Darlene R. House

Estimating the Weight of Children in Kenya: Do the Broselow Tape and Age-Based Formulas Measure Up?

STUDY OBJECTIVE Validated methods for weight estimation of children are readily available in developed countries; however, their utility in developing countries with higher rates of malnutrition and infectious disease is unknown. The goal of this study is to determine the validity of a height-based estimate, the Broselow tape, compared with age-based estimations among pediatric patients in Western Kenya. METHODS A prospective cross-sectional study of all sick children presenting to the emergency department of a government referral hospital in Eldoret, Kenya, was performed. Measured weight was compared with predicted weights according to the Broselow tape and commonly used advanced pediatric life support (APLS) and Nelsons age-based formulas. A Bland-Altman analysis was used to determine agreement between each method and actual weight. The method for weight prediction was determined a priori to be equivalent to the actual weight if the 95% confidence interval for the mean percentage difference between the predicted and actual weight was less than 10%. RESULTS Nine hundred sixty-seven children were included in analysis. The overall mean percentage difference for the actual weight and Broselow predicted weight was -2.2%, whereas APLS and Nelsons predictions were -5.2% and -10.4%, respectively. The overall agreement between Broselow color zone and actual weight was 65.5%, with overestimate typically occurring by only 1 color zone. CONCLUSION The Broselow tape and APLS formula predict the weights of children in western Kenya. According to its better performance, ease of use, and provision of drug dosing and equipment size, the Broselow tape is superior to age-based formulas for estimation of weight in Kenyan children.

Clinical and Translational Research in Global Health and Emergency Care: A Research Agenda

As policy-makers increasingly recognize emergency care to be a global health priority, the need for high-quality clinical and translational research in this area continues to grow. As part of the proceedings of the 2013 Academic Emergency Medicine consensus conference, this article discusses the importance of: 1) including clinical and translational research in the initial emergency care development plan, 2) defining the burden of acute disease and the barriers to conducting research in resource-limited settings, 3) assessing the appropriateness and effectiveness of local and global acute care guidelines within the local context, 4) studying the local research infrastructure needs to understand the best methods to build a sustainable research infrastructure, and 5) studying the long-term effects of clinical research programs on health care systems.

Diagnostic use of lung ultrasound compared to chest radiograph for suspected pneumonia in a resource-limited setting

BackgroundLung ultrasound is an effective tool for diagnosing pneumonia in developed countries. Diagnostic accuracy in resource-limited countries where pneumonia is the leading cause of death is unknown. The objective of this study was to evaluate the sensitivity of bedside lung ultrasound compared to chest X-ray for pneumonia in adults presenting for emergency care in a low-income country.MethodsPatients presenting to the emergency department with suspected pneumonia were evaluated with bedside lung ultrasound, single posterioranterior chest radiograph, and computed tomography (CT). Using CT as the gold standard, the sensitivity of lung ultrasound was compared to chest X-ray for the diagnosis of pneumonia using McNemar’s test for paired samples. Diagnostic characteristics for each test were calculated.ResultsOf 62 patients included in the study, 44 (71%) were diagnosed with pneumonia by CT. Lung ultrasound demonstrated a sensitivity of 91% compared to chest X-ray which had a sensitivity of 73% (p = 0.01). Specificity of lung ultrasound and chest X-ray were 61 and 50% respectively.ConclusionsBedside lung ultrasound demonstrated better sensitivity than chest X-ray for the diagnosis of pneumonia in Nepal.Trial registrationClinicalTrials.gov, registration number NCT02949141. Registered 31 October 2016.

Qualitative study of healthcare providers’ current practice patterns and barriers to successful rehydration for pediatric diarrheal illnesses in Kenya

Background For children worldwide, diarrhea is the second leading cause of death. These deaths are preventable by fluid resuscitation. Nasogastric tubes (NGs) have been shown to be equivalent to intravenous fluids for rehydration and recommended by the World Health Organization (WHO) for use in severe dehydration. Despite this, NGs are rarely used for rehydration in Kenya. Our objective was to evaluate clinicians’ adherence to rehydration guidelines and to identify barriers to the use of NGs for resuscitating dehydrated children. Methods A case-based structured survey was administered to pediatric care providers in western Kenya to determine their choices for alternative rehydration therapies when oral rehydration and intravenous fluids fail. Providers then participated in a qualitative, semi-structured interview to identify barriers to using nasogastric tubes for rehydration. Analysis included manual, progressive coding of interview transcripts to identify emerging central themes. Results Of 44 participants, only four (9%) followed WHO guidelines that recommend quickly switching to NG for rehydration in their case responses. Participants identified that placing intravenous lines in dehydrated children is a challenge. However, when discussing NG use, many believed NGs are not effective for rehydration. Other participants’ concerns surrounded knowledge and training regarding guidelines as well as not having NGs available. Discussion Healthcare providers in western Kenya do not report using NGs for rehydration in accordance with WHO guidelines for diarrheal illness with severe dehydration. Barriers to the use of NG tubes were lack of knowledge and availability. Education and implementation of guidelines using NG tubes for rehydration may improve outcomes of children suffering from diarrheal illness with severe dehydration.

Availability of mobile phones for discharge follow-up of pediatric Emergency Department patients in western Kenya

Objective. Mobile phones have been successfully used for Emergency Department (ED) patient follow-up in developed countries. Mobile phones are widely available in developing countries and may offer a similar potential for follow-up and continued care of ED patients in low and middle-income countries. The goal of this study was to determine the percentage of families with mobile phones presenting to a pediatric ED in western Kenya and rate of response to a follow-up phone call after discharge. Methods. A prospective, cross-sectional observational study of children presenting to the emergency department of a government referral hospital in Eldoret, Kenya was performed. Documentation of mobile phone access, including phone number, was recorded. If families had access, consent was obtained and families were contacted 7 days after discharge for follow-up. Results. Of 788 families, 704 (89.3%) had mobile phone access. Of those families discharged from the ED, successful follow-up was made in 83.6% of cases. Conclusions. Mobile phones are an available technology for follow-up of patients discharged from a pediatric emergency department in resource-limited western Kenya.

Emergency department transport rates of children from the scene of motor vehicle collisions: do booster seats make a difference?

Background Motor vehicle collisions (MVCs) are the leading cause of death and disability among children older than 1 year. Many states currently mandate all children between the ages of 4 and 8 years be restrained in booster seats. The implementation of a booster-seat law is generally thought to decrease the occurrence of injury to children. We hypothesized that appropriate restraint with booster seats would also cause a decrease in emergency department (ED) visits compared with children who were unrestrained. This is an important measure as ED visits are a surrogate marker for injury. Objective The main purpose of this study was to look at the rate of ED visits between children in booster seats compared with those in other or no restraint systems involved in MVCs. Injury severity was compared across restraint types as a secondary outcome of booster-seat use after the implementation of a state law. Methods A prospective observational study was performed including all children 4 to 8 years old involved in MVCs to which emergency medical services was dispatched. Ambulance services used a novel on-scene computer charting system for all MVC-related encounters to collect age, sex, child-restraint system, Glasgow Coma Scale score, injuries, and final disposition. Results One hundred fifty-nine children were studied with 58 children (35.6%) in booster seats, 73 children in seatbelts alone (45.2%), and 28 children (19.1%) in no restraint system. 76 children (47.7%), 74 by emergency medical services and 2 by private vehicle, were transported to the ED with no significant difference between restraint use (P = 0.534). Utilization of a restraint system did not significantly impact MVC injury severity. However, of those children who either died (n = 2) or had an on-scene decreased Glasgow Coma Scale score (n = 6), 75% (6/8) were not restrained in a booster seat. Conclusions The use of booster-seat restraints does not appear to be associated with whether a child will be transported to the ED for trauma evaluation.

Impact of Nepal earthquake on patients presenting for emergency care at Patan Hospital

OBJECTIVE Natural disasters have a significant impact on the health sector. On April 25, 2015, Nepal was struck by a 7.8 magnitude earthquake. The aim of the study was to compare patient volumes and clinical conditions presenting to the emergency department pre- and post-earthquake. METHODS A retrospective study was done at Patan Hospital Emergency Department in Kathmandu, Nepal. Volume, demographics, and patient diagnoses were collected for 4 months post-disaster and compared with cases seen the same months the year before the disaster to control for seasonal variations. RESULTS After the 2015 Nepal earthquake, 12,180 patients were seen in the emergency department. This was a significant decrease in patient volume compared with the 14,971 patients seen during the same months in 2014 (P=0.04). Of those, 5496 patients (4093 pre-disaster and 1433 post-disaster) had a chief complaint or diagnosis recorded for analysis. An increase in cardiovascular and respiratory cases was seen as well as an increase in psychiatric cases (mostly alcohol related) and cases of anemia. There was a decrease in the number of obstetrics/gynecology, infectious disease, and poisoning cases post-earthquake. CONCLUSIONS Understanding emergency department utilization after the earthquake has the potential to give further insight into improving disaster preparedness plans for post-disaster health needs. (Disaster Med Public Health Preparedness. 2019;13:211-216).

In Patients With ST-Segment Elevation Myocardial Infarction, Which Fibrinolytic Agent Is the Safest and Most Effective?

Volume -, no. This is the Shrestha, A the Safest a TAKE-HOME MESSAGE In patients with ST-segment elevation myocardial infarction (STEMI), when percutaneous coronary intervention is not an option, reperfusion therapy with the fibrinolytic agents tenecteplase, reteplase, or accelerated alteplase (90 minutes of infusion) plus parenteral anticoagulation has better overall safety and efficacy than other regimens.