Care-seeking and quality of care for outpatient sick children in rural Hebei,China: a cross-sectional study

Aim

To assess the quality of outpatient pediatric care provided by township and village doctors, prevalence of common childhood diseases, care-seeking behavior, and coverage of key interventions in Zhao County in China.

Methods

We conducted two cross-sectional surveys: 1) maternal, newborn, and child health household survey including1601 caregivers of children younger than two years; 2) health facility survey on case management of 348 sick children younger than five years by local health workers and assessment of the availability of drugs and supplies in health facility.

Results

Our household survey showed that the prevalence of fever, cough, and diarrhea was 16.8%, 9.2%, and 15.6% respectively. Caregivers of children with fever, cough, and diarrhea sought care primarily in village clinics and township hospitals. Only 41.2% of children with suspected pneumonia received antibiotics, and very few children with diarrhea received oral rehydration solutions (1.2%) and zinc (4.4%). Our facility survey indicated that very few sick children were fully assessed, and only 43.8% were correctly classified by health workers when compared with the gold standard. Use of antibiotics for sick children was high and not according to guidelines.

Conclusion

We showed poor quality of services for outpatient sick children in Zhao County. Since Integrated Management of Childhood Illness strategy has shown positive effects on child health in some areas of China, it is advisable to implement it in other areas as well.Globally the number of deaths of children younger than five years decreased from 9.6 million to 7.6 million between 2000 and 2010, despite increases in the number of live births (1-3). During the past 20 years China made great achievements concerning child survival. Between 1990 and 2006, under-five mortality rate decreased from 64.6 to 20.6 per 1000 live births, and Millennium Development Goal 4 (MDG4) was achieved nine years ahead of the target set for 2015 (4-6). In 2011, under-five mortality rate was further reduced to 15.6 per 1000 live births (7). While this progress is remarkable, there remains the challenge of urban-rural mortality rate differences. Under-five mortality rate in rural areas was 2.7 times higher than in urban areas, 19.1 and 7.1 per 1000 live births, respectively (7).Under-five mortality decrease was achieved by focusing on social development and sustained economic growth and investments in health system, including expansion of health intervention coverage (8-10). However, these were much lower in rural areas. In 2010, rural residents’ net income per capita was 5919 Yuan, which was less than one third of urban residents’ income (19 109 Yuan) (11), and the health expenditure per capita in urban areas was 3.5 times lower than in rural areas, 2316 Yuan vs 666 Yuan (7). In 2009, the number of health professionals per 1000 population was 6.03 in urban and 2.46 in rural areas, respectively (12). These factors reduce overall rural health care quality as well as the quality of pediatric care, which in rural China is often less than desirable (13-15).To improve child survival, in the mid-1990s the World Health Organization (WHO) and United Nation’s Children Funds (UNICEF) jointly developed the Integrated Management of Childhood Illness (IMCI) strategy (16,17). The IMCI strategy has reduced the number of deaths due to diarrhea, pneumonia, malaria, measles, and malnutrition, which was estimated to 70% of all global deaths of children younger than 5 years at that time (18). IMCI has already been introduced into more than 100 countries (WHO 2005). In China it was introduced in 1998 and since 2003 has been expanded to 46 counties in 11 provinces, considerably improving health workers’ skills (19,20). Although IMCI has been in force in China for more than 10 years, training coverage remains very low for township and village doctors (21).In 2010, the Ministry of Health of China launched a research project aiming to explore the use of appropriate medical techniques in rural areas, and IMCI was selected as a key component of the project. We carried out a household survey and a health facility survey in Zhao County, Hebei Province before IMCI implementation. The household survey aimed to assess the prevalence of common childhood diseases, care-seeking behaviors, and population coverage of key interventions, and the health facility survey aimed to assess the quality of outpatient pediatric care by township and village doctors.     

The analysis of waiting time and utilization of computed tomography and magnetic resonance imaging in Croatia: a nationwide survey

AimTo assess the variation in the waiting time for diagnostic imaging (DI) services among Croatian public hospitals and the utilization of computed tomography (CT) and magnetic resonance imaging (MRI) scanners.MethodsWe analyzed aggregated data from public hospitals. Counties were classified according to economic strength, and utilization was expressed as the average number of exams per machine. We compared the waiting times for 2018 and utilization for 2015 according to hospital category (high and low level) and economic strength by county.ResultsThe waiting time was longer for MRI compared with CT, 268 vs 77.61 days. Overall CT waiting time was in the unfavorable European Health Consumer Index category. High-level hospitals had longer waiting time for MRI and CT. The waiting time positively correlated with economic strength for MRI (P = 0.019), but not for CT. In low-level hospitals, MRI utilization ranged from 104 to 6032, whereas CT utilization ranged from 48 to 17 852. In high-level hospitals, MRI utilization ranged from 3846 to 11 026, while CT utilization ranged from 503 to 17 234. CT (P = 0.041) and MRI (P = 0.031) utilization in high-level hospitals was significantly higher than in low-level hospitals.ConclusionThe waiting times for CT and MRI were exceptionally long regardless of the hospital category, with highly varying utilization. Croatia performed more exams per scanner compared with other EU countries, but not significantly so. High-level hospitals'' utilization was significantly higher than that of low-level hospitals, and CT utilization was significantly higher than EU average, while the difference for MRI utilization was not significant.

Radiology has a pivotal position within the health care system owing to the indispensable role of diagnostic imaging (DI) procedures, in particular computed tomography (CT) and magnetic resonance imaging (MRI) in current diagnostic and follow-up algorithms. The demand for DI is continuously growing, expectedly prolonging the waiting time. Waiting time is a topic of high interest when evaluating health system performance, therefore health services need to utilize CT and MRI scanners to the fullest extent. The assessment and minimization of waiting time is of utmost importance not only from a medical but also from a social and political perspective. Long waiting times for medical procedures represent a major obstacle toward achieving optimal (or even standard) levels of care in public health care systems (1-3). Waiting for diagnostic tests accounts for the majority of lengthy waits in the public health care system, leading to lower patients’ satisfaction. Besides affecting patients’ physical and mental health, waiting time also has economic implications for the individual patient and society (4). Achieving a more efficient and high-performing health care system represents a primary concern for most patients and a major aim for health authorities. Implementation of good radiological practice can be an efficient strategy to reduce inefficient and unnecessary spending in health care. Although Croatian counties differ in available radiological and economic resources, the association of these factors with waiting time for DI and characteristics of waiting time have not been studied thus far.This article aims to assess the variation in waiting time for CT and MRI services across different hospital categories, and the level of utilization and its association with counties'' economic strength in Croatia.     

Association of Nephrolithiasis and Gene for Glucose Transporter Type 9 (SLC2A9): Study of 145 Patients

Aim

To investigate the association of nephrolithiasis and solute carrier family 2, facilitated glucose transporter, member 9 (SLC2A9), also known as glucose transporter type 9, Glut9.

Methods

A total of 145 participants were recruited in the period April-October 2008 from the Department of Mineral Research of the Medical School Osijek, Osijek, Croatia; 58 (40%) had confirmed nephrolithiasis and 87 (60%) were asymptomatic. Four single nucleotide polymorphisms (SNP) from the SLC2A9 gene were genotyped in both groups (rs733175, rs6449213, rs1014290, and rs737267).

Results

There was a weak but significant association of all 4 SNPs and nephrolithiasis (P = 0.029 for rs733175; P = 0.006 for rs6449213; P = 0.020 for rs1014290, and P = 0.011 for rs737267). Logistic regression in an age- and sex-adjusted model suggested that genotype C/T for rs6449213 had odds ratio for nephrolithiasis of 2.89 (95% confidence interval 1.13-7.40). This SNP explained a total of 4.4% of nephrolithiasis variance.

Conclusion

Development of nephrolithiasis may be associated with SLC2A9 gene. Further studies are needed to clarify the role of SLC2A9 gene as a link between uric acid and nephrolithiasis.Renal stone formation (nephrolithiasis) is a disease characterized by the existence of solid deposits in the upper parts of the urinary tract (1). It is estimated to affect between 3%-9% of the population, with large differences between various populations (2,3). There is a number of causes that may lead to the renal stones formation, including diet and obesity status, some drugs, other diseases, climate changes, metabolic disorders, and genetic factors (2,4,5). The complexity of this disease caused researchers to consider nephrolithiasis as one feature of a broader systemic disease, rather than a local disease restricted to a single organic system (6). This is especially interesting in relation to gout and metabolic syndrome, which are both systemic disorders in close relation to nephrolithiasis (6-8). Even the cohort studies have confirmed the association of gout and kidney stones, suggesting that the history of gout increases the risk for kidney stones (9). Another study showed that, in the age-adjusted model, gout had an odds ratio of 1.97 for previous kidney stones (95% confidence interval [CI], 1.37-2.83) and that even after adjustment for sex, race, body mass index, and presence of hypertension the odds ratio remained significant (10).Genetic contribution to renal stones formation has been identified long time ago (2). In line with these suggestions, heritability of some of the traits associated with nephrolithiasis has been shown to be as high as 95% (11). Heritability of the urinary stones was reported to be lower (56%) (12), but still sufficiently high to be considered a substantial genetic proportion of variance and suggesting that it may be under genetic control. So far, a number of studies have established a link between predominantly oxalate kidney stones and several genes, including vitamin-D receptor gene (VDR) and calcitonin receptor (CTR) gene (13), heparan sulfate (HSPG2) gene (14), or fibronectin gene (FN1) (14).The quantitative trait associated with nephrolithiasis is the serum uric acid concentration, which is under strong genetic control by the gene for glucose transporter type 9 (SLC2A9 or Glut 9) (15). The gene was initially described in an isolated island community (16,17), where genetic properties of the population are expected to act in favor of facilitated gene mapping efforts (18). Subsequent meta-analysis of 14 populations confirmed the association of this gene with serum uric acid concentrations (19). This led to a number of clinical studies that have confirmed its involvement in the uric acid metabolism, including urate handling in the kidney and uptake in the liver (20,21). Based on the previous suggestions that gout and nephrolithiasis may share a common pathway (15), it might be interesting to see if SLC2A9 could explain the commonalities in patients with any of the following conditions. Therefore, the aim of this study was to investigate the association of nephrolithiasis and genetic variants of the SLC2A9.     

Successful early pyeloplasty in infants

BACKGROUND: Early pyeloplasty for the treatment of congenital ureteropelvic junction obstruction to maximize nephron salvage is justified only if potential hazards of operating on small infants are avoided. METHODS: The records were analyzed of all infants who underwent pyeloplasty over a 5-year period. Open pyeloplasty was performed if collecting systems had deteriorated or were demonstrated to be obstructed; it was also performed for severe cases of hydronephrosis. Outcome of surgery in the younger infant (patients <2 months of age) was compared with the older infant group (patients >2 months of age). Preoperative evaluation in case of mild or moderate hydronephrosis was directed toward ruling out a non-obstructed collection system and included voiding cystourethrography, and serial ultrasonography and/or dual isotope diuretic renography. Postoperative assessment consisted of serial ultrasonography and/or nuclear imaging to confirm decompression and relief of obstruction. RESULTS: A total of 24 pyeloplasties were performed on 22 patients in the younger infant group (two bilateral) and 30 were performed on 27 infants in the older infant group (three bilateral). The only significant differences between the groups were as follows: patients in the younger infant group were likely to present in utero (75%, p = 2.69), whereas those in the older infant group were more likely to present with a urinary tract infection (48%, p = 4.12). During follow-up examination, 23 renal units in the younger infant group and 24 in the older infant group were judged to be stable or improved. Four kidneys were not salvaged after pyeloplasty, one in the younger infant group and three in the older infant group. CONCLUSIONS: Good results of pyeloplasties performed in the infants in this series support early correction of ureteropelvic junction obstruction in infants.     

The influence of smoking and parity on serum markers for Down's syndrome screening.

OBJECTIVE: To evaluate the impact of smoking and number of previous births on maternal serum levels of alpha-fetoprotein and free beta-subunit of human chorionic gonadotropin (free beta-hCG). METHODS: The study included 3,252 completed unaffected singleton pregnancies that proceeded beyond 37 weeks' gestation and resulted with a birth of healthy child. Smoking status of mothers and data concerning gravidity and parity were collected at the sampling date. Serum markers were measured between 13 and 22 gestational weeks, corrected for maternal weight, and converted to multiples of median (MoM) for unaffected pregnancy of the corresponding gestational age. Median MoM values for both markers were examined in relation to both: smoking habits and number of previous births. RESULTS: Smokers had significantly decreased free beta-hCG MoM values compared to nonsmokers (p < 0.001). The median levels showed a negative relationship with the number of previous births. The significance of a decreasing trend was proved, both in smokers (p < 0.001) and nonsmokers (p < 0.001). The median maternal serum alpha-fetoprotein MoM values did not show any significant dependence, neither with regard to smoking (p = 0.65) nor with regard to parity (p = 0.07). CONCLUSIONS: The recommendable adjustment of serum markers to smoking habits, especially concerning the free beta-hCG levels, would be worthwhile. The evidence of the coexisting influence of parity on serum levels of free beta-hCG, both in smokers and nonsmokers, should perhaps be a stimulus for reconsideration of which corrections the screening performance is dependent on.     

Viral hepatitis: Croatian consensus statement

There has been a dramatic improvement in diagnostic procedures and therapy of viral hepatitis in the last 20 years. Improvements in therapy caused an increase in actual cost, however, with significant long-term savings through a decreased cost of treatment of advanced liver disease including liver transplantation. The Croatian National Board for Viral Hepatitis has decided to initiate the organization of consensus conference on viral hepatitis enabling the leading experts in the country to give the best possible recommendations for the diagnosis, prophylaxis and therapy in our circumstances. The Consensus Conference took place in Zagreb in June 2004, with update in March 2005, organized by the Croatian National Board for Viral Hepatitis, Reference Centers of the Ministry of Health for Chronic Liver Diseases, Infectious Diseases and AIDS, Croatian Society of Gastroenterology--Hepatology Section, Croatian Society for Nephrology, Dialysis and Transplantation, and Croatian Institute for Health Insurance. Invited experts provided written reports on the respective subjects that appear in this issue and their recommendations resulting in this consensus statement.     

Splenic rupture in pregnancy--traumatic or spontaneous event?

Splenic rupture in pregnancy or postpartum is a rare and frequently misdiagnosed occurrence. Failure to recognise it is common, and can be fatal for both mother and child. With all our highly developed diagnostic methods and equipment, aetiology of splenic ruptures in pregnancy remains a dilemma in many cases.