Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children.

OBJECTIVES: To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN: A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS: The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS: The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS: A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.

Elevated blood pressure and illness beliefs: a cross-sectional study of emergency department patients in Jamaica.

BACKGROUND: Elevated blood pressure (BP) is common among emergency department (ED) patients. While some data exist on the association between ED BP and hypertension (HTN) in the USA, little is known about this relationship in Afro-Caribbean nations. The aim of the study was to evaluate the relationship between elevated systolic BP in the ED and a previous diagnosis of HTN, accounting for potential factors that could contribute to poor HTN control among those with a previous diagnosis: socioeconomic status, health-seeking behavior, underlying HTN illness beliefs, medication adherence, and perceived adherence self-efficacy. METHODS: This was a cross-sectional survey over 6 weeks, from November 19 through December 30, 2014. Those surveyed were non-critically ill or injured adult ED patients (≥ 18 years) presenting to an Afro-Caribbean hospital. Descriptive statistics were derived for study patients as a whole, by HTN history and by presenting BP subgroup (with systolic BP ≥ 140 mmHg considered elevated). Data between groups were compared using chi-square and t tests, where appropriate. RESULTS: A total of 307 patients were included: 145 (47.2%) had a prior history of HTN, 126 (41.4%) had elevated BP, and 89 (61.4%) of those presenting with elevated blood pressure had a previous diagnosis of HTN. Those with less formal education were significantly more likely to present with elevated BP (52.1 vs. 28.8% for those with some high school and 19.2% for those with a college education; p = 0.001). Among those with a history of HTN, only 56 (30.9%) had a normal presenting BP. Those with a history of HTN and normal ED presenting BP were no different from patients with elevated BP when comparing the in duration of HTN, medication compliance, location of usual follow-up care, and HTN-specific illness beliefs. CONCLUSIONS: In this single-center study, two out of every five Jamaican ED patients had elevated presenting BP, the majority of whom had a previous diagnosis of HTN. Among those with a history of HTN, 60% had an elevated presenting BP. The ED can be an important location to identify patients with chronic disease in need of greater disease-specific education. Further studies should evaluate if brief interventions provided by ED medical staff improve HTN control in this patient population.

Acute pancreatitis: A 7 year retrospective cohort study of the epidemiology, aetiology and outcome from a tertiary hospital in Jamaica.

BACKGROUND: Acute pancreatitis (AP) is a significant cause of acute abdominal pain, morbidity and hospitalisation. There was previously a dearth of studies exploring the incidence, risk factors and outcome of AP in the Caribbean region. MATERIALS AND METHODS: All patients with a diagnosis of AP admitted to the University Hospital of the West Indies (UHWI) between 2006 and 2012 were reviewed. The epidemiological profile, risk factors, clinical presentation and outcomes of patients with AP were retrospectively studied. RESULTS: There were 70 females and 21 males with a median age of 44 years (range 2-86). The median age of males was significantly higher than that of females (p = 0.041). The incidence of AP was 74 per 100,000 admissions per year. Vomiting and abdominal tenderness were noted in the majority of patients. The most common aetiology was biliary disease (71.4%), idiopathic (12%), post-ERCP (6.6%) and alcohol (5.5%). Alcoholic pancreatitis was only seen in males whereas idiopathic and post-ERCP pancreatitis only occurred in females. The mean duration of hospitalisation was 9.51 ± 8.28 days. Disease severity was mild in 61.1%, moderately severe in 26.7%, and severe in 12.2% of patients. Factors associated with more severe disease included overweight/obesity, idiopathic aetiology and post-ERCP status. The case fatality rate was 2%. CONCLUSION: The incidence of AP was 74/100,000 hospital admissions annually. There was an unusual female preponderance, with biliary pancreatitis being the most common type occurring at an equal frequency among males and females. Only 12.2% of the total cases seen were severe. The case fatality rate was 2%. Local health policy should target timely interventions for biliary pancreatitis and should also address the local factors affecting disease severity.

Resuscitation Bundle in Pediatric Shock Decreases Acute Kidney Injury and Improves Outcomes.

OBJECTIVE: To investigate the impact of an early emergency department (ED) protocol-driven resuscitation (septic shock protocol [SSP]) on the incidence of acute kidney injury (AKI). STUDY DESIGN: This was a retrospective pediatric cohort with clinical sepsis admitted to the pediatric intensive care unit (PICU) from the ED before (2009, PRE) and after (2010, POST) implementation of the SSP. AKI was defined by pRIFLE (pediatric version of the Risk of renal dysfunction; Injury to kidney; Failure of kidney function; Loss of kidney function, End-stage renal disease creatinine criteria). RESULTS: A total of 202 patients (PRE, n = 98; POST, n = 104) were included (53% male, mean age 7.7 ± 5.6 years, mean Pediatric Logistic Organ Dysfunction [PELOD] 8.9 ± 12.7, mean Pediatric Risk of Mortality score 5.3 ± 13.9). There were no differences in demographics or illness severity between the PRE and POST groups. POST was associated with decreased AKI (54% vs 29%, P < .001), renal-replacement therapy (4 vs 0, P = .04), PICU, and hospital lengths of stay (LOS) (1.9 ± 2.3 vs 4.5 ± 7.6, P < .01; 6.3 ± 5.1 vs 15.3 ± 16.9, P < .001, respectively), and mortality (10% vs 3%, P = .037). The SSP was independently associated with decreased AKI when we controlled for age, sex, and PELOD (OR 0.27, CI 0.13-0.56). In multivariate analyses, the SSP was independently associated with shorter PICU and hospital LOS when we controlled for AKI and PELOD (P = .02, P < .001, respectively). CONCLUSION: A protocol-driven implementation of a resuscitation bundle in the pediatric ED decreased AKI and need for renal-replacement therapy, as well as PICU and hospital LOS and mortality.

Epidemiology of tetanus in Jamaica, 1993–2010

BACKGROUND: Although tetanus is still endemic in Jamaica, the epidemiologic profile has not been evaluated. METHODS: Admission registers at the main tertiary referral hospital were accessed to identify all patients diagnosed with tetanus from 1 January 1993 to 1 December 2010. RESULTS: There were 26 cases of tetanus (annual incidence of 0.57 cases per 1,000,000 population). Tetanus was more common in men (5.2:1) at a mean age of 59 ± 18.1 years. Persons in high-risk occupations (farmers, gardeners and construction workers) accounted for 52% of cases. CONCLUSION: Tetanus remains endemic in Jamaica, occurring more commonly in elderly men. Doctors should be educated about the importance of a high index of suspicion, an immunisation history and promoting booster shots in high-risk groups.

Epidemiology of tetanus in Jamaica, 1993-2010.

BACKGROUND: Although tetanus is still endemic in Jamaica, the epidemiologic profile has not been evaluated. METHODS: Admission registers at the main tertiary referral hospital were accessed to identify all patients diagnosed with tetanus from 1 January 1993 to 1 December 2010. RESULTS: There were 26 cases of tetanus (annual incidence of 0.57 cases per 1,000,000 population). Tetanus was more common in men (5.2:1) at a mean age of 59 ± 18.1 years. Persons in high-risk occupations (farmers, gardeners and construction workers) accounted for 52% of cases. CONCLUSIONS: Tetanus remains endemic in Jamaica, occurring more commonly in elderly men. Doctors should be educated about the importance of a high index of suspicion, an immunisation history and promoting booster shots in high-risk groups.

Cardiovascular disease among Black Americans: comparisons between the U.S. Virgin Islands and the 50 U.S. states.

OBJECTIVES: Consistent findings show that black Americans have high rates of cardiovascular disease (CVD) and related behavioral risk factors. Despite this body of work, studies on black Americans are generally limited to the 50 U.S. states. We examined variation in CVD and related risk factors among black Americans by comparing those residing within the U.S. Virgin Islands (USVI) with those residing in the 50 U.S. states and Washington, D.C. (US 50/DC) and residing in different regions of the US 50/DC (Northeast, Midwest, South, and West). METHODS: Using data from the 2007 and 2009 Behavioral Risk Factor Surveillance System, we compared CVD and CVD risk factor prevalence in non-Hispanic black people (≥20 years of age) in the USVI and US 50/DC, examining the relative contributions of health behaviors, health insurance, and socioeconomic status (SES). RESULTS: Accounting for age, sex, education, health insurance, and health behaviors, US 50/DC black Americans were significantly more likely than USVI black people to report ever having a stroke and coronary heart disease, and to be hypertensive, diabetic, or obese. While there was heterogeneity by region, similar patterns emerged when comparing the USVI with different regions of the US 50/DC. CONCLUSION: USVI black people have lower CVD and risk factor prevalence than US 50/DC black people. These lower rates are not explained by differences in health behaviors or SES. Understanding health in this population may provide important information on the etiology of racial/ethnic variation in health in the U.S. and elsewhere, and highlight relevant public health policies to reduce racial/ethnic group disparities.

EMS response to an airliner crash.

This report of an aircraft crash at a major airport in Kingston, Jamaica examines the response of the local Emergency Medical Services (EMS). Factors that impacted the response are discussed, and the need for more disaster simulation exercises is highlighted. The objective of this case report was to document the response of EMS personnel to the crash of American Airlines Flight 331, and to utilize the information to examine and improve the present protocol. While multiple errors can occur during a mass-casualty event, these can be reduced by frequent simulation exercises during which various personnel practice and learn designated roles. Efficient triage, proper communication, and knowledge of the roles are important in ensuring the best possible outcome. While the triage system and response of the EMS personnel were effective for this magnitude of catastrophe, more work is needed in order to meet predetermined standards. Ways in which this can be overcome include: (1) hosting more disaster simulation exercises; (2) encouraging more involvement with first responders; and (3) strengthening the links in the local EMS system. Vigorous public education must be instituted and maintained.

Colonic perforation: a lethal consequence of cannabis body packing.

Body packing is one method of smuggling cannabis across international borders. The practice is prevalent in Jamaica. There has been one reported death from this practice in medical literature. We report a second fatal case of cannabis body packing, reinforcing the dangerous nature of this practice.

Product or waste? Importation and end-of-life processing of computers in Peru.

This paper considers the importation of used personal computers (PCs) in Peru and domestic practices in their production, reuse, and end-of-life processing. The empirical pillars of this study are analysis of government data describing trade in used and new computers and surveys and interviews of computer sellers, refurbishers, and recyclers. The United States is the primary source of used PCs imported to Peru. Analysis of shipment value (as measured by trade statistics) shows that 87-88% of imported used computers had a price higher than the ideal recycle value of constituent materials. The official trade in end-of-life computers is thus driven by reuse as opposed to recycling. The domestic reverse supply chain of PCs is well developed with extensive collection, reuse, and recycling. Environmental problems identified include open burning of copper-bearing wires to remove insulation and landfilling of CRT glass. Distinct from informal recycling in China and India, printed circuit boards are usually not recycled domestically but exported to Europe for advanced recycling or to China for (presumably) informal recycling. It is notable that purely economic considerations lead to circuit boards being exported to Europe where environmental standards are stringent, presumably due to higher recovery of precious metals.

Arteriovenous fistulas as vascular access for hemodialysis: The preliminary experience at the University Hospital of the West Indies, Jamaica.

BACKGROUND: The demand for vascular hemodialysis access creation is steadily increasing. To satisfy the demand, a vascular access team was established at the University Hospital of the West Indies, Jamaica. The outcomes of this practice are reported. METHODS: A retrospective study of all patients who had permanent vascular dialysis access established at the University Hospital of the West Indies between January 1, 2002, and December 31, 2006, was performed. Data were analyzed using SPSS version 12.0 (SPSS Inc, USA). A direct anastomosis between an autogenous artery and vein was considered an arteriovenous fistula (AVF). When prosthetic material was used, the access was considered to be an arteriovenous graft. Accesses that were nonfunctional after six weeks of maturation were considered to be primary failures, while those that failed after previous successful dialysis were considered to be secondary failures. Primary patency was defined as the interval between access placement and the first intervention for failure. Secondary patency was the interval between access placement and abandonment. Cumulative patency was defined as the number of accesses that remained patent over a given time period, regardless of the number of interventions performed. RESULTS: Of 41 patients, nine were excluded due to incomplete data. Final analyses were performed on 32 patients with a mean (± SD) age of 42.3±15.3 years (range 18 to 66 years, median 43 years). The access type was an AVF in 100% of cases, which included distal radiocephalic fistulas in 27 patients, brachial-cephalic fistulas in three patients and proximal radiocephalic fistulas in two patients. Operations were performed in four (12.5%) incident and 28 (87.5%) prevalent dialysis patients. The mean delay between initiation of dialysis and AVF creation was 21.2±26.1 months (range one to 94 months, median 10 months). There were eight (25%) primary failures. Of the remaining 24 patients, there were seven (29.2%) secondary failures from thrombosis. There was primary patency for a mean of 723.9±422.1 days (range 199 to 1314 days, median 678 days). Only one (4.2%) patient had thrombectomy to prolong AVF function, resulting in secondary patency for 439 days. Cumulative patency was 62.5%, 33.3%, 25% and 4.2% for one, two, three and four years, respectively. CONCLUSIONS: The rate of AVF creation for end-stage renal disease patients in this setting far exceeds the target goals set forward by the National Kidney Foundation published updated Dialysis Outcomes Quality Initiative (NKF/DOQI) Guidelines and the Centers for Medicaid & Medicare Services Fistula First initiative. This is being achieved with acceptable rates of morbidity and patency. There is room for improvement in postoperative surveillance to increase early detection of failing accesses and allow for increased utility of interventions for assisted patency.

Occupational hazard: treating cocaine body packers in Caribbean countries.

Body packing is a common method of smuggling cocaine where individuals ingest several drug-filled parcels for transport. When identified by the authorities, body packers are usually taken to hospital for evaluation. There are several points during management of these patients when the health care team may be placed at risk. We explore the hazards encountered during the management of these patients in developing Caribbean nations.

Emergency department physician training in Jamaica: a national public hospital survey.

BACKGROUND: Emergency Department (ED) medical officers are often the first medical responders to emergencies in Jamaica because pre-hospital emergency response services are not universally available. Over the past decade, several new ED training opportunities have been introduced locally. Their precise impact on the health care system in Jamaica has not yet been evaluated. We sought to determine the level of training, qualifications and experience of medical officers employed in public hospital EDs across the nation. METHODS: A database of all medical officers employed in public hospital EDs was created from records maintained by the Ministry of Health in Jamaica. A specially designed questionnaire was administered to all medical officers in this database. Data was analyzed using SPSS Version 10.0. RESULTS: There were 160 ED medical officers across Jamaica, of which 47.5% were males and the mean age was 32.3 years (SD +/- 7.1; Range 23-57). These physicians were employed in the EDs for a mean of 2.2 years (SD +/- 2.5; Range 0-15; Median 2.5) and were recent graduates of medical schools (Mean 5.1; SD +/- 5.9; Median 3 years).Only 5.5% of the medical officers had specialist qualifications (grade III/IV), 12.8% were grade II medical officers and 80.5% were grade I house officers or interns. The majority of medical officers had no additional training qualifications: 20.9% were exposed to post-graduate training, 27.9% had current ACLS certification and 10.3% had current ATLS certification. CONCLUSION: The majority of medical officers in public hospital EDs across Jamaica are relatively inexperienced and inadequately trained. Consultant supervision is not available in most public hospital EDs. With the injury epidemic that exists in Jamaica, it is logical that increased training opportunities and resources are required to meet the needs of the population.

Inter-hospital transfer of trauma patients in a developing country: a prospective descriptive study.

UNLABELLED: There is no standardised protocol for the transfer of injured patients in Jamaica, a process that is well known to be potentially hazardous. We undertook this study to evaluate the inter-hospital transfer process of injured patients in this developing country. MATERIALS AND METHODS: A prospective descriptive analytical study of all consecutive patients transferred to the University Hospital of the West Indies from other hospitals was conducted over six months. Data were collected on specially designed proformas and analysed using SPSS version 10.0. RESULTS: Of 122 patients studied, 79.5% were male and the mean age was 27.8+/-20.7 years. Most injuries resulted from road traffic accidents (40.2%), falls (27.1%) and assaults (26.2%). Several problems with the transfer process were identified. There was poor documentation of clinical parameters at referring institutions, with records of pulse rates in 13.1% (16/122), blood pressure in 9.8% (12/122), respiratory rate in 9.8% (12/122), Glasgow Coma Score in 10.6% (13/122) and pupillary reaction in 4.9% (6/122) of cases. Transfer arrangements were made by junior medical officers in 93.4% (114/122) of cases while consultants requested only 3.3% (4/122) of transfers. Public hospital ambulances transported 91.8% (112/122) of patients and 7.4% (9/122) were transported by helicopter. These vehicles were equipped with facilities for oxygen administration in 99.2% (121/122) of cases and sphygmomanometers in 91% (111/122) of cases, but functional capacity for suction was only present in 50% of vehicles. These critically ill patients were accompanied by physicians in only 11.5% (14/122) of cases, while 68.9% (84/122) were accompanied only by nurses. CONCLUSIONS: The transfer of injured patients is not being performed in a manner consistent with modern medical practice. There is urgent need for implementation of a standardised protocol for the transfer of such patients in Jamaica.

Treating cocaine body packers: the unspoken personal risks.

Cocaine trafficking is a significant problem that many Caribbean territories must face. "Body packing" is a common method of transport where the smugglers ingest several cocaine filled packages. Body packers may be taken to hospital when they are detained by law enforcement officers, but occasionally they present on their own or accompanied by persons other than the authorities. This scenario poses a difficult management dilemma in any jurisdiction. We describe our experience with one such case in Jamaica.

Adipose tissue arachidonic acid and the metabolic syndrome in Costa Rican adults.

BACKGROUND & AIMS: Arachidonic acid, a precursor to a series of inflammatory mediators, may contribute to the development of insulin resistance. We examined the association between adipose tissue arachidonic acid and the metabolic syndrome in Costa Rica, a country in which the metabolic syndrome is highly prevalent. METHODS: The 484 study participants each provided a fasting blood sample and an adipose tissue biopsy that was analyzed for fatty acid composition. Criteria for the metabolic syndrome were those established in the Third Report of the National Cholesterol Education Program Expert Panel. The data were analyzed by multivariate logistic regression. RESULTS: Subjects with greater adipose tissue arachidonic acid content had an increasing risk of the metabolic syndrome across quintiles: odds ratio (95% confidence interval), 1.00; 1.51 (0.78-2.91); 2.40 (1.26-4.55); 3.50 (1.84-6.66); and 6.01 (3.11-11.61); test for trend, P<0.0001, after adjustment for age, gender and area of residence. Further adjustment for metabolic risk factors, including adipose fatty acids and body mass index, did not significantly modify the result. Adipose tissue arachidonic acid was also independently associated with abdominal obesity, hypertriglyceridemia, elevated fasting glucose, and high blood pressure. CONCLUSIONS: This study identifies arachidonic acid as an important independent marker of metabolic dysregulation. A better understanding of the role of this fatty acid in the pathogenesis of the metabolic syndrome is warranted.