SRNS due to FSGS and MCNS and found improved rates of complete remission in children with idiopathic FSGS and MCNS after combination therapies using ciclosporin A (CSA) and prednisolone (PRED).

Background. Infections such as malaria, schistosomiasis, hepatitis B and HIV have been suggested as major causes of the nephrotic syndrome (NS) in African children. We retrospectively analysed the course of the NS in 32 children from Ghana and reviewed the literature on NS from 18 different African countries for the presence of ‘the tropical nephrotic syndrome’. Methods. Thirty-two children (22 boys, 10 girls, median age 12 years, range 1–18 years) with NS were treated from 2000–2003 at Battor Hospital, Ghana. Thirteen out of 32 children underwent a renal biopsy which was investigated by light, immune and electron microscopy. All 32 patients were initially treated with oral prednisone (PRED) therapy (29 with standard therapy for 8 weeks and three individually tailored), and steroid-resistant children received also intravenous methylprednisolone pulses (three children) or oral cyclophosphamide (two children). Results. All patients fulfilled the clinical and laboratory criteria of a NS. The initial median serum creatinine was 65 µmol/l (range 44–133 µmol/l). Renal biopsy was performed in 13/32 children and revealed focal and segmental glomerulosclerosis (FSGS) in 10 patients, minimal change disease (MCNs) in two and no conclusive result in one patient. Glomerular immune complex deposition was absent in all biopsies. After treatment with PRED, oedema disappeared in 24/32 patients; however, proteinuria normalized in 16/32 patients only. The NS relapsed in 9/16 steroid-sensitive patients after cessation of PRED therapy, and two children were frequent relapsers. The steroid-resistant NS did not respond to an intensified immunosuppression in 5/16 children receiving methylprednisolone or cyclophosphamide. Five out of 32 children died, all were steroid resistant. Conclusions. There was no evidence for a dominating role of steroid-resistant ‘tropical glomerulopathies’ in children with a NS in Ghana. Similar to South Africa, focal and segmental glomerulosclerosis (FSGS) and minimal change disease were the most frequent findings on histology. Contrary to Nigeria, membrano-proliferative glomerulonephritis was not found in these patients. We conclude from this data and from the literature that the histological pattern of NS may vary between different African countries. Concerning therapy of NS under tropical conditions, we emphasize that despite the limited therapeutic facilities half of these patients may benefit from corticosteroids; however, steroid resistance and FSGS resulted in a high mortality.

Five hundred thirty six Sudanese schoolchildren with Schistosoma mansoni infection were treated at random with either 20 mg or 40mg/kg praziquantel. Seven months later 420 children could be reinvestigated by ultrasonography. Reduction of egg excretion and reversibility of sonographically-proven periportal fibrosis (PF) was not significantly different in the two groups. Schistosoma mansoni-induced PF grade II decreased from 22.9% to 6.7% and grade III from 5.2% to 1.6%. An increased prevalence of PF grade I, from 10% to 29.8% of the investigated patients, was observed. This increase was caused partly by a downshifting of patients who had PF II (n = 45) and PF III (n = 8) before therapy, but also by patients who developed PF I in the seven months after therapy (n = 56). The overall percentage of patients with PF before and after treatment was 38.1%. Of 420 children, 17.4% increased in their PF grade, 55% remained at the same level and 27.6% improved. Children younger than 11 years of age had a higher rate of complete reversibility than older ones. The percentage of patients with hepatomegaly decreased significantly (11.6% to 6.9%; p = 0.001). The rate of splenomegaly remained unchanged. It was concluded that within seven months therapy with praziquantel resulted in a considerable qualitative improvement of PF in Sudanese schoolchildren with S. mansoni infection.

To evaluate differences in child health care service delivery in Europe based on comparisons across health care systems active in European nations. A survey involved experts in child health care of 40 national pediatric societies belonging both to European Union and non-European Union member countries. The study investigated which type of health care provider cared for children in 3 different age groups and the pediatric training and education of this workforce. In 24 of 36 countries 70%-100% of children (0-5 years) were cared for by primary care pediatricians. In 12 of 36 of countries, general practitioners (GPs) provided health care to more than 60% of young children. The median percentage of children receiving primary health care by pediatricians was 80% in age group 0-5 years, 50% in age group 6-11, and 25% in children >11 years of age. Postgraduate training in pediatrics ranged from 2 to 6 years. A special primary pediatric care track during general training was offered in 52% of the countries. One-quarter (9/40) of the countries reported a steady state of the numbers of pediatricians, and in one-quarter (11/40) the number of pediatricians was increasing; one-half (20/40) of the countries reported a decreasing number of pediatricians, mostly in those where public health was changing from pediatric to GP systems for primary care. An assessment on the variations in workforce and pediatric training systems is needed in all European nations, using the best possible evidence to determine the ideal skill mix between pediatricians and GPs.

Serious concern has been raised about the sustainability of public health care systems of European Nations and ultimately about the health of European citizens, as a result of the economic crisis that has distressed Europe since 2008. The severe economic crisis of the Euro zone, which is still afflicting Europe in 2016, has in fact threatened to equally impact public health services of nations presenting either a weak or a strong domestic growth. On behalf of the European Paediatric Association, the Union of National European Societies and Associations, the authors of the Commentary debates the relationship between the effects of economic instability and health, through the report on an article recently published in the Italian Journal of Pediatrics, which emphasized the importance of integrating existing public health care services, otherwise independently provided by public hospitals, and Primary Care Paediatric networks. The interconnections between the effects of economic instability and health are briefly commented, following the observation that these two factors are not yet fully understood, and that the definition of proper solutions to be applied in circumstances, where health is negatively impacted by periods of economic distress, is still open for discussion. Furthermore it is noted that the pressure to “deliver more for less” often seems to be the driving force forging the political strategic decisions in the area of pediatric healthcare, rather than social, cultural, and economic sensitivity and competences. Thus, the delivery of appropriate pediatric healthcare seems not to be related exclusively to motivations aimed to the benefit of children, but more often to other intervening factors, including economic, and political rationales. The conclusions emphasize that local European experiences suggest that positive and cost effective healthcare programs are possible, and they could serve as a model in the development of effective cross-border regional program, not weakening the quality of services provided to children.