Pediatric procedural sedation in African clinical settings: A mixed methods study of African providers' sedation practices.

Background: Little is known about the practice of pediatric procedural sedation in Africa, despite being incredibly useful to the emergency care of children. This study describes the clinical experiences of African medical providers who use pediatric procedural sedation, including clinical indications, medications, adverse events, training, clinical guideline use, and comfort level. The goals of this study are to describe pediatric sedation practices in resource-limited settings in Africa and identify potential barriers to the provision of safe pediatric sedation. Methods: This mixed methods study describes the pediatric procedural sedation practices of African providers using semi-structured interviews. Purposive sampling was used to identify key informants working in African resource-limited settings across a broad geographic, economic, and professional range. Quantitative data about provider background and sedation practices were collected concurrently with qualitative data about perceived barriers to pediatric procedural sedation and suggestions to improve the practice of pediatric sedation in their settings. All interviews were transcribed, coded, and analyzed for major themes. Results: Thirty-eight key informants participated, representing 19 countries and the specialties of Anesthesia, Surgery, Pediatrics, Critical Care, Emergency Medicine, and General Practice. The most common indication for pediatric sedation was imaging (42%), the most common medication used was ketamine (92%), and hypoxia was the most common adverse event (61%). Despite 92% of key informants stating that pediatric procedural sedation was critical to their practice, only half reported feeling adequately trained. The three major qualitative themes regarding barriers to safe pediatric sedation in their settings were: lack of resources, lack of education, and lack of standardization across sites and providers. Conclusions: The results of this study suggest that training specialized pediatric sedation teams, creating portable "pediatric sedation kits," and producing locally relevant pediatric sedation guidelines may help reduce current barriers to the provision of safe pediatric sedation in resource-limited African settings.

Association of State-Level Tax Policy and Infant Mortality in the United States, 1996-2019.

Importance: Infant mortality in the United States is highest among peer nations; it is also inequitable, with the highest rates among Black infants. The association between tax policy and infant mortality is not well understood. Objective: To examine the association between state-level tax policy and state-level infant mortality in the US. Design, Setting, and Participants: This state-level, population-based cross-sectional study investigated the association between tax policy and infant mortality in the US from 1996 through 2019. All US infant births and deaths were included, with data obtained from the National Center for Health Statistics. Data were analyzed from November 28, 2021, to July 9, 2022. Exposures: State-level tax policy was operationalized as tax revenue per capita and tax progressivity. The Suits index was used to measure tax progressivity, with higher progressivity indicating increased tax rates for wealthier individuals. Main Outcomes and Measures: The association between tax policy and infant mortality rates was analyzed using a multivariable, negative binomial, generalized estimating equations model. Since 6 years of tax progressivity data were available (1995, 2002, 2009, 2012, 2014, and 2018), 300 state-years were included. Adjusted incidence rate ratios (aIRRs) were calculated controlling for year, state-level demographic variables, federal transfer revenue, and other revenue. Secondary analyses were conducted for racial and ethnic subgroups. Results: There were 148 336 infant deaths in the US from 1996 through 2019, including 27 861 Hispanic infants, 1882 non-Hispanic American Indian or Alaska Native infants, 5792 non-Hispanic Asian or Pacific Islander infants, 41 560 non-Hispanic Black infants, and 68 666 non-Hispanic White infants. The overall infant mortality rate was 6.29 deaths per 1000 live births. Each $1000 increase in tax revenue per capita was associated with a 2.6% decrease in the infant mortality rate (aIRR, 0.97; 95% CI, 0.95-0.99). An increase of 0.10 in the Suits index (ie, increased tax progressivity) was associated with a 4.6% decrease in the infant mortality rate (aIRR, 0.95; 95% CI, 0.91-0.99). Increased tax progressivity was associated with decreased non-Hispanic White infant mortality (aIRR, 0.95; 95% CI, 0.91-0.99), and increased tax revenue was associated with increased non-Hispanic Black infant mortality (aIRR, 1.04; 95% CI, 1.01-1.08). Conclusions and Relevance: In this cross-sectional study, an increase in tax revenue and the Suits index of tax progressivity were both associated with decreased infant mortality. These associations varied by race and ethnicity. Tax policy is an important, modifiable social determinant of health that may influence state-level infant mortality.

Partnerships for Global Child Health.

Child mortality remains a global health challenge and has resulted in demand for expanding the global child health (GCH) workforce over the last 3 decades. Institutional partnerships are the cornerstone of sustainable education, research, clinical service, and advocacy for GCH. When successful, partnerships can become self-sustaining and support development of much-needed training programs in resource-constrained settings. Conversely, poorly conceptualized, constructed, or maintained partnerships may inadvertently contribute to the deterioration of health systems. In this comprehensive, literature-based, expert consensus review we present a definition of partnerships for GCH, review their genesis, evolution, and scope, describe participating organizations, and highlight benefits and challenges associated with GCH partnerships. Additionally, we suggest a framework for applying sound ethical and public health principles for GCH that includes 7 guiding principles and 4 core practices along with a structure for evaluating GCH partnerships. Finally, we highlight current knowledge gaps to stimulate further work in these areas. With awareness of the potential benefits and challenges of GCH partnerships, as well as shared dedication to guiding principles and core practices, GCH partnerships hold vast potential to positively impact child health.

Insuring the uninsured: A student-run initiative to improve access to care in an urban community.

CONTEXT: There are 44 million uninsured Americans. Lack of insurance creates a major barrier for the poor and near poor to get adequate medical attention. A portion of these are eligible for insurance and either do not know they are eligible or have difficulty navigating the application process. OBJECTIVE: To evaluate the success of University at Buffalo medical students at a free clinic in helping patients enroll in government-sponsored insurance plans. DESIGN: Observational study SETTING: The Lighthouse Free Medical Clinic--a student-run free clinic operating in an urban minority Buffalo, NY neighborhood. PATIENTS: Five-hundred-seventy-nine inner-city, low-socioeconomic-status patients age <65. INTERVENTION: All patients are screened, and those eligible are encouraged and assisted in completing insurance applications. OUTCOME MEASURES: Primary outcome is the percentage of patients who completed the application process. RESULTS: Five-hundred-seventy-nine patients were seen from October 2003 through October 2004; 319 (55%) were uninsured. Fifty-nine (26%) of those uninsured were found to be eligible for insurance. Fifty-seven applications were initiated, and 23 (40%) were completed and accepted. CONCLUSIONS: There are a significant number of people using the free clinic who are eligible for insurance. The number-one reason adults were ineligible was household income exceeding the state limit. Success of this project provides support for the use of medical student volunteers to assist in insurance application completion in community settings.