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In 2013, the SickKids-Caribbean Initiative (SCI) was formalised among The Hospital for Sick Children in Toronto, Canada, the University of the West Indies, and Ministries of Health in six Caribbean countries (Barbados, The Bahamas, Jamaica, St. Lucia, St. Vincent and the Grenadines, and Trinidad and Tobago). The aim was to improve the outcomes and quality of life of children (<18 years) with cancer and blood disorders in the partner countries. Core activities included filling a human resource gap by training paediatric haematologists/oncologists and specialised registered nurses; improving capacity to diagnose and treat diverse haematology/oncology cases; developing and maintaining paediatric oncology databases; creating ongoing advocacy activities with international agencies, decision makers, and civil society; and establishing an integrated administration, management, and funding structure. We describe core program components, successes, and challenges to inform others seeking to improve health service delivery in a multidisciplinary and complex partnership.
RESUMO
OBJECTIVE: To evaluate the validity of the Responses to Illness Severity Quantification (RISQ) score to discriminate illness severity and transitions between levels of care during hospitalization. STUDY DESIGN: A prospective observational study conducted in Maiduguri, Nigeria, enrolled inpatients aged 1-59 months with severe acute malnutrition. The primary outcome was the RISQ score associated with the patient state. Heart and respiratory rate, oxygen saturation, respiratory effort, oxygen use, temperature, and level of consciousness are summed to calculate the RISQ score. Five states were defined by levels of care and hospital discharge outcome. The states were classified hierarchically, reflecting illness severity: hospital mortality was the most severe state, then intensive care unit (ICU), care in the stabilization phase (SP), care in the rehabilitation phase (RP), and lowest severity, survival at hospital discharge. A multistate statistical model examined performance of the RISQ score in predicting clinical states and transitions. RESULTS: Of 903 children enrolled (mean age, 14.6 months), 63 (7%) died. Mean RISQ scores during care in each phase were 3.5 (n = 2265) in the ICU, 1.7 (n = 6301) in the SP, and 1.5 (n = 2377) in the RP. Mean scores and HRs for a 3-point change in score at transitions: ICU to death, 6.9 (HR, 1.80); SP to ICU, 2.8 (HR, 2.00); ICU to SP, 2.0 (HR, 0.5); and RP to discharge, 1.4 (HR, 0.91). CONCLUSIONS: The RISQ score can discriminate between points of escalation or de-escalation of care and reflects illness severity in hospitalized children with severe acute malnutrition. Evaluation of clinical implementation and demonstration of benefit will be important before widespread adoption.
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Criança Hospitalizada , Desnutrição Aguda Grave , Criança , Humanos , Lactente , Transferência de Pacientes , Nigéria , Unidades de Terapia Intensiva , Índice de Gravidade de Doença , Gravidade do Paciente , Desnutrição Aguda Grave/diagnóstico , Desnutrição Aguda Grave/terapiaRESUMO
OBJECTIVE: To compare the effects of 2 treatment options on neurodevelopmental and laboratory outcomes in young children with nonanemic iron deficiency. STUDY DESIGN: A blinded, placebo-controlled, randomized trial of children 1-3 years with nonanemic iron deficiency (hemoglobin ≥110 g/L, serum ferritin <14 µg/L) was conducted in 8 primary care practices in Toronto, Canada. Interventions included ferrous sulfate or placebo for 4 months; all parents received diet advice. The primary outcome was the Early Learning Composite (ELC) using the Mullen Scales of Early Learning (mean 100, SD 15). Secondary outcomes included serum ferritin. Measurements were obtained at baseline and 4 and 12 months. Sample size was calculated to detect a between-group difference of 6-7 points in ELC. RESULTS: At enrollment (n = 60), mean age was 24.2 (SD 7.4) months and mean serum ferritin was 10.0 (SD 2.4) µg/L. For ELC, the mean between-group difference at 4 months was 1.1 (95% CI -4.2 to 6.5) and at 12 months was 4.1 (95% CI -1.9 to 10.1). For serum ferritin, at 4 months, the mean between-group difference was 16.9 µg/L (95% CI 6.5 to 27.2), and no child randomized to ferrous sulfate had a serum ferritin <14 µg/L (0% vs 31%, P = .003). CONCLUSIONS: For young children with nonanemic iron deficiency, treatment options include oral iron and/or diet advice. We remain uncertain about which option is superior with respect to cognitive outcomes; however, adding ferrous sulfate to diet advice resulted in superior serum ferritin outcomes after 4 months. Shared decision-making between practitioners and parents may be considered when selecting either option. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01481766.
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Anemia Ferropriva/terapia , Ferritinas/sangue , Hemoglobinas/metabolismo , Ferro/administração & dosagem , Anemia Ferropriva/sangue , Biomarcadores/sangue , Pré-Escolar , Suplementos Nutricionais , Feminino , Humanos , Masculino , Resultado do TratamentoRESUMO
OBJECTIVE: To determine the impact of rapid advancement to more concentrated formula on weight gain and duration of hospitalization for infants after cardiac surgery. STUDY DESIGN: We performed a double-blinded, randomized trial of rapid advancement to higher achieved formula concentration for postoperative infants younger than 1 year of age. After transfer to the inpatient ward from the critical care unit, infants were randomly assigned to rapid advancement to a higher achieved formula concentration (2-day transition) or usual care (5-day transition, lower concentration target). RESULTS: The adequacy of energy intake (expressed as the median percentage of the estimated energy requirement) before discharge from the hospital was 98% in the intervention versus 78% in the usual care group ( P = .01). Before discharge, the median rate of weight gain was greater in the rapid advancement (20 g/d) versus the usual care group (loss of 35 g/d, P < .03). The median postoperative duration of stay on the cardiology inpatient unit was 5 days for the intervention versus 6 days for the usual care group ( P < .05). CONCLUSIONS: Rapid advancement to higher achieved formula concentration significantly improved energy intake and weight gain and decreased duration of postoperative hospital stay in infants after cardiac surgery.
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Ingestão de Energia , Alimentos Infantis , Cuidados Pós-Operatórios , Aumento de Peso , Método Duplo-Cego , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Fenômenos Fisiológicos da Nutrição do Lactente , Recém-Nascido , Tempo de Internação , Período Pós-OperatórioAssuntos
Bebidas , Deficiências Nutricionais/prevenção & controle , Alimentos Fortificados , Deficiências de Ferro , Zinco/deficiência , Disponibilidade Biológica , Criança , Fenômenos Fisiológicos da Nutrição Infantil , Compostos Ferrosos/administração & dosagem , Compostos Ferrosos/farmacocinética , Humanos , Isótopos de Zinco/administração & dosagem , Isótopos de Zinco/farmacocinéticaRESUMO
Los abusos en investigación en niños, los errores, las normas, la inversión mínima y conceptos equivocados por personal profesional contribuyen a que los niños sean huérfanos terapéuticos. Es urgente el imperativo moral de ampliar la farmacología pediátrica, pero tal empresa conlleva riesgos. Los pediatras, por ser expertos en la atención de niños, tienen la situación privilegiada de poder recomendar la ampliación de esta investigación de utilidad invaluable y al mismo tiempo ser abogados y protectores de los niños que participan. Un compromiso mutuo asegurará que en lo futuro habrá mejores medios y situaciones para contar con medicamentos inocuos y eficaces, y con ello brindar una atención mucho mejor a los niños