Patients In Low-resource Settings Research Articles

Systematic review and need assessment of pediatric trauma outcome benchmarking tools for low-resource settings.

Trauma is a leading cause of mortality and disability in children worldwide. The World Health Organization reports that 95% of all childhood injury deaths occur in Low-Middle-Income Countries (LMIC). Injury scores have been developed to facilitate risk stratification, clinical decision making, and research. Trauma registries in LMIC depend on adapted trauma scores that do not rely on investigations that require unavailable material or human resources. We sought to review and assess the existing trauma scores used in pediatric patients. Our objective is to determine their wideness of use, validity, setting of use, outcome measures, and criticisms. We believe that there is a need for an adapted trauma score developed specifically for pediatric patients in low-resource settings. A systematic review of the literature was conducted to identify and compare existing injury scores used in pediatric patients. We constructed a search strategy in collaboration with a senior hospital librarian. Multiple databases were searched, including Embase, Medline, and the Cochrane Central Register of Controlled Trials. Articles were selected based on predefined inclusion criteria by two reviewers and underwent qualitative analysis. The scores identified are suboptimal for use in pediatric patients in low-resource settings due to various factors, including reliance on precise anatomic diagnosis, physiologic parameters maladapted to pediatric patients, or laboratory data with inconsistent accessibility in LMIC. An important gap exists in our ability to simply and reliably estimate injury severity in pediatric patients and predict their associated probability of outcomes in settings, where resources are limited. An ideal score should be easy to calculate using point-of-care data that are readily available in LMIC, and can be easily adapted to the specific physiologic variations of different age groups.

Successful Implementation of a Pediatric Early Warning Score in a Resource-Limited Pediatric Oncology Hospital in Guatemala

Abstract 25 Background: Hospitalized pediatric oncology patients are at high risk for clinical decline and mortality, particularly in resource-limited settings. Pediatric Early Warning Scores (PEWS) are commonly used to aid with early identification of clinical deterioration; however, these scores have never been studied in oncology patients in low-resource settings. We describe the successful implementation of a modified PEWS at Unidad Nacional de Oncología Pediátrica (UNOP), a national pediatric oncology hospital in Guatemala. Methods: The PEWS used at Boston Children's Hospital (BCH) was modified through key informant meetings at UNOP, adjusting for practice variations between the two hospitals. After an initial pilot of the tool, the PEWS was implemented in all non-ICU inpatient areas at UNOP (60 beds with about 2,000 admissions/year). During implementation, systems were created to monitor errors in calculating PEWS, patient transfers to a higher level of care, and high PEWS scores for ongoing quality improvement. Results: Hospital-wide implementation occurred over 6 months, when 113 nurses were trained in the PEWS tool and algorithm. Compliance with PEWS performance and documentation was 100% by the end of the implementation period, with 300 to 400 PEWS measured daily and less than 10% errors. Monitoring of PEWS results reports an average of 5 high PEWS per week with 30% transferring to a higher level of care. Among patients requiring ICU transfer, 86% had an abnormal PEWS prior to transfer, which is similar to results at BCH (90%). Staff surveys showed a high degree of satisfaction with PEWS (4.6/5) and minimal difficulty using the score (2.3/5) (n=67). Conclusions: We describe the successful implementation of a PEWS in a pediatric oncology hospital in Guatemala. This work demonstrates that PEWS is a feasible, well-accepted, and low-cost quality improvement measure in this resource-limited setting. We now plan to evaluate the effects of this implementation on patient care and outcomes. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: No COIs from the authors.

Abstract PR01: Systems-level intervention to increase CRC screening in community health centers

Abstract Introduction: Colorectal cancer (CRC) is a leading cause of cancer death in the US. Although routine screening is effective in reducing CRC incidence and mortality, only 59% of adults are reportedly up-to-date. With even lower rates of screening and higher rates of late-stage diagnoses among under- and uninsured patients, there is a critical need for interventions that are effective, practical, and sustainable in this population. Many of these patients are served in the healthcare safety-net, including federally qualified health centers, which serve patients regardless of their insurance. System- or multi-level interventions have been effective at increasing screening in previous studies, but most have been implemented and evaluated in higher-resource settings. Using community based participatory research (CBPR) methods and a randomized trial design, we aim to select, implement, and test evidence-based systems-level strategies aimed at increasing CRC screening in safety-net healthcare settings that serve patients who are under- or uninsured. Methods: To meet CBPR principles, health centers were engaged in determining study procedures and interventions at their sites. After recruiting eleven safety-net health centers in two networks (one mostly urban, one mostly rural), six health centers were randomly assigned to the intervention arm. Provider reminders, changes to the patient materials, and patient reminders were the most common strategies selected. The primary outcome is CRC screening adherence at 12-months post-baseline as measured by self-report. Data were collected regarding patient socioeconomic factors, healthcare, and screening utilization. Data analysis included examination of bivariate associations as well as logistic regression with GEE robust standard error to assess CRC screening in intervention and control sites. Results: The study population included 490 participants at baseline from 11 health centers in 2 separate health networks; 273 (55.7%) participants completed the 12-month follow-up survey. Of this final sample, most were black (53.5%), unemployed (53.9%), had a monthly income <$1200/month (63.4%), had public insurance (65.6%), and reported they had a particular doctor or health care provider (84.3%). Participants were also evenly divided between the 2 health networks (50.9% and 49.1%). Most participants were up-to-date with any type of CRC screening at 12 months (65.6%) compared to 46.1% at baseline. The up-to-date screening rate was not significantly different between intervention and control (OR=1.06, p>0.05), in an adjusted model. Discussion: We reached a very low income sample, who experienced occasional homelessness, unexpected changes in contact information, and had relatively high unemployment rates. Participants had a relatively high baseline screening rate, but our participatory recruitment methods may have over-selected people who were already screened. The health centers were also under-resourced and faced challenges, particularly in helping patients access colonoscopy. Despite safety-net health centers adopting and adapting evidence-based intervention strategies to fit the needs of their patients, screening rates were not significantly higher in intervention clinics compared to control. There are several possible explanations. Control clinics may have been affected by the intervention, as they were in the same health network and there was occasional but unmeasured cross-over in terms of patients and providers. The lack of Medicaid expansion in Missouri meant that many patients remain uninsured. Also, the urban specialty clinic providing colonoscopy to under- and uninsured patients closed during the study, complicating access and creating long wait times for appointments. The study offers valuable insights into the challenges of implementing screening interventions with low-resource patients in low-resource settings. This abstract is also presented as Poster A43. Citation Format: Meera Muthukrishnan, Yan Yan, Jean Wang, Graham Colditz, Aimee S. James. Systems-level intervention to increase CRC screening in community health centers. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr PR01.

Clinical Characteristics and 30-Day Outcomes of Intermittent Hemodialysis for Acute Kidney Injury in an African Intensive Care Unit.

Introduction. Acute kidney injury (AKI) is a common occurrence in the intensive care unit (ICU). Studies have looked at outcomes of renal replacement therapy using intermittent haemodialysis (IHD) in ICUs with varying results. Little is known about the outcomes of using IHD in resource-limited settings where continuous renal replacement therapy (CRRT) is limited. We sought to determine outcomes of IHD among critically ill patients admitted to a low-income country ICU. Methods. A retrospective review of patient records was conducted. Patients admitted to the ICU who underwent IHD for AKI were included in the study. Patients' demographic and clinical characteristics, cause of AKI, laboratory parameters, haemodialysis characteristics, and survival were interpreted and analyzed. Primary outcome was mortality. Results. Of 62 patients, 40 had complete records. Median age of patients was 38.5 years. Etiologic diagnoses associated with AKI included sepsis, malaria, and ARDS. Mortality was 52.5%. APACHE II (OR 4.550; 95% CI 1.2–17.5, p = 0.028), mechanical ventilation (OR 13.063; 95% CI 2.3–72, p = 0.003), and need for vasopressors (OR 16.8; 95% CI 3.4–82.6, p = 0.001) had statistically significant association with mortality. Conclusion. IHD may be a feasible alternative for RRT in critically ill haemodynamically stable patients in low resource settings where CRRT may not be available.

Low-dose spinal anaesthesia provides effective labour analgesia and does not limit ambulation

Background: While epidural analgesia for labour pain is standard in high-resource countries, minimal to no analgesia is usually provided in low-resource countries. Intrathecal local anaesthetics provide good pain relief, but the potential impact on ambulation is of concern. Our objective was to determine if a low-dose local anaesthetic combined with an opioid would provide reasonable pain relief, while allowing ambulation in a low-resource setting.Method: This prospective, observational study was conducted at the Tamale Teaching Hospital in Tamale, Ghana. Spinal analgesia was administered to healthy women in labour using a pencil-point 25-G spinal needle at the L3–L4 or L4–L5 interspace, with patients in the sitting position. The intrathecal mixture contained 25 μg of fentanyl, 2.5 mg of bupivacaine and 0.2 mg of morphine. The patient’s ability to ambulate following the administration of a low-dose spinal injection was the primary outcome measured. Pain ratings, blood pressure, nausea, vomiting, pruritus, headaches and foetal bradycardia were also recorded.Results: Three hundred and thirty-two parturients consented to participate. Following spinal injection, 328 women (98.8%) experienced mild to no pain, and 4 (1.2%) moderate pain. The administration of spinal analgesia had no effect on ambulation in 291 (87.7%) patients, and a mild effect in 41 (12.3%) patients. Intrathecal analgesia did not severely limit ambulation in any of the patients.Conclusion: Low-dose intrathecal analgesia can provide effective analgesia for labouring patients in low-resource settings without limiting ambulation.

Regulations for Confidentiality of Health Records

The emergence of novel health record devices has opened a new avenue for medical sciences. Portable electronic health record devices are of recently-introduced inventions that would definitely contribute to the facilitation of providing health care for the trauma patients in low-resource settings (1). In addition to the benefits these new tools would provide for the patients, hospital workflow will not be hindered by the burden of providing primary physiological data required for the medical management. However, recently it has been argued that health record data should be considered confidential and rules or guidelines implemented in order to mitigate ethical concerns (2). Undoubtedly, implementation of effective regulations in this regard stands quite necessary. However, these regulations should exempt some fields from obtaining consent from the individuals, especially in the field of critical care medicine. For instance in the intrahospital, perioperative and emergency settings, the physiological data are used quite often to save lives of the patients; yet, no consents are obtained from the patients in this regard. Implementation of such guidelines, though seemingly necessary, should not impede the utilization of physiological or medical health data, especially in the emergency conditions where any delay in the process of data utilization could risk the lives of the individuals.

Rapid and sensitive detection of Bartonella bacilliformis in experimentally infected sand flies by loop-mediated isothermal amplification (LAMP) of the Pap31 gene.

BackgroundCarrion' disease, caused by Bartonella bacilliformis, remains truly neglected due to its focal geographical nature. A wide spectrum of clinical manifestations, including asymptomatic bacteremia, and lack of a sensitive diagnostic test can potentially lead to a spread of the disease into non-endemic regions where competent sand fly vectors may be present. A reliable test capable of detecting B. bacilliformis is urgently needed. Our objective is to develop a loop-mediated isothermal amplification (LAMP) assay targeting the pap31 gene to detect B. bacilliformis. Methods and FindingsThe sensitivity of the LAMP was evaluated in comparison to qPCR using plasmid DNA containing the target gene and genomic DNA in the absence and presence of human or sand fly DNA. The detection limit of LAMP was 1 to 10 copies/µL, depending on the sample metrics. No cross-reaction was observed when testing against a panel of various closely related bacteria. The utility of the LAMP was further compared to qPCR by the examination of 74 Lutzomyia longipalpis sand flies artificially fed on blood spiked with B. bacilliformis and harvested at days (D) 1, 3, 5, 7 and 9 post feeding. Only 86% of sand flies at D1 and 63% of flies at D3 were positive by qPCR. LAMP was able to detect B. bacilliformis in all those flies confirmed positive by qPCR. However, none of the flies after D3 were positive by either LAMP or qPCR. In addition to demonstrating the sensitivity of the LAMP assay, these results suggest that B. bacilliformis cannot propagate in artificially fed L. longipalpis.ConclusionsThe LAMP assay is as sensitive as qPCR for the detection of B. bacilliformis and could be useful to support diagnosis of patients in low-resource settings and also to identify B. bacilliformis in the sand fly vector.

Effect of mobile phone reminders on follow-up medical care of children exposed to or infected with HIV in Cameroon (MORE CARE): a multicentre, single-blind, factorial, randomised controlled trial

Missed scheduled HIV appointments lead to increased mortality, resistance to antiretroviral therapy, and suboptimum virological response. We aimed to assess whether reminders sent to carers by text message, mobile phone call, or concomitant text message and mobile phone call increase attendance at medical appointments for HIV care in a population of children infected with or exposed to HIV in Cameroon. We also aimed to ascertain the most cost-effective method of mobile-phone-based reminder. MORE CARE was a multicentre, single-blind, factorial, randomised controlled trial in urban, semi-urban, and rural settings in Cameroon. Carers of children who were infected with or had been exposed to HIV were randomly assigned electronically in blocks of four and allocated (1:1:1:1) sequentially to receive a text message and a call, a text message only, a call only, or no reminder (control). Investigators were masked to group assignment. Text messages were sent and calls made 2 or 3 days before a scheduled follow-up appointment. The primary outcomes were efficacy (the proportion of patients attending a previously scheduled appointment) and efficiency (attendance/[measures of staff working time × cost of the reminders]), as a measure of cost-effectiveness. The primary analysis was by intention to treat. This study is registered with the Pan African Clinical Trials Register, number PACTR201304000528276. The study took place between Jan 28 and May 24, 2013. We randomly assigned 242 adult-child (carer-patient) pairs into four groups: text message plus call (n=61), call (n=60), text message (n=60), and control (n=61). 54 participants (89%) in the text message plus call group, 51 (85%) in the call group, 45 (75%) in the text message group, and 31 (51%) in the control group attended their scheduled appointment. Compared with control, the odds ratios for improvement in the primary efficacy outcome were 7·5 (95% CI 2·9-19·0; p<0·0001) for text message plus call, 5·5 (2·3-13·1; p=0·0002) for call, and 2·9 (1·3-6·3; p=0·012) for text message. No significant differences were seen in comparisons of the three intervention groups with each other, and there was no synergism between text messages and calls. For the primary efficiency outcome, the mean difference for text message versus text message plus call was 1·5 (95% CI 0·7 to 2·4; p=0·002), for call versus text message plus call was 1·2 (0·7 to 1·6; p<0·0001), and for call versus text message was 0·4 (-1·3 to 0·6; p=0·47). Mobile-phone-based reminders of scheduled HIV appointments for carers of paediatric patients in low-resource settings can increase attendance. The most effective method of reminder was text message plus phone call, but text messaging alone was the most efficient (ie, cost-effective) method. No external funding.

Prevalence of psychological distress and associated factors in tuberculosis patients in public primary care clinics in South Africa

BackgroundPsychological distress has been rarely investigated among tuberculosis patients in low-resource settings despite the fact that mental ill health has far-reaching consequences for the health outcome of tuberculosis (TB) patients. In this study, we assessed the prevalence and predictors of psychological distress as a proxy for common mental disorders among tuberculosis (TB) patients in South Africa, where over 60 % of the TB patients are co-infected with HIV.MethodsWe interviewed 4900 tuberculosis public primary care patients within one month of initiation of anti-tuberculosis treatment for the presence of psychological distress using the Kessler-10 item scale (K-10), and identified predictors of distress using multiple logistic regressions. The Kessler scale contains items associated with anxiety and depression. Data on socio-demographic variables, health status, alcohol and tobacco use and adherence to anti-TB drugs and anti-retroviral therapy (ART) were collected using a structured questionnaire.ResultsUsing a cut off score of ≥28 and ≥16 on the K-10, 32.9 % and 81 % of tuberculosis patients had symptoms of distress, respectively. In multivariable analysis older age (OR = 1.52; 95 % CI = 1.24-1.85), lower formal education (OR = 0.77; 95 % CI = 0.65-0.91), poverty (OR = 1.90; 95 % CI = 1.57-2.31) and not married, separated, divorced or widowed (OR = 0.74; 95 % CI = 0.62-0.87) were associated with psychological distress (K-10 ≥28), and older age (OR = 1.30; 95 % CI = 1.00-1.69), lower formal education (OR = 0.55; 95 % CI = 0.42-0.71), poverty (OR = 2.02; 95 % CI = 1.50-2.70) and being HIV positive (OR = 1.44; 95 % CI = 1.19-1.74) were associated with psychological distress (K-10 ≥16). In the final model mental illness co-morbidity (hazardous or harmful alcohol use) and non-adherence to anti-TB medication and/or antiretroviral therapy were not associated with psychological distress.ConclusionsThe study found high rates of psychological distress among tuberculosis patients. Improved training of providers in screening for psychological distress, appropriate referral to relevant health practitioners and providing comprehensive treatment for patients with TB who are co-infected with HIV is essential to improve their health outcomes. It is also important that structural interventions are promoted in order to improve the financial status of this group of patients.

Idiopathic Membranous Nephropathy

<h3>Introduction</h3> Paediatric under-five mortality in Sierra Leone is one of the highest worldwide at 114/1000 live births in 2016. A history of civil war and viral haemorrhagic fever outbreak has impeded growth and development of the country’s health system. With a lack of resources and very few paediatric trained staff, children’s health care in Sierra Leone is greatly disadvantaged. The ETAT+protocols have been developed to improve emergency care of paediatric patients in low-resource settings. <h3>Aim</h3> To ascertain the impact of implementing national ETAT +protocols on the quality of care and mortality in malaria admissions in a Sierra Leonean district hospital. <h3>Methods</h3> Data on all paediatric malaria admissions were collected over a four-month period between 01/03/17 and 30/06/17. During this period ETAT+protocols were implemented through a three-month training programme. Data collected included demographics, symptoms at presentation, quality of care and outcome. <h3>Results</h3> The results are as presented in the table 1. <h3>Conclusion</h3> This hospital was supported by an international non-government organisation (NGO) at the time of ETAT+implementation, and as such baseline mortality rate was lower than that of unsupported government hospitals. There were challenges of collaberative working. Overall mortality was reduced after the implementation of ETAT+, despite a significant rise in complicated malaria admissions correlating with the start of rainy season. There was a reduction in the number of uncomplicated malaria cases admitted and treated with IV therapy, thus reducing inappropriate use of limited medication. There was an improvement in anti-convulsant prescribing after implementation. Paediatric emergency care training is essential to ensure continued delivery of life-saving treatments, particularly in the context of withdrawal of NGO support.

Caring for Patients in Low-Resource Settings

Case Jaime, a second-year medical student, has traveled to Zimbabwe for the summer to volunteer at a student- and resident-run health clinic. The clinic is located in a rural area where many people live below the poverty line and lack regular access to health care or basic resources like consistently clean water and electricity.

TBscore: Signs and symptoms from tuberculosis patients in a low-resource setting have predictive value and may be used to assess clinical course

We developed a clinical score to monitor tuberculosis patients in treatment and to assess clinical outcome. We used the WHO clinical manual to choose signs and symptoms, including cough, haemoptysis, dyspnoea, chest pain, night sweating, anaemia, tachycardia, lung-auscultation finding, fever, low body-mass index, low mid-upper arm circumference giving patients a TBscore from 0 to 13. We validated the score with data from a cohort of 698 TB patients, assessing sensitivity to change and ability to predict mortality. The TBscore declined for 96% of the surviving patients from initiation to end of treatment, and declined with a similar pattern in HIV-infected and HIV-uninfected patients, as well as in smear negative and smear positive patients. The risk of dying during treatment increased with higher TBscore at inclusion. For patients with a TBscore of >8 at inclusion, mortality during the 8 months treatment was 21% (45/218) versus 11% (55/480) for TBscore <8 (p< 0.001). TBscore assessed at end of treatment also strongly predicted subsequent mortality. The TBscore is a simple and low-cost tool for clinical monitoring of tuberculosis patients in low-resource settings and may be used to predict mortality risk. Low TBscore or fall in TBscore at treatment completion may be used as a measure of improvement.