Impact of a Newly Constructed Motor Vehicle Road on Altitude Illness in the Nepal Himalayas.

OBJECTIVE: This study investigated the impact that motor vehicle travel along a newly constructed road has on altitude illness (including acute mountain sickness, high-altitude cerebral edema, and high-altitude pulmonary edema). The new road from Besisahar (760 m) to Manang (3540 m) in Nepal was completed in December 2014. METHODS: We enrolled all patients diagnosed with altitude illness at the Himalayan Rescue Association Manang clinic in fall 2016. Phi coefficients were calculated to test for an association between Nepali ethnicity and rapid ascent by motor vehicle. A retrospective review looked at all patients with altitude illness from fall (September-November) 2010 to spring (February-May) 2016. RESULTS: In fall 2016, more than half (54%) of patients with altitude illness traveled to Manang by motor vehicle, and one-third (33%) reached Manang from low altitude (Besisahar) in less than 48 hours. Nepali nationality had a significant association with motor vehicle travel (phi +0.69, P < .0001) as well as with rapid ascent to Manang (phi +0.72, P < .0001). Compared to previous seasons, fall 2016 saw the most patients diagnosed with altitude illness. The proportion of people with altitude illness who traveled by vehicle and reached Manang in less than 48 hours was significantly greater than the proportion prior to completion of the road (P < .0001 for both). CONCLUSIONS: Rapid ascent by the newly constructed road from Besisahar to Manang appears to be related to a significant increase in the number of patients with all forms of altitude illness, especially among Nepalis. The authors believe that educational interventions emphasizing prevention are urgently needed.

Access to essential technologies for safe childbirth: a survey of health workers in Africa and Asia.

BACKGROUND: The reliable availability of health technologies, defined as equipment, medicines, and consumable supplies, is essential to ensure successful childbirth practices proven to prevent avoidable maternal and newborn mortality. The majority of global maternal and newborn deaths take place in Africa and Asia, yet few data exist that describe the availability of childbirth-related health technologies in these regions. We conducted a cross-sectional survey of health workers in Africa and Asia in order to profile the availability of health technologies considered to be essential to providing safe childbirth care. METHODS: Health workers in Africa and Asia were surveyed using a web-based questionnaire. A list of essential childbirth-related health technologies was drawn from World Health Organization guidelines for preventing and managing complications associated with the major causes of maternal and newborn mortality globally. Demographic data describing each birth center were obtained and health workers reported on the availability of essential childbirth-related health technologies at their centers. Comparison analyses were conducted using Rao-Scott chi-square test statistics. RESULTS: Health workers from 124 birth centers in 26 African and 15 Asian countries participated. All facilities exhibited gaps in the availability of essential childbirth-related health technologies. Availability was significantly reduced in birth centers that had lower birth volumes and those from lower income countries. On average across all centers, health workers reported the availability of 18 of 23 essential childbirth-related health technologies (79%; 95% CI, 74%, 84%). Low-volume facilities suffered severe shortages; on average, these centers reported reliable availability of 13 of 23 technologies (55%; 95% CI, 39%, 71%). CONCLUSIONS: Substantial gaps exist in the availability of essential childbirth-related health technologies across health sector levels in Africa and Asia. Strategies that facilitate reliable access to vital health technologies in these regions are an urgent priority.

Monomicrobial Pseudomonas necrotizing fasciitis: a case of infection by two strains and a review of 37 cases in the literature.

Necrotizing fasciitis due to Pseudomonas aeruginosa is rare. We report a case of monomicrobial Pseudomonas necrotizing fasciitis and review 37 cases in the literature. The mortality rate was 30%, and most infections occurred in the immunocompromised. Clinicians should consider empiric pseudomonal antibiotic coverage in the severely immunocompromised with potentially necrotizing infections.

Covid-19: Exposing the Lack of Evidence-Based Practice in Medicine.

The Covid-19 pandemic has altered the shape of medicine, making in-person interactions risky for both patients and health care workers. Now, before scheduling in-person appointments or procedures, physicians are forced to reconsider if they are truly necessary. The pandemic has thus thrown into relief the difference between evidence-based medical care and traditional aspects of care that lack a strong evidentiary component. In this essay, we demonstrate how this has played out in prenatal care, as well as in other aspects of medical care, during the pandemic. The extent to which these changes will persist beyond the most emergent phases of the pandemic is not clear, though insurance reimbursement practices and patient expectations will be determining factors. One thing, however, is certain: the longer the pandemic continues, the more difficult it will be for providers and patients to return to pre-Covid norms.

Newborn Resuscitation Training in Resource-Limited Settings: A Systematic Literature Review.

CONTEXT: Birth asphyxia contributes substantially to neonatal mortality in low- and middle-income countries (LMICs). The effects of training birth attendants in neonatal resuscitation (NR) on mortality are limited by falloff of skills and knowledge over time and transference of learned skills into clinical practice. OBJECTIVE: This review examined acquisition and retention of NR knowledge and skills by birth attendants in LMICs and the effectiveness of interventions to improve them. DATA SOURCES: Medline, Cochrane, Embase, CINAHL, Bireme, and African Index Medicus databases were searched. We reviewed Web pages and reports from non-peer-reviewed (or "gray") literature sources addressing NR training in LMICs. STUDY SELECTION: Articles on acquisition and retention of NR knowledge and skills, and interventions to improve them, were limited to LMICs. RESULTS: The initial search identified 767 articles, of which 45 met all inclusion criteria. Of these, 31 articles analyzed acquisition of knowledge and skills, and 19 analyzed retention. Most studies found high acquisition rates, although birth attendants struggled to learn bag-mask ventilation. Although significant falloff of knowledge and skills occurred after training, refresher training seemed to improve retention. Results of the gray literature analysis suggest that formal, structured practice sessions improve retention. LIMITATIONS: This review did not analyze training's direct impact on mortality. CONCLUSIONS: Knowledge and skills falloff is a significant barrier to the success of NR training programs and possibly to reducing newborn mortality in LMICs. Refresher training and structured practice show significant promise. Additional research is needed to implement and assess retention improvement strategies in classroom and clinical settings.

Validation of a novel tool for assessing newborn resuscitation skills among birth attendants trained by the Helping Babies Breathe program.

OBJECTIVE: To validate a simplified objective structured clinical examination (OSCE) tool for evaluating the competency of birth attendants in low-resource countries who have been trained in neonatal resuscitation by the Helping Babies Breathe (HBB) program. METHODS: A prospective cross-sectional study of the OSCE tool was conducted among trained birth attendants working at dispensaries, health centers, or hospitals in five regions of Tanzania between October 1, 2013, and May 1, 2014. A 13-item checklist was used to assess clinical competency in a simulated newborn resuscitation scenario. The OSCE tool was simultaneously administered by HBB trainers and experienced external evaluators. Paired results were compared using the Cohen κ value to measure inter-rater reliability. Participant performance was rated by health cadre, region, and facility type. RESULTS: Inter-rater reliability was moderate (κ = 0.41-0.60) or substantial (κ = 0.61-0.80) for eight of the OSCE items; agreement was fair (κ = 0.21-0.41) for the remaining five items. The best OSCE performances were recorded among nurses and providers from facilities with high annual birth volumes. CONCLUSION: The simplified OSCE tool could facilitate efficient implementation of national-level HBB programs. Limitations in inter-rater reliability might be improved through additional training.

Emergency department management of acute hematogenous osteomyelitis in children.

Acute hematogenous osteomyelitis has an annual incidence of approximately 2 to 13 cases per 100,000 persons in developed countries. It can be difficult to diagnose in pediatric patients due to the condition's often vague presentation. However, it is critical for the emergency clinician to be able to properly identify osteomyelitis, as it can have devastating consequences if left untreated. Because this is a relatively rare condition, there is limited evidence to guide the management, and there is a lack of standardized guidelines. In this issue, a systematic approach to the workup and treatment of a child who presents with possible acute hematogenous osteomyelitis is discussed. The most critical components of the history and physical examination, diagnostic studies, and treatment options are reviewed, including algorithms to guide management. Special populations are given consideration throughout the discussion, and management algorithms are provided.

Risk Factors for Pneumococcal Colonization of the Nasopharynx in Alaska Native Adults and Children.

BACKGROUND: Alaska Native children have high invasive pneumococcal disease (IPD) rates, and lack of in-home running water has been shown to have a significant association with infection. Pneumococcal conjugate vaccines reduced IPD; however, this population saw substantial replacement disease and colonization with nonvaccine serotypes. We evaluated risk factors for nasopharyngeal pneumococcal colonization in Alaska Native adults and children. METHODS: We conducted annual surveys from 2008 through 2011 of residents of all ages in 8 rural Alaskan villages. Interviews were conducted, medical charts were reviewed, and nasopharyngeal swabs were cultured for Streptococcus pneumoniae. Multivariate logistic regression models were developed for 3 age groups (under 10 years, 10-17 years, and 18 years and older) to determine risk factors for colonization. RESULTS: We obtained 12 535 nasopharyngeal swabs from 4980 participants. Our population lived in severely crowded conditions, and 48% of households lacked in-home running water. In children <10 years, colonization was associated with lack of in-home running water, household crowding, and more children in the home. Pneumococcal vaccination status was not associated with colonization. In older children and adults, increased number of persons in the household was associated with pneumococcal colonization. CONCLUSIONS: Higher colonization prevalence may partially explain increased IPD rates seen in those lacking in-home water services. Improving availability of sanitation services and reducing household crowding may reduce the burden of IPD in this population.