High-resource Settings Research Articles

International Consensus Criteria for Pediatric Sepsis and Septic Shock

Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children. To update and evaluate criteria for sepsis and septic shock in children. The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria. Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively. The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.

Building Global Partnerships: A Qualitative Exploration of In-Person Training for HealthCare Simulation Educators Working in Low-Resource Settings.

Effective educational initiatives can elevate the quality of patient care globally. Simulation-based education is widely used in high-resource settings, but barriers exist to its widespread use in low-resource settings. Vital Anesthesia Simulation Training (VAST) overcomes these barriers by offering immersive, low-cost portable simulation along with simulation facilitator training. During the COVID-19 pandemic, in-person courses were stopped for more than 2 years. Postpandemic, a 3-day VAST SIMposium was hosted in Rwanda to unite 42 VAST facilitators from 12 widespread countries to introduce new and revised course materials and to rejuvenate dormant skills. The purpose of this study was to explore how the VAST SIMposium influenced perceived development of skills, confidence, and engagement in a community of practice for simulation educators working in low-resource settings. This qualitative study involved in-depth interviews with a purposive sample of 16 VAST SIMposium attendees. Transcripts of audio recordings were analyzed using inductive thematic analysis. Six themes were identified during data analysis: 1) Diversity with shared passion for medical education; 2) Supportive in-person learning environment; 3) Simulation-based education relevant to low-resource settings; 4) Camaraderie; 5) Building knowledge, skills, and confidence; and 6) Being part of a community of practice. The SIMposium rejuvenated passion, knowledge, skills, and, most importantly, strengthened global connections and partnerships. These collaborations will benefit areas that are underrepresented in simulation and will ultimately improve patient outcomes. A SIMposium of this format is an efficient and effective way to foster sustainable global dissemination of simulation-based global health education.

The evolution of nutrition management in children with severe neurological impairment with a focus on cerebral palsy.

Nutritional management of children with severe neurological impairment (SNI) is highly complex, and the profile of this population is changing. The aim of this narrative review was to give the reader a broad description of evolution of the nutritional management of children with SNI in a high resource setting. In the last decade, there has been an emphasis on using multiple anthropometric measures to monitor nutritional status in children with SNI, and several attempts at standardising the approach have been made. Tools such as the Feeding and Nutrition Screening Tool, the Subjective Global Nutrition Assessment, the Eating and Drinking Ability Classification System and the Focus on Early Eating and Drinking Swallowing (FEEDS) toolkit have become available. There has been an increased understanding of how the gut microbiome influences gastrointestinal symptoms common in children with SNI, and the use of fibre in the management of these has received attention. A new diagnosis, 'gastrointestinal dystonia', has been defined. The increased use and acceptance of blended food tube feeds has been a major development in the nutritional management of children with SNI, with reported benefits in managing gastrointestinal symptoms. New interventions to support eating and drinking skill development in children with SNI show promise. In conclusion, as the life expectancy of people with SNI increases due to advances in medical and nutrition care, our approach necessitates a view to long-term health and quality of life. This involves balancing adequate nutrition to support growth, development and well-being while avoiding overnutrition and its associated detrimental long-term effects.

Leveraging technological advances to assess dyadic visual cognition during infancy in high- and low-resource settings.

Caregiver-infant interactions shape infants' early visual experience; however, there is limited work from low-and middle-income countries (LMIC) in characterizing the visual cognitive dynamics of these interactions. Here, we present an innovative dyadic visual cognition pipeline using machine learning methods which captures, processes, and analyses the visual dynamics of caregiver-infant interactions across cultures. We undertake two studies to examine its application in both low (rural India) and high (urban UK) resource settings. Study 1 develops and validates the pipeline to process caregiver-infant interaction data captured using head-mounted cameras and eye-trackers. We use face detection and object recognition networks and validate these tools using 12 caregiver-infant dyads (4 dyads from a 6-month-old UK cohort, 4 dyads from a 6-month-old India cohort, and 4 dyads from a 9-month-old India cohort). Results show robust and accurate face and toy detection, as well as a high percent agreement between processed and manually coded dyadic interactions. Study 2 applied the pipeline to a larger data set (25 6-month-olds from the UK, 31 6-month-olds from India, and 37 9-month-olds from India) with the aim of comparing the visual dynamics of caregiver-infant interaction across the two cultural settings. Results show remarkable correspondence between key measures of visual exploration across cultures, including longer mean look durations during infant-led joint attention episodes. In addition, we found several differences across cultures. Most notably, infants in the UK had a higher proportion of infant-led joint attention episodes consistent with a child-centered view of parenting common in western middle-class families. In summary, the pipeline we report provides an objective assessment tool to quantify the visual dynamics of caregiver-infant interaction across high- and low-resource settings.

Inequities in global cancer surgery: Challenges and solutions.

The disparity in access to and quality of surgical cancer care between high and low resource settings impacts immediate and long-term oncological outcomes. With cancer incidence and mortality set to increase rapidly in the next few decades, we examine the factors leading to inequities in global cancer surgery, and look at potential solutions to overcome these challenges.

Feasibility of a Dose-Intensive Regimen for Pediatric Burkitt Lymphoma in Malawi

Introduction: Burkitt lymphoma (BL) is the commonest childhood cancer diagnosed in Sub-Saharan Africa (SSA). It is highly curable with survival rates >90% in resource-rich settings with dose-intensive regimens that contain the anti-CD20 monoclonal antibody, rituximab, high-dose methotrexate (HDMTX; ≥ 3000 mg/m 2) and high-dose cytarabine. In contrast, outcomes in SSA where patients typically receive less intense chemotherapy with lower-dose methotrexate (≤1000 mg/m 2) and without rituximab, remain poor. Major drawbacks to implementing HDMTX regimens in SSA include lack of adequate supportive care and inability to monitor drug levels. Improving long-term outcomes for BL in SSA requires graduated, stepwise, and cautious escalation of treatment tailored to available supportive care infrastructure. Based on the available evidence, we adopted a resource-adapted HDMTX-containing regimen as our standard of care for pediatric BL in Lilongwe, Malawi. We report preliminary data on patients treated with this regimen. Methods: This is a prospective study of children (<18 years) with newly diagnosed BL, treated with our locally adapted regimen at Kamuzu Central Hospital in Malawi. This risk-stratified regimen incorporates HDMTX at doses of 1000-3000 mg/m 2 per cycle (Table 1) and is based on the Group B arm of the FAB/LMB backbone (standard of care in high-resource settings) with a 60% dose reduction of anthracycline-based on previously published data. Rituximab and two maintenance cycles were incorporated into the therapy for very high-risk patients (Table 1). Treatments were administered in 14-day cycles. Patients not in complete remission (CR) at the end of the first consolidation cycle received 4 cycles of DHAP (Dexamethasone, Cisplatin, HD-Cytarabine, Prednisone). To mitigate toxicity, we established locally appropriate best practices for supportive care and extended bicarbonate-containing fluid hydration for days with rate adjustments based on changes in daily creatinine levels in lieu of MTX levels-which were unavailable (Table 2). Adverse events (AE) were defined by Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 criteria. Using descriptive statistics, we report on the frequency of severe AEs in this cohort. Results: Between June 2022 and July 2023, 40 consecutive patients with biopsy-proven BL were treated with this approach. They were mostly male (n=26, 65%) with a median age of 9 years (interquartile range, 6-12). The majority (n=22, 55%) had Murphy stage III disease, and 15 (38%) were stage IV at diagnosis. Five patients (13%) had central nervous system (CNS) disease, and 12 (31%) with bone marrow (BM) disease. All patients were stratified as high-risk or very high-risk. Nineteen (48%) have completed their planned first-line therapy, 7 (17%) are currently in therapy, 8 (20%) died before treatment completion, and 6 (15%) abandoned therapy. Treatment delays occurred in 12/107 (11%) HDMTX-containing cycles. For the non-rituximab HDMTX cycles (n=90), there have been 14 episodes (16%) of grade ≥3 febrile neutropenia, 1 episode (1%) of grade ≥3 mucositis, and 5 episodes (6%) of grade ≥3 anemia. One patient developed grade 3 acute kidney injury, which resolved with hydration. In patients who received rituximab (n=17) there have been 3 episodes (18%) of grade ≥3 febrile neutropenia, and 1 episode (6%) of grade ≥3 mucositis or anemia. In total, there were 12 (30%) deaths: 5 disease-related deaths, 4 early deaths from sepsis, or tumor lysis before pre-HDMTX, 1 unknown cause, and 2 (6%) treatment-related deaths associated with HDMTX. Twenty-three patients had interim assessment at the end of the first consolidation and 18 (78%) were in CR. Of the patients with relapse or progressive disease (n=8), 4 (50%) had either CNS or BM disease. Conclusion: We demonstrate feasibility of administering dose-intensive intermediate dose MTX-containing treatment for pediatric BL in a very resource-limited setting with rigorous surveillance and supportive care. We will build on this by incorporating rituximab into all risk-groups, while evaluating its impact on efficacy and the immune reconstitution in a population with high prevalence of malnutrition, malaria, and tropical infections. Furthermore, given higher treatment-failure rates in patients with CNS or BM disease, strategies to intensify treatment in this cohort in the context of available support care resources will be needed.

Avoid equipment graveyards: rigorous process to improve identification and procurement of effective, affordable, and usable newborn devices in low-resource hospital settings

BackgroundMillions of newborns die annually from preventable causes, with the highest rates occurring in Africa. Reducing neonatal mortality requires investment to scale hospital care, which includes providing hospitals with appropriate technology to care for small and sick newborns. Expensive medical devices designed for high-resource settings often fail to withstand conditions in low-resource hospitals, including humidity, dust, frequent user turnover, complex maintenance, lack of stable power, or difficulty sourcing expensive consumables. Rigorous evaluation protocols are needed to identify effective, affordable, rugged, and easy-to-use medical devices appropriate for quality hospital-based newborn care in low-resource hospitals.MethodsWe developed an evidence-based technology review process to identify medical devices suitable for small and sick newborn care in low-resource hospitals. The eight-step process consists of: identifying devices needed for effective newborn care; defining Target Product Profiles (TPPs); identifying commercially-available products that may meet TPPs; conducting desk research to evaluate technologies against TPPs; performing technical performance verification testing under laboratory conditions; verifying technical performance after exposure to heat, humidity, dust, and power loss; performing usability evaluations with nurses, and qualifying devices that pass all steps. Devices were purchased, installed, and monitored in newborn wards across Kenya, Malawi, Nigeria, and Tanzania.ResultsOf 271 devices considered, only 45 (16.6%) met corresponding TPPs based on desk research. Thirty-nine were purchased and evaluated in the laboratory; five (12.8%) failed to meet TPPs. Thirty-four products passing laboratory evaluation underwent short-term environmental testing; only one (2.9%) device failed. Thirty-seven products underwent usability testing with 127 clinicians; surprisingly, 14 (37.8%) failed to meet TPPs. Twenty-three products passed all evaluations, and 2457 devices were installed across 65 newborn wards in Kenya, Malawi, Nigeria, and Tanzania. Continuous device monitoring reported minimal device failures, with failed devices typically returned to service within two days, resulting in an average uptime (service days divided by days installed) of 99%.ConclusionAn evidence-based device selection process can improve procurement of effective, affordable, rugged, usable newborn care devices for low-resource hospitals, and feedback to manufacturers can improve device quality. Similar processes could be adapted beyond newborn care to identify medical devices suitable for implementation in any low-resource setting.

The Bern Birth Cohort (BeBiCo) to study the development of the infant intestinal microbiota in a high-resource setting in Switzerland: rationale, design, and methods

BackgroundMicrobiota composition is fundamental to human health with the intestinal microbiota undergoing critical changes within the first two years of life. The developing intestinal microbiota is shaped by maternal seeding, breast milk and its complex constituents, other nutrients, and the environment. Understanding microbiota-dependent pathologies requires a profound understanding of the early development of the healthy infant microbiota.MethodsTwo hundred and fifty healthy pregnant women (≥20 weeks of gestation) from the greater Bern area will be enrolled at Bern University hospital’s maternity department. Participants will be followed as mother-baby pairs at delivery, week(s) 1, 2, 6, 10, 14, 24, 36, 48, 96, and at years 5 and 10 after birth. Clinical parameters describing infant growth and development, morbidity, and allergic conditions as well as socio-economic, nutritional, and epidemiological data will be documented. Neuro-developmental outcomes and behavior will be assessed by child behavior checklists at and beyond 2 years of age.Maternal stool, milk, skin and vaginal swabs, infant stool, and skin swabs will be collected at enrolment and at follow-up visits. For the primary outcome, the trajectory of the infant intestinal microbiota will be characterized by 16S and metagenomic sequencing regarding composition, metabolic potential, and stability during the first 2 years of life. Secondary outcomes will assess the cellular and chemical composition of maternal milk, the impact of nutrition and environment on microbiota development, the maternal microbiome transfer at vaginal or caesarean birth and thereafter on the infant, and correlate parameters of microbiota and maternal milk on infant growth, development, health, and mental well-being.DiscussionThe Bern birth cohort study will provide a detailed description and normal ranges of the trajectory of microbiota maturation in a high-resource setting. These data will be compared to data from low-resource settings such as from the Zimbabwe-College of Health-Sciences-Birth-Cohort study. Prospective bio-sampling and data collection will allow studying the association of the microbiota with common childhood conditions concerning allergies, obesity, neuro-developmental outcomes , and behaviour.Trial registrationThe trial has been registered at www.clinicaltrials.gov, Identifier: NCT04447742

A Phase 1 Study of Subcutaneous Rituximab Hyaluronidase Combined with Local Standard-of-Care Chemotherapy for the Treatment of Diffuse Large B-Cell Lymphoma in Uganda

Background: Patients with Diffuse Large B-Cell Lymphoma (DLBCL) who are treated in low-resource settings have inferior outcomes compared to those in high-resource settings, with 12-month overall survival (OS) rates typically under 50% with standard chemotherapy (Gopal et al. [PMID:26934054]). Rituximab, an anti-CD20 monoclonal antibody, when combined with chemotherapy, improves OS for DLBCL and is the standard of care for patients with CD20+ DLBCL in resource-rich settings. Despite receiving FDA approval over 25 years ago and its subsequent inclusion in the World Health Organization's List of Essential Medicines, IV rituximab is not readily available or routinely used in sub-Saharan Africa (SSA). This is in part due to cost and the limited availability of infusion centers in SSA. Subcutaneous rituximab hyaluronidase (sqR) is a potential solution, but its safety is not established in these settings. Here, we evaluated the safety and efficacy of a fixed dose of 1400 mg sqR in combination with standard-of-care chemotherapy in Ugandan adults with CD20+ DLBCL. Methods: This open-label phase I study, conducted at the Uganda Cancer Institute [(UCI) Kampala, Uganda], enrolled patients age ≥ 18 with newly diagnosed CD20+ DLBCL with measurable disease, and an ECOG performance status of < 2. Patients living with HIV were eligible if they were receiving antiretroviral therapy and had CD4+ T-cell count >200 cells/uL. The first cohort (n=6) received IV rituximab, 375mg/m 2 on day 1 of cycle 1 plus CHOP chemotherapy (IV cyclophosphamide 750 mg/m 2, IV doxorubicin 50 mg/m 2, IV vincristine 1·4 mg/m 2 (maximum 2 mg/m 2) on day 1, and oral prednisone 100 mg on days 1-5). This cohort received sqR (1400 mg) for subsequent cycles. The second cohort (n=12) received sqR plus CHOP for all cycles. Safety and tolerability were evaluated by monitoring adverse events and graded by Common Terminology Criteria for Adverse Events (CTCAE) version 5; secondary outcomes included response rates and treatment completion. We used Kaplan-Meier methods to estimate OS and progression-free survival (PFS), defined as disease progression or death, with 95% confidence intervals (95% CIs) at 12 months from initiation of treatment. Results: Between October 25 th, 2019 and October 7, 2022, 38 patients were assessed for eligibility; 19 patients met the criteria and were enrolled. One patient was not given the study treatment due to UCI-mandated COVID-19 restrictions. Of the 18 participants, median age was 36.5 years (IQR 25.2-50.0), 10 (56%) were male and 10 (56%) presented with advanced stage (III/IV) disease. Three (16.7%) participants were living with HIV and their median CD4 count was 311. Participants completed a median of 6 cycles of therapy. Grade 3 or 4 hematologic toxicities were reported in 11 (61%) participants; grade 3 or 4 non-hematologic toxicities were reported in 4 (22%). The most common hematologic toxicity was neutropenia (n=9, 50%); the most common non-hematologic toxicities were anorexia (n=7; 39%) and hyponatremia (n=7; 39%). Fifteen of the 18 participants completed treatment; 3 died during treatment. Of the 15 who completed treatment, 14 (93.3%) patients achieved a complete response (CR) and 1 patient (6.7%) had a partial response (PR). The patient who had a PR subsequently developed progressive disease, as did 2 patients who initially had a CR after therapy (Figure 1). The OS and PFS at 12 months was 83% (95% CI, 68-100%) and 66% (95% CI 47-92%) respectively. Conclusion: As demonstrated in other parts of the world, sqR together with CHOP chemotherapy was safe, well-tolerated, and efficacious among Ugandan patients with DLBCL. The very high CR, PFS, and OS rates are nearly double that of historical controls at the UCI, and comparable to outcomes expected in resource-rich settings. Colleagues have previously demonstrated the safety and efficacy of an oral chemotherapy regimen for aggressive non-Hodgkin's lymphoma in East Africa (Mwanda et al. [PMID: 19470940]). Given the results of this study, the potential for a safe and effective regimen, which precludes the need for IV therapy, for the treatment of DLBCL exists. Additionally, this trial strengthened the clinical trial research infrastructure in Uganda; trials conducted locally are critical to determining pragmatic and optimal treatment strategies. We anticipate that this research will improve care for DLBCL patients not only in Uganda but in other resource-limited settings as well.

Self-collected samples as an additional option for STI testing in low-resource settings: a qualitative study of acceptability among adults in Rakai, Uganda

IntroductionSelf-collected samples (SCS) for sexually transmitted infection (STI) testing have been shown to be feasible and acceptable in high-resource settings. However, few studies have assessed the acceptability of SCS for...

Barriers to and facilitators of effective management of fever episodes in hospitalised Kenyan children with cancer: protocol for convergent mixed methods study

IntroductionFebrile neutropenia is an oncological emergency in children with cancer, associated with serious infections and complications. In low-resourced settings, death from infections in children with cancer is 20 times higher...

Managing high cardiovascular disease risk among adults in Argentina using a multicomponent strategy linking key aspects of care: A two-arm cluster-randomized clinical trial (PRIMECare) protocol

BackgroundCardiovascular disease (CVD) imposes a significant burden on the Argentinian population. Management of its leading risk factors can significantly reduce the CVD burden in high-resource settings, but there is insufficient evidence for effective implementation of evidence-based interventions in lower-resource settings like Argentina. MethodsIn this two-arm cluster-randomized trial we seek to compare the effective implementation, of a multicomponent intervention, versus usual care, to improve the management of high CVD risk across the care continuum in three provinces of Argentina. The multicomponent intervention strategy links five primary components of the CVD care continuum to improve its management: (1) a data management system linking a digital mHealth (mobile health) screening tool used by community health workers (CHWs), (2) an electronic appointment scheduler that is integrated with the primary care center electronic appointment system, (3) point of care testing for lipid profiles, (4) a clinical decision support (CDS) system for medication initiation, and (5) a text message (SMS) reminder system to improve treatment adherence and life-style changes. The primary outcome is the mean change in Framingham laboratory-based, 10-year absolute CVD risk score between the study arms from baseline to twelve months after enrollment. ConclusionsThis protocol describes the development of a multicomponent intervention to implement effective management of CVD, developed with partners at the National and provincial Departments of Health in Argentina, with the goal of understanding its effective implementation in a primary health care system strengthened by universal health coverage, provision of free health care services, and provision of free medication.

Help-seeking patterns and level of care for individuals with bipolar disorder in Rwanda.

Most descriptive data on individuals with bipolar disorder originate from high-resource settings. Very little is known about the accessibility and service provision of intensive mental health care to persons living with bipolar disorder in low-resource settings. This information is needed to inform health systems and guide practitioners to improve standard treatment options and access to treatment. This cross-sectional study explored the level of care for outpatients with bipolar disorder and their help-seeking patterns at the two national referral hospitals in Rwanda. The study found that the majority, 93%, of outpatients with bipolar disorder in Rwanda were on prophylactic psychopharmacological treatment, but mainly first-generation antipsychotics and just 3% received lithium treatment. Furthermore, there was a lack of psychosocial intervention; consequently, 44% were not aware that they had bipolar disorder. Moreover, 1 in 5 participants utilized or had previously used traditional medicine. Awareness of own diagnostic status was not associated with educational level or use of traditional medicine. The study's sample size of 154 patients is relatively small, and the cross-sectional design does not provide causal inferences. The results demonstrate a considerable unmet need for improved mental health care services for individuals with bipolar disorder in Rwanda, including access to optimal medication and psychosocial interventions. Psychoeducation could be a possible starting point for improving the standard of care, informing the individual on their diagnosis and medication while empowering them to engage in their treatment plan. Trial registration: ClinicalTrials.gov NCT04671225. Registered on November 2020.

FIGO good practice recommendations for preterm labor and preterm prelabor rupture of membranes: Prep-for-Labor triage to minimize risks and maximize favorable outcomes.

Preterm labor occurs in around 10% of pregnancies worldwide. Once diagnosed, significant efforts must be made to reduce the likelihood of morbidity and mortality associated with preterm birth. In high-resource settings, access to hospitals with a neonatal intensive care unit (NICU) is readily available, whereas access to NICU care is limited in low- and middle-income countries (LMICs) and many rural settings. Use of FIGO's Prep-for-Labor triage method rapidly identifies low- and high-risk patients with preterm labor to enable clinicians to decide whether the patient can be managed on site or if transfer to a level II-IV facility is needed. The management steps described in this paper aim to minimize the morbidity and mortality associated with preterm labor and in the setting of preterm labor with preterm premature rupture of membranes (PPROM). The methods for accurate diagnosis of PPROM and chorioamnionitis are described. When the risk of preterm birth is high, antenatal corticosteroids should be administered for lung maturation combined with limited tocolysis for 48 hours to permit the corticosteroid course to be completed. Magnesium sulfate is also administered for fetal neuroprotection. Implementation of FIGO's Prep-for-Labor triage method in an LMIC setting will help improve maternal and neonatal outcomes.

Creation of an enhanced recovery after surgery protocol for children with Wilms tumours in low- and middle-income countries

IntroductionEnhanced Recovery After Surgery guidelines have been developed and shown to improve outcomes for many surgical procedures. Most existing guidelines have been created for patients in high-resource settings. There is a dearth of guidelines for pediatric populations particularly in low- and middle-income countries (LMIC). All children with Wilms tumours require resection for cure and therefore a perioperative care pathway can streamline care for all curative-intent nephrectomies. MethodsA two-round Delphi consensus of clinicians in LMICs was utilized to determine the scope and content of recommendations for an enhanced recovery protocol for children with Wilms tumours undergoing nephrectomy in LMICs. Consensus was predefined a priori as ≥70% of panelists indicating a topic or recommendation should be included. ResultsTwenty-six topics met consensus for inclusion and were consolidated into twenty recommendations for implementation in the preoperative, intraoperative, and postoperative setting. Predominant themes included perioperative nutrition, surgical safety, anesthetic concerns, and interdisciplinary oncology care. Ten participants completed round one and six completed round two. All recommendations met consensus for inclusion after two rounds. ConclusionsA consensus-derived perioperative care pathway for children with Wilms tumours in low-resource settings is presented. Recommendations share many priorities with high-resource pathways, but also contain unique considerations for a low-resource setting.

Virtual simulations for neonatal education

Virtual simulation (VS) education involves the use of virtual reality, augmented reality, mixed reality and screen-based platforms, collectively referred to as extended reality, to provide education and assessment. This novel simulation modality supports experiential learning and increases access to practice opportunities, supplementing manikin-based simulation. VS has been used successfully for neonatal resuscitation training in high and low resource settings. Virtual simulators can be used to objectively assess learner performance in neonatal resuscitation knowledge and skills. When implementing VS for neonatal resuscitation training, key considerations include matching learning objectives with suitable technology, pre-session preparation, supporting learners, and debriefing. Additional research is needed to evaluate the impact of VS applications on clinical practice and patient outcomes.

Deficiency in the Midst of Abundance: Xerophthalmia Case Series and Vitamin A Levels in a New England Hospital

Purpose: To describe 3 adult cases of keratitis secondary to vitamin A deficiency (VAD) in relation to vitamin A levels Dartmouth-Hitchcock Medical Center (DHMC) population and published literature. Methods: Records of 3 patients with xerophthalmia were reviewed. All serum vitamin A levels obtained at DHMC during the same time period of our 3 cases (2019–2020) were analyzed. Outcomes were examined by age and range of deficiency. Results: Three patients, with short gut syndrome, chronic esophagitis, and alcohol use disorder, presented with xerophthalmia over 1 year. Serum vitamin A levels were 6.4 μg/dL, 16.1 μg/dL, and undetectable (<5.0 μg/dL), respectively (normal: 32.5–78.0 μg/dL). Findings ranged from conjunctival keratinization to corneal perforation. Corneal cultures in patient 3 grew methicillin-sensitive Staphylococcus aureus. The ocular surface improved significantly in 2 patients following vitamin A supplementation. Two patients died during treatment. Analysis of 1596 vitamin A levels at DHMC revealed 431 patients with VAD, including 158 levels at or below those of our presented symptomatic cases. Conclusions: Vitamin A deficiency can occur in adults in high resource settings and lead to severe ocular morbidities, and is commonly associated with comorbidities such as alcohol use disorder and gastrointestinal disease. Vitamin A supplementation improved ocular findings in 2 of our patients. VAD was identified in 431 patients at DHMC over one year, indicating a surprisingly large population of patients at risk for xerophthalmia.

Outcomes and potential for improvement in the prehospital treatment of penetrating chest injuries in a European metropolitan area: A retrospective analysis of 2009 – 2017

BackgroundTrauma is the leading cause of death in patients <45 years living in high-resource settings. However, penetrating chest injuries are still relatively rare in Europe – with an upwards trend. These cases are of particular interest to emergency medical services (EMS) due to available invasive treatment options like chest tube placement or resuscitative thoracotomy. To date, there is no sufficient data from Austria regarding penetrating chest trauma in a metropolitan area, and no reliable source to base decisions regarding further skill proficiency training on. MethodsFor this retrospective observational study, we screened all trauma emergency responses of the Viennese EMS between 01/2009 and 12/2017 and included all those with a National Advisory Committee for Aeronautics (NACA) score ≥ IV (= potentially life-threatening). Data were derived from EMS mission documentations and hospital files, and for those cases with the injuries leading to cardiopulmonary resuscitation (CPR), we assessed the EMS cardiac arrest registry and consulted a forensic physician. ResultsWe included 480 cases of penetrating chest injuries of NACA IV-VII (83% male, 64% > 30 years old, 74% stab wounds, 16% cuts, 8% gunshot wounds, 56% inflicted by another party, 26% self-inflicted, 18% unknown). In the study period, the incidence rose from 1.4/100,000 to 3.5/100,000 capita, and overall, about one case was treated per week. In the cases with especially severe injury patterns (= NACA V-VII, 43% of total), (tension-)pneumothorax was the most common injury (29%). The highest mortality was seen in injuries to pulmonary vessels (100%) or the heart (94%). Fifty-eight patients (12% of total) deceased, whereas in 15 cases, the forensic physician stated survival could theoretically have been possible. However, only five of these CPR patients received at least unilateral thoracostomy. Regarding all penetrating chest injuries, thoracostomy had only been performed in eight patients. ConclusionsSevere cases of penetrating chest trauma are rare in Vienna and happened about once a week between 2009 and 2017. Both incidence and case load increased over the years, and potentially life-saving invasive procedures were only reluctantly applied. Therefore, a structured educational and skill retention approach aimed at both paramedics and emergency physicians should be implemented. Trial registrationRetrospective analysis without intervention.

General Care Considerations for the Pediatric Trauma Patient.

Trauma is a leading cause of morbidity and mortality for children in the United States. Access to trauma care, injury burden, and outcomes following injury, are inequitable. There are many anatomic and physiologic differences between children and adults that affect injury patterns and necessary trauma treatment. The principles of advanced trauma life support (ATLS) should be used by clinicians in high-resource settings for the immediate in-hospital treatment of the injured child.

A Mixed-Methods Approach for Evaluating Implementation Processes and Program Costs for a Hypertension Management Program Implemented in a Federally Qualified Health Center.

Team-based care approaches are effective at improving hypertension control and have been used in clinical practice to improve hypertension outcomes. This study implemented and evaluated the Hypertension Management Program (HMP), which was originally developed in a high-resource health setting, in a health system with fewer resources and a patient population disproportionately affected by hypertension. Our objectives were to describe how a health system could adapt HMP to meet their needs and calculate total program costs. HMP uses a team-based, patient-centered approach involving clinical pharmacists who contribute to managing patients who have hypertension and ultimately preventing premature death due to uncontrolled hypertension. HMP has 10 components (e.g., EHR patient registries and outreach lists, no copayment walk-in blood pressure checks). Our project involved implementing the key components of HMP in a federally qualified health center (FQHC) in South Carolina. Adaptations from the key components of HMP were made to fit the participants' settings. A mixed-methods evaluation assessed implementation processes, program costs, and implementation facilitators and barriers. From September 2018 to December 2019, clinical pharmacists conducted 758 hypertension management visits (HMVs) with 316 patients with hypertension. Total program costs for HMP were $325,532 overall and $16,277 per month. Monthly cost per patient was $3.62. The high engagement among clinical pharmacists, along with provider engagements, followed up by the subsequent referral of patients to HMP, facilitated the implementation process. Staff members observed improvements in hypertension control, which increased participation buy-in. Barriers included staff turnover, the perception among some providers that HMP took too much time, as well as perception of HMP as a pharmacy-specific initiative. A team-based, patient-centered approach to hypertension management can be adapted for FQHCs or similar settings that serve patient populations disproportionately affected by hypertension.