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Angriman F, Muttalib F, Lamontagne F, Adhikari NKJ. The authors reply. Crit Care Med 2023; 51:e283-e284. [PMID: 37971352 DOI: 10.1097/ccm.0000000000006054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Fiona Muttalib
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
| | | | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
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Angriman F, Muttalib F, Lamontagne F, Adhikari NKJ. IV Vitamin C in Adults With Sepsis: A Bayesian Reanalysis of a Randomized Controlled Trial. Crit Care Med 2023; 51:e152-e156. [PMID: 37026849 DOI: 10.1097/ccm.0000000000005871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
OBJECTIVES The Lessening Organ Dysfunction with Vitamin C trial showed a harmful effect of vitamin C on 28-day death or persistent organ dysfunction. To maximize interpretation, we present a post hoc Bayesian reanalysis. DESIGN Bayesian reanalysis of a randomized placebo-controlled trial. SETTING Thirty-five ICUs. PATIENTS Adults with proven or suspected infection, vasopressor support, and no more than 24 hours of ICU admission. INTERVENTIONS Patients were allocated to receive either vitamin C (50 mg/kg of body weight) or placebo every 6 hours for up to 96 hours. MEASUREMENTS AND MAIN RESULTS The primary outcome was the composite of death or persistent organ dysfunction (i.e., vasopressor use, invasive mechanical ventilation, or new renal replacement therapy) at 28 days. We used Bayesian log-binomial models with random effects for hospital site and varying informative prior beliefs for the effect of vitamin C to estimate risk ratios (RRs) with 95% credible intervals (Crls) in the intention to treat population (vitamin C, 435 patients; placebo, 437 patients). Using weakly neutral priors, patients allocated to vitamin C had a higher risk of death or persistent organ dysfunction at 28 days (RR, 1.20; 95% Crl, 1.04-1.39; probability of harm, 99%). This effect was consistent when using optimistic (RR, 1.14; 95% Crl, 1.00-1.31; probability of harm, 98%) and empiric (RR, 1.09; 95% Crl, 0.97-1.22; probability of harm, 92%) priors. Patients allocated to vitamin C also had a higher risk of death at 28 days under weakly neutral (RR, 1.17; 95% Crl, 0.98-1.40; probability of harm, 96%), optimistic (RR, 1.10; 95% Crl, 0.94-1.30; probability of harm, 88%), and empiric (RR, 1.05; 95% Crl, 0.92-1.19; probability of harm, 76%) priors. CONCLUSIONS The use of vitamin C in adult patients with proven or suspected infection and vasopressor support is associated with high probability of harm.
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Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Fiona Muttalib
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
| | | | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
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Roumeliotis N, Ramil J, Garros D, Alnaji F, Bourdages M, Brule V, Dryden-Palmer K, Muttalib F, Nicoll J, Sauthier M, Murthy S, Fontela PS. Designing a national pediatric critical care database: a Delphi consensus study. Can J Anaesth 2023; 70:1216-1225. [PMID: 37217736 PMCID: PMC10202532 DOI: 10.1007/s12630-023-02480-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/09/2022] [Accepted: 11/09/2022] [Indexed: 05/24/2023] Open
Abstract
PURPOSE We sought to describe the processes undertaken for the systematic selection and consensus determination of the common data elements for inclusion in a national pediatric critical care database in Canada. METHODS We conducted a multicentre Delphi consensus study of Canadian pediatric intensive care units (PICUs) participating in the creation of a national database. Participants were PICU health care professionals, allied health professionals, caregivers, and other stakeholders. A dedicated panel group created a baseline survey of data elements based on literature, current PICU databases, and expertise in the field. The survey was then used for a Delphi iterative consensus process over three rounds, conducted from March to June 2021. RESULTS Of 86 invited participants, 68 (79%) engaged and agreed to participate as part of an expert panel. Panel participants were sent three rounds of the survey with response rates of 62 (91%), 61 (90%) and 55 (81%), respectively. After three rounds, 72 data elements were included from six domains, mostly reflecting clinical status and complex medical interventions received in the PICU. While race, gender, and home region were included by consensus, variables such as minority status, indigenous status, primary language, and ethnicity were not. CONCLUSION We present the methodological framework used to select data elements by consensus for a national pediatric critical care database, with participation from a diverse stakeholder group of experts and caregivers from all PICUs in Canada. The selected core data elements will provide standardized and synthesized data for research, benchmarking, and quality improvement initiatives of critically ill children.
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Affiliation(s)
- Nadia Roumeliotis
- Department of Pediatrics, Critical Care, CHU Sainte-Justine, University of Montreal, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
| | - Joanne Ramil
- Pediatric Intensive Care Unit, Montreal Children's Hospital, Montreal, QC, Canada
| | - Daniel Garros
- Division of Critical Care, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Fuad Alnaji
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Macha Bourdages
- Centre Mère Enfant Soleil du CHU de Québec, Université de Laval, Quebec, QC, Canada
| | - Valerie Brule
- The Children's Hospital of Winnipeg, Winnipeg, MB, Canada
| | - Karen Dryden-Palmer
- Pediatric Critical Care Unit, The Hospital for Sick Children, Toronto, ON, Canada
| | - Fiona Muttalib
- Division of Pediatric Critical Care, BC Children's Hospital, Vancouver, BC, Canada
| | - Jessica Nicoll
- Pediatric Intensive Care Unit, Janeway Children's Health and Rehabilitation Centre, St John's, NL, Canada
| | - Michael Sauthier
- Department of Pediatrics, Critical Care, CHU Sainte-Justine, University of Montreal, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Srinivas Murthy
- Division of Pediatric Critical Care, BC Children's Hospital, Vancouver, BC, Canada
| | - Patricia S Fontela
- Pediatric Intensive Care Unit, Montreal Children's Hospital, Montreal, QC, Canada
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Richards-Belle A, Hylands M, Muttalib F, Taran S, Rochwerg B, Day A, Mouncey PR, Radermacher P, Couban R, Asfar P, Adhikari NKJ, Lamontagne F. Lower Versus Higher Exposure to Vasopressor Therapy in Vasodilatory Hypotension: A Systematic Review With Meta-Analysis. Crit Care Med 2023; 51:254-266. [PMID: 36398968 PMCID: PMC9848218 DOI: 10.1097/ccm.0000000000005736] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Balancing the risks of hypotension and vasopressor-associated adverse effects is a daily challenge in ICUs. We conducted a systematic review with meta-analysis to examine the effect of lower versus higher exposure to vasopressor therapy on mortality among adult ICU patients with vasodilatory hypotension. DATA SOURCES We searched Ovid Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies published from inception to October 15, 2021. STUDY SELECTION We included randomized controlled trials of lower versus higher exposure to vasopressor therapy in adult ICU patients with vasodilatory hypotension without language or publication status limits. DATA EXTRACTION The primary outcome was 90-day all-cause mortality, with seven prespecified subgroups. Secondary outcomes included shorter- and longer-term mortality, use of life-sustaining therapies, vasopressor-related complications, neurologic outcome, and quality of life at longest reported follow-up. We conducted random-effects meta-analyses to calculate summary effect measures across individual studies (risk ratio [RR] for dichotomous variables, mean difference for continuous variables, both with 95% CIs). The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluation. We registered this review on the International Prospective Register of Systematic Reviews (CRD42021224434). DATA SYNTHESIS Of 3,403 records retrieved, 68 full-text articles were reviewed and three eligible studies included. Lower exposure to vasopressors probably lowers 90-day mortality but this is based on moderate-certainty evidence, lowered for imprecision (RR, 0.94; 95% CI, 0.87-1.02). There was no credible subgroup effect. Lower vasopressor exposure may also decrease the risk of supraventricular arrhythmia (odds ratio, 0.55; 95% CI, 0.36-0.86; low certainty). CONCLUSIONS In patients with vasodilatory hypotension who are started on vasopressors, moderate-certainty evidence from three randomized trials showed that lower vasopressor exposure probably lowers mortality. However, additional trial data are needed to reach an optimal information size to detect a clinically important 10% relative reduction in mortality with this approach.
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Affiliation(s)
- Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Fiona Muttalib
- Center for Global Child Health, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Shaurya Taran
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Bram Rochwerg
- Departments of Medicine, Critical Care Medicine, Pediatrics and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrew Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, Ulm, Germany
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Pierre Asfar
- Department of Medical Intensive Care, University Hospital of Angers, Angers, France
| | - Neill K J Adhikari
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
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Nyandat J, Murthy S, Muttalib F. Challenges and Opportunities for Implementing Pediatric Early Warning Systems in Low- and Middle-Income Countries-Using Resources Wisely. JAMA Netw Open 2022; 5:e221553. [PMID: 35262722 DOI: 10.1001/jamanetworkopen.2022.1553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joram Nyandat
- Faculty of Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- Directorate of Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Srinivas Murthy
- Faculty of Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fiona Muttalib
- Faculty of Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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Muttalib F, Chung K, Pell LG, Ariff S, Soofi S, Morris SK, Sander B. Cost-effectiveness analysis of implementing an integrated neonatal care kit to reduce neonatal infection in rural Pakistan. BMJ Open 2022; 12:e047793. [PMID: 34983750 PMCID: PMC8728405 DOI: 10.1136/bmjopen-2020-047793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of distribution of the integrated neonatal care kit (iNCK) by community health workers from the healthcare payer perspective in Rahimyar Khan, Pakistan. SETTING Rahimyar Khan, Pakistan. PARTICIPANTS N/A. INTERVENTION Cost-utility analysis using a Markov model based on cluster randomised controlled trial (cRCT: NCT02130856) data and a literature review. We compared distribution of the iNCK to pregnant mothers to local standard of care and followed infants over a lifetime horizon. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was incremental net monetary benefit (INMB, at a cost-effectiveness threshold of US$15.50), discounted at 3%. Secondary outcomes were life years, disability-adjusted life years (DALYs) and costs. RESULTS At a cost-effectiveness threshold of US$15.50, distribution of the iNCK resulted in lower expected DALYs (28.7 vs 29.6 years) at lower expected cost (US$52.50 vs 55.20), translating to an INMB of US$10.22 per iNCK distributed. These results were sensitive to the baseline risk of infection, cost of the iNCK and the estimated effect of the iNCK on the relative risk of infection. At relative risks of infection below 0.79 and iNCK costs below US$25.90, the iNCK remained cost-effective compared with current local standard of care. CONCLUSION The distribution of the iNCK dominated the current local standard of care (ie, the iNCK is less costly and more effective than current care standards). Most of the cost-effectiveness of the iNCK was attributable to a reduction in neonatal infection.
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Affiliation(s)
- Fiona Muttalib
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada
- Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Karen Chung
- Dalla Lana School of Public Health, University of Toronto Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada
| | - Lisa Grace Pell
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shabina Ariff
- Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid Soofi
- Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shaun K Morris
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Infectious Diseases, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Beate Sander
- Dalla Lana School of Public Health, University of Toronto Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
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7
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Wooldridge G, O'Brien N, Muttalib F, Abbas Q, Adabie Appiah J, Baker T, Bansal A, Basnet S, Campos-Miño S, de Souza DC, Díaz F, Dramowski A, Fernández-Sarmiento J, Fustiñana A, González G, Jabornisky R, Jaramillo-Bustamante JC, Yek Kee C, Lang HJ, Soares Lanziotti V, Kohn Loncarica G, Mohsenibod H, Ode B, Murthy S, Andre-von Arnim AVS, Hansmann A, González-Dambrauskas S. Challenges of implementing the Paediatric Surviving Sepsis Campaign International Guidelines 2020 in resource-limited settings: A real-world view beyond the academia. Andes Pediatr 2021; 92:954-962. [PMID: 35506809 DOI: 10.32641/andespediatr.v92i6.4030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/28/2021] [Indexed: 06/14/2023]
Abstract
The Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children was released in 2020 and is intended for use in all global settings that care for children with sepsis. However, practitioners managing children with sep sis in resource-limited settings (RLS) face several challenges and disease patterns not experienced by those in resource-rich settings. Based upon our collective experience from RLS, we aimed to reflect on the difficulties of implementing the international guidelines. We believe there is an urgent need for more evidence from RLS on feasible, efficacious approaches to the management of sepsis and septic shock that could be included in future context-specific guidelines.
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Affiliation(s)
| | | | - Fiona Muttalib
- Department of Paediatric Critical Care, BC Children's Hospital, Vancouver, Canada
| | - Qalab Abbas
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - John Adabie Appiah
- Department of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Arun Bansal
- Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sangita Basnet
- School of Medicine, Southern Illinois University, Springfield, Illinois, USA
| | | | | | - Franco Díaz
- Escuela de Postgrado, Universidad Finis Terrae, Santiago, Chile
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | - Ana Fustiñana
- Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Gustavo González
- Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | | | | - Hans-Joerg Lang
- Global Child Health Department, University Witten/Herdecke. Witten, Germany
| | - Vanessa Soares Lanziotti
- Paediatric Intensive Care Unit & Research and Education Division/Maternal and Child Health Postgraduate Program, Federal University of Rio De Janeiro. Rio De Janeiro, Brazil
| | - Guillermo Kohn Loncarica
- Paediatric Emergency Department, Hospital Juan P. Garrahan. Buenos Aires, Argentina; Universidad de Buenos Aires (UBA). Argentina; and Sociedad Latinoamericana de Emergencia Pediatrica (SLEPE)
| | - Hadi Mohsenibod
- PICU, The Hospital for Sick Children. Toronto, Canada; and ERU delegate, Canadian Red Cross, Canada
| | - Bunmi Ode
- Pédiatre Reanimatrice volante. NGO ALIMA-The Alliance for International Medical Action, Senegal
| | - Srinivas Murthy
- Department of Paediatric Critical Care, BC Children's Hospital. Vancouver, Canada
| | - Amelie von Saint Andre-von Arnim
- Department of Pediatrics, Division of Paediatric Critical Care, University of Washington, Seattle Children's. Seattle, USA; and Paediatric Emergency and Critical Care, University of Nairobi. Nairobi, Kenya
| | | | - Sebastián González-Dambrauskas
- Cuidados Intensivos Pediátricos Especializados (CIPe), Casa de Galicia. Montevideo, Uruguay; and Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
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Fung JST, Wong S, Murthy S, Muttalib F. Hospital outcomes of children admitted to intensive care in British Columbia via interfacility transfer versus direct admission from 2015 to 2017: a descriptive analysis. CMAJ Open 2021; 9:E602-E606. [PMID: 34074634 PMCID: PMC8177907 DOI: 10.9778/cmajo.20200263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pediatric intensive care relies on having experienced and effective transport systems to transfer critically ill children to the appropriate centre for care. Our aim was to compare hospital outcomes among children admitted directly to a pediatric intensive care unit (PICU) with those of children transferred from another facility. METHODS We conducted a descriptive study using electronic medical records and the PICU database from the BC Children's Hospital. Patients admitted to the PICU from January 2015 to December 2017 were included. We excluded patients who were admitted electively, were admitted for recovery postoperatively, or had inconsistent or out-of-range addresses. We compared hospital mortality rates, use of mechanical ventilation within 24 hours of admission and length of PICU stay between children admitted directly from the BC Children's Hospital emergency department and those transferred from a referring institution. RESULTS During the study period, there were 870 unique admissions comprising 386 direct admissions and 484 transferred patients. Transported patients were younger, were more critically ill on presentation and required longer stays. The proportions of children who died and of children who required mechanical ventilation within 24 hours of admission were higher in the transported group than in the group admitted directly from the emergency department (8.3% v. 3.9%, p = 0.008, and 75.8% v. 58.0%, p < 0.001, respectively). INTERPRETATION Mortality rate and use of intensive care resources were higher among children who were transported. Further research is needed to examine the key factors driving the differences in outcomes, including the severity of illness on first presentation, transport team composition, and transport distance and duration.
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Affiliation(s)
- Jollee S T Fung
- Faculty of Medicine (Fung), University of British Columbia, Vancouver, BC; Schulich School of Medicine & Dentistry (Wong), University of Western Ontario, London, Ont.; Division of Critical Care, Department of Pediatrics (Murthy, Muttalib), University of British Columbia, Vancouver, BC; Centre for Global Child Health, Hospital for Sick Children (Muttalib), Toronto, Ont
| | - Sean Wong
- Faculty of Medicine (Fung), University of British Columbia, Vancouver, BC; Schulich School of Medicine & Dentistry (Wong), University of Western Ontario, London, Ont.; Division of Critical Care, Department of Pediatrics (Murthy, Muttalib), University of British Columbia, Vancouver, BC; Centre for Global Child Health, Hospital for Sick Children (Muttalib), Toronto, Ont
| | - Srinivas Murthy
- Faculty of Medicine (Fung), University of British Columbia, Vancouver, BC; Schulich School of Medicine & Dentistry (Wong), University of Western Ontario, London, Ont.; Division of Critical Care, Department of Pediatrics (Murthy, Muttalib), University of British Columbia, Vancouver, BC; Centre for Global Child Health, Hospital for Sick Children (Muttalib), Toronto, Ont
| | - Fiona Muttalib
- Faculty of Medicine (Fung), University of British Columbia, Vancouver, BC; Schulich School of Medicine & Dentistry (Wong), University of Western Ontario, London, Ont.; Division of Critical Care, Department of Pediatrics (Murthy, Muttalib), University of British Columbia, Vancouver, BC; Centre for Global Child Health, Hospital for Sick Children (Muttalib), Toronto, Ont.
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Muttalib F, González-Dambrauskas S, Lee JH, Steere M, Agulnik A, Murthy S, Adhikari NKJ. Pediatric Emergency and Critical Care Resources and Infrastructure in Resource-Limited Settings: A Multicountry Survey. Crit Care Med 2021; 49:671-681. [PMID: 33337665 DOI: 10.1097/ccm.0000000000004769] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe the infrastructure and resources for pediatric emergency and critical care delivery in resource-limited settings worldwide. DESIGN Cross-sectional survey with survey items developed through literature review and revised following piloting. SETTING The electronic survey was disseminated internationally in November 2019 via e-mail directories of pediatric intensive care societies and networks and using social media. PATIENTS Healthcare providers who self-identified as working in resource-limited settings. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Results were summarized using descriptive statistics and resource availability was compared across World Bank country income groups. We received 328 responses (238 hospitals, 60 countries), predominantly in Latin America and Sub-Saharan Africa (n = 161, 67.4%). Hospitals were in low-income (28, 11.7%), middle-income (166, 69.5%), and high-income (44, 18.4%) countries. Across 174 PICU and adult ICU admitting children, there were statistically significant differences in the proportion of hospitals reporting consistent resource availability ("often" or "always") between country income groups (p < 0·05). Resources with limited availability in lower income countries included advanced ventilatory support, invasive and noninvasive monitoring, central venous access, renal replacement therapy, advanced imaging, microbiology, biochemistry, blood products, antibiotics, parenteral nutrition, and analgesic/sedative drugs. Seventy-seven ICUs (52.7%) were staffed 24/7 by a pediatric intensivist or anesthetist. The nurse-to-patient ratio was less than 1:2 in 71 ICUs (49.7%). CONCLUSIONS Contemporary data demonstrate significant disparity in the availability of essential and advanced human and material resources for the care of critically ill children in resource-limited settings. Minimum standards for essential pediatric emergency and critical care in resource-limited settings are needed.
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Affiliation(s)
- Fiona Muttalib
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Sebastián González-Dambrauskas
- Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | - Jan Hau Lee
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
- Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Children's Intensive Care, KK Women's and Children's Hospital, Singapore
- Department of Pediatrics, Duke-NUS Medical School, Singapore
- Pediatric Acute and Critical Care Medicine Asian Network
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kenya
- Pediatric Emergency and Critical Care Africa
- Royal Flying Doctor Service of Australia, Central Operations, Mile End, SA, Australia
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mardi Steere
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
- Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Children's Intensive Care, KK Women's and Children's Hospital, Singapore
- Department of Pediatrics, Duke-NUS Medical School, Singapore
- Pediatric Acute and Critical Care Medicine Asian Network
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kenya
- Pediatric Emergency and Critical Care Africa
- Royal Flying Doctor Service of Australia, Central Operations, Mile End, SA, Australia
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Srinivas Murthy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Neill K J Adhikari
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
- Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Children's Intensive Care, KK Women's and Children's Hospital, Singapore
- Department of Pediatrics, Duke-NUS Medical School, Singapore
- Pediatric Acute and Critical Care Medicine Asian Network
- Department of Pediatrics, AIC Kijabe Hospital, Kijabe, Kenya
- Pediatric Emergency and Critical Care Africa
- Royal Flying Doctor Service of Australia, Central Operations, Mile End, SA, Australia
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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10
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Agarwal A, Fernando SM, Honarmand K, Bakaa L, Brar S, Granton D, Chaudhuri D, Chetan D, Hu M, Basmaji J, Muttalib F, Rochwerg B, Adhikari NKJ, Lamontagne F, Murthy S, Hui DS, Gomersall CD, Mubareka S, Diaz J, Burns KE, Couban R, Vandvik PO. Risk of dispersion or aerosol generation and infection transmission with nasopharyngeal and oropharyngeal swabs for detection of COVID-19: a systematic review. BMJ Open 2021; 11:e040616. [PMID: 33737418 PMCID: PMC7977073 DOI: 10.1136/bmjopen-2020-040616] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES SARS-CoV-2-related disease, referred to as COVID-19, has emerged as a global pandemic since December 2019. While there is growing recognition regarding possible airborne transmission, particularly in the setting of aerosol-generating procedures and treatments, whether nasopharyngeal and oropharyngeal swabs for SARS-CoV-2 generate aerosols remains unclear. DESIGN Systematic review. DATA SOURCES We searched Ovid MEDLINE and EMBASE up to 3 November 2020. We also searched the China National Knowledge Infrastructure, Chinese Medical Journal Network, medRxiv and ClinicalTrials.gov up to 29 March 2020. ELIGIBILITY CRITERIA All comparative and non-comparative studies that evaluated dispersion or aerosolisation of viable airborne organisms, or transmission of infection associated with nasopharyngeal or oropharyngeal swab testing. RESULTS Of 7702 citations, only one study was deemed eligible. Using a dedicated sampling room with negative pressure isolation room, personal protective equipment including N95 or higher masks, strict sterilisation protocols, structured training with standardised collection methods and a structured collection and delivery system, a tertiary care hospital proved a 0% healthcare worker infection rate among eight nurses conducting over 11 000 nasopharyngeal swabs. No studies examining transmissibility with other safety protocols, nor any studies quantifying the risk of aerosol generation with nasopharyngeal or oropharyngeal swabs for detection of SARS-CoV-2, were identified. CONCLUSIONS There is limited to no published data regarding aerosol generation and risk of transmission with nasopharyngeal and oropharyngeal swabs for the detection of SARS-CoV-2. Field experiments to quantify this risk are warranted. Vigilance in adhering to current standards for infection control is suggested.
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Affiliation(s)
- Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kimia Honarmand
- Division of Critical Care, Department of Medicine, Western University, London, Ontario, Canada
| | - Layla Bakaa
- Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Sonia Brar
- School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, New York, USA
| | - David Granton
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dipayan Chaudhuri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Devin Chetan
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Malini Hu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John Basmaji
- Division of Critical Care, Department of Medicine, Western University, London, Ontario, Canada
| | - Fiona Muttalib
- Center for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Francois Lamontagne
- Centre de recherche due CHU de Sherbrooke, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Département de Médecine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Srinivas Murthy
- Faculty of Medicine, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - David S Hui
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong
- Stanley Ho Center for Emerging Infectious Diseases, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charles D Gomersall
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Samira Mubareka
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Janet Diaz
- Pacific Medical Center, San Francisco, California, USA
- World Health Organization, Geneva, Switzerland
| | - Karen Ea Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Critical Care, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rachel Couban
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
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11
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Irfan O, Muttalib F, Tang K, Jiang L, Lassi ZS, Bhutta Z. Clinical characteristics, treatment and outcomes of paediatric COVID-19: a systematic review and meta-analysis. Arch Dis Child 2021; 106:archdischild-2020-321385. [PMID: 33593743 PMCID: PMC8070630 DOI: 10.1136/archdischild-2020-321385] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Compare paediatric COVID-19 disease characteristics, management and outcomes according to World Bank country income level and disease severity. DESIGN Systematic review and meta-analysis. SETTING Between 1 December 2019 and 8 January 2021, 3350 articles were identified. Two reviewers conducted study screening, data abstraction and quality assessment independently and in duplicate. Observational studies describing laboratory-confirmed paediatric (0-19 years old) COVID-19 were considered for inclusion. MAIN OUTCOMES AND MEASURES The pooled proportions of clinical findings, treatment and outcomes were compared according to World Bank country income level and reported disease severity. RESULTS 129 studies were included from 31 countries comprising 10 251 children of which 57.4% were hospitalised. Mean age was 7.0 years (SD 3.6), and 27.1% had a comorbidity. Fever (63.3%) and cough (33.7%) were common. Of 3670 cases, 44.1% had radiographic abnormalities. The majority of cases recovered (88.9%); however, 96 hospitalised children died. Compared with high-income countries, in low-income and middle-income countries, a lower proportion of cases were admitted to intensive care units (ICUs) (9.9% vs 26.0%) yet pooled proportion of deaths among hospitalised children was higher (relative risk 2.14, 95% CI 1.43 to 3.20). Children with severe disease received antimicrobials, inotropes and anti-inflammatory agents more frequently than those with non-severe disease. Subgroup analyses showed that a higher proportion of children with multisystem inflammatory syndrome (MIS-C) were admitted to ICU (47.1% vs 22.9%) and a higher proportion of hospitalised children with MIS-C died (4.8% vs 3.6%) compared with the overall sample. CONCLUSION Paediatric COVID-19 has a favourable prognosis. Further severe disease characterisation in children is needed globally.
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Affiliation(s)
- Omar Irfan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Fiona Muttalib
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kun Tang
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Li Jiang
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Zohra S Lassi
- Robinson Research Institute, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Zulfiqar Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Global Health & Development, Aga Khan University, Karachi, Pakistan
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12
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Muttalib F, Ballard E, Langton J, Malone S, Fonseca Y, Hansmann A, Remy K, Hovmand P, Doctor A. Application of systems dynamics and group model building to identify barriers and facilitators to acute care delivery in a resource limited setting. BMC Health Serv Res 2021; 21:26. [PMID: 33407458 PMCID: PMC7787401 DOI: 10.1186/s12913-020-06014-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/10/2020] [Indexed: 11/17/2022] Open
Abstract
Background Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi. Methods Over 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed. Results Causal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias. Conclusions GMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting.
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Affiliation(s)
- Fiona Muttalib
- Centre for Global Child Health, Hospital for Sick Children, 555 University avenue, Toronto, ON, M5G 1X8, Canada.
| | - Ellis Ballard
- Social System Design Lab, Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | | | - Sara Malone
- Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | - Yudy Fonseca
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Andreas Hansmann
- Neonatal and Paediatric ICU, National Pediatric Hospital, Phnom Penh, Cambodia
| | - Kenneth Remy
- Departments of Pediatrics and Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Peter Hovmand
- Social System Design Lab, Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | - Allan Doctor
- Pediatric Critical Care Medicine and Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, USA
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13
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Abbas Q, Holloway A, Caporal P, López-Barón E, Agulnik A, Remy KE, Appiah JA, Attebery J, Fink EL, Lee JH, Hooli S, Kissoon N, Miller E, Murthy S, Muttalib F, Nielsen K, Puerto-Torres M, Rodrigues K, Sakaan F, Rodrigues AT, Tabor EA, von Saint Andre-von Arnim A, Wiens MO, Blackwelder W, He D, Kortz TB, Bhutta AT. Global PARITY: Study Design for a Multi-Centered, International Point Prevalence Study to Estimate the Burden of Pediatric Acute Critical Illness in Resource-Limited Settings. Front Pediatr 2021; 9:793326. [PMID: 35155314 PMCID: PMC8835113 DOI: 10.3389/fped.2021.793326] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/10/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The burden of pediatric critical illness and resource utilization by children with critical illness in resource limited settings (RLS) are largely unknown. Without specific data that captures key aspects of critical illness, disease presentation, and resource utilization for pediatric populations in RLS, development of a contextual framework for appropriate, evidence-based interventions to guide allocation of limited but available resources is challenging. We present this methods paper which describes our efforts to determine the prevalence, etiology, hospital outcomes, and resource utilization associated with pediatric acute, critical illness in RLS globally. METHODS We will conduct a prospective, observational, multicenter, multinational point prevalence study in sixty-one participating RLS hospitals from North, Central and South America, Africa, Middle East and South Asia with four sampling time points over a 12-month period. Children aged 29 days to 14 years evaluated for acute illness or injury in an emergency department) or directly admitted to an inpatient unit will be enrolled and followed for hospital outcomes and resource utilization for the first seven days of hospitalization. The primary outcome will be prevalence of acute critical illness, which Global PARITY has defined as death within 48 hours of presentation to the hospital, including ED mortality; or admission/transfer to an HDU or ICU; or transfer to another institution for a higher level-of-care; or receiving critical care-level interventions (vasopressor infusion, invasive mechanical ventilation, non-invasive mechanical ventilation) regardless of location in the hospital, among children presenting to the hospital. Secondary outcomes include etiology of critical illness, in-hospital mortality, cause of death, resource utilization, length of hospital stay, and change in neurocognitive status. Data will be managed via REDCap, aggregated, and analyzed across sites. DISCUSSION This study is expected to address the current gap in understanding of the burden, etiology, resource utilization and outcomes associated with pediatric acute and critical illness in RLS. These data are crucial to inform future research and clinical management decisions and to improve global pediatric hospital outcomes.
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Affiliation(s)
- Qalab Abbas
- Department of Pediatrics and Child Health, Aga Khan University Karachi, Karachi, Pakistan
| | - Adrian Holloway
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland Baltimore, Baltimore, MD, United States
| | - Paula Caporal
- Hospital Interzonal Especializado en Pediatría "Sor María Ludovica", La Plata, Argentina.,Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Buenos Aires, Argentina
| | - Eliana López-Barón
- Hospital Pablo Tobón Uribe, Unidad de Cuidado Crítico Pediátrico, Medellín, Colombia
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kenneth E Remy
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University Hospitals of Cleveland and Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - John A Appiah
- Pediatric Intensive Care Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Jonah Attebery
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado, Aurora, CO, United States
| | - Ericka L Fink
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,SingHealth Duke-NUS Global Health Institute, Singapore, Singapore
| | - Shubhada Hooli
- Division of Pediatric Critical Care, Department of Pediatrics, BC Children's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Erika Miller
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland Baltimore, Baltimore, MD, United States
| | - Srinivas Murthy
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Fiona Muttalib
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Katie Nielsen
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington, Seattle Children's, Seattle, WA, United States
| | - Maria Puerto-Torres
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Karla Rodrigues
- Department of Pediatrics, Hospital das Clínicas da UFMG/EBSERH, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Firas Sakaan
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Adriana Teixeira Rodrigues
- Department of Pediatrics, Hospital das Clínicas da UFMG/EBSERH, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Erica A Tabor
- Pennsylvania State University, State College, PA, United States
| | - Amelie von Saint Andre-von Arnim
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington, Seattle Children's, Seattle, WA, United States
| | - Matthew O Wiens
- Center for Child Health at BC Children's Hospital, The University of British Columbia, Vancouver, BC, Canada.,Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda.,Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - William Blackwelder
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, United States
| | - David He
- Analytical Solutions Group, Inc., North Potomac, MD, United States
| | - Teresa B Kortz
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Adnan T Bhutta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland Baltimore, Baltimore, MD, United States.,Center for Vaccine Development and Global Health, University of Maryland, Baltimore, MD, United States
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14
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Muttalib F, Clavel V, Yaeger LH, Shah V, Adhikari NKJ. Performance of Pediatric Mortality Prediction Models in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. J Pediatr 2020; 225:182-192.e2. [PMID: 32439313 DOI: 10.1016/j.jpeds.2020.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/11/2020] [Accepted: 05/12/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To describe the performance of prognostic models for mortality or clinical deterioration events among hospitalized children developed or validated in low- and middle-income countries. STUDY DESIGN A medical librarian systematically searched EMBASE, Ovid Medline, Scopus, Cochrane Library, EBSCO Global Health, LILACS, African Index Medicus, African Journals Online, African Healthline, Med-Carib, and Global Index Medicus (from 2000 to October 2019). We included citations that described the development or validation of a pediatric prognostic model for hospital mortality or clinical deterioration events in low- and middle-income countries. In duplicate and independently, we extracted data on included populations and model prognostic performance and evaluated risk of bias using the Prediction model Risk Of Bias Assessment Tool. RESULTS Of 41 279 unique citations, we included 15 studies describing 15 prognostic models for mortality and 3 models for clinical deterioration events. Six models were validated in >1 external cohort. The Lambarene Organ Dysfunction Score (0.85 [0.77-0.92]) and Signs of Inflammation in Children that Kill (0.85 [0.82-0.88]) had the highest summary C-statistics (95% CI) for discrimination. Calibration and classification measures were poorly reported. All models were at high risk of bias owing to inappropriate selection of predictor variables and handling of missing data and incomplete performance measure reporting. CONCLUSIONS Several prognostic models for mortality and clinical deterioration events have been validated in single cohorts, with good discrimination. Rigorous validation that conforms to current standards for prediction model studies and updating of existing models are needed before clinical implementation.
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Affiliation(s)
- Fiona Muttalib
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Center for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Virginie Clavel
- Faculty of Medicine, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Lauren H Yaeger
- Becker Medical Library Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Vibhuti Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Neill K J Adhikari
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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15
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Agarwal A, Basmaji J, Muttalib F, Granton D, Chaudhuri D, Chetan D, Hu M, Fernando SM, Honarmand K, Bakaa L, Brar S, Rochwerg B, Adhikari NK, Lamontagne F, Murthy S, Hui DSC, Gomersall C, Mubareka S, Diaz JV, Burns KEA, Couban R, Ibrahim Q, Guyatt GH, Vandvik PO. High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission. Can J Anaesth 2020; 67:1217-1248. [PMID: 32542464 PMCID: PMC7294988 DOI: 10.1007/s12630-020-01740-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 01/03/2023] Open
Abstract
PURPOSE We conducted two World Health Organization-commissioned reviews to inform use of high-flow nasal cannula (HFNC) in patients with coronavirus disease (COVID-19). We synthesized the evidence regarding efficacy and safety (review 1), as well as risks of droplet dispersion, aerosol generation, and associated transmission (review 2) of viral products. SOURCE Literature searches were performed in Ovid MEDLINE, Embase, Web of Science, Chinese databases, and medRxiv. Review 1: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy (COT) in critically ill patients with acute hypoxemic respiratory failure. Review 2: we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection transmission associated with HFNC. For both reviews, paired reviewers independently conducted screening, data extraction, and risk of bias assessment. We evaluated certainty of evidence using GRADE methodology. PRINCIPAL FINDINGS No eligible studies included COVID-19 patients. Review 1: 12 RCTs (n = 1,989 patients) provided low-certainty evidence that HFNC may reduce invasive ventilation (relative risk [RR], 0.85; 95% confidence interval [CI], 0.74 to 0.99) and escalation of oxygen therapy (RR, 0.71; 95% CI, 0.51 to 0.98) in patients with respiratory failure. Results provided no support for differences in mortality (moderate certainty), or in-hospital or intensive care length of stay (moderate and low certainty, respectively). Review 2: four studies evaluating droplet dispersion and three evaluating aerosol generation and dispersion provided very low certainty evidence. Two simulation studies and a crossover study showed mixed findings regarding the effect of HFNC on droplet dispersion. Although two simulation studies reported no associated increase in aerosol dispersion, one reported that higher flow rates were associated with increased regions of aerosol density. CONCLUSIONS High-flow nasal cannula may reduce the need for invasive ventilation and escalation of therapy compared with COT in COVID-19 patients with acute hypoxemic respiratory failure. This benefit must be balanced against the unknown risk of airborne transmission.
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Affiliation(s)
- Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - John Basmaji
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Fiona Muttalib
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - David Granton
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Devin Chetan
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Malini Hu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kimia Honarmand
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Schulich School of Medicine and Dentistry, Department of Medicine, Western University, London, ON, Canada
| | - Layla Bakaa
- Honours Life Sciences Program, Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Sonia Brar
- School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, USA
| | - Bram Rochwerg
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Neill K Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Francois Lamontagne
- Université de Sherbrooke, Sherbrooke, Canada
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Srinivas Murthy
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David S C Hui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
- Stanley Ho, Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
| | - Charles Gomersall
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Samira Mubareka
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Janet V Diaz
- Pacific Medical Center, San Francisco, CA, USA
- World Health Organization, Geneva, Switzerland
| | - Karen E A Burns
- Unity Health Toronto - St. Michael's Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Rachel Couban
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Affiliation(s)
- Louise Rose
- Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fiona Muttalib
- Center for Global Child Health, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Rink N, Muttalib F, Morantz G, Chase L, Cleveland J, Rousseau C, Li P. The gap between coverage and care-what can Canadian paediatricians do about access to health services for refugee claimant children? Paediatr Child Health 2017; 22:430-437. [PMID: 29479260 DOI: 10.1093/pch/pxx115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction In June 2012, the government of Canada severely restricted the scope of the Interim Federal Health Program that had hitherto provided coverage for the health care needs of refugee claimants. The Quebec government decided to supplement coverage via the provincial health program. Despite this, we hypothesized that refugee claimant children in Montreal would continue to experience significant difficulties in accessing basic health care. Objectives (1) Report the narrative experiences of refugee claimant families who were denied health care services in Montreal following June 2012, (2) describe the predominant barriers to accessing health care services and understanding their impact using thematic analysis and (3) derive concrete recommendations for child health care providers to improve access to care for refugee claimant children. Methods Eleven parents recruited from two sites in Montreal participated in semi-structured interviews designed to elicit a narrative account of their experiences seeking health care. Interviews were recorded, transcribed, coded using NVivo software and subjected to thematic analysis. Results Thematic analysis of the data revealed five themes concerning barriers to health care access: lack of continuous health coverage, health care administrators/providers' lack of understanding of Interim Federal Health Program coverage, refusal of services or fees charged, refugee claimants' lack of understanding about health care rights and services and language barriers, and four themes concerning the impact of denial of care episodes: potential for adverse health outcomes, psychological distress, financial burden and social stigma. Conclusion We propose eight action points for advocacy by Canadian paediatricians to improve access to health care for refugee claimant children in their communities and institutions.
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Affiliation(s)
- N Rink
- Department of Paediatrics, The Montreal Children's Hospital, McGill University, Montreal, Quebec
| | - F Muttalib
- Department of Paediatrics, The Montreal Children's Hospital, McGill University, Montreal, Quebec
| | - G Morantz
- Department of Paediatrics, The Montreal Children's Hospital, McGill University, Montreal, Quebec
| | - L Chase
- School of Oriental and African Studies, University of London, London, UK
| | - J Cleveland
- CSSS de la Montagne - Centre de recherche et de formation, Montreal, Quebec
| | - C Rousseau
- Division of Social and Cultural Psychiatry, McGill University, Montreal, Quebec
| | - P Li
- Department of Paediatrics, The Montreal Children's Hospital, McGill University, Montreal, Quebec
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