Browsing by Subject "Pediatrics"

Drug-resistant tuberculosis (DR-TB) is a threat to TB control globally. South Africa has the third highest epidemic of DR-TB – following only Russia and China, two much more populous countries. South Africa has stringent guidelines for treating DR-TB; however, little is known about adherence to these guidelines. Additionally, little is known about age appropriate treatment, particularly in youth (13-24 years) who may have differing needs than adults with DR-TB. South Africa also has the world’s largest HIV epidemic – nearly 18% of the population is infected with HIV. Individuals with HIV are 26 to 31 times more likely to become infected with TB than individuals without HIV. Among individuals in South Africa with TB, there is a 57-68% HIV coinfection rate.

This dissertation includes a systematic literature review (Chapter 2) exploring barriers to TB treatment initiation in sub-Saharan Africa with an emphasis on children and youth. Additionally, time to treatment was assessed per South African guidelines (i.e. initiating treatment within five days of diagnosis) and total days from DR-TB diagnosis to DR-TB treatment initiation. This analysis included multi-level modeling with fixed patient- (sex, history of TB, HIV coinfection) and system-characteristics (urban-rural location, province) and random effects of treatment site. Guidelines were further evaluated, by assessing through descriptive statistics and logistic regression, receipt of guideline recommended care in terms of correct medications prescribed, correct dosage prescribed, and correct frequency prescribed at treatment initiation (correct regimen).

Barriers exist for all individuals with TB to initiate treatment regardless of age. These barriers are at the patient- and system-level and include: costs, health seeking behaviors, and infrastructure. More research is needed to identify barriers specifically among children and youth, as only four articles reviewed focused on these vulnerable populations. The time to DR-TB treatment is delayed for 84% of South Africans, and age did not predict delays. Seventeen percent of individuals coinfected with HIV receive care per guidelines compared to 12% of those without coinfection. Additionally, receipt of correct medications was prescribed to 88% of patients, yet only 33% received correct medications and doses, and still, only 30% received the full correct regimen. Age was not a strong predictor for receipt of correct guideline based treatment. In conclusion, more research must be focused on younger individuals with TB, particularly DR-TB. More research investigating guideline recommended care is essential to improve patient outcomes, prevent the transmission of DR-TB in communities, and to prevent further drug resistance.

Background: A staggering 5 billion people worldwide lack access to safe and affordable surgery, and surgical conditions contribute to up to 32% of the global disease burden. However, precise data on the burden of surgical conditions is lacking, particularly for children. This study aims to measure the burden of pediatric surgical conditions in Somaliland using a community-based, household, nationwide survey as well as a national hospital survey to identify the types and volume of pediatric surgical care.

Methods: We surveyed 1450 children, from 839 families, through national community-based sampling using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey to identify the prevalence of surgical conditions. We also performed a hospital capacity survey at 15 hospitals in Somaliland, with surgical records reviewed over a 1-year time frame to identify pediatric surgical procedures performed.

Results: Using a community survey, we identified 226 surgical conditions in 191 children, yielding a surgical condition prevalence of 13.7% in the pediatric population. Only 55 of 226 conditions were treated with a surgical procedure. The most common conditions reported were congenital deformities (34.4%) and wound related injuries (23.8%). Using a hospital survey, we identified 1255 pediatric surgical procedures performed nationally over 1 year. We found that 56.7% procedures were in performed in boys and 79.8% were done at private hospitals. The most common surgical diagnoses were tonsillitis, trauma/wound/snake bite, and hydrocephalus.

Conclusions: Between 91,500 – 209,000 children in Somaliland have an unmet need for pediatric surgery, highlighting the high burden of surgical disease in the country. The estimated number of performed surgical procedures represents a small fraction of the burden of pediatric surgical conditions, highlighting the need for expansion of infrastructure, resources, and workforce to provide needed surgical care.

Background: Patient safety is critical to prevent medical errors and to improve clinical outcomes. The need to implement programs in patient safety is increasingly recognized as a prime component of healthcare delivery in low- and middle- income countries (LMICs). The goal for our study is to assess the implementation of a patient safety program in Guatemala.

Methods: We used a mixed-methods approach to assess implementation of a patient safety program in the pediatric perioperative unit in Hospital Roosevelt, Guatemala. We collected data from unit staff respondents (n=16) using a qualitative de novo survey, the Evidence-Based Practice Attitude Scale-36 (EBPAS-36) survey, and a semi-structured interview. Interviews and surveys were conducted in Spanish, translated, and analyzed in English using NVivo v12. Quantitative data were analyzed to compare group means across survey domains. Data were triangulated, with final analysis guided by the Consolidated Framework for Implementation Research (CFIR). Data were collected over a 10-day period in July 2018.

Results: Responses underscored several emergent thematic determinants representing the Inner Setting and Characteristics of Individuals CFIR domains, indicating a gap in knowledge of patient safety programs and attitude towards the use of evidence-based patient safety programs. Though respondents expressed an openness and willingness to adopt patient safety practices, few existing practices are in place to prevent medical errors.

Conclusions: The main determinants which affect the implementation of an evidence-based patient safety program in the pediatric perioperative unit in Guatemala are related to the internal structure and culture of the unit, and not to external factors or the intervention itself. Positive attitudes and knowledge of patient safety practices are insufficient to overcome the challenges towards implementation. A framework for future implementation should include education and communication programs, adaptation of existing practices to increase leadership engagement, and use of tools to create a strong culture of safety.

Background: Emergency care sensitive conditions are defined as those for which rapid diagnosis and early intervention improve patient outcomes. This thesis aimed to develop a list of important pediatric conditions in low- and middle-income countries (LMIC) to be used for further studies on pediatric epidemiology and resource utilization. Methods: A survey of 79 conditions was sent to LMIC physicians, who rated each condition on three categories (time sensitivity, preventability, and commonality) on a scale of 1-9. Responses were matched to Brazil pediatric hospitalization, ambulatory, and mortality data from 2015-2020. Results: 17 physicians completed the first Round of the survey, and 3 of these (17.65%) completed the second Round. Overall, 67 of the 79 (84.21%) were rated as highly time-sensitive and 26 (32.91%) highly preventable. Survey conditions with the highest ratings overall or country overlap (n=11), that were country-specific but highly rated in all three categories (n=8), or that comprised ~1%+ of hospitalizations (n=9), ~0.5%+ of ambulatory visits (n=6), and ~0.5%+ of mortality cases (n=8) were combined with the most common acute non-elective causes of hospitalizations (n=7) and mortality (n=9) into a list of 29 consolidated conditions overall (excluding overlap). These 29 accounted for 37.83% of hospitalizations, 8.97% of ambulatory visits, and 29.17% of mortality cases. 31 of the 79 survey conditions were age-specific and 32 context-specific. Conclusions: These 29 should be targeted in future health system utilization and burden studies. The modified Delphi approach is important in reaching provider consensus.

Background: HIV-associated cardiac dysfunction has severe consequences, and traditional measures of echocardiography underestimate disease. Novel echocardiographic measures may detect early disease in time for intervention. The aims of this study are to define the prevalence of early cardiac dysfunction in children living with HIV, and the relationships between cardiac function and same-day plasma HIV RNA levels.

Methods: Using a cross-sectional study design, we performed echocardiograms and obtained plasma HIV RNA levels on perinatally HIV-infected children engaged in care at Moi Teaching and Referral Hospital in Eldoret, Kenya. Early cardiac dysfunction was defined as normal ejection fraction but left ventricular global longitudinal strain (LV GLS) z-score < -2 or myocardial performance index (MPI) ≥ 0.5. The relationship between measures of cardiac function and HIV RNA levels and the assessment of other clinical covariates (age, sex, duration on antiretrovirals, and AZT exposure) with measures of cardiac function were modeled using multivariable regression.

Results: 302 perinatally HIV-infected children (mean age 9.8±3.2 years, range 2-16 years) were enrolled. The mean BMI-for-age z-s core was -1.0±1.1. The median duration on antiretrovirals was 5.4 years (IQR 3.2, 7.6). One hundred and sixteen children (38.4%) had been exposed to AZT (median duration of exposure 2.6 years, IQR 0.2, 5.4). One hundred and one of 298 (33.9%) had HIV RNA measurements ≥ 40 copies/ml. Only 1 of 302 children had LV GLS-for-BSA z-score ≤ -2 and normal ejection fraction meeting the criteria for early cardiac dysfunction, and 65 of 292 (22.3%) children had an MPI ≥ 0.5 and normal ejection fraction. In multivariate analysis, neither LVGLS z-score nor MPI were associated with HIV RNA levels ≥ 40 copies/ml or any clinical variables in the model [β -0.08 (95%CI -0.39, 0.23) and β 0.01 (95%CI -0.01, 0.03), respectively]. MPI was very weakly correlated with LVGLS z-score (r -0.15; 95%CI -0.26, -0.04).

Conclusions: Nearly one quarter of these perinatally HIV-infected children demonstrated echocardiographic evidence of early cardiac dysfunction, based primarily on abnormal MPI measurements. This finding was not correlated with same-day HIV RNA levels or other clinically relevant variables. Further investigation into the clinical significance of this finding is urgently needed as abnormal MPI measurements have been shown to be predictive of heart failure in at risk populations.

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Patients undergoing cardiac catheterization are potentially at risk of radiation-induced health effects from the interventional fluoroscopic X-ray imaging used throughout the clinical procedure. The amount of radiation exposure is highly dependent on the complexity of the procedure and the level of optimization in imaging parameters applied by the clinician. For cardiac catheterization, patient radiation dosimetry, for key organs as well as whole-body effective, is challenging due to the lack of fixed imaging protocols, unlike other common X-ray based imaging modalities.

Pediatric patients are at a greater risk compared to adults due to their greater cellular radio-sensitivities as well as longer remaining life-expectancy following the radiation exposure. In terms of radiation dosimetry, they are often more challenging due to greater variation in body size, which often triggers a wider range of imaging parameters in modern imaging systems with automatic dose rate modulation.

The overall objective of this dissertation was to develop a comprehensive method of radiation dose estimation for pediatric patients undergoing cardiac catheterization. In this dissertation, the research is divided into two main parts: the Physics Component and the Clinical Component. A proof-of-principle study focused on two patient age groups (Newborn and Five-year-old), one popular biplane imaging system, and the clinical practice of two pediatric cardiologists at one large academic medical center.

The Physics Component includes experiments relevant to the physical measurement of patient organ dose using high-sensitivity MOSFET dosimeters placed in anthropomorphic pediatric phantoms.

First, the three-dimensional angular dependence of MOSFET detectors in scatter medium under fluoroscopic irradiation was characterized. A custom-made spherical scatter phantom was used to measure response variations in three-dimensional angular orientations. The results were to be used as angular dependence correction factors for the MOSFET organ dose measurements in the following studies. Minor angular dependence (< ±20% at all angles tested, < ±10% at clinically relevant angles in cardiac catheterization) was observed.

Second, the cardiac dose for common fluoroscopic imaging techniques for pediatric patients in the two age groups was measured. Imaging technique settings with variations of individual key imaging parameters were tested to observe the quantitative effect of imaging optimization or lack thereof. Along with each measurement, the two standard system output indices, the Air Kerma (AK) and Dose-Area Product (DAP), were also recorded and compared to the measured cardiac and skin doses – the lack of correlation between the indices and the organ doses shed light to the substantial limitation of the indices in representing patient radiation dose, at least within the scope of this dissertation.

Third, the effective dose (ED) for Posterior-Anterior and Lateral fluoroscopic imaging techniques for pediatric patients in the two age groups was determined. In addition, the dosimetric effect of removing the anti-scatter grid was studied, for which a factor-of-two ED rate reduction was observed for the imaging techniques.

The Clinical Component involved analytical research to develop a validated retrospective cardiac dose reconstruction formulation and to propose the new Optimization Index which evaluates the level of optimization of the clinician’s imaging usage during a procedure; and small sample group of actual procedures were used to demonstrate applicability of these formulations.

In its entirety, the research represents a first-of-its-kind comprehensive approach in radiation dosimetry for pediatric cardiac catheterization; and separately, it is also modular enough that each individual section can serve as study templates for small-scale dosimetric studies of similar purposes. The data collected and algorithmic formulations developed can be of use in areas of personalized patient dosimetry, clinician training, image quality studies and radiation-associated health effect research.

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