The role of twinning in sustainable care for children with cancer: A TIPPing point? SIOP PODC Working Group on Twinning, Collaboration, and Support.

With the World Health Organization (WHO) Global Initiative for Childhood Cancer, there is renewed interest in sustainable interventions to improve childhood cancer care in low-/middle-income countries (LMICs). Practitioners in LMICs have traditionally practiced "twinning," i.e., targeted international pediatric oncology partnerships (TIPPs) between one or more institutions in a high-income country (HIC) and an LMIC, to improve care for children with cancer in the latter. The International Society of Paediatric Oncology Committee for Paediatric Oncology in Developing Countries Working Group on Twinning, Collaboration, and Support reviewed guidelines from https://cancerpointe.com and the current literature, gathered input from practitioners in LMICs, and in this article discuss the role of TIPPs in the WHO initiative.

Pediatric Acute Promyelocytic Leukemia Presenting to the Emergency Department as Refusal to Ambulate.

A previously healthy 10-year-old girl presented to the emergency department (ED) with a headache and vomiting which resolved with oral NSAIDs. The patient returned two days later unable to ambulate with mental slowing and lower extremity bruising. Labs demonstrated marked leukocytosis, severe anemia and thrombocytopenia, and disseminated intravascular coagulation (DIC). Brain MRI showed multiple intracranial hemorrhages. A peripheral blood smear demonstrated blasts with many Auer rods. A diagnosis of acute promyelocytic leukemia (APL) was made and therapy including all-transretinoic acid (ATRA) was initiated. Neurologic status returned to baseline within 1 week in the pediatric intensive care unit.

Developing and Implementing a Pediatric Emergency Care Curriculum for Providers at District Level Hospitals in Sub-Saharan Africa: A Case Study in Kenya.

INTRODUCTION: Emergency medicine is a relatively new field in sub-Saharan Africa and dedicated training in pediatric emergency care is limited. While guidelines from the African Federation of Emergency Medicine (AFEM) regarding emergency training exist, a core curriculum in pediatric emergency care has not yet been established for providers at the district hospital level. METHODS: The objective of the project was to develop a curriculum for providers with limited training in pediatric emergencies, and contain didactic and simulation components with emphasis on treatment and resuscitation using available resources. A core curriculum for pediatric emergency care was developed using a validated model of medical education curriculum development and through review of existing guidelines and literature. Based on literature review, as well as a review of existent guidelines in pediatric and emergency care, 10 core topics were chosen and agreed upon by experts in the field, including pediatric and emergency care providers in Kenya and the United States. These topics were confirmed to be consistent with the principles of emergency care endorsed by AFEM as well as complimentary to existing Kenyan medical school syllabi. A curriculum based on these 10 core topics was created and subsequently piloted with a group of medical residents and clinical officers at a community hospital in western Kenya. RESULTS: The 10 core pediatric topics prioritized were airway management, respiratory distress, thoracic and abdominal trauma, head trauma and cervical spine management, sepsis and shock, endocrine emergencies, altered mental status/toxicology, orthopedic emergencies, burn and wound management, and pediatric advanced life support. The topics were incorporated into a curriculum comprised of ten 1.5-h combined didactic plus low-fidelity simulation modules. Feedback from trainers and participating providers gave high ratings to the ease of information delivery, relevance, and appropriateness of the curriculum. CONCLUSION: We present here a core curriculum in pediatric emergency care for district hospital level providers in Kenya which can be used as a framework for further development and implementation of training programs throughout sub-Saharan Africa.

An innovative safe anesthesia and analgesia package for emergency pediatric procedures and surgeries when no anesthetist is available.

BACKGROUND: Adequate pain control through sedation and anesthesia for emergency procedures is a crucial aspect of pediatric emergency care. Resources for administering such anesthesia are extremely limited in many low-income settings. METHODS: Non-anesthetist providers in Western Kenya were trained in the use of a ketamine-based sedation and anesthesia package for non-anesthetists, Every Second Matters for Mothers and Babies-Ketamine™ (ESM-Ketamine). Data on use and safety of this package for emergent and urgent pediatric procedures was collected. Providers were surveyed as to what they would have done for similar procedures if the ESM-Ketamine package were unavailable. RESULTS: Ninety procedures were completed for 77 pediatric patients utilizing the ESM-Ketamine package. Of these, 29 (32.2 %) cases were orthopedic reductions, 19 (21.1 %) were incision and drainage, and 19 (21.1 %) were debridement and irrigation of burns. Remaining cases included cesarean section, repair of perineal tear, foreign body removal, arthrocentesis, laceration repair, exploratory laparotomy, excision of mass, paracentesis, and circumcision. There were no serious adverse events in any of the cases, 17 % experienced minor adverse events including hypersalivation, hallucinations, or brief, self-resolving, oxygen desaturations. Providers were surveyed for 80 of the 90 cases as to what they would have done in the absence of the ESM-Ketamine package: in 26 cases (32.5 %), they reported they would proceed with the procedure without any anesthesia or analgesia; in 15 (18.75 %), they reported they would significantly delay the procedure while waiting for an anesthetist; in 13 (16.25 %), they reported they would attempt referral to another facility; and in 26 (32.5 %), they reported they would try using an alternate form of analgesia, primarily acetaminophen, ibuprofen, diclofenac, and/or diazepam. All surveyed providers reported they would use the ESM-Ketamine package again in similar cases. CONCLUSIONS: The ESM-Ketamine package, through the use of a simplified protocol and checklist, allows for safe analgesia and anesthesia in children by non-anesthetists in a resource-limited setting for selected emergent and urgent procedures. This package addresses a significant gap in the availability of anesthesia services in low-income settings that would otherwise result in significant delays to procedures or proceeding with painful procedures with inadequate analgesia.

Hemophilia And Von Willebrand Disease In Children: Emergency Department Evaluation And Management.

Hemophilia and von Willebrand disease are the most common inherited bleeding disorders encountered in the emergency department. Evidence suggests that the management of bleeding disorders in the emergency department is currently suboptimal, and literature to guide evaluation and management in this setting is limited, though some guidelines do exist. The emergency clinician must have a high index of suspicion for new diagnoses, particularly in young patients with unprovoked bleeding and children with multiple or severe bleeds. The foundation of hemophilia treatment is urgent clotting factor replacement, with replacement goals guided by the presenting complaint. Bleeding in von Willebrand disease may be treated with products containing von Willebrand factor or with desmopressin. This review focuses on the epidemiology, pathophysiology, common presentations, evaluation strategies, and emergency management of these bleeding disorders.

Simulation in Pre-departure Training for Residents Planning Clinical Work in a Low-Income Country.

INTRODUCTION: Increasingly, pediatric and emergency medicine (EM) residents are pursuing clinical rotations in low-income countries. Optimal pre-departure preparation for such rotations has not yet been established. High-fidelity simulation represents a potentially effective modality for such preparation. This study was designed to assess whether a pre-departure high-fidelity medical simulation curriculum is effective in helping to prepare residents for clinical rotations in a low-income country. METHODS: 43 pediatric and EM residents planning clinical rotations in Liberia, West Africa, participated in a simulation-based curriculum focused on severe pediatric malaria and malnutrition and were then assessed by survey at three time points: pre-simulation, post-simulation, and after returning from work abroad. RESULTS: Prior to simulation, 1/43 (2%) participants reported they were comfortable with the diagnosis and management of severe malnutrition; this increased to 30/42 (71%) after simulation and 24/31 (77%) after working abroad. Prior to simulation, 1/43 (2%) of residents reported comfort with the diagnosis and management of severe malaria; this increased to 26/42 (62%) after simulation and 28/31 (90%) after working abroad; 36/42 (86%) of residents agreed that a simulation-based global health curriculum is more useful than a didactic curriculum alone, and 41/42 (98%) felt a simulator-based curriculum should be offered to all residents planning a clinical trip to a low-income country. CONCLUSION: High-fidelity simulation is effective in increasing residents' self-rated comfort in management of pediatric malaria and malnutrition and a majority of participating residents feel it should be included as a component of pre-departure training for all residents rotating clinically to low-income countries.

Imported pediatric malaria presenting to an urban pediatric emergency department: a case series.

OBJECTIVE: The objective of this study was to identify common presenting signs, symptoms, and laboratory findings of imported pediatric malaria presenting to a US pediatric emergency department (ED). METHODS: This is a retrospective chart review of all patients presenting to an urban pediatric ED between July 1, 2004, and July 1, 2011, who were assigned an ED or inpatient discharge diagnosis of "malaria" and had a confirmed blood smear demonstrating plasmodium species. RESULTS: There were 21 patients included in this study (median age, 12 years; range, 19 months to 22 years). A total of 15 (71%) were infected with Plasmodium falciparum subtype of malaria. Patients presented to the ED between 1 day and 2 years after return from a malaria-endemic area. All 21 patients (100%) reported a history of fever, but only 9 (43%) had a fever documented in the ED. Of the patients, 14 (66%) complained of headache, 13 (62%) complained of anorexia, 11 (52%) complained of chills, and 10 (48%) complained of abdominal pain. The most common sign was tachycardia, present in 18 patients (86%). Consistent with other studies, thrombocytopenia was the most frequently observed laboratory abnormality, present in 16 patients (76%). CONCLUSIONS: The presenting signs and symptoms of imported pediatric malaria are nonspecific and inconsistently present, underscoring the importance of maintaining a high index of suspicion for this diagnosis in any patient returning from a malaria-endemic region.

Photodynamic inactivation of fibroblasts by a cationic porphyrin.

An important determinant of the clinical applicability and value of antimicrobial photodynamic inactivation (PDI) is the cytotoxicity of the treatment to human cells. We evaluated the in vitro cytotoxicity of PDI to human dermal fibroblasts using 5-phenyl-10,15,20-tris(N-methyl-4-pyridyl)porphyrin chloride (TriP[4]) as the photosensitiser. The fibroblasts were exposed to a PDI regime that is known to be sufficient for the inactivation of Staphylococcus aureus, Pseudomonas aeruginosa and Candida albicans. The PDI experiments were carried out in phosphate-buffered saline (PBS) and in 6.25%, 12.5%, 25% and 50% fetal calf serum (FCS)/PBS suspensions. Cell viability subsequent to exposure was evaluated after 0 h, 6 h and 18 h using the methylthiazoletetrazolium (MTT) assay and compared to pretreatment values. At a TriP[4] concentration previously demonstrated to induce a 5 log(10)-unit reduction in a viable count for S. aureus, 79% of the fibroblasts were photo-inactivated. Increasing the FCS concentration in the medium protected the fibroblasts against PDI. Based on our in vitro results, we propose that in vivo PDI of S. aureus holds potential; however, PDI of P. aeruginosa and C. albicans will probably require such a strong PDI regime that it will induce substantial damage to fibroblasts.