The role of collaboration in educating the global pediatric anesthesia workforce.

An estimated 1.7 billion children and adolescents do not have access to safe and affordable surgical care, and the vast majority of these are located in low-middle-income countries (LMICs). Pediatric anesthesia, a specialized field that requires a diverse set of knowledge and skills, has seen various advancements over the years and has become well-established in upper-middle and high-income countries. However, in LMICs, due to a multitude of factors including severe workforce shortages, this has not been the case. Collaborations play a vital role in increasing the capacity of pediatric anesthesiology educators and training the pediatric anesthesia workforce. These efforts directly increase access for children who require surgical intervention. Collaboration models can be operationalized through bidirectional knowledge sharing, training, resource allocation, research and innovation, quality improvement, networking, and advocacy. This article aims to highlight a few of these collaborative efforts. Specifically, the role that the World Federation of Societies of Anaesthesiologists, the Safer Anesthesia from Education program, the Asian Society of Pediatric Anaesthesiologists, Pediatric Anesthesia Training in Africa, the Paediatric Anaesthesia Network New Zealand, the Safe Pediatric Anesthesia Network and two WhatsApp™ groups (global ped anesthesia and the Pediatric Difficult Intubation Collaborative) have played in improving anesthesiology care for children.

[Integrative medicine for patients suffering from addictive disorders alongside other pathologies in general practice]. / Clinique intégrative des addictions coexistant avec d'autres pathologies en médecine générale.

People suffering from substance use disorders frequently suffer from concomitant affections such as other addictions, psychiatric, somatic or social problems. Clarifying objectives and priorities with the patient and coordination of care are the priority in the follow up suggested in this article. We present a clinical example in which the modality of care is adapted depending on the evolution of the patient's needs. The follow up by a general practitioner can be pursued in parallel to specialized care. The modality of this collaboration will have to adapt to the patients' and healthcare workers' needs. This follow-up aims to provide good quality health care all the while supporting the healthcare providers who can, sometimes, feel helplessness.

Les personnes souffrant d'un trouble de l'utilisation de substances présentent fréquemment plusieurs affections parallèles telles que d'autres problématiques addictologiques, psychiatriques, somatiques ou sociales. La clarification des objectifs et priorités avec le patient ainsi que la coordination des soins sont au premier plan de la prise en charge proposée dans cet article. Nous présentons, au travers d'une vignette clinique, un exemple de suivi pour lequel la modalité de prise en charge s'adapte aux besoins changeants du patient au cours du temps. Le suivi par un médecin généraliste peut être combiné à un suivi spécialisé. Le mode de collaboration devra s'adapter aux besoins des soignants et du patient. Ce suivi visera à assurer des soins de qualité tout en soutenant les soignants face à un possible sentiment d'impuissance.

Delivery of Safe Pediatric Anesthesia Care in the First 8000 days: Realities, Challenges, and Solutions in Low- and Middle-Income Countries.

BACKGROUND: Worldwide, perioperative mortality has declined over the past 50 years, but the reduction is skewed toward high-income countries (HICs). Currently, pediatric perioperative mortality is much higher in low- and middle-income countries (LMICs) compared to HICs, despite studied cohorts being predominantly low-risk. These disparities must be studied and addressed. METHODS: A narrative review of the literature was undertaken to identify contributing factors and potential knowledge gaps. Interventions aimed at alleviating the outcomes disparities are discussed, and recommendations are made for future directions. RESULTS AND CONCLUSIONS: There is a lack of adequately trained pediatric anesthesia providers in LMICs, and the number must be bolstered by making such training available. Essential anesthesia medications and equipment, in pediatric-appropriate sizes, are often not available; neither are essential infrastructure items. Perioperative staff are underprepared for emergent situations that may arise and simulation training may help to ameliorate this. The global anesthesia community has implemented several solutions to address these issues. The World Federation of Societies of Anaesthesiologists (WFSA) and Global Initiative for Children's Surgery have published standards that outline essential items for the provision of safe perioperative pediatric care. Several short educational courses have been developed and introduced in LMICs that either specifically address pediatric patients, or contain a pediatric component. The WFSA also maintains a collection of discrete tutorials for educational purposes. Finally, in Africa, large-scale, prospective data collection is underway to examine pediatric perioperative outcomes. More work needs to be done, though, to improve perioperative outcomes for pediatric patients in LMICs.

Current pediatric pain practice in Nigeria, South Africa, Uganda, and Zambia: A prospective survey of anesthetists.

BACKGROUND: Children in hospital experience significant pain, either inherent with their pathology, or caused by diagnostic/therapeutic procedures. Little is known about pediatric pain practices in sub-Saharan Africa. This survey aimed to gain insight into current pain management practices among specialist physician anesthetists in four sub-Saharan African countries. METHODS: A survey was sent to 365 specialist physician anesthetists in Nigeria, South Africa, Uganda and Zambia. Content analysis included descriptive information about the respondents and their work environment. Thematic analysis considered resources available for pediatric pain management, personal and institutional pain practices. RESULTS: One hundred and sixty-six responses were received (response rate 45.5%), with data from 141 analyzed; Nigeria (27), South Africa (52), Uganda (41) and Zambia (21). Most respondents (71.83%) worked at tertiary/national referral hospitals. The majority of respondents (130/141, 91.55%) had received teaching in pediatric pain management. Good availability was reported for simple analgesia, opioids, ketamine, and local anesthetics. Just over half always/often had access to nurses trained in pediatric care, and infusion pumps for continuous drug delivery. Catheters for regional anesthesia techniques and for patient-controlled analgesia were largely unavailable. Two thirds (94/141, 66.67%) did not have an institutional pediatric pain management guideline, but good pharmacological pain management practices were reported, in line with World Health Organization recommendations. Eighty-eight respondents (62.41%) indicated that they felt appropriate pain control in children was always/often achieved in their setting. CONCLUSION: This survey provides insight into pediatric pain practices in these four countries. Good availability of a variety of analgesics, positive pain prescription practices, and utilization of some non-pharmacological pain management strategies are encouraging, and suggest that achieving good pain control despite limited resources is attainable. Areas for improvement include the development of institutional guidelines, routine utilization of pain assessment tools, and access to regional anesthesia and other advanced pain management techniques.

'I just wanted a change, a positive change': Locating hope for young people engaged with residential alcohol and drug services in Victoria, Australia.

In this article, we investigate young people's involvement with residential alcohol and other drug (AOD) services as part of their broader engagement with hope. This study draws on qualitative interviews conducted with 20 young people aged 17-23 from Victoria, Australia, who were either in, or had recently left, residential AOD services. Interviews explored their experiences with AOD services and included questions about their hopes for the future. We found hope located in social relationships, productive discourses and AOD settings themselves. Hope also presented differently according to the external resources young people had available to them, giving some young people greater capacity to action their hoped-for futures than others. Given many young people seek reimagined futures as part of their use of residential AOD services, this creates a valuable opportunity for services to help shape achievable hopes and boost service engagement. We suggest that hope can materialise in a variety of ways but caution against relying on it as a motivational strategy without providing young people with other resources. A more sustainable narrative of hope may require a solid foundation of resources, allowing young people with AOD problems to gain a sense of control over their lives and their imagined futures.

The freighted social histories of HIV and hepatitis C: exploring service providers' perspectives on stigma in the current epidemics.

A virus has a social history. In the case of the hepatitis C virus (HCV) and HIV, this history is one involving stigma and discrimination, advocacy and activism, and recent dramatic improvements in treatment. These social histories influence the experience of people who live with the viruses, and those who work with them. One aspect of this is the impact of social changes on the biographical disruption and integration brought about by illness. Healthcare practitioners who see significant improvements in the effectiveness of treatment for a condition over the course of their professional life will incorporate those changes into their own history and their relationship to that condition.This article is based on a study of the experiences of serodiscordance, or mixed infection status, in families living with HIV and two types of viral hepatitis, hepatitis B and hepatitis C. The article explores the perspectives of healthcare workers who work with people affected by these viruses, who were asked about their experiences in working with serodiscordance in families. Interviews revealed that changing social meanings given to bloodborne viruses, and changes to treatment over time, held a significant place in the accounts that service providers gave of their work. In asking them to describe their work with HIV and HCV, we were also asking about work that has been shaped by changing patterns and sources of stigma, and recently reshaped by changes in treatment and outcomes. While typically the experiences of patients and their families are used to investigate the social histories of diagnosis and stigma, the professional perspectives and life stories of the service providers who work with them are also revealing. We heard accounts in which histories as well as current regimes were prominent, illuminated further by insights from the sociology of health on narrative and biographical disruption.

Challenges with pediatric anesthesia and intraoperative ventilation of the child in the resource-constrained setting.

The systemic challenges in providing safe anesthesia, including safe ventilation, to children in resource-constrained settings are many. For anesthesia providers caring for children, the lack of appropriate equipment, inadequate anesthesia workforce and deficiencies in postoperative care are especially difficult. The clinical decisions made by anesthesia providers around when and how to ventilate a child for surgery are influenced by all of these factors and can result in patient management which may vary significantly from that in a high-resource setting. This educational review considers the intraoperative ventilation of a small child in a resource-constrained setting and discusses specific challenges and context-sensitive solutions.

Family imaginaries in the disclosure of a blood-borne virus.

Contemporary sociological work has emphasised that family is not static, but actively shaped by ideas of who and what makes family. Disclosure of an illness, including diagnosis of stigmatised infections such as HIV, hepatitis B virus and hepatitis C virus, can change the dynamics of family relationships. This paper draws on 61 qualitative semi-structured interviews conducted between 2017 and 2019 with people in Australia with one or more of these blood-borne viruses (BBVs) and their family members, to understand the experiences of serodiscordant (mixed viral status) families. Through a thematic analysis, we explore the family imaginaries that participants evoked when describing their disclosure practices in relation to (self-defined) family members, revealing how some participants disclosed in ways that enabled them to shape their family, to maintain boundaries between self and family or to protect family from distress. Participants' accounts of disclosure to family revealed imaginaries of family as a precious web of connections to be nurtured or protected, but also as sites of ambivalent belonging and complex history. We conclude that BBV disclosure practices within families reveal important ideas about families that are imagined in response to the threat of loss, change and stigma.

Feasibility of a Mobile Health App for Routine Outcome Monitoring and Feedback in SMART Recovery Mutual Support Groups: Stage 1 Mixed Methods Pilot Study.

BACKGROUND: Mutual support groups are an important source of long-term help for people impacted by addictive behaviors. Routine outcome monitoring (ROM) and feedback are yet to be implemented in these settings. SMART Recovery mutual support groups focus on self-empowerment and use evidence-based techniques (eg, motivational and behavioral strategies). Trained facilitators lead all SMART Recovery groups, providing an opportunity to implement ROM. OBJECTIVE: The aim of this stage 1 pilot study is to explore the feasibility, acceptability, and preliminary outcomes of a novel, purpose-built mobile health ROM and feedback app (SMART Track) in mutual support groups coordinated by SMART Recovery Australia (SRAU) over 8 weeks. METHODS: SMART Track was developed during phase 1 of this study using participatory design methods and an iterative development process. During phase 2, 72 SRAU group participants were recruited to a nonrandomized, prospective, single-arm trial of the SMART Track app. Four modes of data collection were used: ROM data directly entered by participants into the app; app data analytics captured by Amplitude Analytics (number of visits, number of unique users, visit duration, time of visit, and user retention); baseline, 2-, and 8-week follow-up assessments conducted through telephone; and qualitative telephone interviews with a convenience sample of study participants (20/72, 28%) and facilitators (n=8). RESULTS: Of the 72 study participants, 68 (94%) created a SMART Track account, 64 (88%) used SMART Track at least once, and 42 (58%) used the app for more than 5 weeks. During week 1, 83% (60/72) of participants entered ROM data for one or more outcomes, decreasing to 31% (22/72) by the end of 8 weeks. The two main screens designed to provide personal feedback data (Urges screen and Overall Progress screen) were the most frequently visited sections of the app. Qualitative feedback from participants and facilitators supported the acceptability of SMART Track and the need for improved integration into the SRAU groups. Participants reported significant reductions between the baseline and 8- week scores on the Severity of Dependence Scale (mean difference 1.93, SD 3.02; 95% CI 1.12-2.73) and the Kessler Psychological Distress Scale-10 (mean difference 3.96, SD 8.31; 95% CI 1.75-6.17), but no change on the Substance Use Recovery Evaluator (mean difference 0.11, SD 7.97; 95% CI -2.02 to 2.24) was reported. CONCLUSIONS: Findings support the feasibility, acceptability, and utility of SMART Track. Given that sustained engagement with mobile health apps is notoriously difficult to achieve, our findings are promising. SMART Track offers a potential solution for ROM and personal feedback, particularly for people with substance use disorders who attend mutual support groups. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619000686101; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377336. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/15113.

[2020 scientific breakthroughs in ambulatory general internal medicine]. / Avancées scientifiques de 2020 en médecine interne générale ambulatoire.

Functional weakness of the limbs has an uncertain prognosis and little chance of recovery. Obese people in precarious situations may succeed in losing weight through an intensive lifestyle-based weight loss program. In patients with gonarthrosis, physiotherapy may decrease pain and disability when compared to injected corticosteroids. Patients suffering from an alcohol dependence syndrome can reduce their consumption with short-term consultations conducted by general practitioners. Fatigue and dyspnea are two frequent symptoms that may persist after the acute phase of the SARS-CoV-2 infection. PCR analysis for the detection of SARS-CoV-2 could be performed with the same degree of sensitivity on a nasopharyngeal or salivary swab.

La faiblesse fonctionnelle des membres a un pronostic incertain et peu de probabilité de guérir. Les personnes souffrant d'obésité en situation de précarité peuvent réussir à perdre du poids par un programme intensif de perte pondérale soutenu par des changements du style de vie. Chez les patients atteints de gonarthrose, la physiothérapie peut diminuer la douleur et l'incapacité lorsqu'elle est comparée à des corticostéroïdes injectés. Les patients qui souffrent d'un syndrome de dépendance à l'alcool peuvent réduire leur consommation avec des consultations de courte durée effectuées par des médecins généralistes. La fatigue et la dyspnée sont deux des symptômes parmi les plus fréquents qui peuvent perdurer après la phase aiguë de l'infection par SARS-CoV-2. L'analyse de détection du SARS-CoV-2 par PCR pourrait être effectuée avec le même degré de sensibilité sur un prélèvement nasopharyngé ou salivaire.

Strengthening prevention in communities through systems change: lessons from the evaluation of Healthy Families NZ.

This article presents the findings from the first 3 years of the evaluation of Healthy Families NZ, a systems-change intervention to prevent chronic diseases in 10 communities. The initiative, which builds on existing prevention activities, aims to strengthen the health prevention system through evidence-driven action to enable people to make good food choices, be physically active, smoke-free and free from alcohol-related harm. Key investment areas are a dedicated systems thinking and acting health promotion workforce, and activating leaders who can influence transformational change. The evaluation to date has found the initiative is being implemented with integrity. Evidence indicates a shift towards greater action on prevention, and the prevention system being strengthened. Maori ownership has been enabled, and prioritizing equity has led teams to utilize methods that amplify diverse local perspectives. There is progress on developing a flexible workforce through adaptive learning, flexible resources, professional development and a responsive National team. There is also progress in activating local leadership and empowering local teams. The initiative design has explicitly taken into account the context of complexity within which it is being implemented. It has evolved to focus on action that can accelerate sharing information and practices within communities, and between policy and decision-makers. Healthy Families NZ and its evaluation have been refunded to 2022. This provides an important opportunity to gather further insight into effective ways to strengthen the community agency and trust needed to promote and deliver evidence-based action on prevention.

Mapping Experiences of Serodiscordance: Using Visual Methodologies to Construct Relationality in Families Living With or Affected by Stigmatized Infectious Disease.

The "my health, our family" research project was established to document stories of what serodiscordance (mixed infection status) means for Australian families affected by HIV, hepatitis B, and/or hepatitis C. A family mapping exercise was developed for the start of interviews as a way to conceptualize serodiscordance as a movement of "closeness" and "distance" within the relational networks that participants defined as "family," the outcome of which was originally intended as a guide to explore the contributions of each family member in the in-depth qualitative interviews that followed. Such static representations of family were soon revealed to be inadequate for capturing the contingent, flexible, and multifaceted nature of familial relationality in the management of these infections. In this article, we explore these shifts for the conceptual openness mapping methods facilitate, and the constraints they reveal, for spatializing family relations in ways that heed diverse experiences of serodiscordance.

Exposure of Nail Salon Workers to Phthalates, Di(2-ethylhexyl) Terephthalate, and Organophosphate Esters: A Pilot Study.

Relatively little is known about the exposure of nail technicians to semivolatile organic compounds (SVOCs) in nail salons. We collected preshift and postshift urine samples and silicone wrist bands (SWBs) worn on lapels and wrists from 10 female nail technicians in the Boston area in 2016-17. We analyzed samples for phthalates, phthalate alternatives, and organophosphate esters (OPEs) or their metabolites. Postshift urine concentrations were generally higher than preshift concentrations for SVOC metabolites; the greatest change was for a metabolite of the phthalate alternative di(2-ethylhexyl) terephthalate (DEHTP): mono(2-ethyl-5-carboxypentyl) terephthalate (MECPTP) more than tripled from 11.7 to 36.6 µg/g creatinine. DEHTP biomarkers were higher in our study participants' postshift urine compared to 2015-2016 National Health and Nutrition Examination Survey females. Urinary MECPTP and another DEHTP metabolite were moderately correlated (r = 0.37-0.60) with DEHTP on the SWBs, suggesting occupation as a source of exposure. Our results suggest that nail technicians are occupationally exposed to certain phthalates, phthalate alternatives, and OPEs, with metabolites of DEHTP showing the largest increase across a work day. The detection of several of these SVOCs on SWBs suggests that they can be used as a tool for examining potential occupational exposures to SVOCs among nail salon workers.

[Nutrition disorders and alcohol use disorder]. / Troubles de l'utilisation d'alcool et malnutrition.

Patients suffering from alcohol use disorder (AUD) are at risk for malnutrition. The mechanisms are presented in this article. Nutrition disorders in the patient with AUD can include malnutrition, micronutrient deficiencies, overweight and obesity. They may contribute to tissue damage and to oncological and cognitive disorders encountered among patients with AUD. Refeeding syndrome can appear during the withdrawal period. A nutrition evaluation should be included in the evaluation of all patients with AUD.

Les patients avec troubles de l'utilisation de l'alcool (TUA) sont à risque de malnutrition. Les mécanismes de celle-ci sont présentés dans cet article. La malnutrition chez le patient avec TUA peut comprendre une dénutrition protéino-calorique, des carences en micronutriments, une surcharge pondérale et l'obésité. La malnutrition peut participer aux lésions tissulaires et aux pathologies oncologiques et cognitives retrouvées chez les patients avec TUA. Le syndrome de renutrition inappropriée peut apparaître durant la période de sevrage. Une évaluation nutritionnelle devrait être incluse dans la prise en charge du patient avec TUA.

[2018 scientific breakthroughs in ambulatory general internal medicine]. / Avancées scientifiques de 2018 en médecine interne générale ambulatoire.

Mindfulness meditation and cognitive-behavioral therapy are more cost-effective than conventional management of chronic low back pain. Women with iron deficiency can be treated with oral iron substitution every other day to improve tolerance. Smokers who smoke four or less cigarettes per day have a disproportionately high risk of cardiovascular and cerebrovascular events. All antidepressants are effective in cases of severe depression. Cannabis derivatives have no analgesic effect and do not improve the quality of life of people with neuropathic pain. Cognitive training is effective in cases of mild cognitive impairment. Delegated medical protocols can aid with blood pressure control in hypertensive patients. Nitrofurantoin is the antibiotic of choice for uncomplicated cystitis.

La méditation de pleine conscience et la thérapie cognitivo-comportementale présentent un profil coût-efficacité plus avantageux qu'une prise en charge classique des lombalgies chroniques. Les femmes avec un déficit en fer peuvent être traitées par une substitution orale en fer prise un jour sur deux afin d'améliorer la tolérance. Les fumeurs de 4 ou moins cigarettes par jour ont un risque d'événement cardiovasculaire et cérébrovasculaire élevé. Les antidépresseurs sont tous efficaces en cas d'état dépressif sévère. Les dérivés du cannabis n'ont pas d'effet antalgique significatif et n'améliorent pas la qualité de vie des personnes avec douleurs neuropathiques. L'entraînement cognitif est efficace en cas de déficit cognitif léger. L'hypertension artérielle peut être contrôlée par des protocoles médico-délégués. La nitrofurantoïne est l'antibiotique de choix en cas de cystite non compliquée.

Evaluating a community-based public health intervention using a complex systems approach.

Background: This article outlines the methods being used to evaluate a community-based public health intervention. This evaluation approach recognizes that not only is the intervention, Healthy Families NZ, complex, but the social systems within which it is being implemented are complex. Methods: To address challenges related to complexity, we discuss three developing areas within evaluation theory and apply them to an evaluation case example. The example, Healthy Families NZ, aims to strengthen the prevention system in Aotearoa/New Zealand to prevent chronic disease in 10 different geographic areas. Central to the evaluation design is the comparative case method which recognizes that emergent outcomes are the result of 'configurations of causes'. 'Thick', mixed-data, case studies are developed, with each case considered a view of a complex system. Qualitative Comparative Analysis is the analytical approach used to systematically compare the cases over time. Conclusions: This article describes an approach to evaluating a community-based public health intervention that considers the social systems in which the initiative is being implemented to be complex. The evaluation case example provides a unique opportunity to operationalize and test these methods, while extending their more frequent use within other fields to the field of public health.

Smoking as an 'informed choice': implications for endgame strategies.

OBJECTIVE: Tobacco companies often assert that adults should be free to make an 'informed choice' about smoking; this argument influences public perceptions and shapes public health policy agendas by promoting educative interventions ahead of regulation. Critically analysing 'informed choice' claims is pivotal in countries that have set endgame goals and require new, more effective policies to achieve their smoke-free aims. METHODS: In-depth interviews with 15 New Zealand politicians, policy analysts and tobacco control advocates examined how they interpreted 'informed choice' arguments. We used a thematic analysis approach to review and explicate interview transcripts. RESULTS: Participants thought 'informed choice' implied that people make an active decision to smoke, knowing and accepting the risks they face; they rejected this assumption and saw it as a cynical self-justification by tobacco companies. Some believed this rhetoric had countered calls for stronger policies and thought governments used 'informed choice' arguments to support inaction. Several called on the government to stop allowing a lethal product to be widely sold while simultaneously advising people not to use it. CONCLUSIONS: 'Informed choice' arguments allow the ubiquitous availability of tobacco to go unquestioned and create a tension between endgame goals and the strategies used to achieve these. Reducing tobacco availability would address this anomaly by aligning government's actions with its advice.

Anesthesia-induced rhabdomyolysis or malignant hyperthermia: is defining the crisis important?

Anesthesia-induced rhabdomyolysis and malignant hyperthermia occur in response to the same agents and present with similar clinical features. Distinguishing between these diagnoses can be challenging in a clinical crisis yet making the distinction is critical as prompt appropriate management may be life-saving, whereas delayed recognition and/or inappropriate management will almost certainly result in death. This focused review examines the differences between these conditions and focuses on the emergency management of anesthesia-induced rhabdomyolysis.