Adaptations in pediatric anesthesia care and airway management in the resource‐poor setting

The need for safe and quality pediatric anesthesia care in low‐ and middle‐income countries (LMICs) is huge. An estimated 1.7 billion children do not have access to surgical care, and the majority are in LMICs. In addition, most LMICs do not have the requisite surgical workforce including anesthesia providers. Surgery is usually performed at three levels of facilities: district, provincial, and national referral hospitals. Unfortunately, the manpower, equipment, and other resources available to provide surgical care for children vary greatly at the different level facilities. The majority of district level hospitals are staffed solely by non‐physician anesthesia providers with variable training and little support to manage complicated pediatric patients. Airway and respiratory complications are known to account for a large portion of pediatric perioperative complications. Management of the difficult pediatric airway pathology is a challenge for anesthesia providers regardless of setting. However, in the low‐resource setting poor infrastructure, lack of transportation systems, and crippled referral systems lead to late presentation. There is often a lack of pediatric‐sized anesthesia equipment and resources, making management of the local pathology even more challenging. Efforts are being made to offer these providers additional training in pediatric anesthesia skills that incorporate low‐fidelity simulation. Out of necessity, anesthesia providers in this setting learn to be resourceful in order to manage complex pathologies with fewer, less ideal resources while still providing a safe anesthetic.     

HIV treatment and care in resource‐constrained environments: challenges for the next decade

Many successes have been achieved in HIV care in low‐ and middle‐income countries (LMIC): increased number of HIV‐infected individuals receiving antiretroviral treatment (ART), wide decentralization, reduction in morbidity and mortality and accessibility to cheapest drugs. However, these successes should not hide existing failures and difficulties. In this paper, we underline several key challenges. First, ensure long‐term financing, increase available resources, in order to meet the increasing needs, and redistribute the overall budget in a concerted way amongst donors. Second, increase ART coverage and treat the many eligible patients who have not yet started ART. Competition amongst countries is expected to become a strong driving force in encouraging the least efficient to join better performing countries. Third, decrease early mortality on ART, by improving access to prevention, case‐finding and treatment of tuberculosis and invasive bacterial diseases and by getting people to start ART much earlier. Fourth, move on from WHO 2006 to WHO 2010 guidelines. Raising the cut‐off point for starting ART to 350 CD4/mm³ needs changing paradigm, adopting opt‐out approach, facilitating pro‐active testing, facilitating task shifting and increasing staff recruitments. Phasing out stavudine needs acting for a drastic reduction in the costs of other drugs. Scaling up routine viral load needs a mobilization for lower prices of reagents and equipments, as well as efforts in relation to point‐of‐care automation and to maintenance. The latter is a key step to boost the utilization of second‐line regimens, which are currently dramatically under prescribed. Finally, other challenges are to reduce lost‐to‐follow‐up rates; manage lifelong treatment and care for long‐term morbidity, including drug toxicity, residual AIDS and HIV‐non‐AIDS morbidity and aging‐related morbidity; and be able to face unforeseen events such as socio‐political and military crisis. An old African proverb states that the growth of a deep‐rooted tree cannot be stopped. Our tree is well rooted in existing field experience and is, therefore, expected to grow. In order for us to let it grow, long‐term cost‐effectiveness approach and life‐saving evidence‐based programming should replace short‐term budgeting approach.     

The reliability and validity of three‐item screening measures for burnout: Evidence from group‐employed health care practitioners in upstate New York

We investigate the psychometric validity and reliability of three‐item screening measures for emotional exhaustion, depersonalization, and personal achievement comprising an abbreviated version of the Maslach Burnout Inventory®. Despite its utilization in multiple studies, the shortened instrument has not been sufficiently validated in diverse settings, populations, and organizational contexts. We examine its ability to assess burnout accruing from patient care practice in a rural, underserved area. Utilizing data from a cross‐sectional survey of 308 rural‐based medical professionals, we investigate how the three short‐form subscales of the nine‐item abbreviated inventory compare with their gold‐standard parent subscales from the original 22‐item human services scale in measuring corresponding dimensions of burnout. The findings provide significant evidence that the three‐item measures are valid and reliable proxies for the long‐form subscales. The short‐form measures are highly correlated with the original subscales and display high convergent and discriminant validity. Each of the abbreviated subscales manifests the kind of high sensitivity with adequate specificity that one would expect to see in a good screening instrument. We conclude that the short‐form measures can be utilized to rapidly screen human service professionals such as rural health care practitioners for symptoms of each of the three dimensions of burnout.     

Lessons learned about prevalence and growth rates of abdominal aortic aneurysms from a 25‐year ultrasound population screening programme

Background

This study aimed to assess how the prevalence and growth rates of small and medium abdominal aortic aneurysms (AAAs) (3·0–5·4 cm) have changed over time in men aged 65 years, and to evaluate long‐term outcomes in men whose aortic diameter is 2·6–2·9 cm (subaneurysmal), and below the standard threshold for most surveillance programmes.

Methods

The Gloucestershire Aneurysm Screening Programme (GASP) started in 1990. Men aged 65 years with an aortic diameter of 2·6–5·4 cm, measured by ultrasonography using the inner to inner wall method, were included in surveillance. Aortic diameter growth rates were estimated separately for men who initially had a subaneurysmal aorta, and those who had a small or medium AAA, using mixed‐effects models.

Results

Since 1990, 81 150 men had ultrasound screening for AAA (uptake 80·7 per cent), of whom 2795 had an aortic diameter of 2·6–5·4 cm. The prevalence of screen‐detected AAA of 3·0 cm or larger decreased from 5·0 per cent in 1991 to 1·3 per cent in 2015. There was no evidence of a change in AAA growth rates during this time. Of men who initially had a subaneurysmal aorta, 57·6 (95 per cent c.i. 54·4 to 60·7) per cent were estimated to develop an AAA of 3·0 cm or larger within 5 years of the initial scan, and 28·0 (24·2 to 31·8) per cent to develop a large AAA (at least 5·5 cm) within 15 years.

Conclusion

The prevalence of screen‐detected small and medium AAAs has decreased over the past 25 years, but growth rates have remained similar. Men with a subaneurysmal aorta at age 65 years have a substantial risk of developing a large AAA by the age of 80 years.     

Surgery for pressure ulcers in spinal cord‐injured patients following a structured treatment programme: a 10‐year follow‐up

With the aim to improve the outcomes for spinal cord‐injured patients undergoing surgery for pressure ulcers, a structured treatment programme regulating pre‐ and postoperative care and rehabilitation was introduced in 2002 in Stockholm. Fifty‐one consecutive patients operated on between 2002 and 2007 were included in a 10‐year follow‐up to evaluate the programme regarding initial healing results and long‐term ulcer and health status. At one month postoperatively, 49 out of 51 (96%) patients were completely healed. Five patients (5/44, 11%) developed recurrent or new ulcers within 3 years of surgery. Two patients were re‐operated on (2/44, 5%). Between 3 and 10 years after surgery, 9 patients (9/33, 27%) had a history of recurrent ulcers, and 6 (6/33, 18%) had a history of new ulcers, a total of 15 patients (15/33, 45%). Of these, three needed re‐operation (3/33, 9 %). The health status values using a visual analogue rating scale were 70 (median) at 3 and 10 years compared with 30 (median) preoperatively. The good initial healing, the low ulcer recurrence rate and the raise in health status indicate the value of a structured treatment programme, especially for the first few postoperative years.     

The operative treatment of pressure wounds: a 10‐year experience in flap selection

This study sought to both assist in the selection of flaps for ischial pressure wound reconstruction and evaluate the overall complication rates associated with reconstruction. A retrospective medical record review was conducted for 78 patients following the surgical reconstruction of an ischial pressure sore. Records were reviewed for demographics, location of sores, methods of reconstruction and flap selection, as well as any complications and recurrences. A total of 72 wounds were reconstructed with an average of 1·4 flaps used per wound. An ischial flap complication rate of 16% was observed in flap follow‐up, with a recurrence rate of 7% recorded. The vast majority of complications went on to heal with 15% of patients requiring a second reconstruction. Our relatively large sample of ischial flaps allowed for a close comparison with previously published work. Both flap selection and site of reconstruction significantly affected the success rates for pressure sore coverage. The overall complication rates by flap and reconstructive site in this review are lower than previously published reports. Our experience with ischial reconstruction was extensive enough to suggest a posterior medial thigh fasciocutaneous flap combined with a biceps femoris muscle flap as a first choice in ischial pressure wound reconstruction.     

The operative treatment of pressure wounds: a 10‐year experience in flap selection

This study sought to both assist in the selection of flaps for ischial pressure wound re‐construction and to evaluate the overall complication rates associated with re‐construction. A retrospective medical record review was conducted for 78 patients following the surgical re‐construction of an ischial pressure sore. Records were reviewed for demographics, location of sores, methods of re‐construction and flap selection, as well as any complications and recurrences. Seventy‐two wounds were re‐constructed with an average of 1·4 flaps used per wound. An ischial flap complication rate of 16% was observed in flap follow up, with a recurrence rate of 7% recorded. The vast majority of complications went on to heal with 15% of patients requiring a second re‐construction. Our relatively large sample of ischial flaps allowed for a close comparison with previously published work. Both flap selection and site of reconstruction significantly affected the success rates for pressure sore coverage. The overall complication rates by flap and re‐constructive site in this review are lower than previously published reports. Our experience with ischial re‐construction was extensive enough to suggest a posterior medial thigh fasciocutaneous flap combined with a biceps femoris muscle flap as a first choice in ischial pressure wound re‐construction.     

The impact of a mobile application‐based treatment for urinary incontinence in adult women: Design of a mixed‐methods randomized controlled trial in a primary care setting

Aims

We aim to assess whether a purpose‐developed mobile application (app) is non‐inferior regarding effectiveness and cost‐effective when used to treat women with urinary incontinence (UI), as compared to care as usual in Dutch primary care. Additionally, we will explore the expectations and experiences of patients and care providers regarding app usage.

Methods

A mixed‐methods study will be performed, combining a pragmatic, randomized‐controlled, non‐inferiority trial with an extensive process evaluation. Women aged ≥18 years, suffering from UI ≥ 2 times per week and with access to a smartphone or tablet are eligible to participate. The primary outcome will be the change in UI symptom scores at 4 months after randomization, as assessed by the International Consultation on Incontinence Modular Questionnaire UI Short Form. Secondary outcomes will be the change in UI symptom scores at 12 months, as well as the patient‐reported global impression of improvement, quality of life, change in sexual functioning, UI episodes per day, and costs at 4 and 12 months. In parallel, we will perform an extensive process evaluation to assess the expectations and experiences of patients and care providers regarding app usage, making use of interviews, focus group sessions, and log data analysis.

Conclusion

This study will assess both the effectiveness and cost‐effectiveness of app‐based treatment for UI. The combination with the process evaluation, which will be performed in parallel, should also give valuable insights into the contextual factors that influence the effectiveness of such a treatment.