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Wei H, Huang X, Zhang Y, Jiang G, Ding R, Deng M, Wei L, Yuan H. Explainable machine learning for predicting neurological outcome in hemorrhagic and ischemic stroke patients in critical care. Front Neurol 2024; 15:1385013. [PMID: 38915793 PMCID: PMC11194386 DOI: 10.3389/fneur.2024.1385013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 05/28/2024] [Indexed: 06/26/2024] Open
Abstract
Aim The objective of this study is to develop accurate machine learning (ML) models for predicting the neurological status at hospital discharge of critically ill patients with hemorrhagic and ischemic stroke and identify the risk factors associated with the neurological outcome of stroke, thereby providing healthcare professionals with enhanced clinical decision-making guidance. Materials and methods Data of stroke patients were extracted from the eICU Collaborative Research Database (eICU-CRD) for training and testing sets and the Medical Information Mart for Intensive Care IV (MIMIC IV) database for external validation. Four machine learning models, namely gradient boosting classifier (GBC), logistic regression (LR), multi-layer perceptron (MLP), and random forest (RF), were used for prediction of neurological outcome. Furthermore, shapley additive explanations (SHAP) algorithm was applied to explain models visually. Results A total of 1,216 hemorrhagic stroke patients and 954 ischemic stroke patients from eICU-CRD and 921 hemorrhagic stroke patients 902 ischemic stroke patients from MIMIC IV were included in this study. In the hemorrhagic stroke cohort, the LR model achieved the highest area under curve (AUC) of 0.887 in the test cohort, while in the ischemic stroke cohort, the RF model demonstrated the best performance with an AUC of 0.867 in the test cohort. Further analysis of risk factors was conducted using SHAP analysis and the results of this study were converted into an online prediction tool. Conclusion ML models are reliable tools for predicting hemorrhagic and ischemic stroke neurological outcome and have the potential to improve critical care of stroke patients. The summarized risk factors obtained from SHAP enable a more nuanced understanding of the reasoning behind prediction outcomes and the optimization of the treatment strategy.
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Affiliation(s)
- Huawei Wei
- Department of Anesthesiology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xingshuai Huang
- Department of Anesthesiology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yixuan Zhang
- Department of Anesthesiology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Guowei Jiang
- Department of Anesthesiology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Ruifeng Ding
- Department of Anesthesiology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Mengqiu Deng
- Department of Anesthesiology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Liangtian Wei
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Hongbin Yuan
- Department of Anesthesiology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, China
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Flores Palacios RJ, Hueda Zavaleta M, Gutiérrez Avila AG, Gómez de la Torre JC, Benites Zapata VA. Characteristics and factors associated with mortality in tracheostomized patients with COVID-19: a retrospective cohort study in a hospital in Tacna, Peru. Rev Peru Med Exp Salud Publica 2024; 40:441-450. [PMID: 38597472 PMCID: PMC11138828 DOI: 10.17843/rpmesp.2023.404.12629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 10/18/2023] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVE We aimed to describe the main demographic, clinical, laboratory and therapeutic characteristics and to identify whether they are associated with mortality in tracheostomized patients. MATERIAL AND METHODS. Retrospective cohort study in adult patients diagnosed with COVID-19, admitted to ICU (Intensive Care Unit) and requiring tracheostomy. Demographic, clinical, laboratory and treatment data were obtained from the medical records of patients admitted to Hospital III Daniel Alcides Carrión in Tacna. The Cox proportional hazards model was used for survival analysis and hazard ratios (HR) with their 95% confidence intervals (95%CI) were calculated. RESULTS. We evaluated 73 patients, 72.6% were men, the most common comorbidities were obesity (68.5%), type 2 diabetes mellitus (35.6%), and arterial hypertension (34.2%). Thirty-seven percent of the participants died during their stay at the ICU. The median time from intubation to tracheostomy and the duration of tracheostomy was 17 (RIC: 15-21) and 21 (RIC: 3-39) days, respectively. Multivariate analysis showed that the factors associated with mortality were procalcitonin > 0.50 ng/dL at the time of tracheostomy (HRa: 2.40 95%CI: 1.03-5.59) and a PaO2/FiO2 ratio less than or equal to 150 mmHg (HRa: 4.44 95%CI: 1.56-12.60). CONCLUSIONS. The factors associated with mortality at the time of tracheostomy were procalcitonin > 0.50 ng/dL and a PaO2/FiO2 ratio less than or equal to 150 mmHg.
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Affiliation(s)
| | - Miguel Hueda Zavaleta
- Hospital III Daniel Alcides Carrión, Tacna, Perú
- Diagnóstico, tratamiento e investigación de enfermedades infecciosas y tropicales, Universidad Privada de Tacna, Tacna, Perú
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Prust ML, Forman R, Ovbiagele B. Addressing disparities in the global epidemiology of stroke. Nat Rev Neurol 2024; 20:207-221. [PMID: 38228908 DOI: 10.1038/s41582-023-00921-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Abstract
Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.
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Affiliation(s)
- Morgan L Prust
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Rachel Forman
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California-San Francisco School of Medicine, San Francisco, CA, USA
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Alismail A, Esteitie R, Leon-Astudillo C, Pantaleón García J, Sangli S, Kumar Sunil S. Twelve Tips to Succeed as Health Profession Clinical Educator in Resource-Limited Settings. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2024; 15:201-206. [PMID: 38505497 PMCID: PMC10949165 DOI: 10.2147/amep.s453993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/06/2024] [Indexed: 03/21/2024]
Abstract
Health professions education is one of the pillars of academic medicine; however, clinical educators often lack the appropriate resources to succeed in this field. Examples of these challenges include: lack of support for faculty development, mentorship, and high cost of resources, when available. In addition, challenges such as the Coronavirus disease (COVID-19) pandemic can affect healthcare personnel who are already struggling to provide adequate patient care while attempting to succeed in the role of educator and supervisor of trainees. Clinical educators face more challenges particularly in low-middle income countries as the limitations are more prominent and become key barriers to success. Similarly, due to COVID-19, these challenges can be far more evident in disadvantaged geographical, economic, and academic environments even in the United States. Herein, in this perspective paper, we define resource-limited settings in medical education, provide an overview of the most common barriers to career development as a clinical educator, and offer practical strategies to overcome some of these shortcomings.
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Affiliation(s)
- Abdullah Alismail
- Department of Cardiopulmonary Sciences, School of Allied Health Professions, Loma Linda University Health, Loma Linda, CA, USA
- Department of Medicine, School of Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Rania Esteitie
- Department of Pulmonary and Critical Care Medicine, Covenant HealthCare, Saginaw, MI, USA
| | | | - Jezreel Pantaleón García
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Swathi Sangli
- Department of Pulmonary and Critical Care, Kaiser Permanente, San Leandro, CA, USA
| | - Sriram Kumar Sunil
- Department of Internal Medicine, Jacobi Medical Center, Bronx, New York City, NY, USA
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Chandna A, Keang S, Vorlark M, Sambou B, Chhingsrean C, Sina H, Vichet P, Patel K, Habsreng E, Riedel A, Mwandigha L, Koshiaris C, Perera-Salazar R, Turner P, Chanpheaktra N, Turner C. A Prognostic Model for Critically Ill Children in Locations With Emerging Critical Care Capacity. Pediatr Crit Care Med 2024; 25:189-200. [PMID: 37947482 PMCID: PMC10904005 DOI: 10.1097/pcc.0000000000003394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVES To develop a clinical prediction model to risk stratify children admitted to PICUs in locations with limited resources, and compare performance of the model to nine existing pediatric severity scores. DESIGN Retrospective, single-center, cohort study. SETTING PICU of a pediatric hospital in Siem Reap, northern Cambodia. PATIENTS Children between 28 days and 16 years old admitted nonelectively to the PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical and laboratory data recorded at the time of PICU admission were collected. The primary outcome was death during PICU admission. One thousand five hundred fifty consecutive nonelective PICU admissions were included, of which 97 died (6.3%). Most existing severity scores achieved comparable discrimination (area under the receiver operating characteristic curves [AUCs], 0.71-0.76) but only three scores demonstrated moderate diagnostic utility for triaging admissions into high- and low-risk groups (positive likelihood ratios [PLRs], 2.65-2.97 and negative likelihood ratios [NLRs], 0.40-0.46). The newly derived model outperformed all existing severity scores (AUC, 0.84; 95% CI, 0.80-0.88; p < 0.001). Using one particular threshold, the model classified 13.0% of admissions as high risk, among which probability of mortality was almost ten-fold greater than admissions triaged as low-risk (PLR, 5.75; 95% CI, 4.57-7.23 and NLR, 0.47; 95% CI, 0.37-0.59). Decision curve analyses indicated that the model would be superior to all existing severity scores and could provide utility across the range of clinically plausible decision thresholds. CONCLUSIONS Existing pediatric severity scores have limited potential as risk stratification tools in resource-constrained PICUs. If validated, our prediction model would be a readily implementable mechanism to support triage of critically ill children at admission to PICU and could provide value across a variety of contexts where resource prioritization is important.
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Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
| | - Suy Keang
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Department of Intensive Care Medicine, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Meas Vorlark
- Department of Intensive Care Medicine, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Bran Sambou
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Chhay Chhingsrean
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Heav Sina
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Pav Vichet
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Kaajal Patel
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Department of Global Child Health, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Eang Habsreng
- Department of Intensive Care Medicine, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Arthur Riedel
- Department of Global Child Health, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Lazaro Mwandigha
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Constantinos Koshiaris
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rafael Perera-Salazar
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Claudia Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
- Angkor Hospital for Children, Siem Reap, Cambodia
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Boswell CL, Minteer SA, Herasevich S, Garcia-Mendez JP, Dong Y, Gajic O, Barwise AK. Early Prevention of Critical Illness in Older Adults: Adaptation and Pilot Testing of an Electronic Risk Score and Checklist. J Prim Care Community Health 2024; 15:21501319241231238. [PMID: 38344983 PMCID: PMC10863481 DOI: 10.1177/21501319241231238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/10/2024] [Accepted: 01/22/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE Given limited critical care resources and an aging population, early interventions to prevent critical illness are vital. In this work, we measured post-implementation outcomes after introducing a novel electronic scoring system (Elders Risk Assessment-ERA) and a risk-factor checklist, Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN), to detect older patients at high risk of critical illness in a primary care setting. METHODS The study was conducted at a family medicine clinic in Kasson, MN. The ADAPT-ITT framework was used to modify the CERTAIN checklist for primary care during 2 co-design workshops involving interdisciplinary clinicians, held in April 2023. The ERA score and modified CERTAIN checklist were implemented between May and July 2023 and identify and assess all patients age ≥60 years at risk of critical illness during their primary care visits. Implementation outcomes were evaluated at the end of the study via an anonymous survey and EHR data extraction. RESULTS Fourteen clinicians participated in 2 co-design workshops. A total of 19 clinicians participated in a post-pilot survey. All survey items were rated on a 5-point Likert type scale. Mean acceptability of the ERA score and checklist was rated 3.35 (SD = 0.75) and 3.09 (SD = 0.64), respectively. Appropriateness had a mean rating of 3.38 (SD = 0.82) for the ERA score and 3.19 (SD = 0.59) for the checklist. Mean feasibility was rated 3.38(SD = 0.85) and 2.92 (SD = 0.76) for the ERA score and checklist, respectively. The adoption rate was 50% (19/38) among clinicians, but the reach was low at 17% (49/289) of eligible patients. CONCLUSIONS This pilot study evaluated the implementation of an intervention that introduced the ERA score and CERTAIN checklist into a primary care practice. Results indicate moderate acceptability, appropriateness, and feasibility of the ERA score, and similar ratings for the checklist, with slightly lower feasibility. While checklist adoption was moderate, reach was limited, indicating inconsistent use. RECOMMENDATIONS We plan to use the open-ended resurvey responses to further modify the CERTAIN-FM checklist and implementation process. The ADAPT-ITT framework is a useful model for adapting the checklist to meet the primary care clinician needs.
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English M, Oliwa J, Khalid K, Onyango O, Willows TM, Mazhar R, Mkumbo E, Guinness L, Schell CO, Baker T, McKnight J. Hospital care for critical illness in low-resource settings: lessons learned during the COVID-19 pandemic. BMJ Glob Health 2023; 8:e013407. [PMID: 37918869 PMCID: PMC10626868 DOI: 10.1136/bmjgh-2023-013407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/08/2023] [Indexed: 11/04/2023] Open
Abstract
Care for the critically ill patients is often considered synonymous with a hospital having an intensive care unit. However, a focus on Essential Emergency and Critical Care (EECC) may obviate the need for much intensive care. Severe COVID-19 presented a specific critical care challenge while also being an exemplar of critical illness in general. Our multidisciplinary team conducted research in Kenya and Tanzania on hospitals' ability to provide EECC as the COVID-19 pandemic unfolded. Important basic inputs were often lacking, especially sufficient numbers of skilled health workers. However, we learnt that higher scores on resource readiness scales were often misleading, as resources were often insufficient or not functional in all the clinical areas they are needed. By following patient journeys, through interviews and group discussions, we revealed gaps in timeliness, continuity and delivery of care. Generic challenges in transitions between departments were identified in the receipt of critically ill patients, the ability to sustain monitoring and treatment and preparation for any subsequent transition. While the global response to COVID-19 focused initially on providing technologies and training, first ventilators and later oxygen, organisational and procedural challenges seemed largely ignored. Yet, they may even be exacerbated by new technologies. Efforts to improve care for the critically ill patients, which is a complex process, must include a whole system and whole facility view spanning all areas of patients' care and their transitions and not be focused on a single location providing 'critical care'. We propose a five-part strategy to support the system changes needed.
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Affiliation(s)
- Mike English
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacquie Oliwa
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
| | - Karima Khalid
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Onesmus Onyango
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
| | - Tamara Mulenga Willows
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rosanna Mazhar
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, London, London, UK
- Centre for Global Development, London, UK
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Karolinska Institute, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Jacob McKnight
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Sun Y, Kashyap R, Heise K, Castillo Zambrano C, Niven A, Gajic O, Dong Y. Digital Delivery of a Global Critical Care Education Program. ATS Sch 2023; 4:198-206. [PMID: 37538073 PMCID: PMC10394714 DOI: 10.34197/ats-scholar.2022-0086in] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 01/25/2023] [Indexed: 08/05/2023] Open
Abstract
Background CERTAIN (Checklist for Early Recognition and Treatment of Acute Illness and iNjury) education program was developed to accelerate the global dissemination of a standardized, systemic, structured approach to critical care delivery. The coronavirus disease (COVID-19) pandemic prompted the evolution of this program from a live in-person course to a blended synchronous and asynchronous learning experience, including virtual simulation. Objectives We describe our experience and insights gained through this digital program transformation and highlight areas in need of further research to advance the delivery of high-quality online education offerings to global interprofessional audiences. Methods The CERTAIN education program was delivered to a broad international audience first in person (2016-2019) and then virtually during the COVID-19 global pandemic (2020-present). During this transition, we adopted a flipped classroom model to deliver the core content asynchronously using an online learning management system, supplemented by a novel synchronous online experience to provide learners with the opportunity to apply these concepts using a series of simulated clinical cases. Results A total of 400 participants attended 11 CERTAIN courses. We transitioned our 10-hour live course to a 3-hour virtual workshop. The duration of simulation activities (admission, rounding, and shared decision-making) remained constant. Didactic lectures were eliminated from the synchronous online course and presented as recorded videos in precourse materials. We collected 306 postcourse surveys (response rate, 76.5%). The majority of the overall course ratings were excellent (147 [49.5%]) and very good (97 [32.7%]), and learner responses were similar to live and online courses. Simulation activities were consistently the most popular elements of our program. Access to digital learning platforms and language barriers during simulation activities proved to be the greatest challenges during our transition. Delivering mobile-friendly online content and close coordination between dedicated bilingual faculty and local champions helped overcome these challenges. Conclusion Critical care education and case-based simulation workshops can be delivered to international interprofessional audiences with similar, high degrees of learner satisfaction to in-person offerings.
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Affiliation(s)
- Yuqiang Sun
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine
- Multidisciplinary Epidemiology and
Translational Research in Intensive Care, and
- Emergency Department, the First Affiliated
Hospital of China Medical University, Shenyang, China
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and
Translational Research in Intensive Care, and
- Department of Anesthesiology and
Perioperative Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Katherine Heise
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine
| | - Claudia Castillo Zambrano
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine
- Multidisciplinary Epidemiology and
Translational Research in Intensive Care, and
| | - Alexander Niven
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine
- Multidisciplinary Epidemiology and
Translational Research in Intensive Care, and
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine
- Multidisciplinary Epidemiology and
Translational Research in Intensive Care, and
| | - Yue Dong
- Multidisciplinary Epidemiology and
Translational Research in Intensive Care, and
- Department of Anesthesiology and
Perioperative Medicine, Mayo Clinic, Rochester, Minnesota; and
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Endeshaw AS, Fekede MS, Gesso AS, Aligaz EM, Aweke S. Survival status and predictors of mortality among patients admitted to surgical intensive care units of Addis Ababa governmental hospitals, Ethiopia: A multicenter retrospective cohort study. Front Med (Lausanne) 2023; 9:1085932. [PMID: 36816723 PMCID: PMC9932811 DOI: 10.3389/fmed.2022.1085932] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/21/2022] [Indexed: 02/05/2023] Open
Abstract
Introduction Critical care is a serious global healthcare burden. Although a high number of surgical patients are being admitted to the surgical intensive care unit (SICU), the mortality remained high, particularly in low and middle-income countries. However, there is limited data in Ethiopia. Therefore, this study aimed to investigate the survival status and predictors of mortality in surgical patients admitted to the SICUs of Addis Ababa governmental hospitals, Ethiopia. Methods A multicenter retrospective cohort study was conducted on 410 surgical patients admitted to the SICUs of three government hospitals in Addis Ababa selected using a simple random sampling from February 2017 to February 2020. The data were entered into Epidata version 4.6 and imported to STATA/MP version 16 for further analysis. Bi-variable and multivariable Cox regression models were fitted in the analysis to determine the predictor variables. A hazard ratio (HR) with a 95% confidence interval (CI) was computed, and variables with a p-value <0.05 were considered statistically significant. Results From a sample of 410 patients, 378 were included for final analysis and followed for a median follow-up of 5 days. The overall mortality among surgical patients in the SICU was 44.97% with an incidence rate of 5.9 cases per 100 person-day observation. Trauma (AHR = 1.83, 95% CI: 1.19-2.08), Glasgow coma score (GCS) <9 (AHR = 2.06, 95% CI: 1.28-3.31), readmission to the SICU (AHR = 3.52, 95% CI: 2.18-5.68), mechanical ventilation (AHR = 2.52, 95% CI: 1.23-5.15), and creatinine level (AHR = 1.09, 95% CI: 1.01-1.18) were found to be significantly associated with mortality in the SICU. Conclusion The mortality of surgical patients in the SICU was high. Trauma, GCS <9 upon admission, readmission to the SICU, mechanical ventilation, and increased in the creatinine level on admission to the SICU were the identified predictors of mortality in the SICU.
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Affiliation(s)
- Amanuel Sisay Endeshaw
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Mulualem Sitot Fekede
- Department of Anesthesia, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia,*Correspondence: Mulualem Sitot Fekede, ✉
| | - Ashenafi Seifu Gesso
- Department of Anesthesia, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Esubalew Muluneh Aligaz
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Senait Aweke
- Department of Anesthesia, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Dendir G, Awoke N, Alemu A, Sintayhu A, Eanga S, Teshome M, Zerfu M, Tila M, Dessu BK, Efa AG, Gashaw A. Factors Associated with the Outcome of a Pediatric Patients Admitted to Intensive Care Unit in Resource-Limited Setup: Cross-Sectional Study. Pediatric Health Med Ther 2023; 14:71-79. [PMID: 36890923 PMCID: PMC9987449 DOI: 10.2147/phmt.s389404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/24/2023] [Indexed: 03/06/2023] Open
Abstract
Background Critical care is a multidisciplinary and interprofessional specialty devoted to treating patients who already have or are at danger of developing acute, life-threatening organ dysfunction. Due to the higher disease load and mortality from preventable illness, patient outcomes in intensive care units are challenging in settings with inadequate resources. This study aimed to determine factors associated with outcomes of pediatric patients admitted to intensive care units. Methods A cross-sectional study was conducted at Wolaita Sodo and Hawassa University teaching hospitals in southern Ethiopia. Data were entered and analyzed using SPSS version 25. Normality tests using the Shapiro-Wilk and Kolmogorov-Smirnov data were normally distributed. The frequency, percentage, and cross-tabulation of the different variables were then determined. Finally, the magnitude and associated factors were first analyzed using binary logistic regression and then multivariate logistic regression. Statistical significance was set at P < 0.05. Results A total of 396 Pediatric ICU patients were included in this study, and 165 (41.7%) deaths were recorded. The odds of patients from urban areas (AOR = 45%, CI 95%: 8%, 67% p-value = 0.025) were less likely to die than those in rural areas. Patients with co morbidities (AOR = 9.4, CI 95%: 4.5, 19.7, p = 0.000) were more likely to die than pediatric patients with no co-morbidities. Patients admitted with Acute respiratory distress syndrome (AOR = 12.86, CI 95%: 4.3, 39.2, p = 0.000) were more likely to die than those with not. Pediatric patients on mechanical ventilation (AOR = 3, CI 95%: 1.7, 5.9, p = 0.000) more likely to die than not mechanically ventilated. Conclusion Mortality of paediatric ICU patients was high (40.7%) in this study. Co-morbid disease, residency, the use of inotropes, and the length of ICU stay were all statistically significant predictors of death.
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Affiliation(s)
- Getahun Dendir
- School of Anesthesia, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Nefsu Awoke
- School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Afework Alemu
- School of Medicine, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Ashagrie Sintayhu
- School of Anesthesia, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Shamill Eanga
- College of Health Science and Medicine, Wolkite University, Wolkite, Ethiopia
| | - Mistire Teshome
- School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Mahlet Zerfu
- School of Medicine, College of Health Science and Medicine, Yekatit 12 Medical College, Addis Ababa, Ethiopia
| | - Mebratu Tila
- School of Anesthesia, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Blen Kassahun Dessu
- School of Anesthesia, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Amelework Gonfa Efa
- School of Medicine, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Amanu Gashaw
- Department of Anesthesia, College of Health Science and Medicine, Hawassa University, Hawassa, Ethiopia
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11
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Kwizera A, Sendagire C, Kamuntu Y, Rutayisire M, Nakibuuka J, Muwanguzi PA, Alenyo-Ngabirano A, Kyobe-Bosa H, Olaro C. Building Critical Care Capacity in a Low-Income Country. Crit Care Clin 2022; 38:747-759. [PMID: 36162908 PMCID: PMC9507099 DOI: 10.1016/j.ccc.2022.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Critical illness is common throughout the world and is associated with high costs of care and resource intensity. The Corona virus disease 2019 (COVID-19) pandemic created a sudden surge of critically ill patients, which in turn led to devastating effects on health care systems worldwide and more so in Africa. This narrative report describes how an attempt was made at bridging the existing gaps in quality of care for critically ill patients at national and regional levels for COVID and the postpandemic era in a low income country.
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Affiliation(s)
- Arthur Kwizera
- Department of Anaesthesia and Critical Care, Makerere University, College of Health Sciences, Plot 1 Upper Mulago Hill Road, P O Box 2191, Kampala, Uganda,Corresponding author
| | - Cornelius Sendagire
- Department of Anaesthesia and Critical Care, Makerere University, College of Health Sciences, Plot 1 Upper Mulago Hill Road, P O Box 2191, Kampala, Uganda
| | - Yewande Kamuntu
- Clinton Health Access Initiative, Plot 8a, Moyo Close, P O Box 2191, Kampala, Uganda
| | - Meddy Rutayisire
- Department of Anaesthesia and Critical Care, Makerere University, College of Health Sciences, Plot 1 Upper Mulago Hill Road, P O Box 2191, Kampala, Uganda
| | - Jane Nakibuuka
- Department of Medicine, Intensive Care Unit, Mulago National Referral Hospital, Plot 1 Upper Mulago Hill Road, P O Box 2191, Kampala, Uganda
| | - Patience A. Muwanguzi
- Department of Nursing, College of Health Sciences, Makerere University, Plot 1 Upper Mulago Hill Road, P O Box 2191, Kampala, Uganda
| | | | - Henry Kyobe-Bosa
- Ministry of Health, Plot 6 Lourdel Road, P O Box 2191, Wandegeya, Kampala, Uganda,Uganda Peoples Defense Forces, Chwa II Road, Mbuya , P O Box 2191, Kampala, Uganda,Kellogg College, University of Oxford, 60-62 Banbury Road, Park Town, Oxford OX2 6PN, United Kingdom
| | - Charles Olaro
- Ministry of Health, Plot 6 Lourdel Road, P O Box 2191, Wandegeya, Kampala, Uganda
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12
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Soni KD, Bansal V, Arora H, Verma S, Wärnberg MG, Roy N. The State of Global Trauma and Acute Care Surgery/Surgical Critical Care. Crit Care Clin 2022; 38:695-706. [PMID: 36162905 DOI: 10.1016/j.ccc.2022.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Trauma is a leading cause of morbidity and mortality globally, with a significant burden attributable to the low- and middle-income countries (LMICs), where more than 90% of injury-related deaths occur. Road injuries contribute largely to the economic burden from trauma and are prevalent among adolescents and young adults. Trauma systems vary widely across the world in their capacity of providing basic and critical care to injured patients, with delays in treatment being present at multiple levels at LMICs. Strengthening existing systems by providing cost-effective and efficient solutions can help mitigate the injury burden in LMICs.
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Affiliation(s)
- Kapil Dev Soni
- Critical & Intensive Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, Ring Road, Raj Nagar, Safdarjung Enclave, New Delhi, Delhi 110029, India
| | - Varun Bansal
- Department of General Surgery, 2nd Floor Registration Building, Seth G.S.M.C. and K.E.M. Hospital, Parel, Mumbai 400012, India
| | - Harshit Arora
- Department of Surgery, Punjab Institute of Medical Sciences, Gadha Road, Jalandhar, Punjab 144006, India
| | - Sukriti Verma
- Department of Blood Bank, Guru Teg Bahadur Hospital, Tahirpur Rd, GTB Enclave, Dilshad Garden, New Delhi, Delhi 110095, India; WHO Collaborating Center for Research on Surgical Care Delivery in LMICs, Department of Surgery, BARC Hospital, Anushaktinagar, Mumbai 400094, India
| | - Martin Gerdin Wärnberg
- Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18, 171 65 Solna, Stockholm 171 65, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, SE - 171 76, Stockholm, Sweden
| | - Nobhojit Roy
- WHO Collaborating Center for Research on Surgical Care Delivery in LMICs, Department of Surgery, BARC Hospital, Anushaktinagar, Mumbai 400094, India; The George Institute of Global Health India, F-BLOCK, 311-312, Third Floor, Jasola Vihar, New Delhi, Delhi 110025, India.
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13
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Ferreira JC, Moreira TCL, de Araújo AL, Imamura M, Damiano RF, Garcia ML, Sawamura MV, Pinna FR, Guedes BF, Gonçalves FAR, Mancini M, Burdmann EA, da Silva Filho DF, Polizel JL, Bento RF, Rocha V, Nitrini R, de Souza HP, Levin AS, Kallas EG, Forlenza OV, Busatto GF, Batistella LR, de Carvalho CRR, Mauad T, Gouveia N. Clinical, sociodemographic and environmental factors impact post-COVID-19 syndrome. J Glob Health 2022; 12:05029. [PMID: 35939273 PMCID: PMC9359428 DOI: 10.7189/jogh.12.05029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Sociodemographic and environmental factors are associated with incidence, severity, and mortality of COVID-19. However, little is known about the role of such factors in persisting symptoms among recovering patients. We designed a cohort study of hospitalized COVID-19 survivors to describe persistent symptoms and identify factors associated with post-COVID-19 syndrome. Methods We included patients hospitalized between March to August 2020 who were alive six months after hospitalization. We collected individual and clinical characteristics during hospitalization and at follow-up assessed ten symptoms with standardized scales, 19 yes/no symptoms, a functional status and a quality-of-life scale and performed four clinical tests. We examined individual exposure to greenspace and air pollution and considered neighbourhood´s population density and socioeconomic conditions as contextual factors in multilevel regression analysis. Results We included 749 patients with a median follow-up of 200 (IQR = 185-235) days, and 618 (83%) had at least one of the ten symptoms measured with scales. Pain (41%), fatigue (38%) and posttraumatic stress disorder (35%) were the most frequent. COVID-19 severity, comorbidities, BMI, female sex, younger age, and low socioeconomic position were associated with different symptoms. Exposure to ambient air pollution was associated with higher dyspnoea and fatigue scores and lower functional status. Conclusions We identified a high frequency of persistent symptoms among COVID-19 survivors that were associated with clinical, sociodemographic, and environmental variables. These findings indicate that most patients recovering from COVID-19 will need post-discharge care, and an additional burden to health care systems, especially in LMICs, should be expected.
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Affiliation(s)
- Juliana Carvalho Ferreira
- Divisao de Pneumologia, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil.,Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brasil
| | - Tiana C Lopes Moreira
- Departamento de Patologia, LIM/05- Laboratório de Poluição Atmosférica Experimental, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Adriana Ladeira de Araújo
- Diretoria Executiva dos LIMs, Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Marta Imamura
- Instituto de Medicina fisica e Reabilitação do Hospital das Clinicas, Departamento de Medicina Legal, Etica Médica e Medicina Social e do Trabalho, Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Rodolfo F Damiano
- Departamento e Instituto de Psiquiatria, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Michelle L Garcia
- Divisao de Pneumologia, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil
| | - Marcio Vy Sawamura
- Departamento de Radiologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Fabio R Pinna
- Departamento de Oftalmologia e Otorrinolaringologia, Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Bruno F Guedes
- Departamento de Neurologia, Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Fabio A Rodrigues Gonçalves
- Departamento de Cardiopneumologia, Laboratório de Cirurgia Cardiovascular e Fisiopatologia da Circulação, Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Marcio Mancini
- Unidade de Obesidade e Síndrome Metabólica, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Emmanuel A Burdmann
- Departamento de Clínica Médica, LIM/12 - Laboratório de Pesquisa Básica em Doenças Renais, Disciplina de Nefrologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Jefferson Lordello Polizel
- Departamento de Ciências Florestais-ESALQ/USP, Laboratório de Métodos Quantitativos, Universidade de São Paulo, Piracicaba, SP, Brasil
| | - Ricardo F Bento
- Departamento de Oftalmologia e Otorrinolaringologia, Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil.,Divisão de Otorrinolaringologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Vanderson Rocha
- Serviço de Hematologia, Hemoterapia e Terapia Celular, Divisão de Clínica Médica I do ICHC, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Ricardo Nitrini
- Departamento de Neurologia, Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Heraldo Possolo de Souza
- Departamento de Clínica Médica, Disciplina de Emergências Clínicas, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Anna S Levin
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Esper G Kallas
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Orestes V Forlenza
- Departamento e Instituto de Psiquiatria, Laboratório de Neurociências - LIM-27, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Geraldo F Busatto
- Diretoria Executiva dos LIMs, Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil.,Departamento e Instituto de Psiquiatria, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Linamara R Batistella
- Instituto de Medicina fisica e Reabilitação do Hospital das Clinicas, Departamento de Medicina Legal, Etica Médica e Medicina Social e do Trabalho, Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Carlos R Ribeiro de Carvalho
- Divisao de Pneumologia, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil
| | - Thais Mauad
- Departamento de Patologia, LIM/05- Laboratório de Poluição Atmosférica Experimental, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
| | - Nelson Gouveia
- Departamento de Medicina Preventiva, Faculdade de Medicina da Universidade de São Paulo HCFMUSP, São Paulo, SP, Brasil
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14
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Kariuki-Barasa I, Adam MB. Living on the Edge of Possibility. Crit Care Clin 2022; 38:853-863. [DOI: 10.1016/j.ccc.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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15
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Holmaas G, Abate A, Woldetsadik A, Hevrøy O. Establishing a sustainable training programme in anaesthesia in Ethiopia. Acta Anaesthesiol Scand 2022; 66:1016-1023. [PMID: 35749233 PMCID: PMC9541354 DOI: 10.1111/aas.14106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/09/2022] [Accepted: 06/16/2022] [Indexed: 11/29/2022]
Abstract
Background Lack of qualified staff is a major hindrance for quality and safety improvements in anaesthesia and critical care in many low‐income countries. Support in specialist training may enhance perioperative treatment and have a positive downstream impact on other hospital services, which may improve the overall standard of care. Methods Between 2011 and 2019, consultant anaesthetists from Haukeland University Hospital in Norway supported a postgraduate anaesthesia‐training programme at Addis Ababa University/Tikur Anbessa Specialised Hospital in Ethiopia. The aim of the programme was to build a self‐sustainable work force of anaesthetists across the country who could perform high quality anaesthesia within the confinement of limited local resources. Over the course of 10 years, an almost continuous rotation of experienced anaesthetists and intensivists assisted training of Ethiopian residents in anaesthesia and critical care. Local specialists organised the programme; however, external support was necessary during this period to establish a sustainable training programme. Results Since the programme's commencement at Addis Ababa University in 2011, 159 residents have entered the programme and 71 have graduated. As the number of qualified anaesthetists increased, Ethiopian specialists gradually obtained responsibility for the programme. Candidates are recruited from various regions and from neighbouring countries. Five other Ethiopian training sites have been established. To date (May 2022), 112 residents have completed their training in Ethiopia, and 195 residents expect to graduate within 3 years. Conclusion Nearly 11 years after establishment of the programme, locally trained highly qualified anaesthetists work in Ethiopia's major hospitals throughout the country.
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Affiliation(s)
- Gunhild Holmaas
- Department of Surgical Services, Haukeland University Hospital, Bergen, Norway
| | - Ananya Abate
- Department of Anesthesiology, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | | | - Olav Hevrøy
- Department of Surgical Services, Haukeland University Hospital, Bergen, Norway
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16
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Gupta M, Agrawal N, Sharma SK, Ansari AK, Mahmood T, Singh L. Study of Utility of Basic Arterial Blood Gas Parameters and Lactate as Prognostic Markers in Patients With Severe Dengue. Cureus 2022; 14:e24682. [PMID: 35663676 PMCID: PMC9163704 DOI: 10.7759/cureus.24682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 01/15/2023] Open
Abstract
Background The importance of prognostication in critical care cannot be over-emphasized, especially in the context of diseases like dengue, as their presentation may vary from mild fever to critical life-threatening illness. With the help of prognostic markers, it is possible to identify patients at higher risk and thus improve their outcome with timely intervention. Basic arterial blood gas (ABG) parameters, i.e., potential of hydrogen (pH), partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2) and bicarbonate are useful parameters, especially in critical care medicine as they are known to vary with the severity of illness. Hyperlactatemia is often referred to as a “powerful predictor of mortality”. Basic ABG parameters and lactate have been used as an essential prognostic modality in critically ill patients for decades; however, the evidence remains limited for their role as prognostic markers in patients with severe dengue. Method We carried out an observational retrospective cohort study comprising 163 patients with severe dengue, admitted between July 2021 and November 2021 at Medical Intensive Care Unit (MICU) of Shri Ram Murti Smarak Institute of Medical Sciences (SRMS IMS), Bareilly, Uttar Pradesh, India. Basic ABG parameters and lactate levels at the time of admission to MICU were compared between survivor and non-survivor groups of patients with severe dengue in order to evaluate their prognostic utility as predictors of mortality. Results pH (p<0.0001), PO2 (p=0.01) and bicarbonate (<0.0001) levels were significantly lower, while PCO2 (p=0.002) and lactate (p<0.0001) levels were significantly higher in non-survivor group as compared to survivor group. Lactate was found to be the best prognostic marker with Area Under the Curve (AUC) of 88.7% on Receiver Operating Characteristics (ROC) analysis. Conclusion Basic arterial blood gas parameters and lactate can be used as feasible prognostic markers in patients with severe dengue.
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17
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Tannor EK, Bieber B, Aylward R, Luyckx V, Shah DS, Liew A, Evans R, Phiri C, Guedes M, Pisoni R, Robinson B, Caskey F, Jha V, Pecoits-Filho R, Dreyer G. The COVID-19 pandemic identifies significant global inequities in hemodialysis care in Low and Lower Middle-Income countries - an ISN/DOPPS survey. Kidney Int Rep 2022; 7:971-982. [PMID: 35291393 PMCID: PMC8912976 DOI: 10.1016/j.ekir.2022.02.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/25/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Ryan Aylward
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Valerie Luyckx
- Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- University Children’s Hospital, Zurich, Switzerland
| | - Dibya Singh Shah
- Department of Nephrology and Transplant Medicine, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Adrian Liew
- Mount Elizabeth Novena Hospital, Singapore, Singapore
| | - Rhys Evans
- Department of Transplantation, Renal Medicine, University College London, Royal Free Hospital, London, UK
| | | | - Murilo Guedes
- Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Fergus Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
- Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
- Correspondence: Roberto Pecoits-Filho, Arbor Research Collaborative for Health, 3700 Earhart Road, Ann Arbor, MI 48105, USA.
| | - Gavin Dreyer
- Department of Renal Medicine, Barts Health NHS Trust, London, UK
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18
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Macey A, O'Reilly G, Williams G, Cameron P. Critical care nursing role in low and lower middle-income settings: a scoping review. BMJ Open 2022; 12:e055585. [PMID: 34983772 PMCID: PMC8728409 DOI: 10.1136/bmjopen-2021-055585] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 12/07/2021] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES A scoping review was conducted to answer the question: How is critical care nursing (CCN) performed in low-income countries and lower middle-income countries (LICs/LMICs)? DESIGN Scoping review guided by the JBI Manual for Evidence Synthesis. DATA SOURCES Six electronic databases and five web-based resources were systematically searched to identify relevant literature published between 2010 and April 2021. REVIEW METHODS The search results received two-stage screening: (1) title and abstract (2) full-text screening. For sources of evidence to progress, agreement needed to be reached by two reviewers. Data were extracted and cross-checked. Data were analysed, sorted by themes and mapped to region and country. RESULTS Literature was reported across five georegions. Nurses with a range formal and informal training were identified as providing critical care. Availability of staff was frequently reported as a problem. No reports provided a comprehensive description of CCN in LICs/LMICs. However, a variety of nursing practices and non-clinical responsibilities were highlighted. Availability of equipment to fulfil the nursing role was widely discussed. Perceptions of inadequate resourcing were common. Undergraduate and postgraduate-level preparation was poorly described but frequently reported. The delivery of short format critical care courses was more fully described. There were reports of educational evaluation, especially regarding internationally supported initiatives. CONCLUSIONS Despite commonalities, CCN is unique to regional and socioeconomic contexts. Nurses work within a complex team, yet the structure and skill levels of such teams will vary according to patient population, resources and treatments available. Therefore, a universal definition of the CCN role in LIC/LMIC health systems is likely unhelpful. Research to elucidate current assets, capacity and needs of nurses providing critical care in specific LIC/LMIC contexts is needed. Outputs from such research would be invaluable in supporting contextually appropriate capacity development programmes.
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Affiliation(s)
- Andy Macey
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- The Learning Hub, Peninsula Health, Frankston, Victoria, Australia
| | - Gerard O'Reilly
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Ged Williams
- School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia
| | - Peter Cameron
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
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Singh M, Maharaj R, Allorto N, Wise R. Profile of referrals to an intensive care unit from a regional hospital emergency centre in KwaZulu-Natal. Afr J Emerg Med 2021; 11:471-476. [PMID: 34804783 PMCID: PMC8581501 DOI: 10.1016/j.afjem.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction The objective was to describe the clinical characteristics, disease profile and outcome of patients referred from a regional hospital Emergency Centre (EC) to the Intensive Care Unit (ICU). Methods A retrospective review was performed using data extracted from the Integrated Critical Care Electronic Database (iCED). Data were extracted from the database with respect to patient characteristics, Society of Critical Care Medicine (SCCM) grading, and outcome of the ICU referral. Modified early warning scores (MEWS) were calculated from EC referral data. Results There were a total of 2187 referrals. Of these, 56.3% (1231/2187) were male. The mean age of referrals was 36 years. Of the referred patients, 41.5% (907/2187) were initially accepted for admission. A further 378 patients were accepted for admission after a follow up ICU review. Medical conditions accounted for the majority of patient referrals, followed by general surgery and trauma. Most patients initially accepted to ICU were classified as SCCM I and II and had a mean MEWS of 4. Almost half of the patients experienced a delay in admission, most commonly due to a lack of ICU bed availability. ICU mortality was 13.6% for patients admitted from the EC. Discussion The EC population referred to the ICU was young with a high burden of medical and trauma conditions. Decisions to accept patients to ICU are limited by available resources, and there was a need to apply ICU triage criteria. Delays in the transfer of ICU patients from the EC increase the workload and contribute to EC crowding.
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Affiliation(s)
- Mika Singh
- Division of Emergency Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Corresponding author.
| | - Roshen Maharaj
- Division of Emergency Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Emergency Medicine, Livingstone Tertiary Hospital, Port Elizabeth, South Africa
| | - Nikki Allorto
- Pietermaritzburg Burn Service, Pietermaritzburg Metropolitan Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - Robert Wise
- Discipline of Anaesthesia and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
- Adult Intensive Care Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Schultz MJ, Roca O, Shrestha GS. Global lessons learned from COVID-19 mass casualty incidents. Br J Anaesth 2021; 128:e97-e100. [PMID: 34865825 PMCID: PMC8590954 DOI: 10.1016/j.bja.2021.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 12/15/2022] Open
Abstract
With healthcare systems rapidly becoming overwhelmed and occupied by patients during a pandemic, effective and safe care for patients is easily compromised. During the course of the current pandemic, numerous treatment guidelines have been developed and published that have improved care for patients with COVID-19. Certain lessons have only been learned during the course of the outbreak, from which we can learn for future pandemics. This editorial aims to raise awareness about the importance of timely stockpiling of sufficient amounts of personal protection equipment and medications, adequate oxygen supplies, uninterrupted electricity, and fair locally adapted triage strategies.
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Affiliation(s)
- Marcus J Schultz
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Vall d'Hebron, Barcelona, Spain; Ciber Enfermedades Respiratorias (CibeRes), Instituto de Salud Carlos III, Madrid, Spain
| | - Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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21
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Capacity and use of diagnostics and treatment for patients with severe acute respiratory infections in the pre-COVID-19 era in district and provincial hospitals in Viet Nam. Western Pac Surveill Response J 2021; 12:1-9. [PMID: 35251746 PMCID: PMC8873919 DOI: 10.5365/wpsar.2021.12.4.835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective To describe the burden of severe acute respiratory infection (SARI) and the infrastructure and current practices of SARI management in hospitals in Viet Nam. Methods We conducted a short observational study at critical care units (CCUs) in 32 district hospitals and 16 provincial hospitals in five provinces in Viet Nam from March to July 2019. We collected data on hospital equipment and medicines used in SARI management. At the patient level, data were collected for 14 consecutive days on all patients presenting to CCUs, including information on demographics, intervention and treatment within 24 hours of CCU admission and 7-day outcome. Results There were significant differences between district and provincial hospitals in the availability of microbial culture, rapid influenza diagnostic tests, inflammatory markers and mechanical ventilation. Among 1722 eligible patients admitted to CCUs, there were 395 (22.9%) patients with SARI. The median age of SARI patients was 74 (interquartile range: 58–84) years; 49.1% were male. Although systemic antibiotics were available in all hospitals and were empirically given to 93.4% of patients, oseltamivir was available in 25% of hospitals, and only 0.5% of patients received empiric oseltamivir within 24 hours of admission. The 7-day mortality was 6.6% (26/395). Independent factors associated with 7-day mortality were septic shock and requiring respiratory support within 24 hours of admission. Discussion SARI is a major burden on CCUs in Viet Nam. Barriers to delivering quality care include the limited availability of diagnostics and medication and non-protocolized management of SARI in CCUs.
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Schell CO, Khalid K, Wharton-Smith A, Oliwa J, Sawe HR, Roy N, Sanga A, Marshall JC, Rylance J, Hanson C, Kayambankadzanja RK, Wallis LA, Jirwe M, Baker T. Essential Emergency and Critical Care: a consensus among global clinical experts. BMJ Glob Health 2021; 6:e006585. [PMID: 34548380 PMCID: PMC8458367 DOI: 10.1136/bmjgh-2021-006585] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/19/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. METHODS In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements. RESULTS The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19. CONCLUSION The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.
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Affiliation(s)
- Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Internal Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Karima Khalid
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Alexandra Wharton-Smith
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jacquie Oliwa
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics & Child Health, University of Nairobi, Nairobi, Kenya
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Nobhojit Roy
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- The George Institute for Global Health India, New Delhi, India
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, BARC Hospital, Mumbai, India
| | - Alex Sanga
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, United Republic of Tanzania
| | - John C Marshall
- Departments of Surgery and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jamie Rylance
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK
| | - Raphael K Kayambankadzanja
- Department of Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Maria Jirwe
- Department of Health Sciences, The Red Cross University College, Huddinge, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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23
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Lim AG, Kivlehan S, Losonczy LI, Murthy S, Dippenaar E, Lowsby R, Yang MLCLC, Jaung MS, Stephens PA, Benzoni N, Sefa N, Bartlett ES, Chaffay BA, Haridasa N, Velasco BP, Yi S, Contag CA, Rashed AL, McCarville P, Sonenthal PD, Shukur N, Bellou A, Mickman C, Ghatak-Roy A, Ferreira A, Adhikari NK, Reynolds T. Critical care service delivery across healthcare systems in low-income and low-middle-income countries: protocol for a systematic review. BMJ Open 2021; 11:e048423. [PMID: 34462281 PMCID: PMC8407204 DOI: 10.1136/bmjopen-2020-048423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Critical care in low-income and low-middle income countries (LLMICs) is an underdeveloped component of the healthcare system. Given the increasing growth in demand for critical care services in LLMICs, understanding the current capacity to provide critical care is imperative to inform policy on service expansion. Thus, our aim is to describe the provision of critical care in LLMICs with respect to patients, providers, location of care and services and interventions delivered. METHODS AND ANALYSIS We will search PubMed/MEDLINE, Web of Science and EMBASE for full-text original research articles available in English describing critical care services that specify the location of service delivery and describe patients and interventions. We will restrict our review to populations from LLMICs (using 2016 World Bank classifications) and published from 1 January 2008 to 1 January 2020. Two-reviewer agreement will be required for both title/abstract and full text review stages, and rate of agreement will be calculated for each stage. We will extract data regarding the location of critical care service delivery, the training of the healthcare professionals providing services, and the illnesses treated according to classification by the WHO Universal Health Coverage Compendium. ETHICS AND DISSEMINATION Reviewed and exempted by the Stanford University Office for Human Subjects Research and IRB on 20 May 2020. The results of this review will be disseminated through scholarly publication and presentation at regional and international conferences. This review is designed to inform broader WHO, International Federation for Emergency Medicine and partner efforts to strengthen critical care globally. PROSPERO REGISTRATION NUMBER CRD42019146802.
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Affiliation(s)
- Andrew George Lim
- Section of Critical Care Medicine, Virginia Mason Medical Center, Seattle, Washington, USA
- Division of Critical Care Medicine, Stanford University, Stanford, California, USA
| | - Sean Kivlehan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard University, Cambridge, Massachusetts, USA
| | - Lia Ilona Losonczy
- Department of Emergency Medicine, Department of Anaesthesia & Critical Care Medicine, The George Washington University Medical Center, Washington, District of Columbia, USA
| | - Srinivas Murthy
- Department of Paediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Enrico Dippenaar
- Emergency Medicine Research Group, Anglia Ruskin University, Chelmsford, Essex, UK
| | - Richard Lowsby
- Department of Critical Care Medicine, Department of Emergency Medicine, Mid Cheshire Hospitals NHS Foundation Trust, Cheshire, Cheshire, UK
| | - Marc Li Chuan L C Yang
- Accident and Emergency Medicine, The Chinese University of Hong Kong Faculty of Medicine, Hong Kong, Hong Kong
| | - Michael S Jaung
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - P Andrew Stephens
- Department of Emergency Medicine, Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nicole Benzoni
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Nana Sefa
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Brandon Alexander Chaffay
- Department of Emergency Medicine, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Naeha Haridasa
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Bernadett Pua Velasco
- Department of Emergency Medicine, East Avenue Medical Center, Quezon City, National Capital Region, Philippines
| | - Sojung Yi
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Caitlin A Contag
- Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Amir Lotfy Rashed
- Department of Emergency Medicine, Jacobi Medical Center, Bronx, New York, USA
| | - Patrick McCarville
- Department of Emergency Medicine, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Paul D Sonenthal
- Division of Pulmonary & Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Nebiyu Shukur
- Department of Emergency Medicine, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Abdelouahab Bellou
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Carl Mickman
- Department of Emergency Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Adhiti Ghatak-Roy
- Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Allison Ferreira
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Neill Kj Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
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Kim KC, Tadrous M, Kane-Gill SL, Barbash IJ, Rothenberger S, Suda KJ. Changes in Purchases for Intensive Care Medicines During the COVID-19 Pandemic: A Global Time Series Study. Chest 2021; 160:2123-2134. [PMID: 34389295 PMCID: PMC8421073 DOI: 10.1016/j.chest.2021.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Drug supply disruptions have increased during the COVID-19 pandemic, especially for medicines used in the intensive care unit (ICU). Despite reported shortages in wealthy countries, global analyses of ICU drug purchasing during COVID-19 are limited. RESEARCH QUESTION Has COVID-19 impacted global drug purchases of first, second- and third-choice agents used in intensive care? STUDY DESIGN AND METHODS We conducted a cross-sectional time series study in a global pharmacy sales dataset comprising approximately 60% of the world's population. We analyzed pandemic-related changes in units purchased per 1,000 population for 69 ICU agents. Interventional autoregressive integrated moving average (ARIMA) models tested for significant changes when the pandemic was declared (March 2020) and during its first stage from April to August 2020, globally and by development status. RESULTS Relative to 2019, ICU drug purchases increased by 23.6% (95% CI: 7.9-37.9%) in March 2020 (P-value<0.001), and then decreased by 10.3% (95% CI:-16.9 to -3.5%) from April to August (P-value=0.006). Purchases for second-choice medicines changed the most, especially in developing countries (e.g.: 45.8% increase in March 2020). Despite similar relative changes (P-value=0.88), absolute purchasing rates in developing nations remained low. The observed decrease from April to August 2020 was only significant in developed countries (-13.1%; 95% CI: -17.4 to -4.4%; P-value< 0.001). Country-level variation appeared unrelated to expected demand and healthcare infrastructure. INTERPRETATION Purchases for intensive care medicines increased globally in the month of the COVID-19 pandemic declaration, but prior to peak infection rates. These changes were most pronounced for second-choice agents, suggesting that inexpensive, generic medicines may be more easily purchased in anticipation of pandemic-related ICU surges. Nevertheless, disparities in access persisted. Trends appeared unrelated to expected demand, and decreased purchasing from April to August 2020 may suggest over-buying. National and international policies are needed to ensure equitable drug purchasing during future pandemics.
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Affiliation(s)
- Katherine Callaway Kim
- University of Pittsburgh School of Medicine, Department of General Internal Medicine Pittsburgh, PA, USA; University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management Pittsburgh, PA, USA.
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto Toronto, ON, Canada; Women's College Research Institute Toronto, ON, Canada
| | | | - Ian J Barbash
- University of Pittsburgh School of Medicine, Department of General Internal Medicine Pittsburgh, PA, USA; CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine Pittsburgh, PA, USA
| | - Scott Rothenberger
- University of Pittsburgh School of Medicine, Department of General Internal Medicine Pittsburgh, PA, USA
| | - Katie J Suda
- University of Pittsburgh School of Medicine, Department of General Internal Medicine Pittsburgh, PA, USA; Center of Health Equity Research and Promotion, VA Pittsburgh Healthcare System Pittsburgh, PA, USA
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25
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Kodama C, Kuniyoshi G, Abubakar A. Lessons learned during COVID-19: Building critical care/ICU capacity for resource limited countries with complex emergencies in the World Health Organization Eastern Mediterranean Region. J Glob Health 2021; 11:03088. [PMID: 34326987 PMCID: PMC8286446 DOI: 10.7189/jogh.11.03088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Chiori Kodama
- World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Gary Kuniyoshi
- World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Abdinasir Abubakar
- World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt
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26
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Pandey A, Sah P, Moghadas SM, Mandal S, Banerjee S, Hotez PJ, Galvani AP. Challenges facing COVID-19 vaccination in India: Lessons from the initial vaccine rollout. J Glob Health 2021; 11:03083. [PMID: 34221355 PMCID: PMC8243816 DOI: 10.7189/jogh.11.03083] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Abhishek Pandey
- Center for Infectious Disease Modeling and Analysis (CIDMA), Yale School of Public Health, New Haven, Connecticut, USA
| | - Pratha Sah
- Center for Infectious Disease Modeling and Analysis (CIDMA), Yale School of Public Health, New Haven, Connecticut, USA
| | - Seyed M Moghadas
- Agent-Based Modelling Laboratory, York University, Toronto, Ontario, Canada
| | - Sandip Mandal
- Indian Council of Medical Research, New Delhi, India
| | - Sandip Banerjee
- Department of Mathematics, Indian Institute of Technology Roorkee, Uttarakhand, India
| | - Peter J Hotez
- National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Alison P Galvani
- Center for Infectious Disease Modeling and Analysis (CIDMA), Yale School of Public Health, New Haven, Connecticut, USA
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27
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Ferreira JC, Ho YL, Besen BAMP, Malbouisson LMS, Taniguchi LU, Mendes PV, Costa ELV, Park M, Daltro-Oliveira R, Roepke RML, Silva-Jr JM, Carmona MJC, Carvalho CRR. Protective ventilation and outcomes of critically ill patients with COVID-19: a cohort study. Ann Intensive Care 2021; 11:92. [PMID: 34097145 PMCID: PMC8182738 DOI: 10.1186/s13613-021-00882-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/26/2021] [Indexed: 12/13/2022] Open
Abstract
Background Approximately 5% of COVID-19 patients develop respiratory failure and need ventilatory support, yet little is known about the impact of mechanical ventilation strategy in COVID-19. Our objective was to describe baseline characteristics, ventilatory parameters, and outcomes of critically ill patients in the largest referral center for COVID-19 in Sao Paulo, Brazil, during the first surge of the pandemic. Methods This cohort included COVID-19 patients admitted to the intensive care units (ICUs) of an academic hospital with 94 ICU beds, a number expanded to 300 during the pandemic as part of a state preparedness plan. Data included demographics, advanced life support therapies, and ventilator parameters. The main outcome was 28-day survival. We used a multivariate Cox model to test the association between protective ventilation and survival, adjusting for PF ratio, pH, compliance, and PEEP. Results We included 1503 patients from March 30 to June 30, 2020. The mean age was 60 ± 15 years, and 59% were male. During 28-day follow-up, 1180 (79%) patients needed invasive ventilation and 666 (44%) died. For the 984 patients who were receiving mechanical ventilation in the first 24 h of ICU stay, mean tidal volume was 6.5 ± 1.3 mL/kg of ideal body weight, plateau pressure was 24 ± 5 cmH2O, respiratory system compliance was 31.9 (24.4–40.9) mL/cmH2O, and 82% of patients were ventilated with protective ventilation. Noninvasive ventilation was used in 21% of patients, and prone, in 36%. Compliance was associated with survival and did not show a bimodal pattern that would support the presence of two phenotypes. In the multivariable model, protective ventilation (aHR 0.73 [95%CI 0.57–0.94]), adjusted for PF ratio, compliance, PEEP, and arterial pH, was independently associated with survival. Conclusions During the peak of the epidemic in Sao Paulo, critically ill patients with COVID-19 often required mechanical ventilation and mortality was high. Our findings revealed an association between mechanical ventilation strategy and mortality, highlighting the importance of protective ventilation for patients with COVID-19. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00882-w.
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Affiliation(s)
- Juliana C Ferreira
- Divisao de Pneumologia, Instituto Do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil. .,Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil.
| | - Yeh-Li Ho
- Divisao de Molestias Infecciosas, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz Marcelo Sa Malbouisson
- Divisao de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Leandro Utino Taniguchi
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Pedro Vitale Mendes
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Eduardo Leite Vieira Costa
- Divisao de Pneumologia, Instituto Do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Marcelo Park
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Renato Daltro-Oliveira
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil.,Divisao de Molestias Infecciosas, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Roberta M L Roepke
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil.,UTI Emergencias Cirurgicas E Trauma, Departamento de Cirurgia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Joao M Silva-Jr
- Divisao de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Maria Jose Carvalho Carmona
- Divisao de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Carlos R R Carvalho
- Divisao de Pneumologia, Instituto Do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
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Abate SM, Assen S, Yinges M, Basu B. Survival and predictors of mortality among patients admitted to the intensive care units in southern Ethiopia: A multi-center cohort study. Ann Med Surg (Lond) 2021; 65:102318. [PMID: 33996053 PMCID: PMC8091884 DOI: 10.1016/j.amsu.2021.102318] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The burden of life-threatening conditions requiring intensive care units has grown substantially in low-income countries related to an emerging pandemic, urbanization, and hospital expansion. The rate of ICU mortality varied from region to region in Ethiopia. However, the body of evidence on ICU mortality and its predictors is uncertain. This study was designed to investigate the pattern of disease and predictors of mortality in Southern Ethiopia. METHODS After obtaining ethical clearance from the Institutional Review Board (IRB), a multi-center cohort study was conducted among three teaching referral hospital ICUs in Ethiopia from June 2018 to May 2020. Five hundred and seventeen Adult ICU patients were selected. Data were entered in Statistical Package for Social Sciences version 22 and STATA version 16 for analysis. Descriptive statistics were run to see the overall distribution of the variables. Chi-square test and odds ratio were determined to identify the association between independent and dependent variables. Multivariate analysis was conducted to control possible confounders and identify independent predictors of ICU mortality. RESULTS The mean (±SD) of the patients admitted in ICU was 34.25(±5.25). The overall ICU mortality rate was 46.8%. The study identified different independent predictors of mortality. Patients with cardiac arrest were approximately 12 times more likely to die as compared to those who didn't, AOR = 11.9(95% CI:6.1 to 23.2). CONCLUSION The overall mortality rate in ICU was very high as compared to other studies in Ethiopia as well as globally which entails a rigorous activity from different stakeholders.
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Key Words
- ACLS, advanced cardiac life support
- AOR, Adjusted Odds Ratio
- APACHE, Acute Physiologic and Chronic Health Evaluation
- ARDS, Acute Respiratory Distress Syndrome
- BMI, Body Mass Index
- CI, Confidence Interval
- CT, Computerized Tomography
- DURH, Dilla University referral hospital
- GCS, Glasgow Coma Scale
- HURH, Hawassa university referral hospital
- Hospital
- ICU, Intensive Care Unit
- IQR, Inter Quartile e Range
- IRB, Institutional Review Board
- Intensive care unit
- LOS, Length of Stay
- Mortality
- Predictor
- SAPS, Simplified Acute Physiology Score
- SD, Standard Deviation
- SOFA, Sequential Organ Failure Assessment
- STROBE, Strengthening the Reporting of Observational Studies in Epidemiology
- WURH, Wolaita Sodo referral hospital
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Affiliation(s)
- Semagn Mekonnen Abate
- Department of Anesthesiology, College of Health Sciences and Medicine, Dilla University, Ethiopia
| | - Sofia Assen
- Department of Anesthesiology, College of Health Sciences and Medicine, Dilla University, Ethiopia
| | - Mengistu Yinges
- Departemnt of Anesthesiology, College of Health Sciences and Medicine, Hawassa University, Ethiopia
| | - Bivash Basu
- Department of Anesthesiology, College of Health Sciences and Medicine, Dilla University, Ethiopia
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29
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Anh NTK, Yen LM, Nguyen NT, Nhat PTH, Thuy TTD, Phong NT, Tuyen PT, Yen NH, Chambers M, Hao NV, Rollinson T, Denehy L, Thwaites CL. Feasibility of establishing a rehabilitation programme in a Vietnamese intensive care unit. PLoS One 2021; 16:e0247406. [PMID: 33657158 PMCID: PMC7928504 DOI: 10.1371/journal.pone.0247406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/08/2021] [Indexed: 11/18/2022] Open
Abstract
Increasing numbers of people are surviving critical illness throughout the world, but survivorship is associated with long-term disability. In high-income settings physical rehabilitation is commonly employed to counter this and improve outcomes. These utilize highly-trained multidisciplinary teams and are unavailable and unaffordable in most low and middle income countries (LMICs). We aimed to design a sustainable intensive care unit (ICU) rehabilitation program and to evaluate its feasibility in a LMIC setting. In this project patients, care-givers and experts co-designed an innovative rehabilitation programme that can be delivered by non-expert ICU staff and family care-givers in a LMIC. We implemented this programme in adult patient with patients with tetanus at the Hospital for Tropical Diseases, Ho Chi Minh City over a 5-month period, evaluating the programme's acceptability, enablers and barriers. A 6-phase programme was designed, supported by written and video material. The programme was piloted in total of 30 patients. Rehabilitation was commenced a median 14 (inter quartile range (IQR) 10-18) days after admission. Each patient received a median of 25.5 (IQR 22.8-34.8) rehabilitation sessions out of a median 27 (22.8-35) intended (prescribed) sessions. There were no associated adverse events. Patients and staff found rehabilitation to be beneficial, enhanced relationships between carers, patients and staff and was deemed to be a positive step towards recovery and return to work. The main barrier was staff time. The programme was feasible for patients with tetanus and viewed positively by staff and participants. Staff time was identified as the major barrier to ongoing implementation.
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Affiliation(s)
| | - Lam Minh Yen
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | | | | | - Pham Thi Tuyen
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Hoang Yen
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Mary Chambers
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Nguyen Van Hao
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | | | | | - C. Louise Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- * E-mail:
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30
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Papali A, Diaz JV, Carter EJ, Ferreira JC, Fowler R, Gebremariam TH, Gordon SB, Lee BW, Murthy S, Riviello ED, West TE, Adhikari NK. Academic careers in global pulmonary and critical care medicine. J Glob Health 2021; 10:010313. [PMID: 32257140 PMCID: PMC7100859 DOI: 10.7189/jogh.10.010313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Alfred Papali
- Division of Pulmonary & Critical Care Medicine, Atrium Health, Charlotte, North Carolina, USA.,Division of Pulmonary & Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | - E Jane Carter
- Department of Medicine, Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Juliana C Ferreira
- Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
| | - Rob Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Stephen B Gordon
- The Malawi Liverpool Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, UK
| | - Burton W Lee
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Srinivas Murthy
- Department of Paediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elisabeth D Riviello
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - T Eoin West
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Neill Kj Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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31
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Fleischmann C, Reichert F, Cassini A, Horner R, Harder T, Markwart R, Tröndle M, Savova Y, Kissoon N, Schlattmann P, Reinhart K, Allegranzi B, Eckmanns T. Global incidence and mortality of neonatal sepsis: a systematic review and meta-analysis. Arch Dis Child 2021; 106:archdischild-2020-320217. [PMID: 33483376 PMCID: PMC8311109 DOI: 10.1136/archdischild-2020-320217] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neonates are at major risk of sepsis, but data on neonatal sepsis incidence are scarce. We aimed to assess the incidence and mortality of neonatal sepsis worldwide. METHODS We performed a systematic review and meta-analysis. 13 databases were searched for the period January 1979-May 2019, updating the search of a previous systematic review and extending it in order to increase data inputs from low-income and middle-income countries (LMICs). We included studies on the population-level neonatal sepsis incidence that used a clinical sepsis definition, such as the 2005 consensus definition, or relevant ICD codes. We performed a random-effects meta-analysis on neonatal sepsis incidence and mortality, stratified according to sepsis onset, birth weight, prematurity, study setting, WHO region and World Bank income level. RESULTS The search yielded 4737 publications, of which 26 were included. They accounted for 2 797 879 live births and 29 608 sepsis cases in 14 countries, most of which were middle-income countries. Random-effects estimator for neonatal sepsis incidence in the overall time frame was 2824 (95% CI 1892 to 4194) cases per 100 000 live births, of which an estimated 17.6% 9 (95% CI 10.3% to 28.6%) died. In the last decade (2009-2018), the incidence was 3930 (95% CI 1937 to 7812) per 100 000 live births based on four studies from LMICs. In the overall time frame, estimated incidence and mortality was higher in early-onset than late-onset neonatal sepsis cases. There was substantial between-study heterogeneity in all analyses. Studies were at moderate to high risk of bias. CONCLUSION Neonatal sepsis is common and often fatal. Its incidence remains unknown in most countries and existing studies show marked heterogeneity, indicating the need to increase the number of epidemiological studies, harmonise neonatal sepsis definitions and improve the quality of research in this field. This can help to design and implement targeted interventions, which are urgently needed to reduce the high incidence of neonatal sepsis worldwide.
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Affiliation(s)
- Carolin Fleischmann
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Felix Reichert
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Berlin, Germany
- Postgraduate Training for Applied Epidemiology (PAE), Robert Koch Institute, Berlin, Germany
- European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Alessandro Cassini
- Infection Prevention and Control Hub, Integrated Health Services, World Health Organization HQ, Geneva, GE, Switzerland
| | - Rosa Horner
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Berlin, Germany
| | - Thomas Harder
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Berlin, Germany
| | - Robby Markwart
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Berlin, Germany
- Institute of General Practice and Family Medicine, Jena University Hospital, Jena, Germany
| | - Marc Tröndle
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Berlin, Germany
| | - Yoanna Savova
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Berlin, Germany
| | - Niranjan Kissoon
- University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Peter Schlattmann
- Institute for Medical Statistics, Computer Science and Data Science, Jena University Hospital, Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Benedetta Allegranzi
- Infection Prevention and Control Hub, Integrated Health Services, World Health Organization HQ, Geneva, GE, Switzerland
| | - Tim Eckmanns
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Berlin, Germany
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32
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Limiting ICU admission from emergency services and wards. Med Clin (Barc) 2021; 157:524-529. [PMID: 33423823 DOI: 10.1016/j.medcli.2020.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/15/2020] [Accepted: 08/20/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Decisions not to admit a patient to intensive care units (ICU) as a way of limiting life support treatment (LLST) is a practice that can affect the operation of the emergency services and the way in which patients die. METHODS Post hoc analysis of the ADENI-UCI study. The main variable analysed was the reason for refusal of admission to the ICU as a measure of LLST. For the present post hoc analysis, the registered patients were divided into 2 groups: the patients assessed in the intensive medicine services from the emergency department and the patients assessed from the conventional hospitalization areas. Student t was used in the comparative statistics when the mean values of the patient sub-cohorts were compared. Categorical variables were compared with the χ2 tests. RESULTS The ADENI-ICU study included 2,284 decisions not to admit to the ICU as a measure of LLST. Estimated poor quality of life (p=.0158), the presence of severe chronic disease (P=.0169) and futility of treatment (P=.0006) were percentage decisions with greater weight within the population of hospitalized patients. The percentage of disagreement between the consulting physician and the intensivist was significantly lower in patients assessed from the emergency services (P=.0021). CONCLUSIONS There are appreciable differences in the reasons for consultation, as well as in those for refusal of admission to an ICU between the consultations made from an emergency department and a conventional hospitalization facility.
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33
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Dondorp AM, Papali AC, Schultz MJ. Recommendations for the Management of COVID-19 in Low- and Middle-Income Countries. Am J Trop Med Hyg 2021; 104:1-2. [PMID: 33410393 PMCID: PMC7957236 DOI: 10.4269/ajtmh.20-1597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 01/13/2023] Open
Affiliation(s)
- Arjen M Dondorp
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Alfred C Papali
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Bhandari S, Grover M, Bhargava S. A step today can be a giant leap tomorrow: COVID-19 management lesson from the developing world. SCRIPTA MEDICA 2021. [DOI: 10.5937/scriptamed52-32911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Background: Although India is relatively better resourced as compared with other low middle income countries in several aspects, it shares several challenges and vulnerabilities like high population, resource constraints (limited number of hospital beds, skilled healthcare personnel, intensive care units) and socioeconomic milieu, and it is important that these resources are spent wisely to maximise lives saved and minimise disruption to health services for all COVID-19 patients. Hence for dealing with this pandemic quickly and efficiently, a centre which could be set up urgently at a low cost for efficient oxygen triage was needed and thus cater to the sudden enormous load of patients who were unnecessarily occupying oxygen beds in hospitals. Methods: This study describes the setting up, management and outcome of seven hundred bedded COVID-19 care centre at Jaipur, India, within three days, at low cost, by multidisciplinary efforts of the Government of Rajasthan for efficient triage of patients and to share the excessive patient load of the biggest Government medical college of the state. Results: More than 700 patients were successfully managed at the centre within a period of one month with a favourable outcome. The perceptions of patients assessed via questionnaire also establish the success of this endeavour in sharing the load of hospitals at the peak of the pandemic. Conclusion: This paper describes the positive impact of setting up this COVID-19 care centre, and experience presented in this paper can be utilised as a novel and future oriented solution to address effectively the unprecedented pressure on the healthcare systems, created by the COVID-19 pandemic.
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35
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Soleimani J, Pinevich Y, Barwise AK, Huang C, Dong Y, Herasevich V, Gajic O, Pickering BW. Feasibility and Reliability Testing of Manual Electronic Health Record Reviews as a Tool for Timely Identification of Diagnostic Error in Patients at Risk. Appl Clin Inform 2020; 11:474-482. [PMID: 32668480 DOI: 10.1055/s-0040-1713750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Although diagnostic error (DE) is a significant problem, it remains challenging for clinicians to identify it reliably and to recognize its contribution to the clinical trajectory of their patients. The purpose of this work was to evaluate the reliability of real-time electronic health record (EHR) reviews using a search strategy for the identification of DE as a contributor to the rapid response team (RRT) activation. OBJECTIVES Early and accurate recognition of critical illness is of paramount importance. The objective of this study was to test the feasibility and reliability of prospective, real-time EHR reviews as a means of identification of DE. METHODS We conducted this prospective observational study in June 2019 and included consecutive adult patients experiencing their first RRT activation. An EHR search strategy and a standard operating procedure were refined based on the literature and expert clinician inputs. Two physician-investigators independently reviewed eligible patient EHRs for the evidence of DE within 24 hours after RRT activation. In cases of disagreement, a secondary review of the EHR using a taxonomy approach was applied. The reviewers categorized patient experience of DE as Yes/No/Uncertain. RESULTS We reviewed 112 patient records. DE was identified in 15% of cases by both reviewers. Kappa agreement with the initial review was 0.23 and with the secondary review 0.65. No evidence of DE was detected in 60% of patients. In 25% of cases, the reviewers could not determine whether DE was present or absent. CONCLUSION EHR review is of limited value in the real-time identification of DE in hospitalized patients. Alternative approaches are needed for research and quality improvement efforts in this field.
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Affiliation(s)
- Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Amelia K Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Chanyan Huang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States.,Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Vitaly Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Brian W Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States
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Prin M, Ji R, Kadyaudzu C, Li G, Charles A. Associations of day of week and time of day of ICU admission with hospital mortality in Malawi. Trop Doct 2020; 50:303-311. [PMID: 32646293 DOI: 10.1177/0049475520936011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This prospective cohort study evaluated the associations of day and time of admission to the Intensive Care Unit (ICU) with hospital mortality at a referral hospital in Malawi, a low-income country in sub-Saharan Africa. Patients admitted to the ICU during the day (08:00-16:00) were compared to those admitted at night (16:01-07:59); patients admitted on weekdays (Monday-Friday) were compared to admissions on weekends/holidays. The primary outcome was hospital mortality. Most patients were admitted during daytime (56%) and on weekdays (72%). There was no difference in mortality between night and day admissions (58% vs. 56%, P = 0.8828; hazard ratio [HR] = 1.09, 95% confidence interval [CI = 0.82-1.44, P = 0.5614) or weekend/holiday versus weekday admissions (56% vs. 57%, P = 0.9011; HR = 0.87, 95% CI = 0.62-1.21, P = 0.4133). No interaction between time and day was found. These results may be affected by high overall hospital mortality.
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Affiliation(s)
- Meghan Prin
- Assistant Professor, Department of Anesthesiology, 1878University of Colorado Medical Center, Aurora, CO, USA
| | - Ruoyu Ji
- Department of Biostatistics, 33638Columbia University Mailman School of Public Health, New York, NY, USA
| | - Clement Kadyaudzu
- Clinical Officer, Department of Anesthesiology, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Guohua Li
- Professor, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Professor, Department of Epidemiology, 33638Columbia University Mailman School of Public Health, New York, NY, USA
| | - Anthony Charles
- Professor, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Abstract
PURPOSE OF REVIEW The aim of this review is to describe the use of usual care arms in randomized trials. RECENT FINDINGS Randomization of patients to an experimental or a control arm remains paramount for the estimation of average causal effects. Selection of the control arm is as important as the definition of the intervention, and it might include a placebo control, specific standards of care, protocolized usual care, or unrestricted clinical practice. Usual care control arms may enhance generalizability, clinician acceptability of the protocol, patient recruitment, and ensure community equipoise, while at the same time introducing significant variability in the care delivered in the control group. This effect may reduce the difference in treatments delivered between the two groups and lead to a negative result or the requirement for a larger sample size. Moreover, usual care control groups can be subject to changes in clinician behavior induced by the trial itself, or by secular trends in time. SUMMARY Usual care control arms may enhance generalizability while introducing significant limitations. Potential solutions include the use of pretrial surveys to evaluate the extent to which a protocolized control arm reflects the current standard of care and the implementation of adaptive trials.
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Diniz-Silva F, Moriya HT, Alencar AM, Amato MBP, Carvalho CRR, Ferreira JC. Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial. Ann Intensive Care 2020; 10:18. [PMID: 32040785 PMCID: PMC7010869 DOI: 10.1186/s13613-020-0638-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/02/2020] [Indexed: 01/06/2023] Open
Abstract
Background Protective mechanical ventilation is recommended for patients with acute respiratory distress syndrome (ARDS), but it usually requires controlled ventilation and sedation. Using neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV) could have additional benefits, including the use of lower sedative doses, improved patient–ventilator interaction and shortened duration of mechanical ventilation. We designed a pilot study to assess the feasibility of keeping tidal volume (VT) at protective levels with NAVA and PSV in patients with ARDS. Methods We conducted a prospective randomized crossover trial in five ICUs from a university hospital in Brazil and included patients with ARDS transitioning from controlled ventilation to partial ventilatory support. NAVA and PSV were applied in random order, for 15 min each, followed by 3 h in NAVA. Flow, peak airway pressure (Paw) and electrical activity of the diaphragm (EAdi) were captured from the ventilator, and a software (Matlab, Mathworks, USA), automatically detected inspiratory efforts and calculated respiratory rate (RR) and VT. Asynchrony events detection was based on waveform analysis. Results We randomized 20 patients, but the protocol was interrupted for five (25%) patients for whom we were unable to maintain VT below 6.5 mL/kg in PSV due to strong inspiratory efforts and for one patient for whom we could not detect EAdi signal. For the 14 patients who completed the protocol, VT was 5.8 ± 1.1 mL/kg for NAVA and 5.6 ± 1.0 mL/kg for PSV (p = 0.455) and there were no differences in RR (24 ± 7 for NAVA and 23 ± 7 for PSV, p = 0.661). Paw was greater in NAVA (21 ± 3 cmH2O) than in PSV (19 ± 3 cmH2O, p = 0.001). Most patients were under continuous sedation during the study. NAVA reduced triggering delay compared to PSV (p = 0.020) and the median asynchrony Index was 0.7% (0–2.7) in PSV and 0% (0–2.2) in NAVA (p = 0.6835). Conclusions It was feasible to keep VT in protective levels with NAVA and PSV for 75% of the patients. NAVA resulted in similar VT, RR and Paw compared to PSV. Our findings suggest that partial ventilatory assistance with NAVA and PSV is feasible as a protective ventilation strategy in selected ARDS patients under continuous sedation. Trial registration ClinicalTrials.gov (NCT01519258). Registered 26 January 2012, https://clinicaltrials.gov/ct2/show/NCT01519258
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Affiliation(s)
- Fabia Diniz-Silva
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, Escola Politécnica da USP, Av. Prof. Luciano Gualberto, trav. 3, 158, Cidade Universitária, São Paulo, SP, CEP 05586-0600, Brazil
| | - Adriano M Alencar
- Instituto de Física, Universidade de São Paulo, Caixa Postal 66318, São Paulo, SP, CEP 05314-970, Brazil
| | - Marcelo B P Amato
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Carlos R R Carvalho
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Juliana C Ferreira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil.
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Ferreira JC, Ho YL, Besen BA, Malbuisson LM, Taniguchi LU, Mendes PV, Costa EL, Park M, Daltro-Oliveira R, Roepke RM, Silva JM, Carmona MJC, Carvalho CRR. Characteristics and outcomes of patients with COVID-19 admitted to the ICU in a university hospital in São Paulo, Brazil - study protocol. Clinics (Sao Paulo) 2020; 75:e2294. [PMID: 32876113 PMCID: PMC7442378 DOI: 10.6061/clinics/2020/e2294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES We designed a cohort study to describe characteristics and outcomes of patients with coronavirus disease (COVID-19) admitted to the intensive care unit (ICU) in the largest public hospital in Sao Paulo, Brazil, as Latin America becomes the epicenter of the pandemic. METHODS This is the protocol for a study being conducted at an academic hospital in Brazil with 300 adult ICU beds dedicated to COVID-19 patients. We will include adult patients admitted to the ICU with suspected or confirmed COVID-19 during the study period. The main outcome is ICU survival at 28 days. Data will be collected prospectively and retrospectively by trained investigators from the hospital's electronic medical records, using an electronic data capture tool. We will collect data on demographics, comorbidities, severity of disease, and laboratorial test results at admission. Information on the need for advanced life support and ventilator parameters will be collected during ICU stay. Patients will be followed up for 28 days in the ICU and 60 days in the hospital. We will plot Kaplan-Meier curves to estimate ICU and hospital survival and perform survival analysis using the Cox proportional hazards model to identify the main risk factors for mortality. ClinicalTrials.gov: NCT04378582. RESULTS We expect to include a large sample of patients with COVID-19 admitted to the ICU and to be able to provide data on admission characteristics, use of advanced life support, ICU survival at 28 days, and hospital survival at 60 days. CONCLUSIONS This study will provide epidemiological data about critically ill patients with COVID-19 in Brazil, which could inform health policy and resource allocation in low- and middle-income countries.
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Affiliation(s)
- Juliana C. Ferreira
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Unidade de Terapia Intensiva, AC Camargo Cancer Center, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Yeh-Li Ho
- Divisao de Molestias Infecciosas, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Bruno A.M.P. Besen
- UTI Clinica, Disciplina de Emergencias Clinicas, Departamento de Clinica Medica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz M.S. Malbuisson
- Divisao de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Leandro U. Taniguchi
- UTI Clinica, Disciplina de Emergencias Clinicas, Departamento de Clinica Medica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Pedro V. Mendes
- UTI Clinica, Disciplina de Emergencias Clinicas, Departamento de Clinica Medica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Eduardo L.V. Costa
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marcelo Park
- UTI Clinica, Disciplina de Emergencias Clinicas, Departamento de Clinica Medica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Renato Daltro-Oliveira
- Unidade de Terapia Intensiva, AC Camargo Cancer Center, Sao Paulo, SP, BR
- Divisao de Molestias Infecciosas, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Roberta M.L. Roepke
- Unidade de Terapia Intensiva, AC Camargo Cancer Center, Sao Paulo, SP, BR
- UTI Emergencias Cirurgicas e Trauma, Departamento de Cirurgia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - João M. Silva
- Divisao de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria José C. Carmona
- Divisao de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Carlos Roberto Ribeiro Carvalho
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Turner HC, Hao NV, Yacoub S, Hoang VMT, Clifton DA, Thwaites GE, Dondorp AM, Thwaites CL, Chau NVV. Achieving affordable critical care in low-income and middle-income countries. BMJ Glob Health 2019; 4:e001675. [PMID: 31297248 PMCID: PMC6590958 DOI: 10.1136/bmjgh-2019-001675] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/18/2019] [Accepted: 05/25/2019] [Indexed: 01/09/2023] Open
Affiliation(s)
- Hugo C Turner
- Oxford University Clinical Research Unit, Wellcome Africa Asia Programme, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Nguyen Van Hao
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, Wellcome Africa Asia Programme, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Van Minh Tu Hoang
- Oxford University Clinical Research Unit, Wellcome Africa Asia Programme, Ho Chi Minh City, Vietnam
| | - David A Clifton
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Wellcome Africa Asia Programme, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - C Louise Thwaites
- Oxford University Clinical Research Unit, Wellcome Africa Asia Programme, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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