Positive effects of ultrasound-guided peripheral IV insertion on pediatric sickle cell anemia/thalassemia patients receiving automated red cell exchange procedures or chronic transfusion therapy.

BACKGROUND: Peripheral vascular access and venipuncture are major causes of distress and anxiety for children and their parents. This is especially difficult for patients with hemoglobinopathies (thalassemia major and sickle cell disease) who require chronic blood transfusions. These patients require peripheral venous access for regular blood transfusions and (in the case of sickle cell disease) for automated red cell exchange procedures. Peripheral intravenous (PIV) catheters are much preferred to central venous lines as they carry far fewer risks. However, when patients experience multiple unsuccessful attempts to initiate a PIV, it can be traumatizing and cause anxiety for future visits. Establishing therapeutic trust and ensuring a smooth experience are of paramount importance for these chronic patients who require regular blood transfusions. AIM: The purpose of this study was to determine whether ultrasound-guided PIV insertion decreases PIV-associated pain and anxiety, and whether the number of attempts and amount of time spent accessing PIVs in children with difficult peripheral intravenous (DPIV) access is reduced. MATERIALS AND METHODS: This was a pilot study with both retrospective and prospective components. Hemoglobinopathies are relatively rare in our population and our study cohort was small (N = 18). RESULTS: We identified four DPIV access patients. We recorded each time these patients had a PIV inserted as an encounter. DISCUSSION/CONCLUSION: We found that while there was a small amount of time gained by using ultrasound-guided PIV insertion, patient and parent satisfaction was significantly improved.

Ifosfamide, gemcitabine, and vinorelbine is an effective salvage regimen with excellent stem cell mobilization in relapsed or refractory pediatric Hodgkin lymphoma.

We describe 12 pediatric patients (8-16 years) with primary refractory (N = 6) or first relapse (N = 6) Hodgkin lymphoma (HL) treated with ifosfamide, gemcitabine, and vinorelbine (IGEV). The overall response rate to IGEV was 100%, with seven (58%) complete responses (CR) and five (42%) partial responses. Successful CD34+ stem cell mobilization was achieved in all patients. Following subsequent autologous stem cell transplantation, 10 patients (83%) achieved CR. At a median follow-up of 71 months, 11 patients had no evidence of disease. Five-year second event-free survival and overall survival were 83% ± 11.0% and 90.0% ± 9.5%, respectively. IGEV is an effective salvage regimen for children with relapsed/refractory HL.

A quality improvement project using statistical process control methods for type 2 diabetes control in a resource-limited setting.

QUALITY ISSUE: Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients. INITIAL ASSESSMENT: Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care. CHOICE OF SOLUTION: This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework. IMPLEMENTATION: A bundle of improvement activities were implemented at the home, clinic and institutional level. EVALUATION: Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control. LESSONS LEARNED: Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients.

A Clinically Significant Difference on the COPM: A Review.

Background. The Canadian Occupational Performance Measure (COPM) assists occupational therapists to identify occupational performance problems using a client-centred approach. Since its first publication in 1991, there has been abundant evidence of the ability of the COPM to detect a statistically significant difference as an outcome measure. There has also been a tacit understanding that a difference of 2 points from pre-test to post-test on either Performance or Satisfaction COPM score represents a clinically significant difference. There is however, some confusion about the origins of this claim. Purpose. To ascertain empirical evidence for the claim that a clinically significant difference is a change score ≥2 points. Method. We conducted a scoping review of peer-reviewed literature (1991-2020) for intervention studies using the COPM as an outcome measure and examined intervention type and change scores. Findings. One hundred studies were identified. The COPM was used to assess effectiveness of eight types of occupational therapy interventions. The common belief, however, was not empirically supported that clinical significance can be asserted on the basis of a two-point change in COPM scores. Implications. Further research is needed to test alternative approaches to asserting clinical significance or a minimal clinically important difference.

Screening for chronic kidney disease in a community-based diabetes cohort in rural Guatemala: a cross-sectional study.

OBJECTIVE: Screening is a key strategy to address the rising burden of chronic kidney disease (CKD) in low-income and middle-income countries. However, there are few reports regarding the implementation of screening programmes in resource-limited settings. The objectives of this study are to (1) to share programmatic experiences implementing CKD screening in a rural, resource-limited setting and (2) to assess the burden of renal disease in a community-based diabetes programme in rural Guatemala. DESIGN: Cross-sectional assessment of glomerular filtration rate (GFR) and urine albumin. SETTING: Central Highlands of Guatemala. PARTICIPANTS: We enrolled 144 adults with type 2 diabetes in a community-based CKD screening activity carried out by the sponsoring institution. OUTCOME MEASURES: Prevalence of renal disease and risk of CKD progression using Kidney Disease: Improving Global Outcomes definitions and classifications. RESULTS: We found that 57% of the sample met GFR and/or albuminuria criteria suggestive of CKD. Over half of the sample had moderate or greater increased risk for CKD progression, including nearly 20% who were classified as high or very high risk. Hypertension was common in the sample (42%), and glycaemic control was suboptimal (mean haemoglobin A1c 9.4%±2.5% at programme enrolment and 8.6%±2.3% at time of CKD screening). CONCLUSIONS: The high burden of renal disease in our patient sample suggests an imperative to better understand the burden and risk factors of CKD in Guatemala. The implementation details we share reveal the tension between evidence-based CKD screening versus screening that can feasibly be delivered in resource-limited global settings.

Complementary feeding intervention on stunted Guatemalan children: a randomised controlled trial.

OBJECTIVE/BACKGROUND: Guatemala's indigenous Maya population has one of the highest rates of childhood stunting in the world. The goal of this study was to examine the impact of an intensive, individualised approach to complementary feeding education for caregivers on feeding practices and growth over usual care. DESIGN: An individually randomised (1:1 allocation ratio), parallel-group superiority trial, with blinding of study staff collecting outcome data. SETTING: Rural Maya communities in Guatemala. PARTICIPANTS: 324 children aged 6-24 months with a height-for-age Z score of less than or equal to -2.5 SD were randomised, 161 to the intervention and 163 to usual care. INTERVENTIONS: Community health workers conducted home visits for 6 months, providing usual care or usual care plus individualised caregiver education. MAIN OUTCOMES MEASURES: The main outcome was change in length/height-for-age Z score. Secondary outcomes were changes in complementary feeding indicators. RESULTS: Data were analysed for 296 subjects (intervention 145, usual care 151). There was a non-significant trend to improved growth in the intervention arm (length/height-for-age Z score change difference 0.07(95% CI -0.04 to 0.18)). The intervention led to a 22% improvement in minimum dietary diversity (RR 1.22, 95% CI 1.11 to 1.35) and a 23% improvement in minimal acceptable diet (RR 1.23, 95% CI 1.08 to 1.40) over usual care. CONCLUSIONS: Complementary feeding outcomes improved in the intervention arm, and a non-significant trend towards improved linear growth was observed. Community health workers in a low-resource rural environment can implement individualised caregiver complementary feeding education with significant improvements in child dietary quality over standard approaches. CLINICAL TRIAL REGISTRATION NUMBER: NCT02509936. Stage: Results.

Implementation and Outcomes of a Comprehensive Type 2 Diabetes Program in Rural Guatemala.

BACKGROUND: The burden of chronic, non-communicable diseases such as diabetes is growing rapidly in low- and middle-income countries. Implementing management programs for diabetes and other chronic diseases for underserved populations is thus a critical global health priority. However, there is a notable dearth of shared programmatic and outcomes data from diabetes treatment programs in these settings. PROGRAM DESCRIPTION: We describe our experiences as a non-governmental organization designing and implementing a type 2 diabetes program serving Maya indigenous people in rural Guatemala. We detail the practical challenges and solutions we have developed to build and sustain diabetes programming in this setting. METHODS: We conduct a retrospective chart review from our electronic medical record to evaluate our program's performance. We generate a cohort profile, assess cross-sectional indicators using a framework adapted from the literature, and report on clinical longitudinal outcomes. RESULTS: A total of 142 patients were identified for the chart review. The cohort showed a decrease in hemoglobin A1C from a mean of 9.2% to 8.1% over an average of 2.1 years of follow-up (p <0.001). The proportions of patients meeting glycemic targets were 53% for hemoglobin A1C < 8% and 32% for the stricter target of hemoglobin A1C < 7%. CONCLUSION: We first offer programmatic experiences to address a gap in resources relating to the practical issues of designing and implementing global diabetes management interventions. We then present clinical data suggesting that favorable diabetes outcomes can be attained in poor areas of rural Guatemala.

Increasing walking: how important is distance to, attractiveness, and size of public open space?

BACKGROUND: Well-designed public open space (POS) that encourages physical activity is a community asset that could potentially contribute to the health of local residents. METHODS: In 1995-1996, two studies were conducted-an environmental audit of POS over 2 acres (n =516) within a 408-km2 area of metropolitan Perth, Western Australia; and personal interviews with 1803 adults (aged 18 to 59 years) (52.9% response rate). The association between access to POS and physical activity was examined using three accessibility models that progressively adjusted for distance to POS, and its attractiveness and size. In 2002, an observational study examined the influence of attractiveness on the use of POS by observing users of three pairs of high- and low-quality (based on attractiveness) POS matched for size and location. RESULTS: Overall, 28.8% of respondents reported using POS for physical activity. The likelihood of using POS increased with increasing levels of access, but the effect was greater in the model that adjusted for distance, attractiveness, and size. After adjustment, those with very good access to large, attractive POS were 50% more likely to achieve high levels of walking (odds ratio, 1.50; 95% confidence level, 1.06-2.13). The observational study showed that after matching POS for size and location, 70% of POS users observed visited attractive POS. CONCLUSIONS: Access to attractive, large POS is associated with higher levels of walking. To increase walking, thoughtful design (and redesign) of POS is required that creates large, attractive POS with facilities that encourage active use by multiple users (e.g., walkers, sports participants, picnickers).

Extended stability of oxytocin in common infusion solutions.

The objective of this study was to evaluate the physical and chemical stability of oxytocin 0.08 U/mL admixed in 5% dextrose injection, 0.9% sodium chloride injection, and lactated Ringer's injection bags. Triplicate test samples of oxytocin 0.08 U/mL in each infusion solution were prepared by adding the required amount of oxytocin injection to bags of the three infusion solutions. The samples were stored protected from light and evaluated at appropriate intervals for up to 90 days at room temperature (near 23 deg C). Physical stability was assessed by using an evaluation procedure that included both turbidimetric measurement and visual inspection. Chemical stability was assessed by using a stability-indicating high-performance liquid chromatographic analytical technique and was based on the determination of drug concentrations initally and at appropriate intervals over the study period. The oxytocin admixtures in 5% dextrose and 0.9% sodium chloride were clear and colorless when viewed in normal fluorescent room light and when viewed with a Tyndall beam initially and throughout 90 days. Measured turbidity was low initially and exhibited little change throughout the study. High-performance liquid chromatographic analysis revealed that little or no decomposition occurred in the samples. Oxytocin in the infusion solutions remained stable at room temperature for 90 days. The lactated Ringer's injection samples remained clear and colorless for up to 28 days. However, after that time a small amount of white fluffy microprecipitate developed in two of the three samples by the 35-day observation point. High-performance liquid chromatographic analysis revealed that oxytocin remained stable in lactated Ringer's injection for 28 days at room temperature; substantial losses of oxytocin occurred in all three samples after that time, with about 10% loss at 35 days and up to 21% loss at 60 days. Oxytocin 0.08 U/mL in 5% dextrose injection or 0.9% sodium chloride injection is physically and chemically stable for at least 90 days at room temperature. However, oxytocin in lactated Ringer's injection should be restricted to a use period no greater than 28 days at room temperature to avoid microprecipitate formation and drug loss.