A model for sustainable short-term international medical trips.

The health status of many people in developing countries is often dismal compared with the norms in industrialized countries. Increasingly, medical practitioners in the United States and other industrialized countries have become interested in global health issues, an interest that often takes the form of short-term international medical trips. We discuss several ethical issues associated with participation in such trips and use our experiences in developing the Children's Health International Medical Project of Seattle (CHIMPS) to outline and illustrate a set of 7 guiding principles for making these trips. CHIMPS is a resident-run, faculty-supported international medical program founded in 2002 by pediatric residents at the University of Washington in Seattle. Members of CHIMPS work with a rural community in El Salvador to support ongoing public health interventions there and provide sustainable medical care in collaboration with the community and a local nongovernmental organization. The 7 principles developed as a result of this work-mission, collaboration, education, service, teamwork, sustainability, and evaluation-can be used as a model for health practitioners as they develop or select international medical trips. The importance of partnering with the community and working within the existing medical and public health infrastructure is emphasized. Many of the challenges of doing international medical work can be overcome when efforts are guided by a few specific principles, such as those we have outlined.     

Respiratory tract infections in children in developing countries

Acute respiratory infections are the main cause of morbidity worldwide, and pneumonia represents one of the main causes of death in children younger than the age of 5 years in developing countries. Several risk factors for acquiring respiratory infections in developing countries, such as poverty, restricted family income, low parental education level, low birth weight, malnutrition, and lack of breastfeeding, have been described. Another important factor in recent years that has aggravated the problem of acute respiratory infections in developing countries is the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pandemic. In developing countries, identifying the etiology is difficult and World Health Organization recommends making the diagnosis of pneumonia based on clinical parameters. The diagnosis and suitable treatment administered by primary healthcare workers, particularly in rural areas, is part of the strategy to prevent mortality. Finally, it is important that industrialized countries support the economic growth of the developing countries to improve their healthcare system and to ensure that performed research studies will give benefits to their populations.     

Indoor air pollution and respiratory health of children in the developing world

Indoor air pollution (IAP) is a key contributor to the global burden of disease mainly in developing countries. The use of solid fuel for cooking and heating is the main source of IAP in developing countries, accounting for an estimated 3.5 million deaths and 4.5% of Disability-Adjusted Life Years in 2010. Other sources of IAP include indoor smoking, infiltration of pollutants from outdoor sources and substances emitted from an array of human utilities and biological materials. Children are among the most vulnerable groups for adverse effects of IAP. The respiratory system is a primary target of air pollutants resulting in a wide range of acute and chronic effects. The spectrum of respiratory adverse effects ranges from mild subclinical changes and mild symptoms to life threatening conditions and even death. However, IAP is a modifiable risk factor having potential mitigating interventions. Possible interventions range from simple behavior change to structural changes and from shifting of unclean cooking fuel to clean cooking fuel. Shifting from use of solid fuel to clean fuel invariably reduces household air pollution in developing countries, but such a change is challenging. This review aims to summarize the available information on IAP exposure during childhood and its effects on respiratory health in developing countries. It specifically discusses the common sources of IAP, susceptibility of children to air pollution, mechanisms of action, common respiratory conditions, preventive and mitigating strategies.     

Effect of early protein intake on linear growth velocity and development of adiposity

Protein deficiency results in retarded growth, and many studies from developing countries have shown that animal protein has a growth-promoting effect in children getting a diet mainly based on vegetable products. To what degree this is caused by an improved protein quality, nutrients associated with animal protein such as zinc, or a growth-stimulating effect of certain amino acids or peptides is not known. In industrialized countries, it is not likely that either the amount of protein or the protein quality will be growth limiting in healthy children. However, there are data suggesting that the high protein intake in infants and young children seen in industrialized countries could have growth-modulating effects and that there could be long-term effects. The aim of this paper is to review data on the association between early protein intake and linear growth velocity and early protein intake and later development of obesity. The review will focus on term healthy infants and young children from industrialized countries. The review will also include data on differences in growth and development of obesity between breastfed and formula-fed infants as there are considerable differences in protein intake between these two groups and one of the suggested causes for these effects has been difference in protein intake.     

Preventing accidents in childhood: A European perspective

Accidental injury is a principal public health issue with important individual, societal and economic consequences. Crude figures show that 2.7 million deaths from injury and poisoning are reported worldwide. In developing and industrialized countries 10–30% of all hospital admissions are due to accidental injuries. In particular, children and adolescents are at risk. In all industrialized countries accidental injuries are the major cause of death and morbidity among children above the age of one. In the domestic safety area much effort has to be invested in improving the safety of the environment and products. In the European region, collaboration among authorities in the framework of the European Community (EC) has been shown to be productive in the area of safety. Although trade interest is predominant in the EC objectives, the need to harmonize national regulations and standards towards common European standards has appeared to be an important vehicle for establishing standards at an optimum level of safety. It has also fostered some collaboration in data collection and analysis and in implementing prevention measures. An even stronger international collaboration is needed for ensuring that appropriate priorities are being set and prevention measures are effectively being implemented.     

Training program in Japan for health caretakers from developing countries.

In 1979, the International Center for Medical Research was organized in Kobe University School of Medicine and promoted the scientific cooperation through invitation of foreign scientists from developing countries as the Core University of Medical Science of Japan Society for the Promotion of Science (JSPS). Perinatal medicine is one of the main subjects in this program and we have accepted more than thirty neonatologists from Indonesia, Philippines, Thailand and other developing countries.     

Indoor air quality and respiratory health of children

Indoor air pollution (IAP) is an important environmental health issue in developing countries and is a major contributor to mortality and morbidity from acute lower respiratory illness in children. In developed countries, IAP in homes is not nearly as severe as it can be in developing countries; however, evidence suggests that it does contribute significantly to the risk of adverse respiratory health in children. Children spend the majority of their time indoors, mostly at home. Homes are built so that air exchange between the indoor and outdoor environments is minimised and there is a large range of pollution emission sources inside. For many pollutants, indoor concentrations regularly exceed those outdoors. Although there has been considerable interest in the health effects of IAP, questions still remain regarding the role of IAP in the exacerbation and/or development of respiratory disease. Prospective, longitudinal studies are required to better clarify the contribution of IAP to the respiratory health of children.     

Antimicrobial resistance in countries with limited resources: unique challenges and limited alternatives

The haphazard use of antimicrobial agents has caused these essential drugs to lose their effectiveness. In the resource-poor parts of the world, the problem is complex, involving inadequate access to antimicrobial agents in the poorest countries along with an excessive variety of drugs in middle-income countries that have inadequate capability to use them well or to control the unnecessary emergence of resistant microbes. Both circumstances may result in the rapid dissemination of antimicrobial resistance. Resistant organisms, which in wealthy countries would result in the increased expense or inconvenience of alternative agents, in poor countries may cause infections that for practical purposes are untreatable. The basic requirements for controlling drug-resistant problems in resource-poor and wealthy countries alike include first-line prevention of infectious diseases, laboratory support for etiologic diagnosis, adequate surveillance and epidemiological information, appropriate drug selection, locally appropriate guidelines for treatment, and proper education about infectious diseases in all levels. These requirements generally are lacking in resource-poor countries. The most important key to success in these countries is a strong central commitment and governmental support for minimizing drug-resistance problems while maintaining the highest effectiveness of health care within the limits of available resources.     

Science and ethics of human immunodeficiency virus/acquired immunodeficiency syndrome controversies in Africa

The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in Africa has raised important ethical issues for both researchers and clinicians. The most notorious controversy has been related to the zidovudine (AZT) trials in Africa in the late 1990s, in which the control groups were given a placebo rather than an effective drug to prevent vertical transmission. This raised concerns in the sponsoring country about exploitation of subjects, injustice and an ethical double standard between donor countries and resource-poor settings. However, the real double standard is between clinical practice standards in Western versus African countries, which must be addressed as part of the increasing global inequity of wealth both between countries and also within countries. There are important limitations to ethical declarations, principles and guidelines on their own without contextual ethical reasoning. The focus on research ethics with the HIV epidemic has led to a relative neglect of ethical issues in clinical practice. Although the scientific advances in HIV/AIDS have changed the ethical issues since the 1990s, there has also been progress in the bioethics of HIV/AIDS in terms of ethical review capability by local committees as well as in exposure to ethical issues by clinicians and researchers in Africa. However, serious concerns remain about the overregulation of research by bureaucratic agencies which could discourage African research on specifically African health issues. There is also a need for African academic institutions and researchers to progressively improve their research capacity with the assistance of research funders and donor agencies.     

Managing severe infection in infancy in resource poor settings

Reducing childhood mortality in resource-poor regions depends on effective interventions to decrease neonatal mortality from severe infection, which contributes up to a half of all neonatal deaths. There are key differences in resource-poor, compared to resource-rich, countries in terms of diagnosis, supportive care and treatment. In resource-poor settings, diagnosis is based on identifying clinical syndromes from international guidelines; microbiological investigations are restricted to a few research facilities. Low levels of staffing and equipment limit the provision of basic supportive care, and most facilities cannot provide respiratory support. Empiric antibiotic treatment guidelines are based on few aetiological and antimicrobial susceptibility data. Research on improving health care systems to provide effective supportive care, and implementation of simple pragmatic interventions, such as low-cost respiratory support, are essential, together with improved surveillance to monitor emerging drug resistance and treatment failures. Reductions in mortality will also be achieved through prevention of infection; including emerging vaccination and anti-sepsis strategies.     

Coautoría y redes de colaboración científica de la pediatría española (2006-2010)

IntroductionScientific collaboration is very important, as it is the basis of the scientific development of every discipline. The aim of this paper is to identify the indicators of scientific collaboration and co-authorship networks of Spanish researchers and institutions publishing in national and international paediatric, multidisciplinary or other knowledge areas journals during the period 2006-2010.MethodsThe papers studied were obtained from the databases including, Science Citation Index Expanded, Scopus, Índice Médico Español and Índice Bibliográfico Español en Ciencias de la Salud, by means of applying different search profiles. All the papers signed by co-authors were quantified in order to identify the authorship and institutional collaboration networks. Furthermore the degree, betweenness index, and closeness index were obtained as a measurement of the structural analysis. Co-authorships were represented graphically by the network analysis and display software Pajek.ResultsA total of 7971 articles were published during the period 2006-2010, with 90.55% completed in collaboration. Using a threshold of 10 or more co-authorships, 77 research groups in Pediatrics were identified. Most papers were published in collaboration between institutions of the same Autonomous Community (42.28%), and 14.84% with international collaboration. The analysis of institutional participation enabled a large nucleus or institutional collaboration network to be identified, with 52 linked institutions. International collaboration was led by the USA and European countries, such as United Kingdom, Germany and Italy.DiscussionAuthors, institutions and the most active working groups in Spanish pediatrics were identified, which is very interesting information to establish contacts to increase the existing networks, to prevent redundancies, and to take advantage of the new emerging groups. It is necessary to promote the collaboration of Spanish researchers, especially with their international colleagues, since a positive relationship is found between international collaboration and quality and impact of publications measured by citation analysis.     

The role of the Thalassaemia International Federation in health professionals' education

The Thalassaemia International Federation (TIF) was established in 1986. The Federation has two important objectives: 1. To promote the continued control of thalassaemia major in countries with existing policies aimed at control, and 2. To support the establishment of policies of control in every affected country of the world. Over the years TIF has: - Held workshops and seminars attended by over 7,000 from 35 countries - Organized 11 International Conferences attended by 5,150 from 62 countries - Organized field trips/delegation visits in 42 countries - Prepared, published and distributed 70,000 books to 96 countries - Trained physicians and scientists from medical centres in the UK, US, Italy, Greece and Cyprus - Initiated and co-ordinated projects and clinical studies overseen by international experts in over 50 countries. - Established a vast network of scientific collaborators from every corner of the world, and - Has promoted close and productive collaborations with major health organizations. One of the most important projects that TIF has conducted was a multi-centre study on endocrine complications in the different affected regions of the world. It is hopeful that through the analysis of data already obtained and expected, other projects related to blood transfusion therapy, iron chelation and chronic hepatitis could be organized.     

Hyperekplexia: a rare differential of neonatal fits described in a developing country

Hyperekplexia is a rare condition in which there is an exaggerated startle response. We report how a case presented in Papua New Guinea (PNG) and was diagnosed with international support. This is the first reported case in PNG. It is an important diagnosis to make to prevent sudden death and inappropriate treatment. The case illustrates the benefit of having a link with an international specialist and we discuss the importance of communication between developing and industrialized countries.     

Perinatal research in developing countries – Is it possible?

Maternal mortality remains the health statistic for which there is the greatest disparity between developing and developed countries. The risk of stillbirth or neonatal death is also high in developing countries. The inequality of research funding between rich and poor countries is dramatic, with only 10% of research funding directed towards diseases which contribute 90% of the global burden of disease. The need for high-quality, relevant perinatal research in developing countries is compelling. There are many examples of good perinatal research in developing countries. Nevertheless, significant challenges remain and are being tackled. We need better information about maternal and perinatal health, and about performance of the health services, we need more evaluation of what helps and what harms within the existing health services, and we need improved strategies for implementation of research findings.     

Update on micronutrients: iron and zinc

The past few years have seen several substantial advances in our understanding of the importance of micronutrients in child health and nutrition. Although historically child nutrition in developing countries has focused on protein and energy sufficiency, more recent efforts have been made to evaluate and eliminate micronutrient deficiencies. Accumulating data have underlined the important long-term health effects that may occur with iron deficiency, and studies continue to confirm the benefits of successful treatment of iron deficiency anemia. Zinc is another micronutrient whose significance to child health is increasingly appreciated. Although breakthroughs in micronutrient research have generally come from populations in developing countries, children in industrialized countries also benefit from increasing knowledge about nutritional requirements and interventions.     

Association of Children with Heart Disease in the World: 10-Year Experience

Thousands of children live in developing countries with untreated but correctable congenital heart disease (CHD), and most of them will die simple because they live in poor countries that do not have suitable medical/surgical facilities. The aim of the Association of Children with Heart Disease in the World is to support the operatory and teaching activities of a group of voluntary doctors engaged in the management of children with CHD in developing countries. Since 1992, the association has obtained 160 grants for foreign doctors who have been trained in our hospitals; performed 75 missions abroad, with more than 2150 cases evaluated and 404 cardiac operations performed; obtained millions of dollars worth of donated medical equipment; and constructed two cardiac surgery departments in Syria and Cameroon. Many efforts have been made, but much more can be done as we attain more experience and develop better coordination and collaboration between the international groups engaged in this emerging social need.     

Experience of working for a medical NGO,a contribution to global child health?

Paediatrics has strongly globalized during the recent decades. Increased collaboration between healthcare workers and institutes beyond national borders is needed to establish and sustain improvement of paediatrics. The growing medical technical progression is mainly applicable in the high-income countries. In contrast, in resource-limited settings the high mortality mainly caused by conditions that are either preventable of treatable with low-cost interventions. Experiencing this increasing gap by working in a resource-poor setting is will make a modern paediatrician a well-balanced doctor.     

Perspectives on the pediatric HIV/AIDS pandemic: catalyzing access of children to care and treatment

The successes of the United States and other developed countries in the prevention and treatment of pediatric HIV/AIDS have not been replicated in the developing world, where children continue to become infected with HIV and die from HIV/AIDS at astounding rates. Children are underrepresented among recipients of antiretroviral therapy in almost every setting worldwide where treatment programs have been established. The barriers to scaling up HIV/AIDS care and treatment globally are substantial. Nevertheless, nearly a decade after the introduction of pediatric highly active antiretroviral therapy in the United States, the opportunity finally exists to provide treatment to huge numbers of HIV-infected children in the developing world, changing forever the way that pediatric HIV/AIDS is perceived and managed. We propose the creation of a Clinical Centers of Excellence Network and Pediatric AIDS Corps of US pediatric health professionals, increased support for pediatric research relevant to resource-poor settings, commitment of the US government and others to proportionate funding for pediatric HIV/AIDS care and treatment, expanded availability of pediatric antiretroviral drug formulations, and a renewed commitment to collaborative partnerships as practical steps that can be taken to dramatically expand access of HIV-infected children and families in the developing world to health-restoring, life-prolonging care and treatment.     

Pediatric oncology research in low income countries: ethical concepts and challenges

Uneven strides in research and care have led to discrepancies in childhood cancer outcomes between high and low income countries (LICs). Collaborative research may help improve outcomes in LICs by generating knowledge for local scientific communities, augmenting knowledge translation, and fostering context-specific evaluation of treatment protocols. However, the risks of such research have received little attention. This paper investigates the relationship between pediatric oncology research in LICs and four core issues in the ethics literature: standard of care, trial benefits, ethics review, and informed consent. Our aims are to highlight the importance of this field and the need for further inquiry.     

PRINTO scholarships: the Italian experience

The increasing availability of the internet allows physicians to access actualized medical information quickly and easily, but it is not comparable with the possibility of working in a well known international medical centre. International collaboration (scholarships, courses and research), such as the PRINTO alpha project, allows professionals not only to increase and share scientific knowledge and experiences but also to integrate into a working team in a foreign country which leads to an understanding among cultures. PRINTO has set up a scientific and technical collaborative research network in Paediatric Rheumatology for Latin American physicians.