Background Children in resource-constrained settings (RCS) have disproportionately high illness and mortality; however, the prevalence in RCS of paediatric acute critical illness (P-ACI; life-threatening conditions that require time-sensitive interventions) is unknown. Most P-ACI can be managed with basic critical care (stabilisation, fluid resuscitation, oxygen, and vital-organ support), but RCS hospitals often lack such essential services. This study estimated the prevalence and examined the aetiology of P-ACI among children at RCS hospitals to support critical care capacity building and inform resource allocation. Methods We conducted a hybrid prospective cohort and multinational point prevalence study of acutely ill or injured children aged 28 days to 14 years who presented to RCS hospitals on four designated days between July 20, 2021, and July 12, 2022. We measured the proportion of participants with P-ACI, applying the definition for acute paediatric critical illness (DEFCRIT) framework for research in resource-variable settings, and followed up admitted patients for hospital outcomes. In participants with P-ACI, we report diagnoses associated with critical illness. We used descriptive statistics to summarise site and cohort data by country sociodemographic category (Socio-demographic Index; SDI) and multivariable logistic regression to assess whether country sociodemographic category was independently associated with P-ACI. Findings The study included 46 sites, 19 countries, and 7538 children, among whom 2651 (352%) were admitted to hospital and 68 died (all-cause mortality 09% [95% CI 07-11]). 985 (131% [95% CI 123-139]) participants had P-ACI. Among all sociodemographic categories, P-ACI prevalence was highest (280% [260-301]; 512 of 1828 participants) in low-SDI countries (p<00001). Mortality among those with P-ACI was 63% (49-80; 62 deaths). The most common P-ACI diagnoses were pneumonia (152 [154%] of 985 participants), sepsis or septic shock (102 [104%]), and malaria (95 [96%]). In an adjusted model, country sociodemographic category was not significantly associated with P-ACI frequency. Among all 68 deaths in the study, 40 (59% [46-71]) occurred within 48 h of presentation. Interpretation P-ACI in RCS hospitals is common, associated with high mortality, disproportionately elevated in low- SDI countries, and associated with conditions that can be managed with basic critical care. This study underlines the need for investment in basic critical care services in RCS to address a major contributor to preventable mortality in hospitalised children.

This article provides an overview of the Barrow Neurological Institute international observership and visiting scholars program, one of the oldest and largest international neurosurgical observership programs in the world, and discusses its past, present, and future directions. Background information was collected from the program manager and through one-on-one interviews with the program's founders and current chairman. A survey was administered to past observers to capture feedback. Interviews were summarized, descriptive statistical analysis was performed on quantitative survey data, and a thematic analysis was completed for qualitative data. Since 2006, 686 neurosurgeons, residents, and medical students from more than 64 countries have traveled to Barrow Neurological Institute for an observership. Five hundred and seventy (86.2%) of 661 observers with historical data on country of origin came from high-income countries or upper middle-income countries, 91 (13.7%) from lower middle-income countries, and none from low-income countries (LICs). Of 94 observers who completed the feedback survey, 67 (71%) specialized in cerebrovascular and 21 (22%) in spine. Most observers (70%) were self-funded. Cost (38%) and time (25%) were considered the greatest barriers to observership. Despite the barriers, 93% would recommend the observership to a colleague. Future aspirations for the program include fully funded observerships geared toward neurosurgeons from lower middle-income countries and LICs. Next steps for the program are better inclusion of observers from lower middle-income countries and LICs and expanded research and mentorship opportunities. Future work should investigate the effect of observership programs on career path and "brain drain."

OBJECTIVE:Despite progress in building surgical infrastructure in East Africa, access to neurosurgical care remains challenging. More than 6000 new cases of pediatric hydrocephalus occur each year in sub-Saharan Africa, but only approximately 50 neurosurgeons are available to treat those cases. Treatment for pediatric hydrocephalus typically involves placement of a ventriculoperitoneal (VP) shunt, but recently the treatment focus has broadened to revisit endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC). However, it is unknown whether ETV with CPC (ETV/CPC) is safe and efficacious in low- and middle-income countries for infants younger than 1 year. This study investigated the implementation of ETV/CPC at a low-resource hospital in northern Tanzania. METHODS:The authors conducted a single-center retrospective study investigating short-term outcomes of ETV/CPC at Arusha Lutheran Medical Centre in Tanzania. Study participants were children 0-18 years old with a diagnosis of hydrocephalus who underwent ETV with or without CPC between February 1, 2020, and February 1, 2022. Data captured included demographics, patient hydrocephalus etiology, and ETV Success Score. Successful treatment was defined as successful control of the hydrocephalus without the need for further shunt placement from the time of ETV through the 3-month follow-up. RESULTS:During the study period, 54 ETV procedures for hydrocephalus were performed, 45 with and 9 without CPC. The mean (SD) patient age at the time of ETV was 1.75 (2.37) years (range < 1 to 10 years). ETV was successful in 49 patients (91%). Five cases (9%) were complicated by significant morbidity or mortality: 3 cases required VP shunt placement and 2 patients died. Most patients (70%) were younger than 1 year at the time of surgery. The failure rate of ETV was 8% (3 of 38) among patients aged 1 year or younger and 13% (2 of 16) among patients older than 1 year. CONCLUSIONS:At this institution, ETV with or without CPC was found to be an alternative treatment option when compared to VP shunting. This study also found that these procedures can be safely performed in children younger than 1 year and can avoid the need for VP shunts in many patients. Further research is needed to evaluate the long-term outcomes of these patients.

BACKGROUND AND OBJECTIVES:Many low- and middle-income countries are experiencing profound health care workforce shortages. Surgical subspecialists generally practice in large urban centers but are in high demand in rural areas. These subspecialists must be trained through sustainable programs to address this disparity. We quantitatively compared the relative effectiveness of 2 unique training models to advance neurosurgical skills in resource-poor settings where formally trained neurosurgeons are unavailable.METHODS:Neurosurgical procedure data were collected from 2 hospitals in Tanzania (Haydom Lutheran Hospital [HLH] and Bugando Medical Centre [BMC]), where 2 distinct training models ("Train Forward" and "Back-to-Back," respectively) were incorporated between 2005 and 2012.RESULTS:The most common procedures performed were ventriculoperitoneal shunt (BMC: 559, HLH: 72), spina bifida repair (BMC: 187, HLH: 54), craniotomy (BMC: 61, HLH: 19), bone elevation (BMC: 42, HLH: 32), and craniotomy and evacuation (BMC: 18, HLH: 34). The number of annual procedures at BMC increased from 148 in 2008 to 357 in 2012; at HLH, they increased from 18 in 2005 to 80 in 2010. Postoperative complications over time decreased or did not significantly change at both sites as the diversity of procedures increased.CONCLUSION:The Train Forward and Back-to-Back training models were associated with increased surgical volume and complexity without increased complications. However, only the Train Forward model resulted in local, autonomous training of surgical subspecialists after completion of the initial training period. Incorporating the Train Forward method into existing training programs in low- and middle-income countries may provide unique benefits over historic training practices.

In 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%–4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9–14)]; respiratory [9 (95% CI 5–13)]; and gastrointestinal [9 (95% CI 6–11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231–280)]; infectious [214 (95% CI 193–234)]; and gastrointestinal [166 (95% CI 143–190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.

The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We present an evidence-informed consensus definition and framework for acute paediatric critical illness. DEFCRIT was developed following a scoping review of 29 studies and key concepts identified by an interdisciplinary, international core expert panel (n=24). A modified Delphi process was then done with a panel of multidisciplinary health-care global experts (n=109) until consensus was reached on eight essential attributes and 28 statements as the basis of DEFCRIT. Consensus was reached in two Delphi rounds with an expert retention rate of 89%. The final consensus definition for acute paediatric critical illness is: an infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal physiological parameters or vital organ dysfunction or failure) or a clinical support requirement (such as frequent or continuous monitoring or time-sensitive interventions) to prevent further deterioration or death. The proposed definition and framework provide the conceptual clarity needed for a unified approach for global research across resource-variable settings. Future work will centre on validating DEFCRIT and determining high priority measures and guidelines for data collection and analysis that will promote its use in research.

BackgroundOne of the greatest challenges to conducting multicenter research studies in low and middle-income countries (LMICs) is the heterogeneity in regulatory processes across sites. Previous studies have reported variations in requirements with a lack of standardization in the Institutional Review Board (IRB) processes between centers, imposing barriers for approval, participation, and development of multicenter research.ObjectivesTo describe the regulatory process, variability and challenges faced by pediatric researchers in LMICs during the IRB process of an international multicenter observational point prevalence study (Global PARITY).DesignA 16-question multiple-choice online survey was sent to site principal investigators (PIs) at PARITY study participating centers to explore characteristics of the IRB process, costs, and barriers to research approval. A shorter survey was employed for sites that expressed interest in participating in Global PARITY and started the approval process, but ultimately did not participate in data collection (non-participating sites) to assess IRB characteristics.ResultsOf the 91 sites that sought IRB approval, 46 were successful in obtaining approval and finishing the data collection process. The survey was completed by 46 (100%) participating centers and 21 (47%) non-participating centers. There was a significant difference between participating and non-participating sites in IRB approval of a waiver consent and in the requirement for a legal review of the protocol. The greatest challenge to research identified by non-participating sites was a lack of research time and the lack of institutional support.ConclusionsGlobal collaborative research is crucial to increase our understanding of pediatric critical care conditions in hospitals of all resource-levels and IRBs are required to ensure that this research complies with ethical standards. Critical barriers restrict research activities in some resource limiting countries. Increasing the efficiency and accessibility of local IRB review could greatly impact participation of resource limited sites and enrollment of vulnerable populations.

Introduction: Multicenter, multinational collaborative research has increased across differing resource capacities by country. Inconsistencies in ethical review processes is an under recognized resource limitation and in resource-limited settings across regions may lead to barriers to rapid deployment of important clinical studies. Methods: An ancillary prospective study of the global PARITY (pediatric acute critical illness study) point prevalence study of pediatric critical illness in resource-limited settings. We surveyed participating sites to explore ethical and board review processes. The aim of the study was to describe the time, costs, and barriers in obtaining institutional review board and ethics approval for a multinational, multicenter, non-interventional study in critically ill children involving low and middle-income countries. Results: Fifty-six centers completed the survey. Of those hospitals, 72% (n= 40) required a full board review of the global PARITY study prior to approval, and 17% (n=9) accepted an ethics approval from a separate institution. The frequency of institutional review board (irb) committee is variable between centers, 16% (n=9) weekly, 56% (n=31) meet every 1 – 2 month, 11% (n=6) every 3 – 6 month and in 16% (n=9) > six months. The IRB approval process took a median of 62 days (n=40; range 1-294 days). Sixteen centers (30%) reported costs associated with ethical review. The waived consent was approved by 71% (n=38) of the centers, and 23% (n=12) required a data sharing agreement. The protocol required translation to local language in 47% (n=26) centers, from which 25% (n=6) required a professional certificated translation. Of the centers surveyed, 32% (n=17) required a legal review of protocol or data sharing agreement. Conclusions: There is great variability in ethical review requirements and time of approval for a non-interventional multinational study of critically ill children in low and middle-income countries in both private and public hospitals. We show that this time resource must be considered when planning multinational studies. Enhancing the capacity for ethics and board review process across regions will allow for better matching of disease burden with clinical research and likely increase participation in this multicenter research.

Arias, A. V.; Lintner Rivera, M.; Shafi, N. I.; Anwar, A.; Bhutta, A. T.; Bleakly Kortz, T.; Agulnik, A.; Abbas, O. (Qalab; Abdelhafeez, Hafeez; Ali, Muhammad; Ammar, Hala; Appiah, John; Attebery, Jonah; Villalobos, Willmer Diaz; Ferreira, Daiane; Dambrauskas, Sebastián González; Habib, Muhammad Irfan; Lee, Jan Hau; Kissoon, Niranjan; Tekleab, Atnafu Mekonnen; Molyneux, Elizabeth M.; Morrow, Brenda M.; Nadkarni, Vinay M.; Rivera, Jocelyn; Silvers, Rebecca; Steere, Mardi; Tatay), Daniel Author Information

Background:The majority of childhood deaths occur in low- and middle-income countries (LMICs). Many of these deaths are avoidable with basic critical care interventions. Quantifying the burden of pediatric critical illness in LMICs is essential for targeting interventions to reduce childhood mortality.Objective:To determine the burden of hospitalization and mortality associated with acute pediatric critical illness in LMICs through a systematic review and meta-analysis of the literature.Data Sources and Search Strategy:We will identify eligible studies by searching MEDLINE, EMBASE, CINAHL, and LILACS using MeSH terms and keywords. Results will be limited to infants or children (ages >28 days to 12 years) hospitalized in LMICs and publications in English, Spanish, or French. Publications with non-original data (e.g., comments, editorials, letters, notes, conference materials) will be excluded.Study Selection:We will include observational studies published since January 1, 2005, that meet all eligibility criteria and for which a full text can be located.Data Extraction:Data extraction will include information related to study characteristics, hospital characteristics, underlying population characteristics, patient population characteristics, and outcomes.Data Synthesis:We will extract and report data on study, hospital, and patient characteristics; outcomes; and risk of bias. We will report the causes of admission and mortality by region, country income level, and age. We will report or calculate the case fatality rate (CFR) for each diagnosis when data allow.Conclusions:By understanding the burden of pediatric critical illness in LMICs, we can advocate for resources and inform resource allocation and investment decisions to improve the management and outcomes of children with acute pediatric critical illness in LMICs.

López Barón, E.; Holloway, A.; Agulnik, A.; Abbas, Q.; Appiah, J. A.; Attebery, J. E.; He, D.; Caporal, P.; Fink, E. L.; Hooli, S.; Kissoon, N.; Lee, J. H.; Miller, E.; Muttalib, F.; Nielsen, K.; Puerto Torres, M.; Remy, K. E.; Andre Von Arnim, A. V.; Sakaan, F. M.; Tabor, E. A.; Wiens, M. O.; Kortz, T. B.; Bhutta, A. T.; Murthy, S. Author Information

Sakaan, F. M.1; Agulnik, A.1; Puerto Torres, M.1; Holloway

We report a case of disseminated tularemia in a previously healthy 8-month-old male. This case highlights an atypical presentation of tularemia with multisystem organ involvement. The diagnosis was complicated by concurrent primary cytomegalovirus infection. Bronchoalveolar lavage culture confirmed the diagnosis. The patient was successfully treated with gentamicin. Pertinent literature reviewed.

INTRODUCTION:There is need for more data on critical care outcomes and interventions from low- and middle-income countries (LMIC). Global research collaborations could help improve health-care delivery for critically ill children in LMIC where child mortality rates remain high.MATERIALS AND METHODS:To inform the role of collaborative research in health-care delivery for critically ill children in LMIC, an anonymous online survey of pediatric critical care (PCC) physicians from LMIC was conducted to assess priorities, major challenges, and potential solutions to PCC research. A convenience sample of 56 clinician-researchers taking care of critically ill children in LMIC was targeted. In addition, the survey was made available on a Latin American PCC website. Descriptive statistics were used for data analysis.RESULTS:The majority of the 47 survey respondents worked at urban, public teaching hospitals in LMIC. Respondents stated their primary PCC research motivations were to improve clinical care and establish guidelines to standardize care. Top challenges to conducting research were lack of funding, high clinical workload, and limited research support staff. Respondent-proposed solutions to these challenges included increasing research funding options for LMIC, better access to mentors from high-income countries, research training and networks, and higher quality medical record documentation.CONCLUSION:LMIC clinician-researchers must be better empowered and resourced to lead and influence the local and global health research agenda for critically ill children. Increased funding options, access to training and mentorship in research methodology, and improved data collection systems for LMIC PCC researchers were recognized as key needs for success.

Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Division of Critical Care, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO Dr. Lin received funding from SCCM (travel costs for ICU liberation campaign organizing meeting). The remaining authors have disclosed that they do not have any potential conflicts of interest.

Objectives: Although transthoracic echocardiography is commonly performed in the PICU, its utility is not specifically known. The purpose of this investigation was to evaluate the clinical impact of echocardiography in the PICU in terms of frequency of unanticipated findings and the frequency and nature of clinical management changes attributed to the results of echocardiography. Design: Prospective cohort study. Setting: Nineteen-bed combined medical-surgical-cardiac PICU at a tertiary care children’s hospital. Patients: All patients in PICU undergoing transthoracic echocardiography. Interventions, Measurements, and Main Results: Data collected included echocardiography indications, pre-echocardiography clinical assessment of anticipated echocardiography findings, height, weight, primary diagnosis, age, and urgency (stat vs routine) of echocardiography. Input of the attending care team (intensivist, cardiologist, and/or cardiovascular surgeon) allowed classification of echocardiography results as either confirming the pre-echocardiography impression, altering the pre-echocardiography clinical impression regarding the indication for which the test was performed, or altering the impression by virtue of new findings unrelated to the specific indication. The nature of the new findings were recorded and categorized. The team recorded clinical management changes made in response to the echocardiography results; the nature of these were listed and categorized. Echocardiograms (n = 416) were performed in 132 patients. Of these, 244 echocardiograms (59%) were ordered on male patients, 31% were under 30 days old, median age was 103 days, 379 (91%) had a primary cardiac diagnosis, and 92 (22%) were ordered stat. Sixty-three percent of echocardiograms confirmed and 24% altered the pre-echocardiography impression regarding the indication for the echocardiography; 13% introduced new findings unrelated to the indication. Cardiac surgical revision was the management change required in 26 patients (6.3%). Stat echocardiography was more likely to alter the pre-echocardiography assessment than routine echocardiography (p < 0.001). Management changes were more commonly associated with stat echocardiograms (p = 0.002) and those with new unexpected findings (p < 0.001) but had no demonstrable association with age less than 30 days (p = 0.332). Conclusions: Unanticipated echocardiography results are common in the PICU, and they often alter the clinical impressions that prompted the echocardiogram or introduce new findings unrelated to the reason for which the echocardiogram was recorded. Clinical management changes attributable to echocardiography findings are frequent in the PICU, including occasional surgical intervention. Echocardiography adds diagnostic value and contributes to the management approach in the PICU, accounting for its frequent use.

OBJECTIVE: As of 2006, only three formally trained neurosurgeons are licensed in Tanzania. Recently, efforts have increased toward training local Tanzanian physicians and assistant medical officers (AMOs) to meet the basic neurosurgical needs of nonurban areas. Between January and July 2006, an initial attempt at such an apprenticeship was undertaken with a locally trained AMO already performing general surgery at Haydom Lutheran Hospital, Tanzania.METHODS: Fifty-one neurosurgical patients were identified and their patient charts were requested from the medical records office. Records were not available for 4 of the 51 patients for undeterminable reasons.RESULTS: The neurosurgical infrastructure at HLH is basic but adequate for a number of procedures. Cases performed included ventriculoperitoneal shunts, repair of myelomeningoceles, and burr holes and craniotomies for trauma and biopsies. Of 51 patients initially identified, 14 (27%) were confirmed deceased and 20 (39%) confirmed living. The remaining 17 (33%) were lost to follow-up. There were no significant differences in the mortality rates of patients receiving care from the American-trained neurosurgeon and those receiving care from the Tanzanian AMO trained and mentored by the American neurosurgeon.CONCLUSIONS: This initial audit provides support for the development of limited neurosurgery programs in underserved communities. Combined utilization of available neurosurgeons and continued training for available local clinicians may help to meet this need.