Delivering health and nutrition interventions for women and children in different conflict contexts: a framework for decision making on what, when, and how.

Existing global guidance for addressing women's and children's health and nutrition in humanitarian crises is not sufficiently contextualised for conflict settings specifically, reflecting the still-limited evidence that is available from such settings. As a preliminary step towards filling this guidance gap, we propose a conflict-specific framework that aims to guide decision makers focused on the health and nutrition of women and children affected by conflict to prioritise interventions that would address the major causes of mortality and morbidity among women and children in their particular settings and that could also be feasibly delivered in those settings. Assessing local needs, identifying relevant interventions from among those already recommended for humanitarian settings or universally, and assessing the contextual feasibility of delivery for each candidate intervention are key steps in the framework. We illustratively apply the proposed decision making framework to show what a framework-guided selection of priority interventions might look like in three hypothetical conflict contexts that differ in terms of levels of insecurity and patterns of population displacement. In doing so, we aim to catalyse further iteration and eventual field-testing of such a decision making framework by local, national, and international organisations and agencies involved in the humanitarian health response for women and children affected by conflict.

The political and security dimensions of the humanitarian health response to violent conflict.

The nature of armed conflict throughout the world is intensely dynamic. Consequently, the protection of non-combatants and the provision of humanitarian services must continually adapt to this changing conflict environment. Complex political affiliations, the systematic use of explosive weapons and sexual violence, and the use of new communication technology, including social media, have created new challenges for humanitarian actors in negotiating access to affected populations and security for their own personnel. The nature of combatants has also evolved as armed, non-state actors might have varying motivations, use different forms of violence, and engage in a variety of criminal activities to generate requisite funds. New health threats, such as the COVID-19 pandemic, and new capabilities, such as modern trauma care, have also created new challenges and opportunities for humanitarian health provision. In response, humanitarian policies and practices must develop negotiation and safety capabilities, informed by political and security realities on the ground, and guidance from affected communities. More fundamentally, humanitarian policies will need to confront a changing geopolitical environment, in which traditional humanitarian norms and protections might encounter wavering support in the years to come.

Scoping Review of Pediatric Early Warning Systems (PEWS) in Resource-Limited and Humanitarian Settings.

Pediatric Early Warning Systems (PEWS) aim to identify hospitalized children at increased risk of deterioration by assigning a score based on vital signs and clinical status and guiding interventions using a response algorithm to improve outcomes. When implemented with quality improvement methodology, these systems have been shown to be effective in high-resource settings and have the potential to improve the care of children in humanitarian and resource-limited settings (RLS). The purpose of this review is to summarize the current evidence for use of PEWS in RLS and identify areas for further research. A review of the current PEWS literature in RLS was performed using Web of Science, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), EMBASE, Portal Regional da BVS, and TRIP Database. While there is limited research available on this topic, eight studies on the use of PEWS, or a PEWS score in a pediatric population in low- or middle-income countries were identified. Two studies assessed the clinical effect of implementation of PEWS; one reported a reduction in clinical deterioration events and the other a reduction in mortality. The remaining studies assessed the association of a PEWS score with signs of clinical deterioration or mortality without a response algorithm. Further research on the impact of PEWS implementation on inpatient care and outcomes in RLS is needed.

Thiamine Deficiency in Tropical Pediatrics: New Insights into a Neglected but Vital Metabolic Challenge.

In humans, thiamine is a micronutrient prone to depletion that may result in severe clinical abnormalities. This narrative review summarizes current knowledge on thiamine deficiency (TD) and bridges the gap between pathophysiology and clinical presentation by integrating thiamine metabolism at subcellular level with its function to vital organs. The broad clinical spectrum of TD is outlined, with emphasis on conditions encountered in tropical pediatric practice. In particular, TD is associated with type B lactic acidosis and classic forms of beriberi in children, but it is often unrecognized. Other severe acute conditions are associated with hypermetabolism, inducing a functional TD. The crucial role of thiamine in infant cognitive development is also highlighted in this review, along with analysis of the potential impact of TD in refeeding syndrome during severe acute malnutrition (SAM). This review aims to increase clinical awareness of TD in tropical settings where access to diagnostic tests is poor, and advocates for an early therapeutic thiamine challenge in resource-limited settings. Moreover, it provides evidence for thiamine as treatment in critical conditions requiring metabolic resuscitation, and gives rationale to the consideration of increased thiamine supplementation in therapeutic foods for malnourished children.

A Retrospective Analysis of Pediatric Cases Handled by the MSF Tele-Expertise System.

We conducted a retrospective analysis of all pediatric cases referred by Médecins Sans Frontières (MSF) field doctors via the MSF telemedicine system during a 4-year period from April 2010. A total of 467 pediatric cases were submitted, representing approximately 40% of all telemedicine cases. The median age of the patients was 4 years. The median response time (i.e., the interval between the case being submitted and the first response from a specialist) was 13 h (interquartile range 4-32 h). We selected a random sample of 12 pediatric cases in each of four age categories for detailed analysis by an experienced MSF pediatrician. In the 48 randomly selected cases, the mean rating for the quality of information provided by the referrer was 2.8 (on a scale from 1 = very poor to 5 = very good), and the mean rating for the appropriateness of the response was 3.3 (same scale). More than two-thirds of the responses were considered to be useful to the patient, and approximately three-quarters were considered to be useful to the medical team. The usefulness of the responses tended to be higher for the medical team than for the patient, and there was some evidence that usefulness to both groups was lower in newborns and adolescent patients. The telemedicine system allows the quality of the medical support given to medical teams in the field to be controlled objectively as there is a record of all cases and answers. Telemedicine has an important role in supporting the aims of medical humanitarian organizations such as MSF.

La obesidad en el Siglo XXI: avances en la etiopatogenia y tratamiento / Obesity in the XXI centuary: advances in etiopathogenesis and treatment

La obesidad es compleja en su etiología y tratamiento. Su incidencia global va en aumento. El promover la pérdida de peso sólo puede traer efectos benéficos. La obesidad es un trastorno crónico de origen multifactorial. El descubrimiento del gen ob y su producto, la proteína OB o Leptina, del neuropéptido Y, así como de las alteraciones del metabolismo de los tejidos lipogénicos que alteran el apetito, son avances significativos para comprender su etiopatogenia y tratamiento. Estos nuevos conocimientos cambiarán la filosofía del tratamiento de la obesidad.La obesidad responde mal al tratamiento no quirúrgico y su control debe ser a largo plazo a pesar de las considerables presiones sociales y biológicas que promueven la recuperación del peso perdido. El tratamiento del paciente obeso debe realizarse por un equipo multidisciplinario, debiendo incluir una dieta hipoenergética, un plan de ejercicios, modificaciones conductuales y, en varios casos, terapia familiar. Su manejo debe ser diseñado en forma individual para cada paciente. El uso de medicamentos en el tratamiento de la obesidad no debe ser un sustituto para la modificación de la dieta ni para la actividad física. La cirugía bariátrica está indicada sólo en aquellos pacientes cuyo IMC es mayor de 30 kg/m2. Los médicos y sus pacientes deben interactuar estrechamente, evaluando los riesgos posibles que implica el tratamiento contra los beneficios reales de éste. Es esencial una buena relación médico-paciente.