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Kabajassi O, Reiter A, Tagoola A, Kenya-Mugisha N, O'Brien K, Wiens MO, Feeley N, Duby J. Facilitators and constraints to family integrated care in low-resource settings informed the adaptation in Uganda. Acta Paediatr 2024. [PMID: 38411347 DOI: 10.1111/apa.17182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 02/28/2024]
Abstract
AIM Family Integrated Care (FICare) was developed in high-income countries and has not been tested in resource-poor settings. We aimed to identify the facilitators and constraints that informed the adaptation of FICare to a neonatal hospital unit in Uganda. METHODS Maternal focus groups and healthcare provider interviews were conducted at Uganda's Jinja Regional Referral Hospital in 2020. Transcripts were analysed using inductive content analysis. An adaptation team developed Uganda FICare based on the identified facilitators and constraints. RESULTS Participants included 10 mothers (median age 28 years) and eight healthcare providers (seven female, median age 41 years). Reducing healthcare provider workload, improving neonatal outcomes and empowering mothers were identified as facilitators. Maternal stress, maternal difficulties in learning new skills and mistrust of mothers by healthcare providers were cited as constraints. Uganda FICare focused on task-shifting important but neglected patient care tasks from healthcare providers to mothers. Healthcare providers learned how to respond to maternal concerns. Intervention material was adapted to prioritise images over text. Mothers familiar with FICare provided peer-to-peer support to other mothers. CONCLUSION Uganda FICare shares the core values of FICare but was adapted to be feasible in low-resource settings.
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Affiliation(s)
| | - Anna Reiter
- Faculty of Medicine, McGill University, Montreal, Québec, Canada
| | | | | | - Karel O'Brien
- Department of Paediatrics, Sinai Health System, Toronto, Ontario, Canada
| | - Matthew O Wiens
- Walimu, Kampala, Uganda
- Centre for International Child Health, BC Children's & Women's Hospital, Vancouver, British Columbia, Canada
| | - Nancy Feeley
- Ingram School of Nursing, McGill University, Montreal, Québec, Canada
- Centre for Nursing Research, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Jessica Duby
- Department of Pediatrics, McGill University, Montreal, Québec, Canada
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Sanchez-Pinto LN, Bennett TD, DeWitt PE, Russell S, Rebull MN, Martin B, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Chisti MJ, Evans I, Horvat CM, Jaramillo-Bustamante JC, Kissoon N, Menon K, Scott HF, Weiss SL, Wiens MO, Zimmerman JJ, Argent AC, Sorce LR, Schlapbach LJ, Watson RS. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024; 331:675-686. [PMID: 38245897 PMCID: PMC10900964 DOI: 10.1001/jama.2024.0196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024]
Abstract
Importance The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force sought to develop and validate new clinical criteria for pediatric sepsis and septic shock using measures of organ dysfunction through a data-driven approach. Objective To derive and validate novel criteria for pediatric sepsis and septic shock across differently resourced settings. Design, Setting, and Participants Multicenter, international, retrospective cohort study in 10 health systems in the US, Colombia, Bangladesh, China, and Kenya, 3 of which were used as external validation sites. Data were collected from emergency and inpatient encounters for children (aged <18 years) from 2010 to 2019: 3 049 699 in the development (including derivation and internal validation) set and 581 317 in the external validation set. Exposure Stacked regression models to predict mortality in children with suspected infection were derived and validated using the best-performing organ dysfunction subscores from 8 existing scores. The final model was then translated into an integer-based score used to establish binary criteria for sepsis and septic shock. Main Outcomes and Measures The primary outcome for all analyses was in-hospital mortality. Model- and integer-based score performance measures included the area under the precision recall curve (AUPRC; primary) and area under the receiver operating characteristic curve (AUROC; secondary). For binary criteria, primary performance measures were positive predictive value and sensitivity. Results Among the 172 984 children with suspected infection in the first 24 hours (development set; 1.2% mortality), a 4-organ-system model performed best. The integer version of that model, the Phoenix Sepsis Score, had AUPRCs of 0.23 to 0.38 (95% CI range, 0.20-0.39) and AUROCs of 0.71 to 0.92 (95% CI range, 0.70-0.92) to predict mortality in the validation sets. Using a Phoenix Sepsis Score of 2 points or higher in children with suspected infection as criteria for sepsis and sepsis plus 1 or more cardiovascular point as criteria for septic shock resulted in a higher positive predictive value and higher or similar sensitivity compared with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria across differently resourced settings. Conclusions and Relevance The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.
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Affiliation(s)
- L. Nelson Sanchez-Pinto
- Departments of Pediatrics (Critical Care) and Preventive Medicine (Health and Biomedical Informatics), Northwestern University Feinberg School of Medicine, and Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics (Critical Care Medicine), University of Colorado School of Medicine, and Children’s Hospital Colorado, Aurora
| | - Peter E. DeWitt
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Seth Russell
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Margaret N. Rebull
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Blake Martin
- Departments of Biomedical Informatics and Pediatrics (Critical Care Medicine), University of Colorado School of Medicine, and Children’s Hospital Colorado, Aurora
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme, Nairobi, Kenya
| | - David J. Albers
- Departments of Biomedical Informatics, Bioengineering, Biostatistics, and Informatics, University of Colorado School of Medicine, Aurora
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, and Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Fran Balamuth
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine and Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohammod Jobayer Chisti
- Intensive Care Unit, Dhaka Hospital, Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Idris Evans
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christopher M. Horvat
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Juan Camilo Jaramillo-Bustamante
- Pediatric Intensive Care Unit, Hospital General de Medellín Luz Castro de Gutiérrez and Hospital Pablo Tobón Uribe, and Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Medellín, Colombia
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario and University of Ottawa, Ottawa, Canada
| | - Halden F. Scott
- Department of Pediatrics (Pediatric Emergency Medicine), University of Colorado School of Medicine, and Children’s Hospital Colorado, Aurora
| | - Scott L. Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children’s Health, Wilmington, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Institute for Global Health, BC Children’s Hospital, Vancouver, British Columbia, Canada
- Walimu, Kampala, Uganda
| | - Jerry J. Zimmerman
- Seattle Children’s Hospital and Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Andrew C. Argent
- Paediatrics and Child Health, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Lauren R. Sorce
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, and Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - R. Scott Watson
- Department of Pediatrics, University of Washington, and Center for Child Health, Behavior, and Development and Pediatric Critical Care, Seattle Children’s Hospital, Seattle
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Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Biban P, Carrol ED, Chiotos K, Chisti MJ, DeWitt PE, Evans I, Flauzino de Oliveira C, Horvat CM, Inwald D, Ishimine P, Jaramillo-Bustamante JC, Levin M, Lodha R, Martin B, Nadel S, Nakagawa S, Peters MJ, Randolph AG, Ranjit S, Rebull MN, Russell S, Scott HF, de Souza DC, Tissieres P, Weiss SL, Wiens MO, Wynn JL, Kissoon N, Zimmerman JJ, Sanchez-Pinto LN, Bennett TD. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024; 331:665-674. [PMID: 38245889 PMCID: PMC10900966 DOI: 10.1001/jama.2024.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
Importance 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. Objective To update and evaluate criteria for sepsis and septic shock in children. Evidence Review 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. Findings 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. Conclusions and Relevance 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.
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Affiliation(s)
- Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - R. Scott Watson
- Department of Pediatrics, University of Washington, Seattle
- Seattle Children’s Research Institute and Pediatric Critical Care, Seattle Children’s, Seattle, Washington
| | - Lauren R. Sorce
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew C. Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- University of Cape Town, Cape Town, South Africa
| | - Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Canada
- University of Ottawa, Ontario, Canada
| | - Mark W. Hall
- Division of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme, Nairobi, Kenya
| | - David J. Albers
- Departments of Biomedical Informatics, Bioengineering, Biostatistics and Informatics, University of Colorado School of Medicine, Aurora
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - Elizabeth R. Alpern
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Division of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Fran Balamuth
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paolo Biban
- Pediatric Intensive Care Unit, Verona University Hospital, Verona, Italy
| | - Enitan D. Carrol
- University of Liverpool, Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Divisions of Critical Care Medicine and Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mohammod Jobayer Chisti
- Intensive Care Unit, Dhaka Hospital, Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Peter E. DeWitt
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Idris Evans
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - Cláudio Flauzino de Oliveira
- AMIB–Associação de Medicina Intensiva Brasileira, São Paulo, Brazil
- LASI–Latin American Institute of Sepsis, São Paulo, Brazil
| | - Christopher M. Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - David Inwald
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics, University of California, San Diego School of Medicine, La Jolla
| | - Juan Camilo Jaramillo-Bustamante
- PICU Hospital General de Medellín “Luz Castro de Gutiérrez” and Hospital Pablo Tobón Uribe, Medellín, Colombia
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
| | - Michael Levin
- Section of Paediatric Infectious Diseases, Department of Infectious Diseases, Imperial College London, London, United Kingdom
- Department of Paediatrics, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Blake Martin
- Departments of Biomedical Informatics and Pediatrics (Division of Critical Care Medicine), University of Colorado School of Medicine and Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
- Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
| | - Simon Nadel
- Paediatric Intensive Care, St Mary’s Hospital, London, United Kingdom
- Imperial College London, London, United Kingdom
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mark J. Peters
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
- Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Suchitra Ranjit
- Pediatric Intensive Care Unit, Apollo Children’s Hospital, Chennai, India
| | - Margaret N. Rebull
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Seth Russell
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Halden F. Scott
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora
- Emergency Department, Children’s Hospital Colorado, Aurora
| | - Daniela Carla de Souza
- LASI–Latin American Institute of Sepsis, São Paulo, Brazil
- Department of Pediatrics (PICU), Hospital Universitario of the University of São Paulo, São Paulo, Brazil
- Department of Pediatrics (PICU), Hospital Sírio Libanês, São Paulo, Brazil
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Scott L. Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children’s Health, Wilmington, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Institute for Global Health, BC Children’s Hospital, Vancouver, Canada and Walimu, Uganda
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Jerry J. Zimmerman
- Department of Pediatrics, University of Washington, Seattle
- Seattle Children’s Research Institute and Pediatric Critical Care, Seattle Children’s, Seattle, Washington
| | - L. Nelson Sanchez-Pinto
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Division of Critical Care, and Department of Preventive Medicine, Division of Health & Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics (Division of Critical Care Medicine), University of Colorado School of Medicine and Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
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Reicherz F, Abu-Raya B, Akinseye O, Rassekh SR, Wiens MO, Lavoie PM. Efficacy of Palivizumab Immunoprophylaxis for Reducing Severe RSV Outcomes in Children with Immunodeficiencies: A Systematic Review. J Pediatric Infect Dis Soc 2024; 13:136-143. [PMID: 38279954 DOI: 10.1093/jpids/piae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/22/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Palivizumab is recommended for prevention of severe respiratory syncytial virus (RSV) disease in immunocompromised children, despite a lack of strong supporting evidence. The recent approval of substitute RSV-neutralizing monoclonal antibodies against RSV, offers an opportunity to synthesize the most current evidence supporting the palivizumab standard of care. OBJECTIVE To evaluate the efficacy of palivizumab in preventing acute respiratory tract infection- or RSV-related hospitalization, or mortality in immunocompromised children. METHODS We searched Ovid MEDLINE and EMBASE for published clinical studies that investigated outcomes of palivizumab use in children. We included clinical trials, cohort studies, and case-control studies. The primary outcomes were RSV-related or respiratory viral infection-related hospitalizations, or RSV-related mortality. This systematic review was registered in PROSPERO (ID CRD42021248619) and is reported in accordance with the PRISMA guidelines. RESULTS From the 1993 records, six studies were eligible and included, for a total of 625 immunocompromised children with an heterogeneous composition of primary and acquired immunodeficiencies enrolled from palivizumab programs. There were no intervention studies. None of the studies included a control group. RSV hospitalizations were infrequent (0%-3.1% of children). Most children included received palivizumab, although one study (n = 56) did not specify how many received palivizumab. RSV mortality was neither observed, in three studies, nor reported, in three other studies. CONCLUSIONS The evidence supporting the use of palivizumab for prevention of severe RSV disease in immunocompromised children remains extremely limited and appears insufficient to justify prioritizing this intervention as the current standard of care over alternative interventions.
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Affiliation(s)
- Frederic Reicherz
- BC Children's Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Bahaa Abu-Raya
- BC Children's Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Canadian Center for Vaccinology, Dalhousie University, IWK Health Centre and the Nova Scotia Health Authority, Canada
- Departments of Pediatrics, Dalhousie University, Nova Scotia, Canada
- Microbiology and Immunology, Dalhousie University, Nova Scotia, Canada
| | - Omolabake Akinseye
- BC Children's Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Shahrad Rod Rassekh
- BC Children's Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Matthew O Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Pascal M Lavoie
- BC Children's Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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Knappett M, Nguyen V, Chaudhry M, Trawin J, Kabakyenga J, Kumbakumba E, Jacob ST, Ansermino JM, Kissoon N, Mugisha NK, Wiens MO. Pediatric post-discharge mortality in resource-poor countries: a systematic review and meta-analysis. EClinicalMedicine 2024; 67:102380. [PMID: 38204490 PMCID: PMC10776442 DOI: 10.1016/j.eclinm.2023.102380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024] Open
Abstract
Background Under-five mortality remains concentrated in resource-poor countries. Post-discharge mortality is becoming increasingly recognized as a significant contributor to overall child mortality. With a substantial recent expansion of research and novel data synthesis methods, this study aims to update the current evidence base by providing a more nuanced understanding of the burden and associated risk factors of pediatric post-discharge mortality after acute illness. Methods Eligible studies published between January 1, 2017 and January 31, 2023, were retrieved using MEDLINE, Embase, and CINAHL databases. Studies published before 2017 were identified in a previous review and added to the total pool of studies. Only studies from countries with low or low-middle Socio-Demographic Index with a post-discharge observation period greater than seven days were included. Risk of bias was assessed using a modified version of the Joanna Briggs Institute critical appraisal tool for prevalence studies. Studies were grouped by patient population, and 6-month post-discharge mortality rates were quantified by random-effects meta-analysis. Secondary outcomes included post-discharge mortality relative to in-hospital mortality, pooled risk factor estimates, and pooled post-discharge Kaplan-Meier survival curves. PROSPERO study registration: #CRD42022350975. Findings Of 1963 articles screened, 42 eligible articles were identified and combined with 22 articles identified in the previous review, resulting in 64 total articles. These articles represented 46 unique patient cohorts and included a total of 105,560 children. For children admitted with a general acute illness, the pooled risk of mortality six months post-discharge was 4.4% (95% CI: 3.5%-5.4%, I2 = 94.2%, n = 11 studies, 34,457 children), and the pooled in-hospital mortality rate was 5.9% (95% CI: 4.2%-7.7%, I2 = 98.7%, n = 12 studies, 63,307 children). Among disease subgroups, severe malnutrition (12.2%, 95% CI: 6.2%-19.7%, I2 = 98.2%, n = 10 studies, 7760 children) and severe anemia (6.4%, 95% CI: 4.2%-9.1%, I2 = 93.3%, n = 9 studies, 7806 children) demonstrated the highest 6-month post-discharge mortality estimates. Diarrhea demonstrated the shortest median time to death (3.3 weeks) and anemia the longest (8.9 weeks). Most significant risk factors for post-discharge mortality included unplanned discharges, severe malnutrition, and HIV seropositivity. Interpretation Pediatric post-discharge mortality rates remain high in resource-poor settings, especially among children admitted with malnutrition or anemia. Global health strategies must prioritize this health issue by dedicating resources to research and policy innovation. Funding No specific funding was received.
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Affiliation(s)
- Martina Knappett
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Vuong Nguyen
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Maryum Chaudhry
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jessica Trawin
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jerome Kabakyenga
- Maternal Newborn & Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
- Faculty of Medicine, Dept of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Dept of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Shevin T. Jacob
- Walimu, Plot 5-7, Coral Crescent, Kololo, P.O. Box 9924, Kampala, Uganda
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - J. Mark Ansermino
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
| | - Niranjan Kissoon
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
- Dept of Pediatrics, BC Children’s Hospital, University of British Columbia, Rm 2D19, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada
| | | | - Matthew O. Wiens
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- Walimu, Plot 5-7, Coral Crescent, Kololo, P.O. Box 9924, Kampala, Uganda
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
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Wiens MO, Trawin J, Pillay Y, Nguyen V, Komugisha C, Kenya-Mugisha N, Namala A, Bebell LM, Ansermino JM, Kissoon N, Payne BA, Vidler M, Christoffersen-Deb A, Lavoie PM, Ngonzi J. Prognostic algorithms for post-discharge readmission and mortality among mother-infant dyads: an observational study protocol. Front Epidemiol 2023; 3:1233323. [PMID: 38455948 PMCID: PMC10911031 DOI: 10.3389/fepid.2023.1233323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/13/2023] [Indexed: 03/09/2024]
Abstract
Introduction In low-income country settings, the first six weeks after birth remain a critical period of vulnerability for both mother and newborn. Despite recommendations for routine follow-up after delivery and facility discharge, few mothers and newborns receive guideline recommended care during this period. Prediction modelling of post-delivery outcomes has the potential to improve outcomes for both mother and newborn by identifying high-risk dyads, improving risk communication, and informing a patient-centered approach to postnatal care interventions. This study aims to derive post-discharge risk prediction algorithms that identify mother-newborn dyads who are at risk of re-admission or death in the first six weeks after delivery at a health facility. Methods This prospective observational study will enroll 7,000 mother-newborn dyads from two regional referral hospitals in southwestern and eastern Uganda. Women and adolescent girls aged 12 and above delivering singletons and twins at the study hospitals will be eligible to participate. Candidate predictor variables will be collected prospectively by research nurses. Outcomes will be captured six weeks following delivery through a follow-up phone call, or an in-person visit if not reachable by phone. Two separate sets of prediction models will be built, one set of models for newborn outcomes and one set for maternal outcomes. Derivation of models will be based on optimization of the area under the receiver operator curve (AUROC) and specificity using an elastic net regression modelling approach. Internal validation will be conducted using 10-fold cross-validation. Our focus will be on the development of parsimonious models (5-10 predictor variables) with high sensitivity (>80%). AUROC, sensitivity, and specificity will be reported for each model, along with positive and negative predictive values. Discussion The current recommendations for routine postnatal care are largely absent of benefit to most mothers and newborns due to poor adherence. Data-driven improvements to postnatal care can facilitate a more patient-centered approach to such care. Increasing digitization of facility care across low-income settings can further facilitate the integration of prediction algorithms as decision support tools for routine care, leading to improved quality and efficiency. Such strategies are urgently required to improve newborn and maternal postnatal outcomes. Clinical trial registration https://clinicaltrials.gov/, identifier (NCT05730387).
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Affiliation(s)
- Matthew O. Wiens
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
- WALIMU, Kampala, Uganda
| | - Jessica Trawin
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
| | - Yashodani Pillay
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Vuong Nguyen
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
| | | | | | - Angella Namala
- Department of Obstetrics & Gynaecology, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Lisa M. Bebell
- Department of Medicine, Division of Infectious Diseases, Medical Practice Evaluation Center, Center for Global Health, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - J. Mark Ansermino
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Niranjan Kissoon
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Beth A. Payne
- Digital Health Research, BC Children’s Hospital Research Institute, Vancouver, BC, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Marianne Vidler
- Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Astrid Christoffersen-Deb
- Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Pascal M. Lavoie
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Digital Health Research, BC Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science & Technology, Mbarara, Uganda
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Akinseye O, Popescu CR, Chiume-Kayuni M, Irvine MA, Lufesi N, Mvalo T, Kissoon N, Wiens MO, Lavoie PM. World Health Organization Danger Signs to predict bacterial sepsis in young infants: A pragmatic cohort study. PLOS Glob Public Health 2023; 3:e0001990. [PMID: 37988384 PMCID: PMC10662722 DOI: 10.1371/journal.pgph.0001990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/12/2023] [Indexed: 11/23/2023]
Abstract
Bacterial sepsis is generally a major concern in ill infants. To help triaging decisions by front-line health workers in these situations, the World Health Organization (WHO) has developed danger signs (DS). The objective of this study was to evaluate the extent to which nine DS predict bacterial sepsis in young infants presenting with suspected sepsis in a low-income country setting. The study pragmatically evaluated nine DS in infants younger than 3 months with suspected sepsis in a regional hospital in Lilongwe, Malawi, between June 2018 and April 2020. Main outcomes were positive blood or cerebrospinal fluid (CSF) cultures for neonatal pathogens, and mortality. Among 401 infants (gestational age [mean ± SD]: 37.1±3.3 weeks, birth weight 2865±785 grams), 41 had positive blood or CSF cultures for a neonatal pathogen. In-hospital mortality occurred in 9.7% of infants overall (N = 39/401), of which 61.5% (24/39) occurred within 48 hours of admission. Mortality was higher in infants with bacterial sepsis compared to other infants (22.0% [9/41] versus 8.3% [30/360]; p = 0.005). All DS were associated with mortality except for temperature instability and tachypnea, whereas none of the DS were significantly associated with bacterial sepsis, except for "unable to feed" (OR 2.25; 95%CI: 1.17-4.44; p = 0.017). The number of DS predicted mortality (OR: 1.75; 95%CI: 1.43-2.17; p<0.001; AUC: 0.756), but was marginally associated with positive cultures with a neonatal pathogen (OR 1.22; 95%CI: 1.00-1.49; p = 0.046; AUC: 0.743). The association between number of DS and mortality remained significant after adjusting for admission weight, the only statistically significant co-variable (OR 1.75 [95% CI: 1.39-2.23]; p<0.001). Considering all positive cultures including potential bacterial contaminants resulted a non-significant association between number of DS and sepsis (OR 1.09 [95% CI: 0.93-1.28]; p = 0.273). In conclusion, this study shows that DS were strongly associated with death, but were marginally associated with culture-positive pathogen sepsis in a regional hospital setting. These data imply that the incidence of bacterial sepsis and attributable mortality in infants in LMIC settings may be inaccurately estimated based on clinical signs alone.
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Affiliation(s)
- Omolabake Akinseye
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Constantin R. Popescu
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, Université Laval, Québec, Canada
| | - Msandeni Chiume-Kayuni
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
- Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - Michael A. Irvine
- British Columbia Centre for Disease Control, Vancouver, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Norman Lufesi
- Department of Curative and Medical Rehabilitation, Ministry of Health, Lilongwe, Malawi
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Niranjan Kissoon
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Pascal M. Lavoie
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
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8
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Owokuhaisa J, Schwartz JI, Wiens MO, Musinguzi P, Rukundo GZ. Planning for Hospital Discharge for Older Adults in Uganda: A Qualitative Study Among Healthcare Providers Using the COM-B Framework. J Multidiscip Healthc 2023; 16:3235-3248. [PMID: 37936911 PMCID: PMC10627173 DOI: 10.2147/jmdh.s430489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/22/2023] [Indexed: 11/09/2023] Open
Abstract
Background Proper discharge planning enhances continuity of patient care, reduces readmissions, and ensures safe and timely transition from health facility to home-based care. The current study aimed at exploring the healthcare providers' perspectives of discharge planning among older adults, with respect to barriers and facilitators within the Ugandan health system. Methods We conducted a qualitative exploratory study that used one-on-one interviews (Additional file 1) to describe individual perspectives of healthcare providers in their routine clinical care setting. The study included medical doctors (including consultants and physicians), nurses and physiotherapists directly involved in providing care to older adults. We conducted 25 in-depth interviews among healthcare providers for older adults with non-communicable diseases. The audio-recorded interviews were transcribed verbatim. Data were manually organized using a framework matrix guided by the COM-B domains (capability, opportunity and motivation) as the broad themes and sub-themes (physical and psychological capability, social and physical opportunity, reflective and automatic motivation) that influence behavior change (discharge planning). Results Discharge planning was facilitated by availability of discharge forms, continuous medical education and working experience. The barriers to discharge planning were understaffing, workload/insufficient time, lack of discharge planning guidelines, lack of multidisciplinary approach and congested inpatient wards. Both barriers and facilitators were at various levels of healthcare service delivery such as patient, caregiver, healthcare provider, health facility and policy levels. Conclusion Barriers to discharge planning spread across all levels of healthcare service delivery, but they can be addressed by enhancing the facilitators. This calls for a multi-level action to ensure adequate and quality patient care during and after hospitalization.
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Affiliation(s)
- Judith Owokuhaisa
- Faculty of Medicine, Department of Physiotherapy, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew O Wiens
- Institute for Global Health, British Colombia Children’s Hospital, Vancouver, British Columbia, Canada
- Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pius Musinguzi
- Department of Nursing, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Godfrey Zari Rukundo
- Department of Psychiatry, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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9
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Knappett M, Hooft A, Maqsood MB, Lavoie PM, Kortz T, Mehta S, Duby J, Akech S, Maina M, Carter R, Popescu CR, Daftary R, Mugisha NK, Mwesigwa D, Kabakyenga J, Kumbakumba E, Ansermino JM, Kissoon N, Mutekanga A, Hau D, Moschovis P, Kangwa M, Chen C, Firnberg M, Glomb N, Argent A, Reid SJ, Bhutta A, Wiens MO. Verbal Autopsy to Assess Postdischarge Mortality in Children With Suspected Sepsis in Uganda. Pediatrics 2023; 152:e2023062011. [PMID: 37800272 PMCID: PMC11006254 DOI: 10.1542/peds.2023-062011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Reducing child mortality in low-income countries is constrained by a lack of vital statistics. In the absence of such data, verbal autopsies provide an acceptable method to determining attributable causes of death. The objective was to assess potential causes of pediatric postdischarge mortality in children younger than age 5 years (under-5) originally admitted for suspected sepsis using verbal autopsies. METHODS Secondary analysis of verbal autopsy data from children admitted to 6 hospitals across Uganda from July 2017 to March 2020. Structured verbal autopsy interviews were conducted for all deaths within 6 months after discharge. Two physicians independently classified a primary cause of death, up to 4 alternative causes, and up to 5 contributing conditions using the Start-Up Mortality List, with discordance resolved by consensus. RESULTS Verbal autopsies were completed for 361 (98.6%) of the 366 (5.9%) children who died among 6191 discharges (median admission age: 5.4 months [interquartile range, 1.8-16.7]; median time to mortality: 28 days [interquartile range, 9-74]). Most deaths (62.3%) occurred in the community. Leading primary causes of death, assigned in 356 (98.6%) of cases, were pneumonia (26.2%), sepsis (22.1%), malaria (8.5%), and diarrhea (7.9%). Common contributors to death were malnutrition (50.5%) and anemia (25.7%). Reviewers were less confident in their causes of death for neonates than older children (P < .05). CONCLUSIONS Postdischarge mortality frequently occurred in the community in children admitted for suspected sepsis in Uganda. Analyses of the probable causes for these deaths using verbal autopsies suggest potential areas for interventions, focused on early detection of infections, as well as prevention and treatment of underlying contributors such as malnutrition and anemia.
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Affiliation(s)
- Martina Knappett
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
| | - Anneka Hooft
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Muhammad Bilal Maqsood
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Pascal M. Lavoie
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
| | - Teresa Kortz
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, California
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California
| | - Sonia Mehta
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Jessica Duby
- Department of Pediatrics, McGill University, Montreal, Canada
| | - Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Centre for Geographic Medicine Research–Coast, Kilifi, Kenya
| | - Michuki Maina
- Health Services Research Group, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Rebecca Carter
- Division of Neonatology, Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Constantin R. Popescu
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
- Division of Neonatology, Department of Pediatrics, Université Laval, Québec, Canada
| | - Rajesh Daftary
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | | | | | - Jerome Kabakyenga
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - J. Mark Ansermino
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Niranjan Kissoon
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | | | - Duncan Hau
- Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Peter Moschovis
- Division of Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mukuka Kangwa
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Carol Chen
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Maytal Firnberg
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Nicolaus Glomb
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Andrew Argent
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Stephen J. Reid
- Department of Family, Community and Emergency Care, University of Cape Town, Cape Town, South Africa
| | - Adnan Bhutta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew O. Wiens
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Walimu, Kampala, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
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10
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Jimenez-Zambrano A, Ritger C, Rebull M, Wiens MO, Kabajaasi O, Jaramillo-Bustamante JC, Argent AC, Kissoon N, Schlapbach LJ, Sorce LR, Watson RS, Dorsey Holliman B, Sanchez-Pinto LN, Bennett TD. Clinical decision support tools for paediatric sepsis in resource-poor settings: an international qualitative study. BMJ Open 2023; 13:e074458. [PMID: 37879683 PMCID: PMC10603473 DOI: 10.1136/bmjopen-2023-074458] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/04/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVE New paediatric sepsis criteria are being developed by an international task force. However, it remains unknown what type of clinical decision support (CDS) tools will be most useful for dissemination of those criteria in resource-poor settings. We sought to design effective CDS tools by identifying the paediatric sepsis-related decisional needs of multidisciplinary clinicians and health system administrators in resource-poor settings. DESIGN Semistructured qualitative focus groups and interviews with 35 clinicians (8 nurses, 27 physicians) and 5 administrators at health systems that regularly provide care for children with sepsis, April-May 2022. SETTING Health systems in Africa, Asia and Latin America, where sepsis has a large impact on child health and healthcare resources may be limited. PARTICIPANTS Participants had a mean age of 45 years, a mean of 15 years of experience, and were 45% female. RESULTS Emergent themes were related to the decisional needs of clinicians caring for children with sepsis and to the needs of health system administrators as they make decisions about which CDS tools to implement. Themes included variation across regions and institutions in infectious aetiologies of sepsis and available clinical resources, the need for CDS tools to be flexible and customisable in order for implementation to be successful, and proposed features and format of an ideal paediatric sepsis CDS tool. CONCLUSION Findings from this study will directly contribute to the design and implementation of CDS tools to increase the uptake and impact of the new paediatric sepsis criteria in resource-poor settings.
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Affiliation(s)
- Andrea Jimenez-Zambrano
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Carly Ritger
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Margaret Rebull
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matthew O Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
- Walimu, Kampala, Uganda
| | | | | | - Andrew C Argent
- Paediatrics and Child Health, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Rondebosch, South Africa
| | - Niranjan Kissoon
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
- Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatalogy, University Children's Hospital Zürich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Lauren R Sorce
- Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - R Scott Watson
- Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Brooke Dorsey Holliman
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lazaro N Sanchez-Pinto
- Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tellen D Bennett
- Departments of Biomedical Informatics and Pediatrics (Critical Care Medicine), University of Colorado School of Medicine, Aurora, Colorado, USA
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Kabajaasi O, Trawin J, Derksen B, Komugisha C, Mwaka S, Waiswa P, Nsungwa-Sabiiti J, Ansermino JM, Kissoon N, Duby J, Kenya-Mugisha N, Wiens MO. Transitions from hospital to home: A mixed methods study to evaluate pediatric discharges in Uganda. PLOS Glob Public Health 2023; 3:e0002173. [PMID: 37703267 PMCID: PMC10499195 DOI: 10.1371/journal.pgph.0002173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/09/2023] [Indexed: 09/15/2023]
Abstract
The World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) guidelines recognize the importance of discharge planning to ensure continuation of care at home and appropriate follow-up. However, insufficient attention has been paid to post discharge planning in many hospitals contributing to poor implementation. To understand the reasons for suboptimal discharge, we evaluated the pediatric discharge process from hospital admission through the transition to care within the community in Ugandan hospitals. This mixed methods prospective study enrolled 92 study participants in three phases: patient journey mapping for 32 admitted children under-5 years of age with suspected or proven infection, discharge process mapping with 24 pediatric healthcare workers, and focus group discussions with 36 primary caregivers and fathers of discharged children. Data were descriptively and thematically analyzed. We found that the typical discharge process is often not centered around the needs of the child and family. Discharge planning often does not begin until immediately prior to discharge and generally does not include caregiver input. Discharge education and counselling are generally limited, rarely involves the father, and does not focus significantly on post-discharge care or follow-up. Delays in the discharge process itself occur at multiple points, including while awaiting a physical discharge order and then following a discharge order, mainly with billing or transportation issues. Poor peri-discharge care is a significant barrier to optimizing health outcomes among children in Uganda. Process improvements including initiation of early discharge planning, improved communication between healthcare workers and caregivers, as well as an increased focus on post-discharge care, are key to ensuring safe transitions from facility-based care to home-based care among children recovering from severe illness.
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Affiliation(s)
| | - Jessica Trawin
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, Vancouver, British Columbia, Canada
| | - Brooklyn Derksen
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | | | - Peter Waiswa
- Makerere University School of Public Health, Kampala, Uganda
| | | | - J. Mark Ansermino
- Institute for Global Health, BC Children’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Niranjan Kissoon
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Jessica Duby
- Department of Pediatrics, McGill University, Montreal, Canada
| | | | - Matthew O. Wiens
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- Walimu, Kampala Uganda; Mbarara University of Science and Technology, Mbarara, Uganda
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12
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Asdo A, Mawji A, Agaba C, Komugisha C, Novakowski SK, Pillay Y, Kamau S, Wiens MO, Akech S, Tagoola A, Kissoon N, Ansermino JM, Dunsmuir D. Repeatability of Pulse Oximetry Measurements in Children During Triage in 2 Ugandan Hospitals. Glob Health Sci Pract 2023; 11:e2200544. [PMID: 37640488 PMCID: PMC10461707 DOI: 10.9745/ghsp-d-22-00544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND In low- and middle-income countries, health workers use pulse oximeters for intermittent spot measurements of oxygen saturation (SpO2). However, the accuracy and reliability of pulse oximeters for spot measurements have not been determined. We evaluated the repeatability of spot measurements and the ideal observation time to guide recommendations during spot check measurements. METHODS Two 1-minute measurements were taken for the 3,903 subjects enrolled in the study conducted April 2020-January 2022 in Uganda, collecting 1 Hz SpO2 and signal quality index (SQI) data. The repeatability between the 2 measurements was assessed using an intraclass correlation coefficient (ICC), calculated using a median of all seconds of non-zero SpO2 values for each recording (any quality, Q1) and again with a quality filter only using seconds with SQI 90% or higher (good quality, Q2). The ICC was also recalculated for both conditions of Q1 and Q2 using the initial 5 seconds, then the initial 10 seconds, and continuing with 5-second increments up to the full 60 seconds. Lastly, the whole minute ICC was calculated with good quality (Q2), including only records where both measurements had a mean SQI of more than 70% (Q3). RESULTS The repeatability ICC with condition Q1 was 0.591 (95% confidence interval [CI]=0.570, 0.611). Using only the first 5 seconds of each measurement reduced the repeatability to 0.200 (95% CI=0.169, 0.230). Filtering with Q2, the whole-minute ICC was 0.855 (95% CI=0.847, 0.864). The ICC did not improve beyond the first 35 seconds. For Q3, the repeatability rose to 0.908 (95% CI=0.901, 0.914). CONCLUSIONS Training guidelines must emphasize the importance of signal quality and duration of measurement, targeting a minimum of 35 seconds of adequate-quality, stable data. In addition, the design of new devices should incorporate user prompts and force quality checks to encourage more accurate pulse oximetry measurements.
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Affiliation(s)
- Ahmad Asdo
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
| | - Alishah Mawji
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
| | - Collins Agaba
- World Alliance for Lung and Intensive Care Medicine in Uganda, Kampala, Uganda
| | - Clare Komugisha
- World Alliance for Lung and Intensive Care Medicine in Uganda, Kampala, Uganda
| | - Stefanie K. Novakowski
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
| | - Yashodani Pillay
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
| | - Stephen Kamau
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
- World Alliance for Lung and Intensive Care Medicine in Uganda, Kampala, Uganda
| | - Samuel Akech
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Abner Tagoola
- Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Niranjan Kissoon
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - J. Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
| | - Dustin Dunsmuir
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
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Wiens MO, Bone JN, Kumbakumba E, Businge S, Tagoola A, Sherine SO, Byaruhanga E, Ssemwanga E, Barigye C, Nsungwa J, Olaro C, Ansermino JM, Kissoon N, Singer J, Larson CP, Lavoie PM, Dunsmuir D, Moschovis PP, Novakowski S, Komugisha C, Tayebwa M, Mwesigwa D, Zhang C, Knappett M, West N, Nguyen V, Mugisha NK, Kabakyenga J. Mortality after hospital discharge among children younger than 5 years admitted with suspected sepsis in Uganda: a prospective, multisite, observational cohort study. Lancet Child Adolesc Health 2023; 7:555-566. [PMID: 37182535 PMCID: PMC10543357 DOI: 10.1016/s2352-4642(23)00052-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Substantial mortality occurs after hospital discharge in children younger than 5 years with suspected sepsis, especially in low-income countries. A better understanding of its epidemiology is needed for effective interventions to reduce child mortality in these countries. We evaluated risk factors for death after discharge in children admitted to hospital for suspected sepsis in Uganda, and assessed how these differed by age, time of death, and location of death. METHODS In this prospective, multisite, observational cohort study, we recruited and consecutively enrolled children aged 0-60 months admitted with suspected sepsis from the community to the paediatric wards of six Ugandan hospitals. Suspected sepsis was defined as the need for admission due to a suspected or proven infectious illness. At admission, trained study nurses systematically collected data on clinical variables, sociodemographic variables, and baseline characteristics with encrypted study tablets. Participants were followed up for 6 months after discharge by field officers who contacted caregivers at 2 months and 4 months after discharge by telephone and at 6 months after discharge in person to measure vital status, health-care seeking after discharge, and readmission details. We assessed 6-month mortality after hospital discharge among those discharged alive, with verbal autopsies conducted for children who had died after hospital discharge. FINDINGS Between July 13, 2017, and March 30, 2020, 16 991 children were screened for eligibility. 6545 children (2927 [44·72%] female children and 3618 [55·28%] male children) were enrolled and 6191 were discharged from hospital alive. 6073 children (2687 [44·2%] female children and 3386 [55·8%] male children) completed follow-up. 366 children died in the 6-month period after discharge (weighted mortality rate 5·5%). Median time from discharge to death was 28 days (IQR 9-74). For the 360 children for whom location of death was documented, deaths occurred at home (162 [45·0%]), in transit to care (66 [18·3%]), or in hospital (132 [36·7%]) during a subsequent readmission. Death after hospital discharge was strongly associated with weight-for-age Z scores less than -3 (adjusted risk ratio [aRR] 4·7, 95% CI 3·7-5·8 vs a Z score of >-2), discharge or referral to a higher level of care (7·3, 5·6-9·5), and unplanned discharge (3·2, 2·5-4·0). Hazard ratios (HRs) for severe anaemia (<7g/dL) increased with time since discharge, from 1·7 (95% CI 0·9-3·0) for death occurring in the first time tertile to 5·2 (3·1-8·5) in the third time tertile. HRs for some discharge vulnerabilities decreased significantly with increasing time since discharge, including unplanned discharge (from 4.5 [2·9-6·9] in the first tertile to 2·0 [1·3-3·2] in the third tertile) and poor feeding status (from 7·7 [5·4-11·0] to 1·84 [1·0-3·3]). Age interacted with several variables, including reduced weight-for-age Z score, severe anaemia, and reduced admission temperature. INTERPRETATION Paediatric mortality following hospital discharge after suspected sepsis is common, with diminishing, although persistent, risk during the first 6 months after discharge. Efforts to improve outcomes after hospital discharge are crucial to achieving Sustainable Development Goal 3.2 (ending preventable childhood deaths under age 5 years). FUNDING Grand Challenges Canada, Thrasher Research Fund, BC Children's Hospital Foundation, and Mining4Life.
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Affiliation(s)
- Matthew O Wiens
- Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada; BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Walimu, Kampala, Uganda.
| | - Jeffrey N Bone
- Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada; BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Elias Kumbakumba
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Abner Tagoola
- Department of Paediatrics, Jinja Regional Referral Hospital, Jinja City, Uganda
| | | | | | | | | | - Jesca Nsungwa
- Ministry of Health for the Republic of Uganda, Kampala, Uganda
| | - Charles Olaro
- Ministry of Health for the Republic of Uganda, Kampala, Uganda
| | - J Mark Ansermino
- Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada; BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Niranjan Kissoon
- BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, BC, Canada; Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Charles P Larson
- School of Population and Global Health, McGill University, Montreal, QC, Canada
| | - Pascal M Lavoie
- BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, BC, Canada; Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Dustin Dunsmuir
- Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada; BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Peter P Moschovis
- Division of Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Stefanie Novakowski
- Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | - Cherri Zhang
- Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
| | - Martina Knappett
- Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
| | - Nicholas West
- BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Vuong Nguyen
- Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
| | | | - Jerome Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda; Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Symonds NE, Vidler M, Wiens MO, Omar S, English LL, Ukah UV, Ansermino JM, Ngonzi J, Bebell LM, Hwang B, Christoffersen-Deb A, Kissoon N, Payne BA. Risk factors for postpartum maternal mortality and hospital readmission in low- and middle-income countries: a systematic review. BMC Pregnancy Childbirth 2023; 23:303. [PMID: 37120529 PMCID: PMC10148415 DOI: 10.1186/s12884-023-05459-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 02/20/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND In low- and middle-income countries, approximately two thirds of maternal deaths occur in the postpartum period. Yet, care for women beyond 24 h after discharge is limited. The objective of this systematic review is to summarize current evidence on socio-demographic and clinical risk factors for (1) postpartum mortality and (2) postpartum hospital readmission. METHODS A combination of keywords and subject headings (i.e. MeSH terms) for postpartum maternal mortality or readmission were searched. Articles published up to January 9, 2021 were identified in MEDLINE, EMBASE, and CINAHL databases, without language restrictions. Studies reporting socio-demographic or clinical risk factors for postpartum mortality or readmission within six weeks of delivery among women who delivered a livebirth in a low- or middle-income country were included. Data were extracted independently by two reviewers based on study characteristics, population, and outcomes. Included studies were assessed for quality and risk of bias using the Downs and Black checklist for ratings of randomized and non-randomized studies. RESULTS Of 8783 abstracts screened, seven studies were included (total N = 387,786). Risk factors for postpartum mortality included Caesarean mode of delivery, nulliparity, low or very low birthweight, and shock upon admission. Risk factors for postpartum readmission included Caesarean mode of delivery, HIV positive serostatus, and abnormal body temperature. CONCLUSIONS Few studies reported individual socio-demographic or clinical risk factors for mortality or readmission after delivery in low- and middle-income countries; only Caesarean delivery was consistently reported. Further research is needed to identify factors that put women at greatest risk of post-discharge complications and mortality. Understanding post-discharge risk would facilitate targeted postpartum care and reduce adverse outcomes in women after delivery. TRIAL REGISTRATION PROSPERO registration number: CRD42018103955.
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Affiliation(s)
- Nicola E Symonds
- The Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-339, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.
| | - Matthew O Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- Walimu, Kampala, Uganda
| | - Shazmeen Omar
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-339, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - L Lacey English
- Department of Internal Medicine and Pediatrics, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - U Vivian Ukah
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - J Mark Ansermino
- The Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lisa M Bebell
- Infectious Diseases Division, and Center for Global Health, Massachusetts General Hospital Medical Practice Evaluation Center, Boston, MA, USA
| | - Bella Hwang
- The Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
| | - Astrid Christoffersen-Deb
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-339, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Niranjan Kissoon
- The Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Beth A Payne
- School of Public and Population Health, University of British Columbia, Vancouver, BC, Canada
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15
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Ponticiello M, Nuwagira E, Tayebwa M, Mugerwa J, Nahabwe H, Nakasita C, Tumuhimbise JB, Lam NL, Wiens MO, Vallarino J, Allen JG, Muyanja D, Tsai AC, Sundararajan R, Lai PS. "If you have light, your heart will be at peace": A qualitative study of household lighting and social integration in southwestern Uganda. J Glob Health 2023; 13:04026. [PMID: 37052216 PMCID: PMC10099441 DOI: 10.7189/jogh.13.04026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
Background Expanding electrification and access to other clean and affordable energy, such as solar energy, is a critical component of the Sustainable Development Goals, particularly in sub-Saharan Africa where 70% of people are energy insecure. Intervention trials related to access or less polluting household energy alternatives have typically focused on air quality and biological outcomes rather than on how an intervention affects the end user's lived experiences, a key determinant of uptake and adoption outside of a research setting. We explored perceptions of and experiences with a household solar lighting intervention in rural Uganda. Methods In 2019, we completed a one-year parallel group, randomized wait-list controlled trial of indoor solar lighting systems (ClinicalTrials.gov NCT03351504) in rural Uganda where participants are largely relying on kerosene and other fuel-based lighting received household indoor solar lighting systems. In this qualitative sub-study, we conducted one-on-one, in-depth qualitative interviews with all 80 female participants enrolled in the trial. Interviews explored how solar lighting and illumination impacted participants' lives. We applied a theoretical model linking social integration and health to analyse dynamic interactions across aspects of study participants' lived experiences. Sensors were used to measure daily lighting use before and after receipt of the intervention solar lighting system. Results Introduction of the solar lighting system increased daily household lighting use by 6.02 (95% confidence intervals (CI) = 4.05-8.00) hours a day. The solar lighting intervention had far-reaching social implications with improved social integration and, consequently, social health. Participants felt that lighting improved their social status, mitigated the stigma of poverty, and increased the duration and frequency of social interactions. Household relationships improved with access to lighting because of reduced conflicts over light rationing. Participants also described a communal benefit of lighting due to improved feelings of safety. At the individual-level, many reported improved self-esteem, sense of well-being, and reduced stress. Conclusion Improved access to lighting and illumination had far reaching implications for participants, including improved social integration. More empirical research, particularly in the light and household energy field, is needed that emphasizes the impacts of interventions on social health. Registration ClinicalTrials.gov No. NCT03351504.
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Affiliation(s)
| | - Edwin Nuwagira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mellon Tayebwa
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joseph Mugerwa
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Hellen Nahabwe
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | - Nicholas L Lam
- Department of Public Health, California State University East Bay, Hayward, California, USA
- Schatz Energy Research Center, California State Polytechnic University, Humboldt, Arcata, California, USA
| | - Matthew O Wiens
- Centre for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jose Vallarino
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joseph G Allen
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Daniel Muyanja
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Radhika Sundararajan
- Weill Cornell Center for Global Health, New York, New York, USA
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Peggy S Lai
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
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16
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Duby J, Kabajaasi O, Muteteri J, Kisooka E, Barth D, Feeley N, O'Brien K, Nathan KM, Tagoola A, Wiens MO. Family Integrated Care in Uganda: a feasibility study. Arch Dis Child 2023; 108:180-184. [PMID: 36385005 DOI: 10.1136/archdischild-2022-324638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 11/01/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the feasibility of adapting Family Integrated Care to a neonatal hospital unit in a low-income country. DESIGN Single-centre, pre/post-pilot study of an adapted Family Integrated Care programme in Uganda (UFICare). SETTING Special Care Nursery at a Ugandan hospital. PATIENTS Singleton, inborn neonates with birth weight ≥2 kg. INTERVENTIONS As part of UFICare, mothers weighed their infant daily, assessed for severe illness ('danger signs') twice daily and tracked feeds. MAIN OUTCOME MEASURES Feasibility outcomes included maternal proficiency and completion of monitoring tasks. Secondary outcomes included maternal stress, discharge readiness and post-discharge healthcare seeking. RESULTS Fifty-three mother-infant dyads and 51 mother-infant dyads were included in the baseline and intervention groups, respectively. Most mothers were proficient in the tasks 2-4 days after training (weigh 43 of 51; assess danger signs 49 of 51; track feeds 49 of 51). Mothers documented their danger sign assessments 82% (IQR 71-100) of the expected times and documented feeds 83% (IQR 71-100) of hospital days. In the baseline group, nurses weighed babies 29% (IQR 18-50) of hospitalised days, while UFICare mothers weighed their babies 71% (IQR 57-80) of hospitalised days (p<0.001). UFICare mothers had higher Readiness for Discharge scores compared with the baseline group (baseline 6.8; UFICare 7.9; p<0.001). There was no difference in maternal stress scores or post-discharge healthcare seeking. CONCLUSIONS Ugandan mothers can collaborate in the medical care of their hospitalised infant. By performing tasks identified as important for infant care, mothers felt more prepared to care for their infant at discharge.
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Affiliation(s)
- Jessica Duby
- Department of Pediatrics, McGill University Faculty of Medicine, Montreal, Québec, Canada
| | | | | | | | - Delaney Barth
- Department of Microbiology and Immunology, McGill University Montreal, Montreal, Québec, Canada
| | - Nancy Feeley
- Ingram School of Nursing, McGill University, Montreal, Québec, Canada
| | - Karel O'Brien
- Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Abner Tagoola
- Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Matthew O Wiens
- Walimu, Kampala, Uganda.,Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
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Akech S, Kwambai T, Wiens MO, Chandna A, Berkley JA, Snow RW. Tackling post-discharge mortality in children living in LMICs to reduce child deaths. Lancet Child Adolesc Health 2023; 7:149-151. [PMID: 36682368 DOI: 10.1016/s2352-4642(22)00375-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 01/21/2023]
Affiliation(s)
- Samuel Akech
- Kenya Medical Research Institute Wellcome Trust Research Programme, Nairobi, Kenya.
| | - Titus Kwambai
- Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Matthew O Wiens
- Center for International Child Health, BC Children's Hospital, Child and Family Research Institute, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Walimu, Kampala, Uganda
| | - Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia; Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - James A Berkley
- Kenya Medical Research Institute Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert W Snow
- Kenya Medical Research Institute Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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18
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Chaudhry M, Knappett M, Nguyen V, Trawin J, Mugisha NK, Kabakyenga J, Kumbakumba E, Jacob S, Ansermino JM, Kissoon N, Wiens MO. Pediatric post-discharge mortality in resource-poor countries: A protocol for an updated systematic review and meta-analysis. PLoS One 2023; 18:e0281732. [PMID: 36827241 PMCID: PMC9955921 DOI: 10.1371/journal.pone.0281732] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/31/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND More than 50 countries, mainly in Sub-Saharan Africa and South Asia, are not on course to meet the neonatal and under-five mortality target set by the Sustainable Development Goals (SDGs) for the year 2030. One important, yet neglected, aspect of child mortality rates is deaths occurring during the post-discharge period. For children living in resource-poor countries, the rate of post-discharge mortality within the first several months after discharge is often as high as the rates observed during the initial admission period. This has generally been observed within the context of acute illness and has been closely linked to underlying conditions such as malnutrition, HIV, and anemia. These post-discharge mortality rates tend to be underreported and present a major oversight in the efforts to reduce overall child mortality. This review will explore recurrent illness following discharge through determination of rates of, and risk factors for, pediatric post-discharge mortality in resource-poor settings. METHODS Eligible studies will be retrieved using MEDLINE, EMBASE, and CINAHL databases. Only studies with a post-discharge observation period of more than 7 days following discharge will be eligible for inclusion. Secondary outcomes will include post-discharge mortality relative to in-hospital mortality, overall readmission rates, pooled estimates of risk factors (e.g. admission details vs discharge factors, clinical vs social factors), pooled post-discharge mortality Kaplan-Meier survival curves, and outcomes by disease subgroups (e.g. malnutrition, anemia, general admissions). A narrative description of the included studies will be synthesized to categorize commonly affected patient population categories and a random-effects meta-analysis will be conducted to quantify overall post-discharge mortality rates at the 6-month time point. DISCUSSION Post-discharge mortality contributes to global child mortality rates with a greater burden of deaths occurring in resource-poor settings. Literature concentrated on child mortality published over the last decade has expanded to focus on the fatal outcomes of children post-discharge and associated risk factors. The results from this systematic review will inform current policy and interventions on the epidemiological burden of post-discharge mortality and morbidity following acute illness among children living in resource-poor settings. SYSTEMATIC REVIEW REGISTRATION PROSPERO Registration ID: CRD42022350975.
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Affiliation(s)
- Maryum Chaudhry
- Department of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Centre for International Child Health, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Martina Knappett
- Centre for International Child Health, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Vuong Nguyen
- Centre for International Child Health, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Jessica Trawin
- Centre for International Child Health, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | | | - Jerome Kabakyenga
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Shevin Jacob
- Walimu, Kampala, Uganda
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - J. Mark Ansermino
- Centre for International Child Health, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Niranjan Kissoon
- Centre for International Child Health, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew O. Wiens
- Centre for International Child Health, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
- Walimu, Kampala, Uganda
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Mbarara University of Science and Technology, Mbarara, Uganda
- * E-mail:
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19
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Mawji A, Longstaff H, Trawin J, Dunsmuir D, Komugisha C, Novakowski SK, Wiens MO, Akech S, Tagoola A, Kissoon N, Ansermino JM. A proposed de-identification framework for a cohort of children presenting at a health facility in Uganda. PLOS Digit Health 2022; 1:e0000027. [PMID: 36812586 PMCID: PMC9931294 DOI: 10.1371/journal.pdig.0000027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/08/2022] [Indexed: 11/18/2022]
Abstract
Data sharing has enormous potential to accelerate and improve the accuracy of research, strengthen collaborations, and restore trust in the clinical research enterprise. Nevertheless, there remains reluctancy to openly share raw data sets, in part due to concerns regarding research participant confidentiality and privacy. Statistical data de-identification is an approach that can be used to preserve privacy and facilitate open data sharing. We have proposed a standardized framework for the de-identification of data generated from cohort studies in children in a low-and-middle income country. We applied a standardized de-identification framework to a data sets comprised of 241 health related variables collected from a cohort of 1750 children with acute infections from Jinja Regional Referral Hospital in Eastern Uganda. Variables were labeled as direct and quasi-identifiers based on conditions of replicability, distinguishability, and knowability with consensus from two independent evaluators. Direct identifiers were removed from the data sets, while a statistical risk-based de-identification approach using the k-anonymity model was applied to quasi-identifiers. Qualitative assessment of the level of privacy invasion associated with data set disclosure was used to determine an acceptable re-identification risk threshold, and corresponding k-anonymity requirement. A de-identification model using generalization, followed by suppression was applied using a logical stepwise approach to achieve k-anonymity. The utility of the de-identified data was demonstrated using a typical clinical regression example. The de-identified data sets was published on the Pediatric Sepsis Data CoLaboratory Dataverse which provides moderated data access. Researchers are faced with many challenges when providing access to clinical data. We provide a standardized de-identification framework that can be adapted and refined based on specific context and risks. This process will be combined with moderated access to foster coordination and collaboration in the clinical research community.
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Affiliation(s)
- Alishah Mawji
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- * E-mail:
| | - Holly Longstaff
- Privacy and Access, PHSA Research and New Initiatives, Provincial Health Services Authority, Vancouver, British Columbia Canada
| | - Jessica Trawin
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Dustin Dunsmuir
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | | | - Stefanie K. Novakowski
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew O. Wiens
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- WALIMU, Kololo, Kampala, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Abner Tagoola
- Department of Pediatrics, Jinja Regional Referral Hospital, Rotary Rd, Jinja, Uganda
| | - Niranjan Kissoon
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - J. Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
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Reiter A, De Meulemeester J, Kenya-Mugisha N, Tagoola A, Kabajaasi O, Wiens MO, Duby J. Parental participation in the care of hospitalized neonates in low- and middle-income countries: A systematic review and meta-analysis. Front Pediatr 2022; 10:987228. [PMID: 36090576 PMCID: PMC9453204 DOI: 10.3389/fped.2022.987228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/28/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION To determine the effect of parental participation in hospital care on neonatal and parental outcomes in low- and middle-income countries (LMICs) and to identify the range of parental duties in the care of hospitalized neonates in LMICs. METHODS We searched CINAHL, CENTRAL, LILACs, MEDLINE, EMBASE and Web of Science from inception to February 2022. Randomized and non-randomized studies from LMICs were eligible if parents performed one or more roles traditionally undertaken by healthcare staff. The primary outcome was hospital length-of-stay. Secondary outcomes included mortality, readmission, breastfeeding, growth, development and parental well-being. Data was extracted in duplicate by two independent reviewers using a piloted extraction form. RESULTS Eighteen studies (eight randomized and ten non-randomized) were included from seven middle-income countries. The types of parental participation included hygiene and infection prevention, feeding, monitoring and documentation, respiratory care, developmental care, medication administration and decision making. Meta-analyses showed that parental participation was not associated with hospital length-of-stay (MD -2.35, 95% CI -6.78-2.07). However, parental involvement was associated with decreased mortality (OR 0.46, 95% CI 0.22-0.95), increased breastfeeding (OR 2.97 95% CI 1.65-5.35) and decreased hospital readmission (OR 0.36, 95% CI 0.16-0.81). Narrative synthesis demonstrated additional benefits for growth, short-term neurodevelopment and parental well-being. Ten of the eighteen studies had a high risk of bias. CONCLUSION Parental participation in neonatal hospital care is associated with improvement in several key neonatal outcomes in middle-income countries. The lack of data from low-income countries suggests that there remains barriers to parental participation in resource-poor settings. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=187562], identifier [CRD42020187562].
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Affiliation(s)
- Anna Reiter
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | | | | | | | | | - Matthew O Wiens
- Walimu, Kampala, Uganda.,Center for International Child Health, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
| | - Jessica Duby
- Department of Pediatrics, McGill University, Montreal, QC, Canada
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21
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Menon K, Schlapbach LJ, Akech S, Argent A, Biban P, Carrol ED, Chiotos K, Jobayer Chisti M, Evans IVR, Inwald DP, Ishimine P, Kissoon N, Lodha R, Nadel S, Oliveira CF, Peters M, Sadeghirad B, Scott HF, de Souza DC, Tissieres P, Watson RS, Wiens MO, Wynn JL, Zimmerman JJ, Sorce LR. Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce. Crit Care Med 2022; 50:21-36. [PMID: 34612847 PMCID: PMC8670345 DOI: 10.1097/ccm.0000000000005294] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock. DATA SOURCES MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020. STUDY SELECTION Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract. DATA EXTRACTION Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed. DATA SYNTHESIS One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001). CONCLUSIONS Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.
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Affiliation(s)
- Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Luregn J. Schlapbach
- Pediatric and Neonatal ICU, University Children`s Hospital Zurich, Zurich, Switzerland, and Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Samuel Akech
- KEMRI Wellcome Trust Research Program, Nairobi, Kenya
| | - Andrew Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, Cape Town, South Africa
| | - Paolo Biban
- Department of Paediatrics, Verona University Hospital, Verona, Italy
| | - Enitan D. Carrol
- Department of Clinical Infection Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | | | | | - Idris V. R. Evans
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, and The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA
| | - David P. Inwald
- Paediatric Intensive Care Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics, University of California San Diego School of Medicine, La Jolla, CA
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia and British Columbia Children’s Hospital, Vancouver, BC, Canada
| | - Rakesh Lodha
- All India Institute of Medical Sciences, Delhi, India
| | - Simon Nadel
- St. Mary’s Hospital, Imperial College Healthcare NHS Trust, and Imperial College London, London, United Kingdom
| | | | - Mark Peters
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Benham Sadeghirad
- Departments of Anesthesia and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Halden F. Scott
- Departments of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Daniela C. de Souza
- Departments of Pediatrics, Hospital Sírio-Libanês and Hospital Universitário da Universidade de São Paulo, São Paolo, Brazil
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Matthew O. Wiens
- University of British Columbia, Vancouver, BC, Canada
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville, FL
| | - Jerry J. Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Lauren R. Sorce
- Ann & Robert H. Lurie Children’s Hospital and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Lurie Children’s Pediatric Research & Evidence Synthesis Center (PRECIISE): A JBI Affiliated Group, Chicago, IL
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22
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Kortz TB, Nielsen KR, Mediratta RP, Reeves H, O'Brien NF, Lee JH, Attebery JE, Bhutta EG, Biewen C, Coronado Munoz A, deAlmeida ML, Fonseca Y, Hooli S, Johnson H, Kissoon N, Leimanis-Laurens ML, McCarthy AM, Pineda C, Remy KE, Sanders SC, Takwoingi Y, Wiens MO, Bhutta AT. The Burden of Critical Illness in Hospitalized Children in Low- and Middle-Income Countries: Protocol for a Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:756643. [PMID: 35372149 PMCID: PMC8970052 DOI: 10.3389/fped.2022.756643] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/31/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The majority of childhood deaths occur in low- and middle-income countries (LMICs). Many of these deaths are avoidable with basic critical care interventions. Quantifying the burden of pediatric critical illness in LMICs is essential for targeting interventions to reduce childhood mortality. OBJECTIVE To determine the burden of hospitalization and mortality associated with acute pediatric critical illness in LMICs through a systematic review and meta-analysis of the literature. DATA SOURCES AND SEARCH STRATEGY We will identify eligible studies by searching MEDLINE, EMBASE, CINAHL, and LILACS using MeSH terms and keywords. Results will be limited to infants or children (ages >28 days to 12 years) hospitalized in LMICs and publications in English, Spanish, or French. Publications with non-original data (e.g., comments, editorials, letters, notes, conference materials) will be excluded. STUDY SELECTION We will include observational studies published since January 1, 2005, that meet all eligibility criteria and for which a full text can be located. DATA EXTRACTION Data extraction will include information related to study characteristics, hospital characteristics, underlying population characteristics, patient population characteristics, and outcomes. DATA SYNTHESIS We will extract and report data on study, hospital, and patient characteristics; outcomes; and risk of bias. We will report the causes of admission and mortality by region, country income level, and age. We will report or calculate the case fatality rate (CFR) for each diagnosis when data allow. CONCLUSIONS By understanding the burden of pediatric critical illness in LMICs, we can advocate for resources and inform resource allocation and investment decisions to improve the management and outcomes of children with acute pediatric critical illness in LMICs.
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Affiliation(s)
- Teresa B Kortz
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Katie R Nielsen
- Division of Critical Care, Department of Pediatrics, University of Washington, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States
| | - Rishi P Mediratta
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Hailey Reeves
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Nicole F O'Brien
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University/Nationwide Children's Hospital, Columbus, OH, United States
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,SingHealth Duke-NUS Global Health Institute, Singapore, Singapore
| | - Jonah E Attebery
- Division of Critical Care, Department of Pediatrics, University of Colorado, Aurora, CO, United States
| | - Emaan G Bhutta
- Eberly College of Science, Pennsylvania State University, State College, PA, United States
| | - Carter Biewen
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Alvaro Coronado Munoz
- Division of Critical Care, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Mary L deAlmeida
- Division of Critical Care, Department of Pediatrics, Emory University, Atlanta, GA, United States
| | - Yudy Fonseca
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Shubhada Hooli
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Hunter Johnson
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University/Nationwide Children's Hospital, Columbus, OH, United States
| | - Niranjan Kissoon
- Children's and Women's Global Health, University of British Columbia, Vancouver, BC, Canada.,Department of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mara L Leimanis-Laurens
- Pediatric Critical Care Unit, Helen DeVos Children's Hospital, Grand Rapids, MI, United States.,Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, East Lansing, MI, United States
| | - Amanda M McCarthy
- Division of Critical Care, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Carol Pineda
- Division of Critical Care, Department of Pediatrics, Baystate Medical Center, University of Massachusetts Chan Medical School, Springfield, MA, United States
| | - Kenneth E Remy
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, United States
| | - Sara C Sanders
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University/Nationwide Children's Hospital, Columbus, OH, United States
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.,National Institute for Health Research Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service Foundation Trust and University of Birmingham, Birmingham, United Kingdom
| | - Matthew O Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Adnan T Bhutta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
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Mawji A, Li E, Dunsmuir D, Komugisha C, Novakowski SK, Wiens MO, Vesuvius TA, Kissoon N, Ansermino JM. Smart triage: Development of a rapid pediatric triage algorithm for use in low-and-middle income countries. Front Pediatr 2022; 10:976870. [PMID: 36483471 PMCID: PMC9723221 DOI: 10.3389/fped.2022.976870] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/01/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Early and accurate recognition of children at risk of progressing to critical illness could contribute to improved patient outcomes and resource allocation. In resource limited settings digital triage tools can support decision making and improve healthcare delivery. We developed a model for rapid identification of critically ill children at triage. METHODS This was a prospective cohort study of acutely ill children presenting at Jinja Regional Referral Hospital in Eastern Uganda. Variables collected in the emergency department informed the development of a logistic model based on hospital admission using bootstrap stepwise regression. Low and high-risk thresholds for 90% minimum sensitivity and specificity, respectively generated three risk level categories. Performance was assessed using receiver operating characteristic curve analysis on a held-out test set generated by an 80:20 split with 10-fold cross validation. A risk stratification table informed clinical interpretation. RESULTS The model derivation cohort included 1,612 participants, with an admission rate of approximately 23%. The majority of admitted patients were under five years old and presenting with sepsis, malaria, or pneumonia. A 9-predictor triage model was derived: logit (p) = -32.888 + (0.252, square root of age) + (0.016, heart rate) + (0.819, temperature) + (-0.022, mid-upper arm circumference) + (0.048 transformed oxygen saturation) + (1.793, parent concern) + (1.012, difficulty breathing) + (1.814, oedema) + (1.506, pallor). The model afforded good discrimination, calibration, and risk stratification at the selected thresholds of 8% and 40%. CONCLUSION In a low income, pediatric population, we developed a nine variable triage model with high sensitivity and specificity to predict who should be admitted. The triage model can be integrated into any digital platform and used with minimal training to guide rapid identification of critically ill children at first contact. External validation and clinical implementation are in progress.
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Affiliation(s)
- Alishah Mawji
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Edmond Li
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Dustin Dunsmuir
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | | | - Stefanie K Novakowski
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Matthew O Wiens
- Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | | | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - J Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
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Krepiakevich A, Khowaja AR, Kabajaasi O, Nemetchek B, Ansermino JM, Kissoon N, Mugisha NK, Tayebwa M, Kabakyenga J, Wiens MO. Out of pocket costs and time/productivity losses for pediatric sepsis in Uganda: a mixed-methods study. BMC Health Serv Res 2021; 21:1252. [PMID: 34798891 PMCID: PMC8605527 DOI: 10.1186/s12913-021-07272-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 10/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Sepsis disproportionately affects children from socioeconomically disadvantaged families in low-resource settings, where care seeking may consume scarce family resources and lead to financial hardships. Those financial hardships may, in turn, contribute to late presentation or failure to seek care and result in high mortality during hospitalization and during the post discharge period, a period of increasingly recognized vulnerability. The purpose of this study is to explore the out-of-pocket costs related to sepsis hospitalizations and post-discharge care among children admitted with sepsis in Uganda. Methods This mixed-methods study was comprised of focus group discussions (FGD) with caregivers of children admitted for sepsis, which then informed a quantitative cross-sectional household survey to measure out-of-pocket costs of sepsis care both during initial admission and during the post-discharge period. All participants were families of children enrolled in a concurrent sepsis study. Results Three FGD with mothers (n = 20) and one FGD with fathers (n = 7) were conducted. Three primary themes that emerged included (1) financial losses, (2) time and productivity losses and (3) coping with costs. A subsequently developed cross-sectional survey was completed for 153 households of children discharged following admission for sepsis. The survey revealed a high cost of care for families attending both private and public facilities, although out-of-pocket cost were higher at private facilities. Half of those surveyed reported loss of income during hospitalization and a third sold household assets, most often livestock, to cover costs. Total mean out-of-pocket costs of hospital care and post-discharge care were 124.50 USD and 44.60 USD respectively for those seeking initial care at private facilities and 62.10 USD and 14.60 USD at public facilities, a high sum in a country with widespread poverty. Conclusions This study reveals that families incur a substantial economic burden in accessing care for children with sepsis.
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Affiliation(s)
- A Krepiakevich
- First Nations Health Authority, Vancouver, British Columbia, Canada
| | - A R Khowaja
- Faculty of Applied Health Sciences, Brock University, St. Catherines, Ontario, Canada
| | | | - B Nemetchek
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - J M Ansermino
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Center for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
| | - N Kissoon
- Center for International Child Health, BC Children's Hospital, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | | | - M Tayebwa
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - J Kabakyenga
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - M O Wiens
- Walimu, Kampala, Uganda.,Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Center for International Child Health, BC Children's Hospital, Vancouver, BC, Canada.,Mbarara University of Science and Technology, Mbarara, Uganda
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25
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Wiens MO, Kissoon N, Holsti L. Challenges in pediatric post-sepsis care in resource limited settings: a narrative review. Transl Pediatr 2021; 10:2666-2677. [PMID: 34765492 PMCID: PMC8578768 DOI: 10.21037/tp-20-390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 04/23/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The objective of this narrative review is to outline the current epidemiology and interventional research within the context of sepsis recovery, and to provide a summary of key priorities for future work in this area. BACKGROUND Morbidity and mortality secondary to sepsis disproportionately affects children, especially those in low- and middle-income countries (LMICs), where over 85% of global cases and deaths occur. These regions are plagued by poorly resilient health systems, widespread socio-economic deprivation and unique vulnerabilities such as malnutrition. Reducing the overall burden of sepsis will require a multi-pronged strategy that addresses all three important periods along the sepsis care continuum - pre-facility, facility and post-facility. Of these aspects, post-facility issues have been largely neglected in research, practice and policy, and are thus the focus of this review. METHODS Relevant data for this review was identified through a literature search using PubMed, through a review of the citations of select systematic reviews and from the personal repositories of articles collected by the authors. Data is presented within three sections. The first two sections on the short and long-term outcomes among sepsis survivors each outline the epidemiology as well as review relevant interventional research done. Where clear gaps exist, these are stated. The third section focuses on priorities for future research. This section highlights the importance of data (and data systems) and of innovative interventional approaches, as key areas to improve research of post-sepsis outcomes in children. CONCLUSIONS During the initial post-facility period, mortality is high with as many children dying during this period as during the acute period of hospitalization, mostly due to recurrent illness (including infections) which are associated with malnutrition and severe acute disease. Long-term outcomes, often labelled as post-sepsis syndrome (PSS), are characterized by a lag in developmental milestones and suboptimal quality of life (QoL). While long-term outcomes have not been well characterized in resource limited settings, they are well described in high-income countries (HICs), and likely are important contributors to long-term morbidity in resource limited settings. The paucity of interventional research to improve post-discharge outcomes (short- or long-term) is a clear gap in addressing its burden. A focus on the development of improved data systems for collecting routine data, standardized definitions and terminology and a health-systems approach in research need to be prioritized during any efforts to improve outcomes during the post-sepsis phase.
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Affiliation(s)
- Matthew O Wiens
- Center for International Child Health, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Niranjan Kissoon
- Center for International Child Health, BC Children's Hospital, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Liisa Holsti
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, BC, Canada
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26
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Mawji A, Akech S, Mwaniki P, Dunsmuir D, Bone J, Wiens MO, Görges M, Kimutai D, Kissoon N, English M, Ansermino MJ. Derivation and internal validation of a data-driven prediction model to guide frontline health workers in triaging children under-five in Nairobi, Kenya. Wellcome Open Res 2021; 4:121. [PMID: 33997296 PMCID: PMC8097734 DOI: 10.12688/wellcomeopenres.15387.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 01/22/2023] Open
Abstract
Background: Many hospitalized children in developing countries die from infectious diseases. Early recognition of those who are critically ill coupled with timely treatment can prevent many deaths. A data-driven, electronic triage system to assist frontline health workers in categorizing illness severity is lacking. This study aimed to develop a data-driven parsimonious triage algorithm for children under five years of age. Methods: This was a prospective observational study of children under-five years of age presenting to the outpatient department of Mbagathi Hospital in Nairobi, Kenya between January and June 2018. A study nurse examined participants and recorded history and clinical signs and symptoms using a mobile device with an attached low-cost pulse oximeter sensor. The need for hospital admission was determined independently by the facility clinician and used as the primary outcome in a logistic predictive model. We focused on the selection of variables that could be quickly and easily assessed by low skilled health workers. Results: The admission rate (for more than 24 hours) was 12% (N=138/1,132). We identified an eight-predictor logistic regression model including continuous variables of weight, mid-upper arm circumference, temperature, pulse rate, and transformed oxygen saturation, combined with dichotomous signs of difficulty breathing, lethargy, and inability to drink or breastfeed. This model predicts overnight hospital admission with an area under the receiver operating characteristic curve of 0.88 (95% CI 0.82 to 0.94). Low- and high-risk thresholds of 5% and 25%, respectively were selected to categorize participants into three triage groups for implementation. Conclusion: A logistic regression model comprised of eight easily understood variables may be useful for triage of children under the age of five based on the probability of need for admission. This model could be used by frontline workers with limited skills in assessing children. External validation is needed before adoption in clinical practice.
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Affiliation(s)
- Alishah Mawji
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, V6T1Z3, Canada
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
| | - Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Paul Mwaniki
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dustin Dunsmuir
- Digital Health Innovation Lab, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, V6T1Z4, Canada
| | - Matthew O. Wiens
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
| | - Matthias Görges
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, V6T1Z3, Canada
| | | | - Niranjan Kissoon
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, V6H3V4, Canada
| | - Mike English
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Mark J. Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, V6T1Z3, Canada
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
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Abbas Q, Holloway A, Caporal P, López-Barón E, Agulnik A, Remy KE, Appiah JA, Attebery J, Fink EL, Lee JH, Hooli S, Kissoon N, Miller E, Murthy S, Muttalib F, Nielsen K, Puerto-Torres M, Rodrigues K, Sakaan F, Rodrigues AT, Tabor EA, von Saint Andre-von Arnim A, Wiens MO, Blackwelder W, He D, Kortz TB, Bhutta AT. Global PARITY: Study Design for a Multi-Centered, International Point Prevalence Study to Estimate the Burden of Pediatric Acute Critical Illness in Resource-Limited Settings. Front Pediatr 2021; 9:793326. [PMID: 35155314 PMCID: PMC8835113 DOI: 10.3389/fped.2021.793326] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/10/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The burden of pediatric critical illness and resource utilization by children with critical illness in resource limited settings (RLS) are largely unknown. Without specific data that captures key aspects of critical illness, disease presentation, and resource utilization for pediatric populations in RLS, development of a contextual framework for appropriate, evidence-based interventions to guide allocation of limited but available resources is challenging. We present this methods paper which describes our efforts to determine the prevalence, etiology, hospital outcomes, and resource utilization associated with pediatric acute, critical illness in RLS globally. METHODS We will conduct a prospective, observational, multicenter, multinational point prevalence study in sixty-one participating RLS hospitals from North, Central and South America, Africa, Middle East and South Asia with four sampling time points over a 12-month period. Children aged 29 days to 14 years evaluated for acute illness or injury in an emergency department) or directly admitted to an inpatient unit will be enrolled and followed for hospital outcomes and resource utilization for the first seven days of hospitalization. The primary outcome will be prevalence of acute critical illness, which Global PARITY has defined as death within 48 hours of presentation to the hospital, including ED mortality; or admission/transfer to an HDU or ICU; or transfer to another institution for a higher level-of-care; or receiving critical care-level interventions (vasopressor infusion, invasive mechanical ventilation, non-invasive mechanical ventilation) regardless of location in the hospital, among children presenting to the hospital. Secondary outcomes include etiology of critical illness, in-hospital mortality, cause of death, resource utilization, length of hospital stay, and change in neurocognitive status. Data will be managed via REDCap, aggregated, and analyzed across sites. DISCUSSION This study is expected to address the current gap in understanding of the burden, etiology, resource utilization and outcomes associated with pediatric acute and critical illness in RLS. These data are crucial to inform future research and clinical management decisions and to improve global pediatric hospital outcomes.
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Affiliation(s)
- Qalab Abbas
- Department of Pediatrics and Child Health, Aga Khan University Karachi, Karachi, Pakistan
| | - Adrian Holloway
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland Baltimore, Baltimore, MD, United States
| | - Paula Caporal
- Hospital Interzonal Especializado en Pediatría "Sor María Ludovica", La Plata, Argentina.,Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Buenos Aires, Argentina
| | - Eliana López-Barón
- Hospital Pablo Tobón Uribe, Unidad de Cuidado Crítico Pediátrico, Medellín, Colombia
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kenneth E Remy
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University Hospitals of Cleveland and Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - John A Appiah
- Pediatric Intensive Care Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Jonah Attebery
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado, Aurora, CO, United States
| | - Ericka L Fink
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,SingHealth Duke-NUS Global Health Institute, Singapore, Singapore
| | - Shubhada Hooli
- Division of Pediatric Critical Care, Department of Pediatrics, BC Children's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Erika Miller
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland Baltimore, Baltimore, MD, United States
| | - Srinivas Murthy
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Fiona Muttalib
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Katie Nielsen
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington, Seattle Children's, Seattle, WA, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Karla Rodrigues
- Department of Pediatrics, Hospital das Clínicas da UFMG/EBSERH, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Firas Sakaan
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Adriana Teixeira Rodrigues
- Department of Pediatrics, Hospital das Clínicas da UFMG/EBSERH, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Erica A Tabor
- Pennsylvania State University, State College, PA, United States
| | - Amelie von Saint Andre-von Arnim
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington, Seattle Children's, Seattle, WA, United States
| | - Matthew O Wiens
- Center for Child Health at BC Children's Hospital, The University of British Columbia, Vancouver, BC, Canada.,Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda.,Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - William Blackwelder
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, United States
| | - David He
- Analytical Solutions Group, Inc., North Potomac, MD, United States
| | - Teresa B Kortz
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Adnan T Bhutta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland Baltimore, Baltimore, MD, United States.,Center for Vaccine Development and Global Health, University of Maryland, Baltimore, MD, United States
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Mawji A, Akech S, Mwaniki P, Dunsmuir D, Bone J, Wiens MO, Görges M, Kimutai D, Kissoon N, English M, Ansermino MJ. Derivation and internal validation of a data-driven prediction model to guide frontline health workers in triaging children under-five in Nairobi, Kenya. Wellcome Open Res 2020; 4:121. [PMID: 33997296 PMCID: PMC8097734 DOI: 10.12688/wellcomeopenres.15387.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2020] [Indexed: 04/03/2024] Open
Abstract
Background: Many hospitalized children in developing countries die from infectious diseases. Early recognition of those who are critically ill coupled with timely treatment can prevent many deaths. A data-driven, electronic triage system to assist frontline health workers in categorizing illness severity is lacking. This study aimed to develop a data-driven parsimonious triage algorithm for children under five years of age. Methods: This was a prospective observational study of children under-five years of age presenting to the outpatient department of Mbagathi Hospital in Nairobi, Kenya between January and June 2018. A study nurse examined participants and recorded history and clinical signs and symptoms using a mobile device with an attached low-cost pulse oximeter sensor. The need for hospital admission was determined independently by the facility clinician and used as the primary outcome in a logistic predictive model. We focused on the selection of variables that could be quickly and easily assessed by low skilled health workers. Results: The admission rate (for more than 24 hours) was 12% (N=138/1,132). We identified an eight-predictor logistic regression model including continuous variables of weight, mid-upper arm circumference, temperature, pulse rate, and transformed oxygen saturation, combined with dichotomous signs of difficulty breathing, lethargy, and inability to drink or breastfeed. This model predicts overnight hospital admission with an area under the receiver operating characteristic curve of 0.88 (95% CI 0.82 to 0.94). Low- and high-risk thresholds of 5% and 25%, respectively were selected to categorize participants into three triage groups for implementation. Conclusion: A logistic regression model comprised of eight easily understood variables may be useful for triage of children under the age of five based on the probability of need for admission. This model could be used by frontline workers with limited skills in assessing children. External validation is needed before adoption in clinical practice.
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Affiliation(s)
- Alishah Mawji
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, V6T1Z3, Canada
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
| | - Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Paul Mwaniki
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dustin Dunsmuir
- Digital Health Innovation Lab, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, V6T1Z4, Canada
| | - Matthew O. Wiens
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
| | - Matthias Görges
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, V6T1Z3, Canada
| | | | - Niranjan Kissoon
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, V6H3V4, Canada
| | - Mike English
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Mark J. Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, V6T1Z3, Canada
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
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Popescu CR, Tembo B, Chifisi R, Cavanagh MMM, Lee AHY, Chiluzi B, Ciccone EJ, Tegha G, Alonso-Prieto E, Claydon J, Dunsmuir D, Irvine M, Dumont G, Ansermino JM, Wiens MO, Juliano JJ, Kissoon N, Mvalo T, Lufesi N, Chiume-Kayuni M, Lavoie PM. Whole blood genome-wide transcriptome profiling and metagenomics next-generation sequencing in young infants with suspected sepsis in a low-and middle-income country: A study protocol. Gates Open Res 2020; 4:139. [PMID: 33447735 PMCID: PMC7783117 DOI: 10.12688/gatesopenres.13172.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 11/24/2022] Open
Abstract
Conducting collaborative and comprehensive epidemiological research on neonatal sepsis in low- and middle-income countries (LMICs) is challenging due to a lack of diagnostic tests. This prospective study protocol aims to obtain epidemiological data on bacterial sepsis in newborns and young infants at Kamuzu Central Hospital in Lilongwe, Malawi. The main goal is to determine if the use of whole blood transcriptome host immune response signatures can help in the identification of infants who have sepsis of bacterial causes. The protocol includes a detailed clinical assessment with vital sign measurements, strict aseptic blood culture protocol with state-of-the-art microbial analyses and RNA-sequencing and metagenomics evaluations of host responses and pathogens, respectively. We also discuss the directions of a brief analysis plan for RNA sequencing data. This study will provide robust epidemiological data for sepsis in neonates and young infants in a setting where sepsis confers an inordinate burden of disease.
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Affiliation(s)
- Constantin R Popescu
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Pediatrics, Université Laval, Québec, QC, Canada
| | | | | | | | - Amy Huei-Yi Lee
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | | | - Emily J Ciccone
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Gerald Tegha
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Esther Alonso-Prieto
- BC Children's & Women's Health Centre, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Claydon
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Dustin Dunsmuir
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Mike Irvine
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Guy Dumont
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC, Canada
| | - J Mark Ansermino
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,BC Children's & Women's Health Centre, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Matthew O Wiens
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Walimu, Kampala, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jonathan J Juliano
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.,Curriculum in Genetics and Molecular Biology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Niranjan Kissoon
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,BC Children's & Women's Health Centre, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi.,Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Norman Lufesi
- Clinical Services Directorate, Ministry of Health, Lilongwe, Malawi
| | | | - Pascal M Lavoie
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,BC Children's & Women's Health Centre, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Lee V, Dunsmuir D, Businge S, Tumusiime R, Karugaba J, Wiens MO, Görges M, Kissoon N, Orach S, Kasyaba R, Ansermino JM. Evaluation of a digital triage platform in Uganda: A quality improvement initiative to reduce the time to antibiotic administration. PLoS One 2020; 15:e0240092. [PMID: 33007047 PMCID: PMC7531789 DOI: 10.1371/journal.pone.0240092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 09/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Sepsis is the leading cause of death in children under five in low- and middle-income countries. The rapid identification of the sickest children and timely antibiotic administration may improve outcomes. We developed and implemented a digital triage platform to rapidly identify critically ill children to facilitate timely intravenous antibiotic administration. Objective This quality improvement initiative sought to reduce the time to antibiotic administration at a dedicated children’s hospital outpatient department in Mbarara, Uganda. Intervention and study design The digital platform consisted of a mobile application that collects clinical signs, symptoms, and vital signs to prioritize children through a combination of emergency triggers and predictive risk algorithms. A computer-based dashboard enabled the prioritization of children by displaying an overview of all children and their triage categories. We evaluated the impact of the digital triage platform over an 11-week pre-implementation phase and an 11-week post-implementation phase. The time from the end of triage to antibiotic administration was compared to evaluate the quality improvement initiative. Results There was a difference of -11 minutes (95% CI, -16.0 to -6.0; p < 0.001; Mann-Whitney U test) in time to antibiotics, from 51 minutes (IQR, 27.0–94.0) pre-implementation to 44 minutes (IQR, 19.0–74.0) post-implementation. Children prioritized as emergency received the greatest time benefit (-34 minutes; 95% CI, -9.0 to -58.0; p < 0.001; Mann-Whitney U test). The proportion of children who waited more than an hour until antibiotics decreased by 21.4% (p = 0.007). Conclusion A data-driven patient prioritization and continuous feedback for healthcare workers enabled by a digital triage platform led to expedited antibiotic therapy for critically ill children with sepsis. This platform may have a more significant impact in facilities without existing triage processes and prioritization of treatments, as is commonly encountered in low resource settings.
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Affiliation(s)
- Victor Lee
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Dustin Dunsmuir
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | | | | | | | - Matthew O. Wiens
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthias Görges
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Niranjan Kissoon
- Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sam Orach
- Uganda Catholic Medical Bureau, Kampala, Uganda
| | | | - J. Mark Ansermino
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- * E-mail:
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Popescu CR, Tembo B, Chifisi R, Cavanagh MM, Lee AHY, Chiluzi B, Ciccone EJ, Tegha G, Alonso-Prieto E, Claydon J, Dunsmuir D, Irvine M, Dumont G, Ansermino JM, Wiens MO, Juliano JJ, Kissoon N, Mvalo T, Lufesi N, Chiume-Kayuni M, Lavoie PM. Whole blood genome-wide transcriptome profiling and metagenomics next-generation sequencing in young infants with suspected sepsis in low-and middle-income countries: A study protocol. Gates Open Res 2020; 4:139. [DOI: 10.12688/gatesopenres.13172.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 11/20/2022] Open
Abstract
Conducting collaborative and comprehensive epidemiological research on neonatal sepsis in low- and middle-income countries (LMICs) is challenging due to a lack of diagnostic tests. This prospective study protocol aims to obtain epidemiological data on bacterial sepsis in newborns and young infants at Kamuzu Central Hospital in Lilongwe, Malawi. The main goal is to determine if the use of whole blood transcriptome host immune response signatures can help in the identification of infants who have sepsis of bacterial causes. The protocol includes a detailed clinical assessment with vital sign measurements, strict aseptic blood culture protocol with state-of-the-art microbial analyses and RNA-sequencing and metagenomics evaluations of host responses and pathogens, respectively. We also discuss the directions of a brief analysis plan for RNA sequencing data. This study will provide robust epidemiological data for sepsis in neonates and young infants in a setting where sepsis confers an inordinate burden of disease.
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Mawji A, Li E, Komugisha C, Akech S, Dunsmuir D, Wiens MO, Kissoon N, Kenya-Mugisha N, Tagoola A, Kimutai D, Bone JN, Dumont G, Ansermino JM. Smart triage: triage and management of sepsis in children using the point-of-care Pediatric Rapid Sepsis Trigger (PRST) tool. BMC Health Serv Res 2020; 20:493. [PMID: 32493319 PMCID: PMC7268489 DOI: 10.1186/s12913-020-05344-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/20/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Sepsis is the leading cause of death and disability in children. Every hour of delay in treatment is associated with an escalating risk of morbidity and mortality. The burden of sepsis is greatest in low- and middle-income countries where timely treatment may not occur due to delays in diagnosis and prioritization of critically ill children. To circumvent these challenges, we propose the development and clinical evaluation of a digital triage tool that will identify high risk children and reduce time to treatment. We will also implement and clinically validate a Radio-Frequency Identification system to automate tracking of patients. The mobile platform (mobile device and dashboard) and automated patient tracking system will create a low cost, highly scalable solution for critically ill children, including those with sepsis. METHODS This is pre-post intervention study consisting of three phases. Phase I will be a baseline period where data is collected on key predictors and outcomes before implementation of the digital triage tool. In Phase I, there will be no changes to healthcare delivery processes in place at the study hospitals. Phase II will involve model derivation, technology development, and usability testing. Phase III will be the intervention period where data is collected on key predictors and outcomes after implementation of the digital triage tool. The primary outcome, time to treatment initiation, will be compared to assess effectiveness of the digital health intervention. DISCUSSION Smart technology has the potential to overcome the barrier of limited clinical expertise in the identification of the child at risk. This mobile health platform, with sensors and data-driven applications, will provide real-time individualized risk prediction to rapidly triage patients and facilitate timely access to life-saving treatments for children in low- and middle-income countries, where specialists are not regularly available and deaths from sepsis are common. TRIAL REGISTRATION Clinical Trials.gov Identifier: NCT04304235, Registered 11 March 2020.
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Affiliation(s)
- Alishah Mawji
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Edmond Li
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Clare Komugisha
- Walimu, P.O. Box 9924, Plot 5-7, Coral Crescent, Kololo, Kampala, Uganda
| | - Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Dustin Dunsmuir
- Digital Health Innovation Lab, BC Children's Hospital Research Institute, 948 W 28th Ave, Vancouver, BC, V5Z 4H4, Canada
| | - Matthew O Wiens
- Center for International Child Health, BC Children's Hospital Research Institute, 948 W 28th Ave, Vancouver, BC, V5Z 4H4, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Rm B2W, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada
| | | | | | - David Kimutai
- Mbagathi County Hospital, P.O. Box 20725-00202, Nairobi, Kenya
| | - Jeffrey N Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, 1125 Howe Street, Vancouver, BC, V6Z 2K8, Canada
| | - Guy Dumont
- Electrical and Computer Engineering, The University of British Columbia, 5500 - 2332 Main Mall, Vancouver, BC, V6T 1Z4, Canada
| | - J Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
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Ansermino JM, Wiens MO, Kissoon N. Evidence and Transparency are Needed to Develop a Frontline Health Worker mHealth Assessment Platform. Am J Trop Med Hyg 2019; 101:948. [PMID: 32519659 PMCID: PMC6779222 DOI: 10.4269/ajtmh.19-0411a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Nemetchek B, Khowaja A, Kavuma A, Kabajaasi O, Olirus Owilli A, Ansermino JM, Fowler-Kerry S, Jacob ST, Kenya-Mugisha N, Kabakyenga J, Wiens MO. Exploring healthcare providers' perspectives of the paediatric discharge process in Uganda: a qualitative exploratory study. BMJ Open 2019; 9:e029526. [PMID: 31494611 PMCID: PMC6731949 DOI: 10.1136/bmjopen-2019-029526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The burden of childhood mortality continues to be born largely by low-income and middle-income countries. The critical postdischarge period has been largely neglected despite evidence that mortality rates during this period can exceed inpatient mortality rates. However, there is a paucity of data on the paediatric discharge process from the perspective of the healthcare provider. Provider perspectives may be important in the development of an improved understanding of the barriers and facilitators to improving the transition from hospital to home. OBJECTIVES To explore healthcare providers' and facility administrators' perspectives of the paediatric discharge process with respect to: (1) current procedures, (2) barriers and challenges, (3) ideas for change, (4) facilitators for change and (5) the importance of discharge planning. DESIGN A qualitative exploratory approach using focus groups (14) and in-depth interviews (7). SETTING This study was conducted at seven hospitals providing paediatric care in Uganda. RESULTS Current discharge procedures are largely based on hospital-specific protocols or clinician opinion, as opposed to national guidelines. Some key barriers to an improved discharge process included caregiver resources and education, critical communication gaps, traditional practices, and a lack of human and physical resources. Teamwork and motivation to see improved paediatric transitions to home were identified as facilitators to implementing the ideas for change proposed by participants. The need for a standardised national policy guiding paediatric discharges, implemented through education at many levels and coupled with appropriate community referral and follow-up, was broadly perceived as essential to improving outcomes for children. CONCLUSIONS Although significant challenges and gaps were identified within the current health system, participants' ideas and the identified facilitators provide a significant basis from which change may occur. This work can facilitate the development of sustainable and effective interventions to improve postdischarge outcomes in Uganda and other similar settings.
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Affiliation(s)
- Brooklyn Nemetchek
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Asif Khowaja
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Alex Olirus Owilli
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - J Mark Ansermino
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Susan Fowler-Kerry
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Shevin T Jacob
- Walimu, Mbarara, Uganda
- Department of Clinical Services, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Jerome Kabakyenga
- Maternal, Newborn, and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Matthew O Wiens
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Chang JL, Reyes R, Matte M, Ntaro M, Mulogo E, Wiens MO, Meshnick SR, Siedner MJ, Boyce RM. Who Stays and Who Goes: Predictors of Admission among Patients Presenting with Febrile Illness and a Positive Malaria Rapid Diagnostic Test in a Rural Ugandan Health Center. Am J Trop Med Hyg 2019; 99:1080-1088. [PMID: 30062988 DOI: 10.4269/ajtmh.18-0338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Not much is known about clinical decision-making in rural, low-resource settings regarding fever, a common reason for presentation to care. In this prospective cohort study of patients presenting with febrile illness to a rural Ugandan health center, we examined demographic and clinical factors predictive of an initial disposition of inpatient admission after clinical evaluation, but before laboratory testing. We then assessed the association of laboratory results and system factors with a change between initial and final disposition plans. Four thousand nine hundred twenty-four patients with suspected febrile illness were included in the primary analysis. The strongest predictors for an initial disposition of admission after clinical examination were impaired consciousness (adjusted risk ratio [aRR], 3.21; 95% confidence interval [CI]: 2.44-4.21) and fever on examination (aRR, 2.27; 95% CI: 1.79-2.87). Providers initially planned to discharge patients with significant vital sign abnormalities, including tachypnea (3.6%) and hypotension (1.3%). Anemia strongly predicted a final disposition of admission after an initial disposition of discharge (aRR, 48.34; 95% CI: 24.22-96.49); other laboratory abnormalities, including hypoglycemia and acidosis, did not change disposition planning. In those with an initial disposition of admission, living farther than the two neighboring villages was associated with a final disposition of discharge (aRR, 2.12; 95% CI: 1.10-4.12). A concerning number of patients with abnormal vital signs and laboratory results were not admitted for inpatient care. Geographic factors may influence a patient's final disposition contrary to a provider's initial disposition plan. Future work should assess longer term outcomes after discharge and a broader study population.
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Affiliation(s)
- Jonathan L Chang
- Duke University School of Medicine, Durham, North Carolina.,School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Raquel Reyes
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael Matte
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Moses Ntaro
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edgar Mulogo
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Matthew O Wiens
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Steven R Meshnick
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mark J Siedner
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ross M Boyce
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Mbarara University of Science and Technology, Mbarara, Uganda
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Mawji A, Akech S, Mwaniki P, Dunsmuir D, Bone J, Wiens MO, Görges M, Kimutai D, Kissoon N, English M, Ansermino MJ. Derivation and internal validation of a data-driven prediction model to guide frontline health workers in triaging children under-five in Nairobi, Kenya. Wellcome Open Res 2019; 4:121. [PMID: 33997296 PMCID: PMC8097734 DOI: 10.12688/wellcomeopenres.15387.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 04/03/2024] Open
Abstract
Background: Many hospitalized children in developing countries die from infectious diseases. Early recognition of those who are critically ill coupled with timely treatment can prevent many deaths. A data-driven, electronic triage system to assist frontline health workers in categorizing illness severity is lacking. This study aimed to develop a data-driven parsimonious triage algorithm for children under five years of age. Methods: This was a prospective observational study of children under-five years of age presenting to the outpatient department of Mbagathi Hospital in Nairobi, Kenya between January and June 2018. A study nurse examined participants and recorded history and clinical signs and symptoms using a mobile device with an attached low-cost pulse oximeter sensor. The need for hospital admission was determined independently by the facility clinician and used as the primary outcome in a logistic predictive model. We focused on the selection of variables that could be quickly and easily assessed by low skilled health workers. Results: The admission rate (for more than 24 hours) was 12% (N=138/1,132). We identified an eight-predictor logistic regression model including continuous variables of weight, mid-upper arm circumference, temperature, pulse rate, and transformed oxygen saturation, combined with dichotomous signs of difficulty breathing, lethargy, and inability to drink or breastfeed. This model predicts overnight hospital admission with an area under the receiver operating characteristic curve of 0.88 (95% CI 0.82 to 0.94). Low- and high-risk thresholds of 5% and 25%, respectively were selected to categorize participants into three triage groups for implementation. Conclusion: A logistic regression model comprised of eight easily understood variables may be useful for triage of children under the age of five based on the probability of need for admission. This model could be used by frontline workers with limited skills in assessing children. External validation is needed before adoption in clinical practice.
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Affiliation(s)
- Alishah Mawji
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, V6T1Z3, Canada
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
| | - Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Paul Mwaniki
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dustin Dunsmuir
- Digital Health Innovation Lab, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, V6T1Z4, Canada
| | - Matthew O. Wiens
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
| | - Matthias Görges
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, V6T1Z3, Canada
| | | | - Niranjan Kissoon
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, V6H3V4, Canada
| | - Mike English
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Mark J. Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, V6T1Z3, Canada
- Centre for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, V5Z4H4, Canada
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Chami N, Hau DK, Masoza TS, Smart LR, Kayange NM, Hokororo A, Ambrose EE, Moschovis PP, Wiens MO, Peck RN. Very severe anemia and one year mortality outcome after hospitalization in Tanzanian children: A prospective cohort study. PLoS One 2019; 14:e0214563. [PMID: 31220109 PMCID: PMC6586275 DOI: 10.1371/journal.pone.0214563] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/04/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Africa has the highest rates of child mortality. Little is known about outcomes after hospitalization for children with very severe anemia. OBJECTIVE To determine one year mortality and predictors of mortality in Tanzanian children hospitalized with very severe anemia. METHODS We conducted a prospective cohort study enrolling children 2-12 years hospitalized from August 2014 to November 2014 at two public hospitals in northwestern Tanzania. Children were screened for anemia and followed until 12 months after discharge. The primary outcome measured was mortality. Predictors of mortality were determined using Cox regression analysis. RESULTS Of the 505 children, 90 (17.8%) had very severe anemia and 415 (82.1%) did not. Mortality was higher for children with very severe anemia compared to children without over a one year period from admission, 27/90 (30.0%) vs. 59/415 (14.2%) respectively (Hazard Ratio (HR) 2.42, 95% Cl 1.53-3.83). In-hospital mortality was 11/90 (12.2%) and post-hospital mortality was 16/79 (20.2%) for children with very severe anemia. The strongest predictors of mortality were age (HR 1.01, 95% Cl 1.00-1.03) and decreased urine output (HR 4.30, 95% Cl 1.04-17.7). CONCLUSIONS Children up to 12 years of age with very severe anemia have nearly a 30% chance of mortality following admission over a one year period, with over 50% of mortality occurring after discharge. Post-hospital interventions are urgently needed to reduce mortality in children with very severe anemia, and should include older children.
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Affiliation(s)
- Neema Chami
- Department of Pediatrics, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Duncan K Hau
- Department of Pediatrics, Weill Cornell Medical College, New York, New York, United States of America
| | - Tulla S Masoza
- Department of Pediatrics, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Luke R Smart
- Division of Hematology/Oncology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Neema M Kayange
- Department of Pediatrics, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Adolfine Hokororo
- Department of Pediatrics, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Emmanuela E Ambrose
- Department of Pediatrics, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Peter P Moschovis
- Divisions of Pediatric Global Health and Pulmonary Medicine, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Matthew O Wiens
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- Center for International Child Health, BC Children's Hospital & University of British Columbia, Vancouver, Canada
| | - Robert N Peck
- Department of Pediatrics, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America
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Fung JST, Akech S, Kissoon N, Wiens MO, English M, Ansermino JM. Determining predictors of sepsis at triage among children under 5 years of age in resource-limited settings: A modified Delphi process. PLoS One 2019; 14:e0211274. [PMID: 30689660 PMCID: PMC6349330 DOI: 10.1371/journal.pone.0211274] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 01/10/2019] [Indexed: 01/16/2023] Open
Abstract
Sepsis is a life-threatening dysfunction of the immune system leading to multiorgan failure that is precipitated by infectious diseases and is a leading cause of death in children under 5 years of age. It is necessary to be able to identify a sick child at risk of developing sepsis at the earliest point of presentation to a healthcare facility so that appropriate care can be provided as soon as possible. Our study objective was to generate a list of consensus-driven predictor variables for the derivation of a prediction model that will be incorporated into a mobile device and operated by low-skilled healthcare workers at triage. By conducting a systematic literature review and examination of global guideline documents, a list of 72 initial candidate predictor variables was generated. A two-round modified Delphi process involving 26 experts from both resource-rich and resource-limited settings, who were also encouraged to suggest new variables, yielded a final list of 45 predictor variables after evaluating each variable based on three domains: predictive potential, measurement reliability, and level of training and resources required. The final list of predictor variables will be used to collect data and contribute to the derivation of a prediction model.
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Affiliation(s)
- Jollee S. T. Fung
- Centre for International Child Health, BC Children’s Hospital, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Samuel Akech
- CanadaHealth Services Unit, KEMRI/Wellcome Trust, Nairobi, Kenya
| | - Niranjan Kissoon
- Centre for International Child Health, BC Children’s Hospital, Vancouver, BC, Canada
- Department of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC
| | - Matthew O. Wiens
- Centre for International Child Health, BC Children’s Hospital, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC
| | - Mike English
- CanadaHealth Services Unit, KEMRI/Wellcome Trust, Nairobi, Kenya
| | - J. Mark Ansermino
- Centre for International Child Health, BC Children’s Hospital, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC
- CanadaSchool of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- * E-mail:
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Nemetchek B, English L, Kissoon N, Ansermino JM, Moschovis PP, Kabakyenga J, Fowler-Kerry S, Kumbakumba E, Wiens MO. Paediatric postdischarge mortality in developing countries: a systematic review. BMJ Open 2018; 8:e023445. [PMID: 30593550 PMCID: PMC6318528 DOI: 10.1136/bmjopen-2018-023445] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To update the current evidence base on paediatric postdischarge mortality (PDM) in developing countries. Secondary objectives included an evaluation of risk factors, timing and location of PDM. DESIGN Systematic literature review without meta-analysis. DATA SOURCES Searches of Medline and EMBASE were conducted from October 2012 to July 2017. ELIGIBILITY CRITERIA Studies were included if they were conducted in developing countries and examined paediatric PDM. 1238 articles were screened, yielding 11 eligible studies. These were added to 13 studies identified in a previous systematic review including studies prior to October 2012. In total, 24 studies were included for analysis. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted and synthesised data using Microsoft Excel. RESULTS Studies were conducted mostly within African countries (19 of 24) and looked at all admissions or specific subsets of admissions. The primary subpopulations included malnutrition, respiratory infections, diarrhoeal diseases, malaria and anaemia. The anaemia and malaria subpopulations had the lowest PDM rates (typically 1%-2%), while those with malnutrition and respiratory infections had the highest (typically 3%-20%). Although there was significant heterogeneity between study populations and follow-up periods, studies consistently found rates of PDM to be similar, or to exceed, in-hospital mortality. Furthermore, over two-thirds of deaths after discharge occurred at home. Highly significant risk factors for PDM across all infectious admissions included HIV status, young age, pneumonia, malnutrition, anthropometric variables, hypoxia, anaemia, leaving hospital against medical advice and previous hospitalisations. CONCLUSIONS Postdischarge mortality rates are often as high as in-hospital mortality, yet remain largely unaddressed. Most children who die following discharge do so at home, suggesting that interventions applied prior to discharge are ideal to addressing this neglected cause of mortality. The development, therefore, of evidence-based, risk-guided, interventions must be a focus to achieve the sustainable development goals.
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Affiliation(s)
- Brooklyn Nemetchek
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lacey English
- Department of Medicine, University of North Carolina, Raleigh, North Carolina, USA
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - John Mark Ansermino
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
- Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
| | - Peter P Moschovis
- Division of Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jerome Kabakyenga
- Maternal, Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Susan Fowler-Kerry
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Elias Kumbakumba
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Matthew O Wiens
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Nemetchek BR, Liang LD, Kissoon N, Ansermino JM, Kabakyenga J, Lavoie PM, Fowler-Kerry S, Wiens MO. Predictor variables for post-discharge mortality modelling in infants: a protocol development project. Afr Health Sci 2018; 18:1214-1225. [PMID: 30766588 PMCID: PMC6354852 DOI: 10.4314/ahs.v18i4.43] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Over two-thirds of the five million annual deaths in children under five occur in infants, mostly in developing countries and many after hospital discharge. However, there is a lack of understanding of which children are at higher risk based on early clinical predictors. Early identification of vulnerable infants at high-risk for death post-discharge is important in order to craft interventional programs. OBJECTIVES To determine potential predictor variables for post-discharge mortality in infants less than one year of age who are likely to die after discharge from health facilities in the developing world. METHODS A two-round modified Delphi process was conducted, wherein a panel of experts evaluated variables selected from a systematic literature review. Variables were evaluated based on (1) predictive value, (2) measurement reliability, (3) availability, and (4) applicability in low-resource settings. RESULTS In the first round, 18 experts evaluated 37 candidate variables and suggested 26 additional variables. Twenty-seven variables derived from those suggested in the first round were evaluated by 17 experts during the second round. A final total of 55 candidate variables were retained. CONCLUSION A systematic approach yielded 55 candidate predictor variables to use in devising predictive models for post-discharge mortality in infants in a low-resource setting.
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Affiliation(s)
| | - Li Danny Liang
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, Canada
- Center for International Child Health, BC Children's Hospital, Vancouver, Canada
| | - J Mark Ansermino
- BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, Canada
- Center for International Child Health, BC Children's Hospital, Vancouver, Canada
| | - Jerome Kabakyenga
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Pascal M Lavoie
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, Canada
| | | | - Matthew O Wiens
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, Canada
- Center for International Child Health, BC Children's Hospital, Vancouver, Canada
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Liang L, Kotadia N, English L, Kissoon N, Ansermino JM, Kabakyenga J, Lavoie PM, Wiens MO. Predictors of Mortality in Neonates and Infants Hospitalized With Sepsis or Serious Infections in Developing Countries: A Systematic Review. Front Pediatr 2018; 6:277. [PMID: 30356806 PMCID: PMC6190846 DOI: 10.3389/fped.2018.00277] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 09/12/2018] [Indexed: 01/27/2023] Open
Abstract
Background: Neonates and infants comprise the majority of the 6 million annual deaths under 5 years of age around the world. Most of these deaths occur in low/middle income countries (LMICs) and are preventable. However, the clinical identification of neonates and infants at imminent risk of death is challenging in developing countries. Objective: To systematically review the literature on clinical risk factors for mortality in infants under 12 months of age hospitalized for sepsis or serious infections in LMICs. Methods: MEDLINE and EMBASE were systematically searched using MeSH terms through April 2017. Abstracts were independently screened by two reviewers. Subsequently, full-text articles were selected by two independent reviewers based on PICOS criteria for inclusion in the final analysis. Study data were qualitatively synthesized without quantitative pooling of data due to heterogeneity in study populations and methodology. Results: A total of 1,139 abstracts were screened, and 169 full-text articles were selected for text review. Of these, 45 articles were included in the analysis, with 21 articles featuring neonatal populations (under 28 days of age) exclusively. Most studies were from Sub-Saharan Africa and South Asia. Risk factors for mortality varied significantly according to study populations. For neonatal deaths, prematurity, low birth-weight and young age at presentation were most frequently associated with mortality. For infant deaths, malnutrition, lack of breastfeeding and low oxygen saturation were associated with mortality in the highest number of studies. Conclusions: Risk factors for mortality differ between the neonatal and young infant age groups and were also dependant on the study population. These data can serve as a starting point for the development of individualized predictive models for in-hospital and post-discharge mortality and for the development of interventions to improve outcomes among these high-risk groups.
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Affiliation(s)
- Li(Danny) Liang
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Naima Kotadia
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lacey English
- School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - J. Mark Ansermino
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesia, British Columbia Children's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Jerome Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Pascal M. Lavoie
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Matthew O. Wiens
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Liang L, Wiens MO, Lubega P, Spillman I, Mugisha S. A Locally Developed Electronic Health Platform in Uganda: Development and Implementation of Stre@mline. JMIR Form Res 2018; 2:e20. [PMID: 30684419 PMCID: PMC6334711 DOI: 10.2196/formative.9658] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/14/2018] [Accepted: 07/26/2018] [Indexed: 11/17/2022] Open
Abstract
Background Electronic health records (EHRs) are especially important in low-resource settings due to their potential to address unique challenges such as a high number of patients requiring long-term treatments who are lost to follow-up, the frequent shortages of essential drugs, poor maintenance and storage of records, and inefficient clinical triaging. However, there is a lack of affordable and practical EHR solutions. Stre@mline is an EHR platform that has been locally developed by Ugandan clinicians and engineers in Southwestern Uganda. It is tailored to the specific context and needs of low-resource hospitals. It operates without internet access, incorporates locally relevant standards and key patient safety features, has a medication inventory management component, has local technical support available, and is economically sustainable without funding from international donors. Stre@mline is currently used by over 60,000 patients at 2 hospitals, with plans to expand across Uganda. Objective The purpose of this article is to describe the key opportunities and challenges in EHR development in sub-Saharan Africa and to summarize the development and implementation of a “Made-for-Africa” EHR, Stre@mline, and how it has led to improved care for over 60,000 vulnerable patients in a rural region of Southwestern Uganda. Methods A quantitative user survey consisting of a set of 33 questions on usability and performance was conducted at Kisiizi Hospital. Users responded to each question through a Likert scale with the values of strongly disagree, disagree, agree, and strongly agree. Through purposive sampling, 30 users were identified and 28 users completed the survey. Results We found that users were generally very satisfied with the ease of use of Stre@mline, with 96% (27/28) finding it easy to learn and 100% (28/28) finding it easy to use. Users found that Stre@mline was helpful in improving both clinical efficiency and enhancing patient care. Conclusions The partnership of local clinicians and developers is crucial to the design and adoption of user-centered technologies tailored to the specific needs of low-resource settings. The EHR described here could serve as a model for the development of future technologies suitable for developing countries.
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Affiliation(s)
- Li Liang
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Phaisal Lubega
- Mbarara University of Science and Technology, Mbarara, Uganda
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Affiliation(s)
- J Mark Ansermino
- Departments of Anesthesiology, Pharmacology and Therapeutics (Ansermino, Wiens), and Pediatrics (Kissoon), Faculty of Medicine, The University of British Columbia; Centre for International Child Health, BC Children's Hospital, Vancouver, BC
| | - Matthew O Wiens
- Departments of Anesthesiology, Pharmacology and Therapeutics (Ansermino, Wiens), and Pediatrics (Kissoon), Faculty of Medicine, The University of British Columbia; Centre for International Child Health, BC Children's Hospital, Vancouver, BC
| | - Niranjan Kissoon
- Departments of Anesthesiology, Pharmacology and Therapeutics (Ansermino, Wiens), and Pediatrics (Kissoon), Faculty of Medicine, The University of British Columbia; Centre for International Child Health, BC Children's Hospital, Vancouver, BC
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44
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Moschovis PP, Wiens MO, Arlington L, Antsygina O, Hayden D, Dzik W, Kiwanuka JP, Christiani DC, Hibberd PL. Individual, maternal and household risk factors for anaemia among young children in sub-Saharan Africa: a cross-sectional study. BMJ Open 2018; 8:e019654. [PMID: 29764873 PMCID: PMC5961577 DOI: 10.1136/bmjopen-2017-019654] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Anaemia affects the majority of children in sub-Saharan Africa (SSA). Previous studies of risk factors for anaemia have been limited by sample size, geography and the association of many risk factors with poverty. In order to measure the relative impact of individual, maternal and household risk factors for anaemia in young children, we analysed data from all SSA countries that performed haemoglobin (Hb) testing in the Demographic and Health Surveys. DESIGN AND SETTING This cross-sectional study pooled household-level data from the most recent Demographic and Health Surveys conducted in 27 SSA between 2008 and 2014. PARTICIPANTS 96 804 children age 6-59 months. RESULTS The prevalence of childhood anaemia (defined as Hb <11 g/dL) across the region was 59.9%, ranging from 23.7% in Rwanda to 87.9% in Burkina Faso. In multivariable regression models, older age, female sex, greater wealth, fewer household members, greater height-for-age, older maternal age, higher maternal body mass index, current maternal pregnancy and higher maternal Hb, and absence of recent fever were associated with higher Hb in tested children. Demographic, socioeconomic factors, family structure, water/sanitation, growth, maternal health and recent illnesses were significantly associated with the presence of childhood anaemia. These risk factor groups explain a significant fraction of anaemia (ranging from 1.0% to 16.7%) at the population level. CONCLUSIONS The findings from our analysis of risk factors for anaemia in SSA underscore the importance of family and socioeconomic context in childhood anaemia. These data highlight the need for integrated programmes that address the multifactorial nature of childhood anaemia.
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Affiliation(s)
| | - Matthew O Wiens
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Olga Antsygina
- Scientific Research Institute of Healthcare Organization and Medical Management, Moscow, Russia
| | - Douglas Hayden
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Walter Dzik
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - David C Christiani
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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Affiliation(s)
- Matthew O Wiens
- University of British Columbia, Vancouver, British Columbia, Canada.,Center for International Child Health, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Niranjan Kissoon
- University of British Columbia, Vancouver, British Columbia, Canada.,Center for International Child Health, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Jerome Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
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English LL, Mugyenyi G, Nightingale I, Kiwanuka G, Ngonzi J, Grunau BE, MacLeod S, Koren G, Delano K, Kabakyenga J, Wiens MO. Prevalence of Ethanol Use Among Pregnant Women in Southwestern Uganda. Matern Child Health J 2017; 20:2209-15. [PMID: 27299903 DOI: 10.1007/s10995-016-2025-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Introduction The prevalence of ethanol use in many Sub-Saharan African countries is high, but little research exists on use during pregnancy. The objective of this study was to assess the prevalence and predictors of ethanol use among pregnant women in Southwestern Uganda. Methods This descriptive, cross-sectional study was conducted in the maternity ward at Mbarara Regional Referral Hospital (MRRH). All pregnant women giving birth at MRRH between September 23, 2013 and November 23, 2013 were eligible for enrollment. The primary outcome was the proportion of women with ethanol use during pregnancy as determined by self-report. Secondary outcomes included the proportion with positive fatty acid ethyl ester (FAEE) results (indicating ethanol use) and positive TWEAK questionnaire results (indicating possible problem drinking). Predictors of ethanol use were assessed and stratified by patterns of ethanol intake. Results Overall, 505 mother-child dyads enrolled in the study. The proportion of women who reported any ethanol use during pregnancy was 16 % (n = 81, 95 % CI 13-19 %) and the prevalence of heavy drinking 6.3 % (n = 32, 95 % CI 3.8-7.9 %). The strongest predictor of use during pregnancy was pre-pregnancy use, with maternal education as a protective factor. Few neonates (n = 11, 2 %) tested positive for FAEE > 2.00 nmol/g in meconium. The TWEAK questionnaire captured 75 % of women who reported moderate/heavy drinking and aligned more with self-reported ethanol use than meconium results. Conclusions The substantial prevalence and clear predictors of ethanol use suggest that legislative action and educational interventions to increase awareness of potential harms could assist in efforts to decrease use during pregnancy in Southwestern Uganda.
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Affiliation(s)
- L L English
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - G Mugyenyi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - I Nightingale
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, Canada
| | - G Kiwanuka
- Department of Biochemistry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - J Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - B E Grunau
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - S MacLeod
- Child and Family Research Institute, BC Children's Hospital, Vancouver, Canada
| | - G Koren
- Motherisk, Toronto Hospital for Sick Children, Toronto, Canada
| | - K Delano
- Motherisk, Toronto Hospital for Sick Children, Toronto, Canada
| | - J Kabakyenga
- Institute for Maternal Child Heath, Mbarara University of Science and Technology, Mbarara, Uganda
| | - M O Wiens
- School of Population and Public Health, University of British Columbia, Vancouver, Canada.
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Kanters S, Socias ME, Paton NI, Vitoria M, Doherty M, Ayers D, Popoff E, Chan K, Cooper DA, Wiens MO, Calmy A, Ford N, Nsanzimana S, Mills EJ. Comparative efficacy and safety of second-line antiretroviral therapy for treatment of HIV/AIDS: a systematic review and network meta-analysis. Lancet HIV 2017; 4:e433-e441. [PMID: 28784426 DOI: 10.1016/s2352-3018(17)30109-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/30/2017] [Accepted: 06/01/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Selection of optimal second-line antiretroviral therapy (ART) has important clinical and programmatic implications. To inform the 2016 revision of the WHO ART guidelines, we assessed the comparative effectiveness and safety of available second-line ART regimens for adults and adolescents in whom first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens have failed. METHODS In this systematic review and network meta-analysis, we searched for randomised controlled trials and prospective and retrospective cohort studies that evaluated outcomes in treatment-experienced adults living with HIV who switched ART regimen after failure of a WHO-recommended first-line NNRTI-based regimen. We searched Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials for reports published from Jan 1, 1996, to Aug 8, 2016, and searched conference abstracts published from Jan 1, 2014, to Aug 8, 2016. Outcomes of interest were viral suppression, mortality, AIDS-defining illnesses or WHO stage 3-4 disease, discontinuations, discontinuations due to adverse events, and serious adverse events. We assessed comparative efficacy and safety in a network meta-analysis, using Bayesian hierarchical models. FINDINGS We identified 12 papers pertaining to eight studies, including 4778 participants. The network was centred on ritonavir-boosted lopinavir plus two nucleoside or nucleotide reverse transcriptase inhibitors. Ritonavir-boosted lopinavir monotherapy was the only regimen inferior to others. With the lower estimate of the 95% credible interval (CrI) not exceeding the predefined threshold of 15%, evidence at 48 weeks supported the non-inferiority of ritonavir-boosted lopinavir plus raltegravir to regimens including ritonavir-boosted protease inhibitor plus two NRTIs with respect to viral suppression (odds ratio 1·09, 95% CrI 0·88-1·35). Estimated efficacy of ritonavir-boosted darunavir (800 mg once daily) was too imprecise to determine non-inferiority. Overall, regimens did not differ significantly with respect to continuations, AIDS-defining illnesses or WHO stage 3-4 disease, or mortality. INTERPRETATION With the exception of ritonavir-boosted lopinavir plus raltegravir, the evidence base is unable to provide strong support to alternative second-line options to ritonavir-boosted protease inhibitor plus two NRTIs, and thus more trials are warranted. FUNDING WHO.
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Affiliation(s)
- Steve Kanters
- Precision Global Health, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Maria Eugenia Socias
- Precision Global Health, Vancouver, BC, Canada; Intersdisciplinary Graduate Program, University of British Columbia, Vancouver, BC, Canada
| | - Nicholas I Paton
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Meg Doherty
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | | | - Evan Popoff
- Precision Global Health, Vancouver, BC, Canada
| | - Keith Chan
- Precision Global Health, Vancouver, BC, Canada
| | - David A Cooper
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Matthew O Wiens
- Precision Global Health, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alexandra Calmy
- HIV/AIDS Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Nathan Ford
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda; Basel Clinical Epidemiology and Biostatistics Institute and Swiss Tropical and Public Health Institute, University of Basel, Switzerland
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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English L, Kumbakumba E, Larson CP, Kabakyenga J, Singer J, Kissoon N, Ansermino JM, Wong H, Kiwanuka J, Wiens MO. Pediatric out-of-hospital deaths following hospital discharge: a mixed-methods study. Afr Health Sci 2016; 16:883-891. [PMID: 28479878 DOI: 10.4314/ahs.v16i4.2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Out-of-hospital death among children living in resource poor settings occurs frequently. Little is known about the location and circumstances of child death following a hospital discharge. OBJECTIVES This study aimed to understand the context surrounding out-of-hospital deaths and the barriers to accessing timely care for Ugandan children recently discharged from the hospital. METHODS This was a mixed-methods sub-study within a larger cohort study of post-discharge mortality conducted in the Southwestern region of Uganda. Children admitted with an infectious illness were eligible for enrollment in the cohort study, and then followed for six months after discharge. Caregivers of children who died outside of the hospital during the six month post-discharge period were eligible to participate in this sub-study. Qualitative interviews and univariate logistic regression were conducted to determine predictors of out-of-hospital deaths. RESULTS Of 1,242 children discharged, 61 died during the six month post-discharge period, with most (n=40, 66%) dying outside of a hospital. Incremental increases in maternal education were associated with lower odds of out-of-hospital death compared to hospital death (OR: 0.38, 95% CI: 0.19 - 0.81). The qualitative analysis identified health seeking behaviors and common barriers within the post-discharge period which delayed care seeking prior to death. For recently discharged children, caregivers often expressed hesitancy to seek care following a recent episode of hospitalization. CONCLUSION Mortality following discharge often occurs outside of a hospital context. In addition to resource limitations, the health knowledge and perceptions of caregivers can be influential to timely access to care. Interventions to decrease child mortality must consider barriers to health seeking among children following hospital discharge.
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Affiliation(s)
- Lacey English
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Elias Kumbakumba
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Charles P Larson
- Center for International Child Health, BC Children's Hospital, Child and Family Research Institute, Vancouver Canada
| | - Jerome Kabakyenga
- Maternal, Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Canadian HIV Trials Network, St. Paul's Hospital and University of British Columbia, Vancouver, Canada
| | - Niranjan Kissoon
- Center for International Child Health, BC Children's Hospital, Child and Family Research Institute, Vancouver Canada
- Department of Pediatrics, BC Children's Hospital and University of British Columbia, Vancouver, Canada
| | - J Mark Ansermino
- Center for International Child Health, BC Children's Hospital, Child and Family Research Institute, Vancouver Canada
- Department of Pediatric Anesthesiology, BC Children's Hospital and University of British Columbia, Vancouver, Canada
| | - Hubert Wong
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Julius Kiwanuka
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - M O Wiens
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Wiens MO, Kumbakumba E, Larson CP, Moschovis PP, Barigye C, Kabakyenga J, Ndamira A, English L, Kissoon N, Zhou G, Ansermino JM. Scheduled Follow-Up Referrals and Simple Prevention Kits Including Counseling to Improve Post-Discharge Outcomes Among Children in Uganda: A Proof-of-Concept Study. Glob Health Sci Pract 2016; 4:422-34. [PMID: 27628107 PMCID: PMC5042698 DOI: 10.9745/ghsp-d-16-00069] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/25/2016] [Indexed: 11/15/2022]
Abstract
Post-hospital discharge is a vulnerable time for recurrent illness and death among children. An intervention package consisting of (1) referrals for scheduled follow-up visits, (2) discharge counseling, and (3) simple prevention items such as soap and oral rehydration salts resulted in much higher health seeking and hospital readmissions compared with historical controls. Background: Recurrent illness following hospital discharge is a major contributor to childhood mortality in resource-poor countries. Yet post-discharge care is largely ignored by health care workers and policy makers due to a lack of resources to identify children with recurrent illness and a lack of cohesive systems to provide care. The purpose of this proof-of-concept study was to evaluate the effectiveness of a bundle of interventions at discharge to improve health outcomes during the vulnerable post-discharge period. Methods: The study was conducted between December 2014 and April 2015. Eligible children were between ages 6 months and 5 years who were admitted with a suspected or proven infectious disease to one of two hospitals in Mbarara, Uganda. A bundle of interventions was provided at the time of discharge. This bundle included post-discharge referrals for follow-up visits and a discharge kit. The post-discharge referral was to ensure follow-up with a nearby health care provider on days 2, 7, and 14 following discharge. The discharge kit included brief educational counseling along with simple preventive items as incentives (soap, a mosquito net, and oral rehydration salts) to reinforce the education. The primary study outcome was the number of post-discharge referral visits completed. Secondary study outcomes included satisfaction with the intervention, rates of readmission after 60 days, and post-discharge mortality rates. In addition, outcomes were compared with a historical control group, enrolled using the same inclusion criteria and outcome-ascertainment methods. Results: During the study, 216 children were admitted, of whom 14 died during hospitalization. Of the 202 children discharged, 85% completed at least 1 of the 3 follow-up referral visits, with 48% completing all 3 visits. Within 60 days after discharge, 22 children were readmitted at least once and 5 children (2.5%) died. Twelve (43%) readmissions occurred during a scheduled follow-up visit. Compared with prospectively enrolled historical controls, the post-discharge referral for follow-up increased the odds of readmission (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.14 to 3.23) and care sought after discharge (OR, 14.61; 95% CI, 9.41 to 22.67). Overall satisfaction with the bundle of interventions was high, with most caregivers strongly agreeing that the discharge kit and post-discharge referrals improved their ability to care for their child. Conclusions: Interventions initiated at the time of discharge have the potential to profoundly affect the landscape of care during illness recovery and lead to significantly improved outcomes among children under 5 years of age.
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Affiliation(s)
| | | | | | | | | | | | - Andrew Ndamira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lacey English
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Guohai Zhou
- University of British Columbia, Vancouver, Canada
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Wiens MO, Kissoon N, Kumbakumba E, Singer J, Moschovis PP, Ansermino JM, Ndamira A, Kiwanuka J, Larson CP. Selecting candidate predictor variables for the modelling of post-discharge mortality from sepsis: a protocol development project. Afr Health Sci 2016; 16:162-9. [PMID: 27358628 DOI: 10.4314/ahs.v16i1.22] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Post-discharge mortality is a frequent but poorly recognized contributor to child mortality in resource limited countries. The identification of children at high risk for post-discharge mortality is a critically important first step in addressing this problem. OBJECTIVES The objective of this project was to determine the variables most likely to be associated with post-discharge mortality which are to be included in a prediction modelling study. METHODS A two-round modified Delphi process was completed for the review of a priori selected variables and selection of new variables. Variables were evaluated on relevance according to (1) prediction (2) availability (3) cost and (4) time required for measurement. Participants included experts in a variety of relevant fields. RESULTS During the first round of the modified Delphi process, 23 experts evaluated 17 variables. Forty further variables were suggested and were reviewed during the second round by 12 experts. During the second round 16 additional variables were evaluated. Thirty unique variables were compiled for use in the prediction modelling study. CONCLUSION A systematic approach was utilized to generate an optimal list of candidate predictor variables for the incorporation into a study on prediction of pediatric post-discharge mortality in a resource poor setting.
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Affiliation(s)
- Matthew O Wiens
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Elias Kumbakumba
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Peter P Moschovis
- Pediatric Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - J Mark Ansermino
- Department of Anesthesiology, University of British Columbia, Vancouver, Canada
| | - Andrew Ndamira
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Julius Kiwanuka
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Charles P Larson
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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