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Graham HR, King C, Duke T, Ahmed S, Baqui AH, Colbourn T, Falade AG, Hildenwall H, Hooli S, Kamuntu Y, Subhi R, McCollum ED. Hypoxaemia and risk of death among children: rethinking oxygen saturation, risk-stratification, and the role of pulse oximetry in primary care. Lancet Glob Health 2024; 12:e1359-e1364. [PMID: 38914087 PMCID: PMC11254785 DOI: 10.1016/s2214-109x(24)00209-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/30/2024] [Accepted: 05/08/2024] [Indexed: 06/26/2024]
Abstract
Pulse oximeters are essential for assessing blood oxygen levels in emergency departments, operating theatres, and hospital wards. However, although the role of pulse oximeters in detecting hypoxaemia and guiding oxygen therapy is widely recognised, their role in primary care settings is less clear. In this Viewpoint, we argue that pulse oximeters have a crucial role in risk-stratification in both hospital and primary care or outpatient settings. Our reanalysis of hospital and primary care data from diverse low-income and middle-income settings shows elevated risk of death for children with moderate hypoxaemia (ie, peripheral oxygen saturations [SpO2] 90-93%) and severe hypoxaemia (ie, SpO2 <90%). We suggest that moderate hypoxaemia in the primary care setting should prompt careful clinical re-assessment, consideration of referral, and close follow-up. We provide practical guidance to better support front-line health-care workers to use pulse oximetry, including rethinking traditional binary SpO2 thresholds and promoting a more nuanced approach to identification and emergency treatment of the severely ill child.
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Affiliation(s)
- Hamish R Graham
- Melbourne Children's Global Health, Murdoch Children's Research Institute, University of Melbourne, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria.
| | - Carina King
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Trevor Duke
- Melbourne Children's Global Health, Murdoch Children's Research Institute, University of Melbourne, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Salahuddin Ahmed
- Projahnmo Study Group, Johns Hopkins University, Dhaka, Bangladesh
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria; Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Helena Hildenwall
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Shubhada Hooli
- Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Yewande Kamuntu
- Essential Medicines, Clinton Health Access Initiative, Kampala, Uganda
| | - Rami Subhi
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Eric D McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Global Program in Pediatric Respiratory Sciences, Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Olagunju OJ, Ekwebene OC, Olagunju OE, Osanyinlusi O, Oyebanji OA, Egbo B. Malaria Parasitemia and Severe Health Complications in Children Under Five Years of Age in Nigeria: A Study Using the Demographic and Health Survey (DHS) Malaria Indicator Survey (MIS) 2021. Cureus 2024; 16:e58907. [PMID: 38800144 PMCID: PMC11118779 DOI: 10.7759/cureus.58907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND In Nigeria, 97% of the population is at risk of contracting malaria. It is transmitted by female Anopheles mosquitoes carrying the Plasmodium parasite and can be lethal. An estimated 55 million illnesses and 80,000 deaths per year result from it. Children under five are more likely to contract malaria. Efforts to control malaria in Nigeria include indoor residual spraying, insecticide-treated bed nets, and quick detection and treatment of confirmed cases with effective antimalarial medications. These attempts have been impeded by limited healthcare access, poor financing, and drug-resistant parasites. Thus, the study of the relationship between malaria complications and housing for children under five is essential. METHODS The Demographic and Health Survey (DHS) Malaria Indicator Survey (MIS) 2021, a nationally representative data set from developing countries on population and health, was used for this study. A sample size of 13,727 was employed (n=13,727). Logistic regression analyses were conducted to test the association between the type of place of residence and malaria complications (outcome). RESULTS Overall, 4.2% (n=570, weight HV005) of participants in the sample reported malaria complications. The results of the logistic regression revealed that children residing in urban settlements (aOR 0.37, 95% CI 0.37-0.37, p-value <0.001), children from the poorest class families (aOR 11.63, 95% CI 1.62-1.63, p-value 0.004), children from poorer class families (aOR 7.56, 95% CI 7.55-7.57, p-value <0.001), children from middle-class families (aOR 4.05, 95% CI 4.03-9.06, p-value <0.001), children from richer class families (aOR 1.22, 95% CI 2.21-2.23, p-value <0.001), children of mothers with primary education (aOR 0.42, 95% CI 2.32-4.112, p-value 0.001), children of mothers with secondary education (aOR 0.24, 95% CI 3.21-3.22, p-value <0.001), children of mothers with higher education (aOR 0.08, 95% CI 0.72-0.80, p-value <0.001), and children of the female gender (aOR 0.65, 95% CI 0.65-0.66, p-value <0.001) are all associated with severe malaria complications. CONCLUSIONS In conclusion, the study examined malaria complications in Nigerian children under five by residency. The findings imply that rural children are more likely to have serious malaria complications than urban children. This emphasizes the necessity for targeted malaria therapies in rural areas with limited healthcare access.
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Affiliation(s)
- Olajide J Olagunju
- Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Onyeka C Ekwebene
- Biostatistics and Epidemiology, East Tennessee State University, Johnson City, USA
| | | | - Olagoke Osanyinlusi
- Pulmonology, Washington University School of Medicine in St. Louis, St. Louis, USA
| | - Oladayo A Oyebanji
- Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Ben Egbo
- Radiology, Potiskum Medical Centre, Potiskum, NGA
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Machini B, Achia TNO, Kipruto H, Amboko B, Chesang J. Factors associated with hospital length of stay in patients admitted with suspected malaria in Kenya: secondary analysis of a cross-sectional survey. BMJ Open 2022; 12:e059263. [PMID: 35725248 PMCID: PMC9214361 DOI: 10.1136/bmjopen-2021-059263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To investigate factors associated with hospital length of stay (LOS) in patients admitted with suspected malaria using a competing risk approach. SETTING County government referrals and major faith-based hospitals in Kenya in 2018. DESIGN Secondary analysis of a cross-sectional survey data. PARTICIPANTS Data were extracted from 2396 medical records of patients admitted with suspected malaria at 90 hospitals. OUTCOME MEASURES LOS, defined as time to discharge, was the primary event of interest, and time to death was the competing event against patient factors assessed during admission and hospitalisation. RESULTS Among the patients analysed, 2283 were discharged, 49 died and 64 were censored. The median LOS was 4 days (IQR: 3-6 days). The cumulative incidence of discharge significantly decreased (p<0.05) by 12.7% (subdistribution-HR (SDHR): 0.873; 95% CI 0.789 to 0.967) when the respiratory rate was assessed, by 14.1% (SDHR 0.859; 95% CI 0.754 to 0.978) when oxygen saturation was monitored, by 23.1% (SDHR 0.769; 95% CI 0.709 to 0.833) and 23.4% (SDHR 0.766; 95% CI 0.704 to 0.833) when haemoglobin/haematocrit and glucose/random blood sugar were performed, respectively, and by 30.4% (SDHR 0.696; 95% CI 0.626 to 0.774) when patients had at least one clinical feature of severe malaria. Conversely, patients with confirmed severe malaria and those treated with injectable artesunate had a significantly increased cumulative incidence of discharge by 21.4% (SDHR 1.214; 95% CI 1.082 to 1.362) and 33.9% (SDHR 1.339; 95% CI 1.184 to 1.515), respectively. CONCLUSIONS Factors of inpatient clinical processes that influence hospital LOS were identified. These can be targeted during quality improvement interventions to enhance health service delivery in Kenya. Early recognition and appropriate management of the signs of malaria severity could greatly affect beneficial outcomes. Strengthening clinical practices and nursing care according to national case management guidelines should be a priority for malaria control managers in Kenya.
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Affiliation(s)
- Beatrice Machini
- Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya
- Department of Public and Global Health, University of Nairobi, Nairobi, Kenya
| | - Thomas N O Achia
- Department of Public and Global Health, University of Nairobi, Nairobi, Kenya
- School of Mathematics and Computer Science, University of Kwa Zulu Natal, Durban, South Africa
| | - Hillary Kipruto
- Regional Office for Africa, Eastern and Southern Africa, World Health Organization, Harare, Zimbabwe
| | | | - Jacqueline Chesang
- Department of Public and Global Health, University of Nairobi, Nairobi, Kenya
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Rahman AE, Hossain AT, Nair H, Chisti MJ, Dockrell D, Arifeen SE, Campbell H. Prevalence of hypoxaemia in children with pneumonia in low-income and middle-income countries: a systematic review and meta-analysis. THE LANCET GLOBAL HEALTH 2022; 10:e348-e359. [PMID: 35180418 PMCID: PMC8864303 DOI: 10.1016/s2214-109x(21)00586-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/31/2021] [Accepted: 12/07/2021] [Indexed: 12/23/2022] Open
Abstract
Background Pneumonia accounts for around 15% of all deaths of children younger than 5 years globally. Most happen in resource-constrained settings and are potentially preventable. Hypoxaemia is one of the strongest predictors of these deaths. We present an updated estimate of hypoxaemia prevalence among children with pneumonia in low-income and middle-income countries. Methods We conducted a systematic review using the following key concepts “children under five years of age” AND “pneumonia” AND “hypoxaemia” AND “low- and middle-income countries” by searching in 11 bibliographic databases and citation indices. We included all articles published between Nov 1, 2008, and Oct 8, 2021, based on observational studies and control arms of randomised and non-randomised controlled trials. We excluded protocol papers, articles reporting hypoxaemia prevalence based on less than 100 pneumonia cases, and articles published before 2008 from the review. Quality appraisal was done with the Joanna Briggs Institute tools. We reported pooled prevalence of hypoxaemia (SpO2 <90%) by classification of clinical severity and by clinical settings by use of the random-effects meta-analysis models. We combined our estimate of the pooled prevalence of pneumonia with a previously published estimate of the number of children admitted to hospital due to pneumonia annually to calculate the total annual number of children admitted to hospital with hypoxaemic pneumonia. Findings We identified 2825 unique records from the databases, of which 57 studies met the eligibility criteria: 26 from Africa, 23 from Asia, five from South America, and four from multiple continents. The prevalence of hypoxaemia was 31% (95% CI 26–36; 101 775 children) among all children with WHO-classified pneumonia, 41% (33–49; 30 483 children) among those with very severe or severe pneumonia, and 8% (3–16; 2395 children) among those with non-severe pneumonia. The prevalence was much higher in studies conducted in emergency and inpatient settings than in studies conducted in outpatient settings. In 2019, we estimated that over 7 million children (95% CI 5–8 million) were admitted to hospital with hypoxaemic pneumonia. The studies included in this systematic review had high τ2 (ie, 0·17), indicating a high level of heterogeneity between studies, and a high I2 value (ie, 99·6%), indicating that the heterogeneity was not due to chance. This study is registered with PROSPERO, CRD42019126207. Interpretation The high prevalence of hypoxaemia among children with severe pneumonia, particularly among children who have been admitted to hospital, emphasises the importance of overall oxygen security within the health systems of low-income and middle-income countries, particularly in the context of the COVID-19 pandemic. Even among children with non-severe pneumonia that is managed in outpatient and community settings, the high prevalence emphasises the importance of rapid identification of hypoxaemia at the first point of contact and referral for appropriate oxygen therapy. Funding UK National Institute for Health Research (Global Health Research Unit on Respiratory Health [RESPIRE]; 16/136/109).
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Affiliation(s)
- Ahmed Ehsanur Rahman
- The University of Edinburgh, Edinburgh, UK; International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
| | - Aniqa Tasnim Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | | | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Chew R, Zhang M, Chandna A, Lubell Y. The impact of pulse oximetry on diagnosis, management and outcomes of acute febrile illness in low-income and middle-income countries: a systematic review. BMJ Glob Health 2021; 6:bmjgh-2021-007282. [PMID: 34824136 PMCID: PMC8627405 DOI: 10.1136/bmjgh-2021-007282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/08/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Acute fever is a common presenting symptom in low/middle-income countries (LMICs) and is strongly associated with sepsis. Hypoxaemia predicts disease severity in such patients but is poorly detected by clinical examination. Therefore, including pulse oximetry in the assessment of acutely febrile patients may improve clinical outcomes in LMIC settings. METHODS We systematically reviewed studies of any design comparing one group where pulse oximetry was used and at least one group where it was not. The target population was patients of any age presenting with acute febrile illness or associated syndromes in LMICs. Studies were obtained from searching PubMed, EMBASE, CABI Global Health, Global Index Medicus, CINAHL, Cochrane CENTRAL, Web of Science and DARE. Further studies were identified through searches of non-governmental organisation websites, snowballing and input from a Technical Advisory Panel. Outcomes of interest were diagnosis, management and patient outcomes. Study quality was assessed using the Cochrane Risk of Bias 2 tool for Cluster Randomised Trials and Risk of Bias in Non-randomized Studies of Interventions tools, as appropriate. RESULTS Ten of 4898 studies were eligible for inclusion. Their small number and heterogeneity prevented formal meta-analysis. All studies were in children, eight only recruited patients with pneumonia, and nine were conducted in Africa or Australasia. Six were at serious risk of bias. There was moderately strong evidence for the utility of pulse oximetry in diagnosing pneumonia and identifying severe disease requiring hospital referral. Pulse oximetry used as part of a quality-assured facility-wide package of interventions may reduce pneumonia mortality, but studies assessing this endpoint were at serious risk of bias. CONCLUSIONS Very few studies addressed this important question. In LMICs, pulse oximetry may assist clinicians in diagnosing and managing paediatric pneumonia, but for the greatest impact on patient outcomes should be implemented as part of a health systems approach. The evidence for these conclusions is not widely generalisable and is of poor quality.
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Affiliation(s)
- Rusheng Chew
- Economics and Implementation Research Group, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand .,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Meiwen Zhang
- Economics and Implementation Research Group, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Arjun Chandna
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
| | - Yoel Lubell
- Economics and Implementation Research Group, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Tuti T, Aluvaala J, Akech S, Agweyu A, Irimu G, English M. Pulse oximetry adoption and oxygen orders at paediatric admission over 7 years in Kenya: a multihospital retrospective cohort study. BMJ Open 2021; 11:e050995. [PMID: 34493522 PMCID: PMC8424839 DOI: 10.1136/bmjopen-2021-050995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/13/2021] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES To characterise adoption and explore specific clinical and patient factors that might influence pulse oximetry and oxygen use in low-income and middle-income countries (LMICs) over time; to highlight useful considerations for entities working on programmes to improve access to pulse oximetry and oxygen. DESIGN A multihospital retrospective cohort study. SETTINGS All admissions (n=132 737) to paediatric wards of 18 purposely selected public hospitals in Kenya that joined a Clinical Information Network (CIN) between March 2014 and December 2020. OUTCOMES Pulse oximetry use and oxygen prescription on admission; we performed growth-curve modelling to investigate the association of patient factors with study outcomes over time while adjusting for hospital factors. RESULTS Overall, pulse oximetry was used in 48.8% (64 722/132 737) of all admission cases. Use rose on average with each month of participation in the CIN (OR: 1.11, 95% CI 1.05 to 1.18) but patterns of adoption were highly variable across hospitals suggesting important factors at hospital level influence use of pulse oximetry. Of those with pulse oximetry measurement, 7% (4510/64 722) had hypoxaemia (SpO2 <90%). Across the same period, 8.6% (11 428/132 737) had oxygen prescribed but in 87%, pulse oximetry was either not done or the hypoxaemia threshold (SpO2 <90%) was not met. Lower chest-wall indrawing and other respiratory symptoms were associated with pulse oximetry use at admission and were also associated with oxygen prescription in the absence of pulse oximetry or hypoxaemia. CONCLUSION The adoption of pulse oximetry recommended in international guidelines for assessing children with severe illness has been slow and erratic, reflecting system and organisational weaknesses. Most oxygen orders at admission seem driven by clinical and situational factors other than the presence of hypoxaemia. Programmes aiming to implement pulse oximetry and oxygen systems will likely need a long-term vision to promote adoption, guideline development and adherence and continuously examine impact.
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Affiliation(s)
- Timothy Tuti
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine and Department of Paediatrics, University of Oxford, Oxford, UK
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Batte A, Berrens Z, Murphy K, Mufumba I, Sarangam ML, Hawkes MT, Conroy AL. Malaria-Associated Acute Kidney Injury in African Children: Prevalence, Pathophysiology, Impact, and Management Challenges. Int J Nephrol Renovasc Dis 2021; 14:235-253. [PMID: 34267538 PMCID: PMC8276826 DOI: 10.2147/ijnrd.s239157] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/26/2021] [Indexed: 01/02/2023] Open
Abstract
Acute kidney injury (AKI) is emerging as a complication of increasing clinical importance associated with substantial morbidity and mortality in African children with severe malaria. Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to define AKI, an estimated 24–59% of African children with severe malaria have AKI with most AKI community-acquired. AKI is a risk factor for mortality in pediatric severe malaria with a stepwise increase in mortality across AKI stages. AKI is also a risk factor for post-discharge mortality and is associated with increased long-term risk of neurocognitive impairment and behavioral problems in survivors. Following injury, the kidney undergoes a process of recovery and repair. AKI is an established risk factor for chronic kidney disease and hypertension in survivors and is associated with an increased risk of chronic kidney disease in severe malaria survivors. The magnitude of the risk and contribution of malaria-associated AKI to chronic kidney disease in malaria-endemic areas remains undetermined. Pathways associated with AKI pathogenesis in the context of pediatric severe malaria are not well understood, but there is emerging evidence that immune activation, endothelial dysfunction, and hemolysis-mediated oxidative stress all directly contribute to kidney injury. In this review, we outline the KDIGO bundle of care and highlight how this could be applied in the context of severe malaria to improve kidney perfusion, reduce AKI progression, and improve survival. With increased recognition that AKI in severe malaria is associated with substantial post-discharge morbidity and long-term risk of chronic kidney disease, there is a need to increase AKI recognition through enhanced access to creatinine-based and next-generation biomarker diagnostics. Long-term studies to assess severe malaria-associated AKI’s impact on long-term health in malaria-endemic areas are urgently needed.
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Affiliation(s)
- Anthony Batte
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Zachary Berrens
- Department of Pediatrics, Pediatric Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristin Murphy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ivan Mufumba
- CHILD Research Laboratory, Global Health Uganda, Kampala, Uganda
| | | | - Michael T Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
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Graham H, Bakare AA, Fashanu C, Wiwa O, Duke T, Falade AG. Oxygen therapy for children: A key tool in reducing deaths from pneumonia. Pediatr Pulmonol 2020; 55 Suppl 1:S61-S64. [PMID: 31962010 PMCID: PMC7317213 DOI: 10.1002/ppul.24656] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/09/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Hamish Graham
- Centre for International Child Health, Royal Children's Hospital, MCRI, University of Melbourne, Parkville, Australia.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital, Ibadan, Nigeria
| | | | - Owens Wiwa
- Clinton Health Access Initiative, Abuja, Nigeria
| | - Trevor Duke
- Centre for International Child Health, Royal Children's Hospital, MCRI, University of Melbourne, Parkville, Australia
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
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9
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Kaiser A, Heiss K, Mueller AK, Fimmers R, Matthes J, Njuguna JT. Inhibition of EIF-5A prevents apoptosis in human cardiomyocytes after malaria infection. Amino Acids 2020; 52:693-710. [PMID: 32367435 DOI: 10.1007/s00726-020-02843-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 04/11/2020] [Indexed: 10/24/2022]
Abstract
In this study, a determination of Troponin I and creatine kinase activity in whole-blood samples in a cohort of 100 small infants in the age of 2-5 years from Uganda with complicated Plasmodium falciparum malaria suggests the prevalence of cardiac symptoms in comparison to non-infected, healthy patients. Troponin I and creatine kinase activity increased during infection. Different reports showed that complicated malaria coincides with hypoxia in children. The obtained clinical data prompted us to further elucidate the underlying regulatory mechanisms of cardiac involvement in human cardiac ventricular myocytes. Complicated malaria is the most common clinical presentation and might induce cardiac impairment by hypoxia. Eukaryotic initiation factor 5A (eIF-5A) is involved in hypoxia induced factor (HIF-1α) expression. EIF-5A is a protein posttranslationally modified by hypusination involving catalysis of the two enzymes deoxyhypusine synthase (DHS) and deoxyhypusine hydroxylase. Treatment of human cardiomyocytes with GC7, an inhibitor of DHS, catalyzing the first step in hypusine biosynthesis led to a decrease in proinflammatory and proapoptotic myocardial caspase-1 activity in comparison to untreated cardiomyocytes. This effect was even more pronounced after co-administration of GC7 and GPI from P. falciparum simulating the pathology of severe malaria. Moreover, in comparison to untreated and GC7-treated cardiomyocytes, co-administration of GC7 and GPI significantly decreased the release of cytochrome C and lactate from damaged mitochondria. In sum, coadministration of GC7 prevented cardiac damage driven by hypoxia in vitro. Our approach demonstrates the potential of the pharmacological inhibitor GC7 to ameliorate apoptosis in cardiomyocytes in an in vitro model simulating severe malaria. This regulatory mechanism is based on blocking EIF-5A hypusination.
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Affiliation(s)
- Annette Kaiser
- Medical Research Centre, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Kirsten Heiss
- Centre for Infectious Diseases, Parasitology Unit, University Hospital Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
- German Center for Infectious Diseases (DZIF), Heidelberg, Germany
| | - Ann-Kristin Mueller
- Centre for Infectious Diseases, Parasitology Unit, University Hospital Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
- German Center for Infectious Diseases (DZIF), Heidelberg, Germany
| | - Rolf Fimmers
- Institut für Medizinische Biometrie, Informatik Und Epedimologie, Sigmund-Freud-Strasse 25, 53107, Bonn, Germany
| | - Jan Matthes
- Centre of Pharmcology, University of Cologne, Gleueler Strasse 24, 50931, Köln, Germany
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Lam F, Subhi R, Houdek J, Schroder K, Battu A, Graham H. The prevalence of hypoxemia among pediatric and adult patients presenting to healthcare facilities in low- and middle-income countries: protocol for a systematic review and meta-analysis. Syst Rev 2020; 9:67. [PMID: 32228696 PMCID: PMC7106676 DOI: 10.1186/s13643-020-01326-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 03/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypoxemia is a severe condition associated with high rates of mortality, particularly in low- and middle-income countries (LMICs) with poor access to oxygen therapy. Despite its clinical significance, there have been few studies to describe the burden of hypoxemia. Thus, the primary objective of this study is to systematically describe the prevalence of hypoxemia among pediatric and adult patients in low- and middle-income countries. METHODS/DESIGN Standard systematic review methods will be used. Bibliographic databases (MEDLINE, EMBASE, CINAHL) will be searched from 1998 onwards. The search strategy aims to identify studies that have measured peripheral blood oxygen saturation (SpO2) in children and adults presenting to health facilities in LMICs. Studies will be included if oxygen saturation measurements by pulse oximetry were measured. No studies will be excluded based on study design though patients recruited from intensive care units and post-operative care will be excluded. The primary outcome is the prevalence of hypoxemia on presentation to the healthcare facility. We define hypoxemia on the basis of SpO2 measurements, and use a threshold of SpO2 less than 90% at sea level though allow for a lower threshold for studies conducted at higher altitude and where justified. Standardized tools will be used to extract data on number of patients with SpO2 measurements, number of patients with hypoxemia, patient population characteristics, and study characteristics. Quality of the included studies will be assessed using the "Checklist for Prevalence Studies" developed by the Joanna Briggs Institute. If there are enough studies to do so, we will conduct meta-analysis using a random effects model to estimate prevalence of hypoxemia and conduct subgroup analyses by age and disease groups. DISCUSSION Hypoxemia is a critical condition and understanding the burden of hypoxemia may support decision-making in LMICs to deploy pulse oximeters and oxygen treatments more efficiently to address diseases and patient populations with the highest burden. Previous studies on hypoxemia prevalence have focused too narrowly on a few diseases or specific patient populations (e.g., pneumonia in children under five) whereas any effort to improve access to oxygen requires understanding of the potential demand for oxygen for all diseases and population groups. Governments, UN agencies, donors, and NGOs are investing strongly to improve oxygen systems in LMICs. Effective oxygen system planning requires estimation of oxygen need, informed by robust data on hypoxemia prevalence and admission patterns at all the levels of the health system. This study aims to fill that gap by providing comprehensive estimates of hypoxemia prevalence. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019136622.
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Affiliation(s)
- Felix Lam
- Clinton Health Access Initiative, Inc., 383 Dorchester Ave, Suite 400, Boston, MA, 02127, USA.
| | - Rami Subhi
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, Victoria, 3052, Australia
| | - Jason Houdek
- Clinton Health Access Initiative, Inc., 383 Dorchester Ave, Suite 400, Boston, MA, 02127, USA
| | - Kate Schroder
- Clinton Health Access Initiative, Inc., 383 Dorchester Ave, Suite 400, Boston, MA, 02127, USA
| | - Audrey Battu
- Clinton Health Access Initiative, Inc., 383 Dorchester Ave, Suite 400, Boston, MA, 02127, USA
| | - Hamish Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, Victoria, 3052, Australia
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11
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Enoch AJ, English M, McGivern G, Shepperd S. Variability in the use of pulse oximeters with children in Kenyan hospitals: A mixed-methods analysis. PLoS Med 2019; 16:e1002987. [PMID: 31891572 PMCID: PMC6938307 DOI: 10.1371/journal.pmed.1002987] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/21/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pulse oximetry, a relatively inexpensive technology, has the potential to improve health outcomes by reducing incorrect diagnoses and supporting appropriate treatment decisions. There is evidence that in low- and middle-income countries, even when available, widespread uptake of pulse oximeters has not occurred, and little research has examined why. We sought to determine when and with which children pulse oximeters are used in Kenyan hospitals, how pulse oximeter use impacts treatment provision, and the barriers to pulse oximeter use. METHODS AND FINDINGS We analyzed admissions data recorded through Kenya's Clinical Information Network (CIN) between September 2013 and February 2016. We carried out multiple imputation and generated multivariable regression models in R. We also conducted interviews with 30 healthcare workers and staff from 14 Kenyan hospitals to examine pulse oximetry adoption. We adapted the Integrative Model of Behavioural Prediction to link the results from the multivariable regression analyses to the qualitative findings. We included 27,906 child admissions from 7 hospitals in the quantitative analyses. The median age of the children was 1 year, and 55% were male. Three-quarters had a fever, over half had a cough; other symptoms/signs were difficulty breathing (34%), difficulty feeding (34%), and indrawing (32%). The most common diagnoses were pneumonia, diarrhea, and malaria: 45%, 35%, and 28% of children, respectively, had these diagnoses. Half of the children obtained a pulse oximeter reading, and of these, 10% had an oxygen saturation level below 90%. Children were more likely to receive a pulse oximeter reading if they were not alert (odds ratio [OR]: 1.30, 95% confidence interval (CI): 1.09, 1.55, p = 0.003), had chest indrawing (OR: 1.28, 95% CI: 1.17, 1.40, p < 0.001), or a very high respiratory rate (OR: 1.27, 95% CI: 1.13, 1.43, p < 0.001), as were children admitted to certain hospitals, at later time periods, and when a Paediatric Admission Record (PAR) was used (OR PAR used compared with PAR not present: 2.41, 95% CI: 1.98, 2.94, p < 0.001). Children were more likely to be prescribed oxygen if a pulse oximeter reading was obtained (OR: 1.42, 95% CI:1.25, 1.62, p < 0.001) and if this reading was below 90% (OR: 3.29, 95% CI: 2.82, 3.84, p < 0.001). The interviews indicated that the main barriers to pulse oximeter use are inadequate supply, broken pulse oximeters, and insufficient training on how, when, and why to use pulse oximeters and interpret their results. According to the interviews, variation in pulse oximeter use between hospitals is because of differences in pulse oximeter availability and the leadership of senior doctors in advocating for pulse oximeter use, whereas variation within hospitals over time is due to repair delays. Pulse oximeter use increased over time, likely because of the CIN's feedback to hospitals. When pulse oximeters are used, they are sometimes used incorrectly and some healthcare workers lack confidence in readings that contradict clinical signs. The main limitations of the study are that children with high levels of missing data were not excluded, interview participants might not have been representative, and the interviews did not enable a detailed exploration of differences between counties or across senior management groups. CONCLUSIONS There remain major challenges to implementing pulse oximetry-a cheap, decades old technology-into routine care in Kenya. Implementation requires efficient and transparent procurement and repair systems to ensure adequate availability. Periodic training, structured clinical records that include prompts, the promotion of pulse oximetry by senior doctors, and monitoring and feedback might also support pulse oximeter use. Our findings can inform strategies to support the use of pulse oximeters to guide prompt and effective treatment, in line with the Sustainable Development Goals. Without effective implementation, the potential benefits of pulse oximeters and possible hospital cost-savings by targeting oxygen therapy might not be realized.
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Affiliation(s)
- Abigail J Enoch
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (former DPhil student)
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Gerald McGivern
- Warwick Business School, University of Warwick, Coventry, United Kingdom
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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12
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Graham HR, Bakare AA, Ayede AI, Gray AZ, McPake B, Peel D, Olatinwo O, Oyewole OB, Neal EFG, Nguyen CD, Qazi SA, Izadnegahdar R, Carlin JB, Falade AG, Duke T. Oxygen systems to improve clinical care and outcomes for children and neonates: A stepped-wedge cluster-randomised trial in Nigeria. PLoS Med 2019; 16:e1002951. [PMID: 31710601 PMCID: PMC6844455 DOI: 10.1371/journal.pmed.1002951] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/11/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Improving oxygen systems may improve clinical outcomes for hospitalised children with acute lower respiratory infection (ALRI). This paper reports the effects of an improved oxygen system on mortality and clinical practices in 12 general, paediatric, and maternity hospitals in southwest Nigeria. METHODS AND FINDINGS We conducted an unblinded stepped-wedge cluster-randomised trial comparing three study periods: baseline (usual care), pulse oximetry introduction, and stepped introduction of a multifaceted oxygen system. We collected data from clinical records of all admitted neonates (<28 days old) and children (28 days to 14 years old). Primary analysis compared the full oxygen system period to the pulse oximetry period and evaluated odds of death for children, children with ALRI, neonates, and preterm neonates using mixed-effects logistic regression. Secondary analyses included the baseline period (enabling evaluation of pulse oximetry introduction) and evaluated mortality and practice outcomes on additional subgroups. Three hospitals received the oxygen system intervention at 4-month intervals. Primary analysis included 7,716 neonates and 17,143 children admitted during the 2-year stepped crossover period (November 2015 to October 2017). Compared to the pulse oximetry period, the full oxygen system had no association with death for children (adjusted odds ratio [aOR] 1.06; 95% confidence interval [CI] 0.77-1.46; p = 0.721) or children with ALRI (aOR 1.09; 95% CI 0.50-2.41; p = 0.824) and was associated with an increased risk of death for neonates overall (aOR 1.45; 95% CI 1.04-2.00; p = 0.026) but not preterm/low-birth-weight neonates (aOR 1.30; 95% CI 0.76-2.23; p = 0.366). Secondary analyses suggested that the introduction of pulse oximetry improved oxygen practices prior to implementation of the full oxygen system and was associated with lower odds of death for children with ALRI (aOR 0.33; 95% CI 0.12-0.92; p = 0.035) but not for children, preterm neonates, or neonates overall (aOR 0.97, 95% CI 0.60-1.58, p = 0.913; aOR 1.12, 95% CI 0.56-2.26, p = 0.762; aOR 0.90, 95% CI 0.57-1.43, p = 0.651). Limitations of our study are a lower-than-anticipated power to detect change in mortality outcomes (low event rates, low participant numbers, high intracluster correlation) and major contextual changes related to the 2016-2017 Nigerian economic recession that influenced care-seeking and hospital function during the study period, potentially confounding mortality outcomes. CONCLUSIONS We observed no mortality benefit for children and a possible higher risk of neonatal death following the introduction of a multifaceted oxygen system compared to introducing pulse oximetry alone. Where some oxygen is available, pulse oximetry may improve oxygen usage and clinical outcomes for children with ALRI. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12617000341325.
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Affiliation(s)
- Hamish R. Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Ayobami A. Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Adejumoke I. Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Amy Z. Gray
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Parkville, Australia
| | | | - Olatayo Olatinwo
- Biomedical Services, University College Hospital, Ibadan, Nigeria
| | | | - Eleanor F. G. Neal
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
- Asia-Pacific Health, New Vaccines, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Cattram D. Nguyen
- Clinical Epidemiology and Biostatistics Unit, MCRI, Royal Children’s Hospital, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville, Australia
| | - Shamim A. Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Rasa Izadnegahdar
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - John B. Carlin
- Clinical Epidemiology and Biostatistics Unit, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Adegoke G. Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
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13
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Graham H, Bakare AA, Ayede AI, Oyewole OB, Gray A, Peel D, McPake B, Neal E, Qazi SA, Izadnegahdar R, Duke T, Falade AG. Hypoxaemia in hospitalised children and neonates: A prospective cohort study in Nigerian secondary-level hospitals. EClinicalMedicine 2019; 16:51-63. [PMID: 31832620 PMCID: PMC6890969 DOI: 10.1016/j.eclinm.2019.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/15/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hypoxaemia is a common complication of pneumonia and a major risk factor for death, but less is known about hypoxaemia in other common conditions. We evaluated the epidemiology of hypoxaemia and oxygen use in hospitalised neonates and children in Nigeria. METHODS We conducted a prospective cohort study among neonates and children (<15 years of age) admitted to 12 secondary-level hospitals in southwest Nigeria (November 2015-November 2017) using data extracted from clinical records (documented during routine care). We report summary statistics on hypoxaemia prevalence, oxygen use, and clinical predictors of hypoxaemia. We used generalised linear mixed-models to calculate relative odds of death (hypoxaemia vs not). FINDINGS Participating hospitals admitted 23,926 neonates and children during the study period. Pooled hypoxaemia prevalence was 22.2% (95%CI 21.2-23.2) for neonates and 10.2% (9.7-10.8) for children. Hypoxaemia was common among children with acute lower respiratory infection (28.0%), asthma (20.4%), meningitis/encephalitis (17.4%), malnutrition (16.3%), acute febrile encephalopathy (15.4%), sepsis (8.7%) and malaria (8.5%), and neonates with neonatal encephalopathy (33.4%), prematurity (26.6%), and sepsis (21.0%). Hypoxaemia increased the adjusted odds of death 6-fold in neonates and 7-fold in children. Clinical signs predicted hypoxaemia poorly, and their predictive ability varied across ages and conditions. Hypoxaemic children received oxygen for a median of 2-3 days, consuming ∼3500 L of oxygen per admission. INTERPRETATION Hypoxaemia is common in respiratory and non-respiratory acute childhood illness and increases the risk of death substantially. Given the limitations of clinical signs, pulse oximetry is an essential tool for detecting hypoxaemia, and should be part of the routine assessment of all hospitalised neonates and children.
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Affiliation(s)
- Hamish Graham
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
- Corresponding author at: Centre for International Child Health, Department of Paediatrics, Level 2 East, 50 Flemington Road, Parkville, VIC 3052, Australia.
| | - Ayobami A. Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Adejumoke I. Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | | | - Amy Gray
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
| | | | - Barbara McPake
- Nossal Institute of Global Health, University of Melbourne, Parkville, Australia
| | - Eleanor Neal
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
- Pneumococcal Research, MCRI, Royal Children's Hospital, Parkville, Australia
| | - Shamim A. Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
| | - Adegoke G. Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
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14
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King C, Boyd N, Walker I, Zadutsa B, Baqui AH, Ahmed S, Islam M, Kainja E, Nambiar B, Wilson I, McCollum ED. Opportunities and barriers in paediatric pulse oximetry for pneumonia in low-resource clinical settings: a qualitative evaluation from Malawi and Bangladesh. BMJ Open 2018; 8:e019177. [PMID: 29382679 PMCID: PMC5829842 DOI: 10.1136/bmjopen-2017-019177] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To gain an understanding of what challenges pulse oximetry for paediatric pneumonia management poses, how it has changed service provision and what would improve this device for use across paediatric clinical settings in low-income countries. DESIGN Focus group discussions (FGDs), with purposive sampling and thematic analysis using a framework approach. SETTING Community, front-line outpatient, and hospital outpatient and inpatient settings in Malawi and Bangladesh, which provide paediatric pneumonia care. PARTICIPANTS Healthcare providers (HCPs) from Malawi and Bangladesh who had received training in pulse oximetry and had been using oximeters in routine paediatric care, including community healthcare workers, non-physician clinicians or medical assistants, and hospital-based nurses and doctors. RESULTS We conducted six FGDs, with 23 participants from Bangladesh and 26 from Malawi. We identified five emergent themes: trust, value, user-related experience, sustainability and design. HCPs discussed the confidence gained through the use of oximeters, resulting in improved trust from caregivers and valuing the device, although there were conflicts between the weight given to clinical judgement versus oximeter results. HCPs reported the ease of using oximeters, but identified movement and physically smaller children as measurement challenges. Challenges in sustainability related to battery durability and replacement parts, however many HCPs had used the same device longer than 4 years, demonstrating robustness within these settings. Desirable features included back-up power banks and integrated respiratory rate and thermometer capability. CONCLUSIONS Pulse oximetry was generally deemed valuable by HCPs for use as a spot-check device in a range of paediatric low-income clinical settings. Areas highlighted as challenges by HCPs, and therefore opportunities for redesign, included battery charging and durability, probe fit and sensitivity in paediatric populations. TRIAL REGISTRATION NUMBER NCT02941237.
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, London, UK
| | - Nicholas Boyd
- UCL Institute of Child Health, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Isabeau Walker
- UCL Institute of Child Health, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | | | - Abdullah H Baqui
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Salahuddin Ahmed
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mazharul Islam
- Department of Anthropology, Shahjalal University of Science and Technology, Sylhet, Bangladesh
| | - Esther Kainja
- Parent and Child Health Initiative, Lilongwe, Malawi
| | - Bejoy Nambiar
- Institute for Global Health, University College London, London, UK
| | | | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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15
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Graham HR, Ayede AI, Bakare AA, Oyewole OB, Peel D, Gray A, McPake B, Neal E, Qazi S, Izadnegahdar R, Falade AG, Duke T. Improving oxygen therapy for children and neonates in secondary hospitals in Nigeria: study protocol for a stepped-wedge cluster randomised trial. Trials 2017; 18:502. [PMID: 29078810 PMCID: PMC5659007 DOI: 10.1186/s13063-017-2241-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 10/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oxygen is a life-saving, essential medicine that is important for the treatment of many common childhood conditions. Improved oxygen systems can reduce childhood pneumonia mortality substantially. However, providing oxygen to children is challenging, especially in small hospitals with weak infrastructure and low human resource capacity. METHODS/DESIGN This trial will evaluate the implementation of improved oxygen systems at secondary-level hospitals in southwest Nigeria. The improved oxygen system includes: a standardised equipment package; training of clinical and technical staff; infrastructure support (including improved power supply); and quality improvement activities such as supportive supervision. Phase 1 will involve the introduction of pulse oximetry alone; phase 2 will involve the introduction of the full, improved oxygen system package. We have based the intervention design on a theory-based analysis of previous oxygen projects, and used quality improvement principles, evidence-based teaching methods, and behaviour-change strategies. We are using a stepped-wedge cluster randomised design with participating hospitals randomised to receive an improved oxygen system at 4-month steps (three hospitals per step). Our mixed-methods evaluation will evaluate effectiveness, impact, sustainability, process and fidelity. Our primary outcome measures are childhood pneumonia case fatality rate and inpatient neonatal mortality rate. Secondary outcome measures include a range of clinical, quality of care, technical, and health systems outcomes. The planned study duration is from 2015 to 2018. DISCUSSION Our study will provide quality evidence on the effectiveness of improved oxygen systems, and how to better implement and scale-up oxygen systems in resource-limited settings. Our results should have important implications for policy-makers, hospital administrators, and child health organisations in Africa and globally. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12617000341325 . Retrospectively registered on 6 March 2017.
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Affiliation(s)
- Hamish R Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia. .,Department of Paediatrics, University College Hospital, Ibadan, Nigeria.
| | - Adejumoke I Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Oladapo B Oyewole
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | | | - Amy Gray
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Eleanor Neal
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Shamim Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia
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16
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Sypniewska P, Duda JF, Locatelli I, Althaus CR, Althaus F, Genton B. Clinical and laboratory predictors of death in African children with features of severe malaria: a systematic review and meta-analysis. BMC Med 2017; 15:147. [PMID: 28768513 PMCID: PMC5541406 DOI: 10.1186/s12916-017-0906-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 06/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The criteria for defining severe malaria have evolved over the last 20 years. We aimed to assess the strength of association of death with features currently characterizing severe malaria through a systematic review and meta-analysis. METHOD Electronic databases (Medline, Embase, Cochrane Database of Systematic Reviews, Thomson Reuters Web of Knowledge) were searched to identify publications including African children with severe malaria. PRISMA guidelines were followed. Selection was based on design (epidemiological, clinical and treatment studies), setting (Africa), participants (children < 15 years old with severe malaria), outcome (survival/death rate), and prognostic indicators (clinical and laboratory features). Quality assessment was performed following the criteria of the 2011 Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). Odds ratios (ORs) were calculated for each study and prognostic indicator, and, when a test was assessed in at least two studies, pooled estimates of ORs were computed using fixed- or random-effects meta-analysis. RESULTS A total of 601 articles were identified and screened and 30 publications were retained. Features with the highest pooled ORs were renal failure (5.96, 95% CI 2.93-12.11), coma score (4.83, 95% CI 3.11-7.5), hypoglycemia (4.59, 95% CI 2.68-7.89), shock (4.31, 95% CI 2.15-8.64), and deep breathing (3.8, 95% CI 3.29-4.39). Only half of the criteria had an OR > 2. Features with the lowest pooled ORs were impaired consciousness (0.58, 95% CI 0.25-1.37), severe anemia (0.76, 95% CI 0.5- 1.13), and prostration (1.12, 95% CI 0.45-2.82). CONCLUSION The findings of this meta-analysis show that the strength of association between the criteria defining severe malaria and death is quite variable for each clinical and/or laboratory feature (OR ranging from 0.58 to 5.96). This ranking allowed the identification of features weakly associated with death, such as impaired consciousness and prostration, which could assist to improve case definition, and thus optimize antimalarial treatment.
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Affiliation(s)
- Paulina Sypniewska
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
- RWTH Aachen University, Aachen, Germany
| | - Jose F Duda
- International Committee of the Red Cross, Geneva, Switzerland
| | - Isabella Locatelli
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | | | - Fabrice Althaus
- International Committee of the Red Cross, Geneva, Switzerland
| | - Blaise Genton
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland.
- Division of Infectious Diseases, University Hospital, Lausanne, Switzerland.
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17
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Aggarwal HK, Jain D, Rao A, Kalra R. Role of Coma Acidosis Malaria Score in Patients with Severe Malaria among Indian Population: a Tertiary Care Center Experience. Eurasian J Med 2017; 49:30-35. [PMID: 28416929 DOI: 10.5152/eurasianjmed.2017.16069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE Malaria is a prime public health threat in developing countries like India. There is an unmet need of a simplified methodology for the purpose of triage and provision of intensive care to the severely infected patients in these areas. MATERIALS AND METHODS We did a prospective study in patients (n=60) admitted with severe malaria in a single tertiary care center in the state of Haryana, India. We assessed the role of coma acidosis malaria (CAM) score in these patients when predicting mortality and morbidity events. Stepwise logistic regression analysis was applied to identify patients requiring intensive care based on the CAM score, and the prediction value of the scoring system was assessed among these patients. RESULTS Cerebral malaria (measured using the Glasgow coma scale) and acidosis (base deficit) were the major determinants of the CAM score. Serum bicarbonate levels and respiratory rates were assessed as the proxy markers of the base deficit as it is not always available. Morbidity increased steadily as the CAM scores increased. Sensitivity and negative predictive value of 100% depicted that the scoring system was able to identify patients who needed intensive care and accurately exclude the patients who could be conservatively managed in the ward. Positive predictive values of 73.9%, 68%, and 80.9% indicated that CAM, bicarbonate-based CAM (BCAM), and respiratory rate-based CAM (RCAM) scores, respectively, could precisely predict the morbidity and mortality events among patients with CAM scores ≥2. CONCLUSION CAM scores have precise predictive values in assessing patients with severe malaria. The scoring system helps in accurate and systemic triage of patients, irrespective of species, and directs the treating physicians toward vigilant treatment and emergency care.
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Affiliation(s)
- Hari Krishan Aggarwal
- Department of Medicine, Pt B.D. Sharma University of Health Sciences, Haryana, India
| | - Deepak Jain
- Department of Medicine, Pt B.D. Sharma University of Health Sciences, Haryana, India
| | - Avinash Rao
- Department of Medicine, Pt B.D. Sharma University of Health Sciences, Haryana, India
| | - Rajinish Kalra
- Department of Pathology, Pt B.D. Sharma University of Health Sciences, Haryana, India
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Abstract
OBJECTIVE To describe the relationship between PaO2 at intensive care admission and mortality in critically ill children and to review systematically the literature describing this relationship. DESIGN Cohort study: A review of consecutive tertiary pediatric intensive care admissions (January 2004 to December 2014) in a single center. The relationship between admission Pao2 and crude and standardized mortality was explored using nonlinear regression. Systematic review: A search of MEDLINE (1950 to January 2015), EMBASE (1980 to January 2015), Cochrane and Database of Abstracts of Reviews of Effects databases was undertaken using the following terms: "hyperoxia," "hypoxia," "critically ill children," "pediatric intensive care," "mortality," and/or "survival." SETTING Tertiary PICU. PATIENTS Patients younger than 18 years of age. INTERVENTIONS The association of hyperoxia (PaO2, > 300 torr [40 kPa]) and hypoxia (PaO2, < 60 torr [8 kPa] or peripheral oxygen saturations, < 90%) to mortality in critically ill children was explored. MEASUREMENTS AND MAIN RESULTS Cohort study: Of 14,321 admissions, 7,410 children had recorded PaO2 and FIO2 at admission. Crude mortality was 7.4% (555/7,410). This varied with admission PaO2 from 15.4% (204/1,324) in the hypoxia group (< 8 kPa) to 5.3% (287/5,385) with normoxia and 9.1% (64/701) in the hyperoxic group (> 40 kPa). Nonlinear regression displayed a "U-shaped" relationship between PaO2 and crude and case-mix adjusted mortality. Systematic review: Fourteen studies and one conference abstract were eligible for inclusion. Eleven studies (n = 5,280) relate to hypoxia with combined odds ratio for death, of 3.13 (95% CI, 1.79-5.48; p < 0.001) compared to normoxia. Six studies (n = 2,012) relate to hyperoxia and suggest no effect on mortality compared to normoxia (odds ratio, 1.15; 95% CI, 0.42-3.17; p = 0.77). CONCLUSIONS Hypoxia at admission is associated with increased mortality in critically ill children, whereas the association with hyperoxia is less clear. The cohort study demonstrated a U-shaped association between admission PaO2 and mortality. Further examination is needed to explore the effect of hyperoxia upon mortality prediction accuracy.
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Enoch AJ, English M, Shepperd S. Does pulse oximeter use impact health outcomes? A systematic review. Arch Dis Child 2016; 101:694-700. [PMID: 26699537 PMCID: PMC4975806 DOI: 10.1136/archdischild-2015-309638] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/24/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Do newborns, children and adolescents up to 19 years have lower mortality rates, lower morbidity and shorter length of stay in health facilities where pulse oximeters are used to inform diagnosis and treatment (excluding surgical care) compared with health facilities where pulse oximeters are not used? DESIGN Studies were obtained for this systematic literature review by systematically searching the Database of Abstracts of Reviews of Effects, Cochrane, Medion, PubMed, Web of Science, Embase, Global Health, CINAHL, WHO Global Health Library, international health organisation and NGO websites, and study references. PATIENTS Children 0-19 years presenting for the first time to hospitals, emergency departments or primary care facilities. INTERVENTIONS Included studies compared outcomes where pulse oximeters were used for diagnosis and/or management, with outcomes where pulse oximeters were not used. MAIN OUTCOME MEASURES mortality, morbidity, length of stay, and treatment and management changes. RESULTS The evidence is low quality and hypoxaemia definitions varied across studies, but the evidence suggests pulse oximeter use with children can reduce mortality rates (when combined with improved oxygen administration) and length of emergency department stay, increase admission of children with previously unrecognised hypoxaemia, and change physicians' decisions on illness severity, diagnosis and treatment. Pulse oximeter use generally increased resource utilisation. CONCLUSIONS As international organisations are investing in programmes to increase pulse oximeter use in low-income settings, more research is needed on the optimal use of pulse oximeters (eg, appropriate oxygen saturation thresholds), and how pulse oximeter use affects referral and admission rates, length of stay, resource utilisation and health outcomes.
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Affiliation(s)
- Abigail J Enoch
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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20
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Barennes H, Sayavong E, Pussard E. High Mortality Risk in Hypoglycemic and Dysglycemic Children Admitted at a Referral Hospital in a Non Malaria Tropical Setting of a Low Income Country. PLoS One 2016; 11:e0150076. [PMID: 26910320 PMCID: PMC4766095 DOI: 10.1371/journal.pone.0150076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 02/09/2016] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Hypoglycemia is a recognized feature of severe malaria but its diagnosis and management remain problematic in resource-limited settings. There is limited data on the burden and prognosis associated with glycemia dysregulation in non-neonate children in non-malaria areas. We prospectively assessed the abnormal blood glucose prevalence and the outcome and risk factors of deaths in critically ill children admitted to a national referral hospital in Laos. METHODS Consecutive children (1 month-15 years) admitted to the pediatric ward of Mahosot hospital, were categorized using the integrated management of childhood illness (IMCI). Blood glucose was assessed once on admission through a finger prick using a bedside glucometer. Glycemia levels: hypoglycemia: < 2.2 mmol/L (< 40 mg⁄ dl), low glycemia: 2.2-4.4 mmol/L (40-79 mg⁄ dl), euglycemia: 4.4-8.3 mmol/L (80-149 mg⁄ dl), and hyperglycemia: > 8.3 mmol/L (≥150 mg⁄ dl), were related to the IMCI algorithm and case fatality using univariate and multivariate analysis. RESULTS Of 350 children, 62.2% (n = 218) were severely ill and 49.1% (n = 172) had at least one IMCI danger sign. A total of 15 (4.2%, 95%CI: 2.4-6.9) had hypoglycemia, 99 (28.2%, 95%CI: 23.6-33.3) low glycemia, 201 (57.4%, 95% CI: 52.0-62.6) euglycemia and 35 (10.0%, 95% CI: 7.0-13.6) hyperglycemia. Hypoglycemia was associated with longer fasting (p = 0.001) and limited treatment before admission (p = 0.09). Hypoglycemia and hyperglycemia were associated with hypoxemia (SaO2) (p = 0.001). A total of 21 (6.0%) of the children died: 66.6% with hypoglycemic, 6.0% with low glycemic, 5.7% with hyperglycemic and 1.4% with euglycemic groups. A total of 9 (2.5%) deaths occurred during the first 24 hours of admission and 5 (1.7%) within 3 days of hospital discharge. Compared to euglycemic children, hypoglycemic and low glycemic children had a higher rate of early death (20%, p<0.001 and 5%, p = 0.008; respectively). They also had a higher risk of death (OR: 132; 95%CI: 29.0-596.5; p = 0.001; and OR: 4.2; 95%CI: 1.1-15.6; p = 0.02; respectively). In multivariate analyses, hypoglycemia (OR: 197; 95%CI: 33-1173.9), hypoxemia (OR: 5.3; 95%CI: 1.4-20), presence of hepatomegaly (OR: 8.7; 95%CI: 2.0-37.6) and having an illiterate mother (OR: 25.9; 95%CI: 4.2-160.6) were associated with increased risk of death. CONCLUSION Hypoglycemia is linked with a high risk of mortality for children in non malaria tropical settings. Blood sugar should be monitored and treatment provided for sick children, especially with danger signs and prolonged fasting. Further evaluations of intervention using thresholds including low glycemia is recommended in resource-limited settings. Research is also needed to determine the significance, prognosis and care of hyperglycemia.
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Affiliation(s)
- Hubert Barennes
- Institut de la Francophonie pour la Médecine Tropicale, Vientiane, Lao PDR
- Agence Nationale de Recherche sur le VIH et les Hépatites, Phnom Penh, Cambodia
- Epidemiologie-Biostatistique, ISPED, Centre INSERM U897, Bordeaux University, F-Bordeaux, France
- Epidemiology Unit, Pasteur Institute, Phnom Penh, Cambodia
| | - Eng Sayavong
- Institut de la Francophonie pour la Médecine Tropicale, Vientiane, Lao PDR
| | - Eric Pussard
- Génétique Moléculaire, Pharmacogénétique et Hormonologie, Kremlin Bicêtre University Hospital, Paris, France
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Hom LA, Silber TJ, Ennis-Durstine K, Hilliard MA, Martin GR. Legal and Ethical Considerations in Allowing Parental Exemptions From Newborn Critical Congenital Heart Disease (CCHD) Screening. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:11-17. [PMID: 26734736 DOI: 10.1080/15265161.2015.1115140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Critical congenital heart disease (CCHD) screening is rapidly becoming the standard of care in the United States after being added to the Recommended Uniform Screening Panel (RUSP) in 2011. Newborn screens typically do not require affirmative parental consent. In fact, most states allow parents to exempt their baby from receiving the required screen on the basis of religious or personally held beliefs. There are many ethical considerations implicated with allowing parents to exempt their child from newborn screening for CCHD. Considerations include the treatment of religious exemptions in our current legal system, as well as medical and ethical principles in relation to the rights of infants. Although there are significant benefits to screening newborns for CCHD, when a parent refuses for religious or personal beliefs, in the case of CCHD screening, the parental decision should stand.
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