Advancing pediatric perioperative care in India: A contemporary overview

BACKGROUND

In the last 30 years, significant advances have been made in pediatric medical care globally. However, there is a persistent urban-rural gap which is more pronounced in low middle-income countries than high-income countries, similar urban-rural gap exists in India. While on one hand, health care is on par or better than healthier nations thriving international medical tourism industry, some rural parts have reduced access to high-quality care.

AIM

With this background, we aim to provide an overview of the present and future of healthcare in India.

METHODOLOGY

With the cumulative health experience of the authors or more than 100 years, we have provided our experience and expertise about healthcare in India in this narrative educational review. This is supplemented by the government plans and non government plans as appropriate. References are used to justify as applicable.

RESULTS

With the high percentage of pediatric population like other low to middle-income countries, India faces challenges in pediatric surgery and anesthesia due to limited resources and paucity of specialized training, especially in rural areas. Data on the access and quality of care is scarce, and the vast rural population and uneven resource distribution add to the challenges along with the shortage of pediatric surgeons in these areas of specialized care . Addressing these challenges requires a multi faceted strategy that targets both immediate and long-term healthcare needs, focusing on improving the facilities and training healthcare professionals. Solutions could include compulsory rural service, district residency programs, increasing postgraduate or residency positions, and safety courses offered by national and international organizations like Safer Anesthesia from Education Pediatrics, Vital Anesthesia Simulation Training, and World Federation of Society of Anesthesiologists pediatric fellowships.

CONCLUSION

India has achieved great strides in perioperative health care and safety. It has become the major international medical industry due to high-quality care, access and costs. Crucially, India needs to establish local hubs for pediatric perioperative care training to enhance healthcare delivery for children.

Characterization of Antibiotic Treatment among Children Aged 0-59 Months Hospitalized for Acute Bacterial Gastroenteritis in Israel

BACKGROUND

We examined the extent and correlates of appropriate antibiotic use among children hospitalized with bacterial acute gastroenteritis (AGE) in Israel, a high-income country setting.

METHODS

Data were collected from children aged 0-59 months who participated in active hospital-based surveillance of AGE undertaken during 2007-2015. Bacterial AGE was defined as having a positive stool culture for Salmonella, Shigella, Campylobacter, or dysentery. Appropriate antibiotic use was defined as the administration of ciprofloxacin, azithromycin, or third-generation cephalosporins during hospitalization or at discharge.

RESULTS

Overall, 550 children had bacterial AGE; of those, 369 (67.1% [95% CI 63.1-70.9]) received antibiotics, mostly azithromycin (61.8%) and third-generation cephalosporins (37.9%). Appropriate antibiotic treatment was given to 318/550 (57.8% [95% CI 53.7-61.9]). Children aged 0-11 months vs. 24-49 months were more likely to receive appropriate antibiotic treatment (OR = 1.90 [95% CI 1.09-3.33]). Having dysentery (OR = 5.30 [95% CI 3.35-8.39]), performing blood culture (OR = 1.59 [95% CI 1.02-2.48]), and C-reactive protein (CRP) levels (OR = 1.01 [95% CI 1.01-1.02]) were positively associated with receiving appropriate antibiotic treatment.

CONCLUSIONS

Most children with bacterial AGE received appropriate antibiotic treatment, which correlated with young age, dysentery, CRP level, and performing blood culture, suggesting more severe illness, thus supporting the clinical decisions of physicians.

Impact of Deprivation on the Incidence and Severity of Tuberculosis in Children: A Retrospective Study from 2007 to 2020 in a Tertiary Care Center in Paris, France

OBJECTIVE

To assess the association between deprivation and the incidence and clinical severity of tuberculosis (TB) in children.

STUDY DESIGN

Children ≤18 years old who were admitted for TB between 2007 and 2020 at a tertiary hospital were included in this retrospective study. Deprivation was assessed using the French Deprivation Index. TB severity was assessed using the Wiseman classification. Multivariate analyses were carried out.

RESULTS

In total, 222 patients were included. The median age was 10.8 years (IQR 4.5-14.4). TB was considered severe in 126 patients (56.8%), with 50% of the patients included in the 2 most deprived groups. The most-deprived children had a TB incidence that was 58 times greater than that of the least-deprived children (95% CI 28.49-119.40). There was no significant association between deprivation and severity in the multivariable analysis after adjusting for age and circumstances of diagnosis. Deprivation was associated with an increased length of stay in the most-deprived groups (OR 3.79, 95% CI 1.55-10.23). There was a trend toward a greater proportion of symptomatic children in the most-deprived group.

CONCLUSIONS

TB incidence and hospital length of stay increased with deprivation levels but not with the severity of TB.

Current approach and attitudes toward neonatal near-miss and perinatal audits: An exploratory international survey

BACKGROUND

Combined with perinatal mortality review, neonatal near-miss (NNM) audit has the potential to inform strategies to better prevent adverse perinatal outcomes. Nonetheless, there is lack of standardised definitions of NNM and limited evidence of implementation of NNM audits.

AIM

To describe definitions of NNM and assess current approaches and attitudes toward perinatal mortality and morbidity audit.

MATERIALS AND METHODS

Online survey from December 2021 to February 2022, with a mix of Likert scales, polar, pool, multi-choice, and open-ended questions, disseminated through national and international organisations to perinatal healthcare workers from high-income countries.

RESULTS

One hundred and twenty participants came from Australia (n = 86), New Zealand (n = 18), Canada (n = 7), USA (n = 4), Netherlands (n = 2), other countries (n = 3). Neonatologists (35%), midwives (21.7%), obstetricians (12.5%), neonatal nurse practitioners (11.7%) and others (23.3%) responded. Most respondents thought the main characteristics to define NNM were birth asphyxia needing therapeutic hypothermia (68.3%), unexpected resuscitation at birth (67.5%), need for intubation/chest compression/adrenaline (65.0%) and metabolic acidosis at birth (60.0%). There were 97.5% of participants who considered NNM important for identifying cases for perinatal morbidity audits. However, only 10.0% of their institutions used a NNM definition. Overall, 98.4% of participants considered perinatal mortality and morbidity audits important to prevent adverse outcomes.

CONCLUSION

Neonatal near-miss audit is viewed as a valuable tool to reduce adverse neonatal outcomes. There was reasonable consensus that NNM encompassed evidence of birth asphyxia and/or advanced neonatal resuscitation. Data from this international survey identifies a starting point for a consensus definition of NNM, which can be used for perinatal audits to identify opportunities for improvement.

Cost-Effectiveness of Respiratory Syncytial Virus Preventive Interventions in Children: A Model Comparison Study

OBJECTIVES

Model-based cost-effectiveness analyses on maternal vaccine (MV) and monoclonal antibody (mAb) interventions against respiratory syncytial virus (RSV) use context-specific data and produce varied results. Through model comparison, we aim to characterize RSV cost-effectiveness models and examine drivers for their outputs.

METHODS

We compared 3 static and 2 dynamic models using a common input parameter set for a hypothetical birth cohort of 100 000 infants. Year-round and seasonal programs were evaluated for MV and mAb interventions, using available evidence during the study period (eg, phase III MV and phase IIb mAb efficacy).

RESULTS

Three static models estimated comparable medically attended (MA) cases averted versus no intervention (MV, 1019-1073; mAb, 5075-5487), with the year-round MV directly saving ∼€1 million medical and €0.3 million nonmedical costs, while gaining 4 to 5 discounted quality-adjusted life years (QALYs) annually in <1-year-olds, and mAb resulting in €4 million medical and €1.5 million nonmedical cost savings, and 21 to 25 discounted QALYs gained. In contrast, both dynamic models estimated fewer MA cases averted (MV, 402-752; mAb, 3362-4622); one showed an age shift of RSV cases, whereas the other one reported many non-MA symptomatic cases averted, especially by MV (2014). These differences can be explained by model types, assumptions on non-MA burden, and interventions' effectiveness over time.

CONCLUSIONS

Our static and dynamic models produced overall similar hospitalization and death estimates, but also important differences, especially in non-MA cases averted. Despite the small QALY decrement per non-MA case, their larger number makes them influential for the costs per QALY gained of RSV interventions.

Basilar artery occlusion management: An international survey of middle versus high-income countries

BACKGROUND AND PURPOSE

Two early basilar artery occlusion (BAO) randomized controlled trials (RCTs) did not establish the superiority of endovascular thrombectomy (EVT) over medical management. Yet many providers continued to recommend EVT. The goal of the present article is to compare physicians' diagnostic and management strategies of BAO among middle-income and high-income countries (MICs and HICs, respectively).

METHODS

We conducted an international survey from January to March 2022 regarding management strategies in acute BAO, to examine clinical and imaging parameters influencing clinician management of patients with BAO. We compared responses between physicians from HIC and MIC.

RESULTS

Among the 1245 respondents from 73 countries, 799 (64.2%) were from HIC, with the remaining 393 (31.6%) from MIC. Most respondents perceived that EVT was superior to medical management for acute BAO, but more so in respondents from HIC (98.0% vs. 94.2%, p < 0.01). MIC respondents were more likely to believe further RCTs were warranted (91.6% vs. 74.0%, p < 0.01) and were more likely to find it acceptable to enroll any patient who met a trial's criteria in the standard medical treatment arm (58.8% vs. 38.5%, p < 0.01).

CONCLUSIONS

In an area where clinical equipoise was called into question despite the lack of RCT evidence, we found that respondents from MIC were more likely to express willingness to enroll patients with BAO in an RCT than their HIC counterparts.

Maternal factors associated with interbirth intervals in Australia: Results from a population-based longitudinal study

BACKGROUND AND OBJECTIVE

Short and long intervals between successive births are associated with adverse birth outcomes, especially in low-income and middle-income countries, yet the birth intervals in high-income countries remain relatively understudied. The aim was to examine maternal factors associated with birth intervals in Australia.

METHODS

The sample comprised 6130 participants in the Australian Longitudinal Study on Women's Health who were born in 1973-1978, had two or more births, and responded to regular surveys between 1996 and 2018. Interbirth interval (IBI) was defined as the time between successive live births. Maternal factors were examined using accelerated failure time models.

RESULTS

For women with only two births (n = 3802), the median time to the second birth was 34.0 months (IQR 23.1, 46.2) with shorter IBI associated with higher socioeconomic status (eg, university education (31.9 months), less income stress (31.1)), and longer IBI associated with age over 35 (39.7), fair/poor health (43.0), untreated fertility problems (45.5), miscarriage (39.4), or abortion (41.0). For women with three or more births (n = 2328), the median times to the second and third births were 31.2 months (19.9, 42.1) and 36.5 months (25.3, 50.1), respectively; some factors were consistent between the first IBI and second IBI (eg, university education and being married were associated with shorter IBI), whereas income stress was associated with longer first IBI but not with second IBI.

CONCLUSIONS

Understanding maternal factors associated with birth intervals in a high-income country like Australia may enable more nuanced tailoring of guidelines for prepregnancy care.

To parachute or not

This editorial was prompted by a criticism of our inability to identify all existing local oncologic human resources prior to the initiation of a women's cancer care platform in the Democratic Republic of the Congo. We discuss the act of parachuting, i.e., intermittent visits by investigators from high-income countries to low-and middle-income countries, its dichotomization (positive and negative), role in bilateral collaborations between high-income and low-and middle-income countries, contributing etiologies and potential harms. Lastly, we highlight our use of parachuting to successfully transfer breast and cervical cancer diagnostic and surgical skills to healthcare providers in a low-income African nation, while simultaneously building clinical infrastructure for women's cancers. We conclude with recommendations that pertain to the development of better research ecosystems in Africa.

Women's Experiences of Physical Features in a Specially Designed Birthing Room: A Mixed-Methods Study in Sweden

Aim:

To explore women’s experiences of physical features in a birthing room designed to be adaptable to personal wishes and needs during labor and birth.

Background:

Childbirth is a central life event influenced by numerous factors, including the healthcare environment; however, there is insufficient knowledge on how the physical design affects women during birth.

Methods:

This study was part of a randomized controlled trial in the Room4Birth research project, including women randomized to receive care in a new birthing room designed with physical features changeable according to personal wishes. Data consisted of responses to two questions analyzed with descriptive statistics (n = 202) and semi-structured interviews analyzed for content (n = 19).

Results:

A total of 93.6% (n = 189) assessed the physical features in the birthing room as meaningful to a very high or high extent. The overall impression of the room was positive and exceeded women’s expectations. They felt welcomed and strengthened by the room, which shifted the focus to a more positive emotional state. The room differed from traditional hospital birthing rooms, contained familiar features that maintained integrity, and had space for companions. The variety of physical features was appreciated. Of nine listed physical features, the bathtub was ranked most important, followed by the projection of nature scenery, and dimmable lighting, but the room as a whole appeared most important.

Conclusions:

When planning and designing hospital-based birthing rooms, it is crucial to offer possibilities to adapt the room and physical features according to personal wishes.

Identification and Evaluation of Methodologies to Assess the Quality of Mobile Health Apps in High-, Low-, and Middle-Income Countries: Rapid Review

BACKGROUND

In recent years, there has been rapid growth in the availability and use of mobile health (mHealth) apps around the world. A consensus regarding an accepted standard to assess the quality of such apps has yet to be reached. A factor that exacerbates the challenge of mHealth app quality assessment is variations in the interpretation of quality and its subdimensions. Consequently, it has become increasingly difficult for health care professionals worldwide to distinguish apps of high quality from those of lower quality. This exposes both patients and health care professionals to unnecessary risks. Despite progress, limited understanding of the contributions of researchers in low- and middle-income countries (LMICs) exists on this topic. Furthermore, the applicability of quality assessment methodologies in LMIC settings remains relatively unexplored.

OBJECTIVE

This rapid review aims to identify current methodologies in the literature to assess the quality of mHealth apps, understand what aspects of quality these methodologies address, determine what input has been made by authors from LMICs, and examine the applicability of such methodologies in LMICs.

METHODS

This review was registered with PROSPERO (International Prospective Register of Systematic Reviews). A search of PubMed, EMBASE, Web of Science, and Scopus was performed for papers related to mHealth app quality assessment methodologies, which were published in English between 2005 and 2020. By taking a rapid review approach, a thematic and descriptive analysis of the papers was performed.

RESULTS

Electronic database searches identified 841 papers. After the screening process, 52 papers remained for inclusion. Of the 52 papers, 5 (10%) proposed novel methodologies that could be used to evaluate mHealth apps of diverse medical areas of interest, 8 (15%) proposed methodologies that could be used to assess apps concerned with a specific medical focus, and 39 (75%) used methodologies developed by other published authors to evaluate the quality of various groups of mHealth apps. The authors in 6% (3/52) of papers were solely affiliated to institutes in LMICs. A further 15% (8/52) of papers had at least one coauthor affiliated to an institute in an LMIC.

CONCLUSIONS

Quality assessment of mHealth apps is complex in nature and at times subjective. Despite growing research on this topic, to date, an all-encompassing appropriate means for evaluating the quality of mHealth apps does not exist. There has been engagement with authors affiliated to institutes across LMICs; however, limited consideration of current generic methodologies for application in LMIC settings has been identified.

TRIAL REGISTRATION

PROSPERO CRD42020205149; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=205149.

Tuberculosis in Migrants is Among the Challenges of Tuberculosis Control in High-Income Countries

The incidence of tuberculosis (TB) is high among migrants in high-income countries. The migration process could contribute to the high incidence of TB among them. Achieving TB elimination from these settings will be difficult unless countries address the burden of TB among migrants. The aim of this review was to describe the challenges of international migration on TB control in high-income, low TB incidence countries. Among migrants, there is a high prevalence of risk factors for TB, such as exposure to TB, HIV, malnutrition, substance use, delayed diagnosis, low education, poor health-seeking, the culture, stigma and marginalization. Discriminatory policies of TB care and social barriers such as language, cultural issues and unfriendly health services may also contribute to the high prevalence of TB among them. TB control among migrants in these settings is important as migrants are vulnerable to TB infection and disease, and implementing TB care among them is difficult; it is important to reduce the TB burden in migrants and the community at large and the high risk of multidrug-resistant TB (MDR-TB). TB elimination from high-income countries requires acquiring data and analyzing it to measure the burden, having migrant-sensitive health systems, having policy and legal frameworks and multi-country partnerships and conducting research.

Drowning mortality in children aged 0-14 years in Victoria, Australia: detailed epidemiological study 2001-2016

BACKGROUND

Major reductions in child drowning mortality rates have been observed historically in Victoria, Australia, for the period 1863-2000. Despite this trend, drowning remains the leading cause of unintentional child death in Victoria. This study investigates the residual fatal drowning problem in the Victorian child population (0-14 years) for the period 2001-2016.

AIMS

Describe the epidemiology of child drowning deaths in the Victorian population in 2001-2016; investigate risk factors and direct antecedents to these deaths.

METHODS

Population-based retrospective case data were extracted from the National Coronial Information System for 16 years (January 2001-December 2016), and case-by-case analysis was conducted. Associated factors were determined using univariate and Poisson analyses.

RESULTS

88 of 97 cases had information available for analysis, pools were the most frequent location (30%); 70% of all cases occurred between 08:00 and 17:00; most victims were not deliberately in the body of the water (73%), for example, the pool. Supervision lapses included carers leaving the room when the child was in the bath (16/18), siblings left to supervise the child in private pools (7/23), inadequate pool fences (8/23) or faulty/open gates (4/23), or neighbours' pool spa (4/23). Delays in finding the child occurred when searches occurred elsewhere, before the body of water (21/88) and when carers were asleep (5/88). Fourteen of the 88 children had an intellectual disability or predisposing medical condition. The grouped Poisson analysis demonstrated that age 0-4 years, male gender and rural place of residence were significant. A downward trend in drowning rate continued in this period.

DISCUSSION AND CONCLUSIONS

A case-by-case analysis of a drowned population of children identified details of risk factors and antecedents not previously described. Missing data on antecedents were common, likely resulting in undercounting. Further enhancements to systematic data collection are needed. The results support a systems approach to drowning prevention.

Effect of pharmaceutical care interventions on glycemic control in patients with diabetes: a systematic review and meta-analysis

Purpose

Diabetes is a chronic lifelong condition, and adherence to medications and self-monitoring of blood glucose are challenging for diabetic patients. The dramatic increase in the prevalence of diabetes is largely due to the incidence of type 2 diabetes in low- and middle-income countries (LMIc) besides high-income countries (HIc). We aimed to evaluate whether pharmacist care (PC) service model in LMIc and HIc could improve clinical outcomes in diabetic patients by performing a meta-analysis.

Methods

PubMed, Embase, and ProQuest Dissertations Unlimited Published Literature database were searched to find publications pertaining to pharmacist-led intervention in patients with diabetes. The inclusion criteria were as follows: 1) randomized controlled trials, 2) confirmed diabetic patients (type 1 or type 2), 3) pharmaceutical care intervention by clinical pharmacist or/and multidisciplinary team, and 4) reporting HbA1c at baseline and end of study or the mean change in these values.

Results

A total of 37 articles were included in the meta-analysis. The overall result was significant and in favor of PC intervention on HbA1c change (standard difference in mean values [SDM]: 0.379, 95% CI: 0.208–0.550, P<0.001). The stratified meta-analysis showed that PC was significant in both HIc (n=20; SDM: 0.351, 95% CI: 0.207–0.495) and LMIc (n=15; SDM: 0.426, 95% CI: 0.071–0.780). More than 6 months is needed to obtain adequate effects on clinical diabetes parameters.

Conclusion

Our study presented that an adequate duration of pharmacist-led pharmaceutical care was effective in improving HbA1c in patients with diabetes in both LMIc and HIc.