Improved oxygen systems in district hospitals in Lao PDR: a prospective field trial of the impact on outcomes for childhood pneumonia and equipment sustainability

BACKGROUND

Hypoxaemia is a common and potentially fatal complication of many childhood, newborn and maternal conditions but often not well recognised or managed in settings where resources are limited. Oxygen itself is often inaccessible due to cost or logistics. This paper describes implementation of oxygen systems in Lao district hospitals, clinical outcomes after 24 months and equipment outcomes after 40 months postimplementation.

METHODS

A prospective field trial was conducted in 20 district hospitals, including 10 intervention hospitals that received oxygen concentrators and 10 control hospitals. Equipment outcomes were evaluated at baseline, 12, 24 and 40 months. Clinical outcomes of children under 5 years of age with pneumonia were evaluated using a before-and-after controlled study design with information retrospectively collected from medical records.

RESULTS

Fourteen (37%), 7 (18%) and 12 (34%) of 38 concentrators required repair at 12, 24 and 40 months, respectively. The proportion of children discharged well increased in intervention (90% (641/712) to 95.2% (658/691)) and control hospitals (87.1% (621/713) to 92.1% (588/606)). In intervention hospitals, case fatality rates for childhood pneumonia fell from 2.7% (19/712) preintervention to 0.80% (6/691) postintervention with no change in control hospitals (1.7% (12/713) preintervention and 2.3% (14/606) postintervention).

CONCLUSION

Medium-term sustainability of oxygen concentrators in hospitals accompanied by reduced case fatality for childhood pneumonia has been demonstrated in Lao PDR. Significant local engineering capacity to address multiple causes of equipment malfunction was critical. The ongoing requirements and fragile structures within the health system remain major risks to long-term sustainability.

Implementing WHO hospital guidelines improves quality of paediatric care in central hospitals in Lao PDR

OBJECTIVES

To evaluate the impact of implementing a multifaceted intervention based on the WHO Pocketbook of Hospital Care for Children on the quality of case management of common childhood illnesses in hospitals in Lao PDR.

METHODS

The quality of case management of four sentinel conditions was assessed in three central hospitals before and after the implementation of the WHO Pocketbook as part of a broader mixed-methods study. Data on performance of key steps in case management in more than 600 admissions were collected by medical record abstraction pre- and post-intervention, and change was measured according to the proportion of cases which key steps were performed as well as an overall score of case management for each condition.

RESULTS

Improvements in mean case management scores were observed post-intervention for three of the four conditions, with the greatest change in pneumonia (53-91%), followed by diarrhoea and low birthweight. Rational drug prescribing, appropriate use of IV fluids and appropriate monitoring all occurred more frequently post-intervention. Non-recommended practices such as prescription of antitussives became less frequent.

CONCLUSIONS

A multifaceted intervention based on the WHO Pocketbook of Hospital Care for children led to better paediatric care in central Lao hospitals. The degree of improvement was dependent on the condition assessed.

Ex vivo pediatric brain tumors express Fas (CD95) and FasL (CD95L) and are resistant to apoptosis induction

Fas (APO-1/CD95/TNFRSF6) is a member of the tumor necrosis/nerve growth factor receptor family that signals apoptotic cell death in sensitive cells. Expression of Fas and its agonistic ligand (FasL/TNFSF6) was investigated in ex vivo pediatric brain tumor specimens of various histologic types. Fas expression was identified in all of the 18 tumors analyzed by flow cytometry and immunohistochemistry. FasL expression was identified in most of the 13 tumors analyzed by both Western analysis and immunohistochemistry. Nine of these tumor specimens were treated with either the agonistic anti-Fas antibody (APO-1) in combination with protein A or FasL in short-term cytotoxicity assays. Sensitivity to apoptosis induced by the topoisomerase II inhibitor, etoposide, was also assessed. Despite the presence of Fas, all the specimens analyzed demonstrated a high degree of resistance to Fas-mediated apoptosis. These 9 specimens also showed a high degree of resistance to etoposide. Only 2 of the 9 specimens were susceptible to etoposide-induced cell death, whereas only 3 were sensitive to Fas-mediated apoptosis. One brain tumor was sensitive to both Fas ligation and etoposide treatment. This contrasted with the high degree of susceptibility to both etoposide- and Fas-induced apoptosis observed in the reference Jurkat cell line. The results suggest that Fas expression may be a general feature of tumors of the CNS and that a significant degree of resistance to Fas-mediated apoptosis may exist in ex vivo pediatric brain tumor specimens.

In vitro fusion of human inguinal hernia with associated epithelial transformation

The processus vaginalis (PV) is a peritoneal diverticulum which forms to allow descent of the fetal testis to the scrotum. During human development fusion and obliteration of the PV often fails to occur with the result that inguinal hernias are the most prevalent congenital abnormality requiring surgery in childhood. Androgen is proposed to regulate testicular descent via the genitofemoral nerve which releases the neuropeptide calcitonin gene-related peptide (CGRP). It is possible that subsequent fusion of the PV and tissue remodelling following descent is indirectly controlled by androgen via CGRP action. An organ culture assay was developed to assess fusion of the PV taken from inguinal herniotomy in infants. Fusion was induced in vitro by CGRP but not by CGRP 8-37, CGRP 27-37 or dihydrotestosterone in equimolar concentrations. Fusion was accompanied by transformation of the epithelium, as shown by staining of intermediate filament proteins, cytokeratin and vimentin. Localization studies for CGRP receptors on 25 specimens indicated CGRP acts on mesenchymal fibroblasts but not directly on PV epithelium suggesting an indirect pathway. Hepatocyte growth factor/scatter factor was found to induce fusion of PV and may be involved as an intermediate molecule in the fusion cascade. This study represents the first approach to understanding the humoral control and underlying mechanism by which the PV fuses.