Essential human and material resources for emergency care in the district hospitals of Burundi.

Introduction: Burundi, like many African nations, faces challenges in providing accessible emergency care. The aim of this study was to assess the type of staff training, accessibility to imaging, and availability of essential equipment in the district hospitals of Burundi in order to inform strategic planning for healthcare delivery. Methods: In June 2022 an online survey was sent to each district hospital of the country. Complete responses were analysed and, where appropriate, significance determined by chi-square analysis, with p<0.05 considered significant. Results: Forty of 45 district hospitals completed the survey, of which 35 were rural (matching national demographics). The majority of district hospitals (21/40) had ready access to ≥4/5 critical drugs while few (5/40) were equipped with ≥4/5 key material. One quarter had 24/7 physician coverage and X-ray available. Only 3 had continuous access to ultrasound studies despite most district hospitals having ultrasound machines. Trained emergency room staff were almost totally absent from the field, with only 6 nurses, 4 generalists, and 1 specialist reported across 9 sites. Even a single EM-trained staff member was significantly correlated with being better equipped for emergencies (p<0.01). Conclusion: Burundi needs a strategic investment in emergency preparedness and care. Policy initiatives and technology purchases have demonstrated reasonable penetration down to the district hospital level, however, trained personnel are essential to develop sustainable emergency capacity.

Bedside colorimetric reagent dipstick in the diagnosis of meningitis in low- and middle-income countries: A prospective, international blinded comparison with laboratory analysis.

Background: Colorimetric reagent dipstick (CRD) for leukocyte esterase (LE) has shown potential for diagnosing and ruling out bacterial meningitis. Potential advantages over traditional cerebrospinal fluid (CSF) analysis include the small quantity of CSF required, rapid results, and easy interpretation. Our study aimed to determine whether clinicians in LMICs could accurately diagnose bacterial meningitis using CRD at the bedside. Methods: A convenience sample of 143 patients requiring lumbar puncture for possible meningitis were enrolled from 1 October 2018 to 31 December 2019 at three hospitals, one each in rural Burundi, the Democratic Republic of Congo, and Kenya. CSF was analyzed using CRD followed by traditional laboratory-based analysis by technicians blinded to bedside results. Results were analyzed for concordance rates, sensitivity/specificity, positive and negative predictive values and impact on clinical decision-making. Results: One hundred and one patients were included in the analysis. The prevalence of bacterial meningitis in the convenience sample was 35% (35/101) as defined by microscopy or positive Gram stain. Using a threshold of "any positivity" for LE on the CRD, bedside testing correctly identified 33/35 cases (sensitivity 94.3%) and had a NPV of 92%. When only a clearly positive (≥ "+" for LE) CRD criterion was used, sensitivity and NPV were 77.1% and 86.2%, respectively. Conclusion: Despite considerable promise, in our study, color reagent dipstick analysis of CSF did not perform well enough to rule out meningitis or screen samples for the need for microscopy. The development of a CSF-specific dipstick should be considered.

Targeting metastatic cancer from the inside: a new generation of targeted gene delivery vectors enables personalized cancer vaccination in situ.

The advent of pathotropic (disease-seeking) targeting technologies, combined with advanced gene delivery vectors, provides a unique opportunity for the systemic delivery of immunomodulatory cytokine genes to remote sites of cancer metastasis. When injected intravenously, such pathotropic nanoparticles seek out and accumulate selectively at sites of tumor invasion and neo-angiogenesis, resulting in enhanced gene delivery, and thus cytokine production, within the tumor nodules. Used in conjunction with a primary tumoricidal agent (e.g., Rexin-G) that exposes tumor neoantigens, the tumor-targeted immunotherapy vector is intended to promote the recruitment and activation of host immune cells into the metastastic site(s), thereby initiating cancer immunization in situ. In this study, we examine the feasibility of cytokine gene delivery to cancerous lesions in vivo using intravenously administered pathotropically targeted nanoparticles bearing the gene encoding granulocyte/macrophage colony-stimulating factor (GM-CSF; i.e., Reximmune-C). In vitro, transduction of target cancer cells with Reximmune-C resulted in the quantitative production of bioactive and immunoreactive GM-CSF protein. In tumor-bearing nude mice, intravenous infusions of Reximmune-C-induced GM-CSF production by transduced cancer cells and paracrine secretion of the cytokine within the tumor nodules, which promoted the recruitment of host mononuclear cells, including CD40+ B cells and CD86+ dendritic cells, into the tumors. With the first proofs of principle established in preclinical studies, we generated an optimized vector configuration for use in advanced clinical trial designs, and extended the feasibility studies to the clinic. Targeted delivery and localized expression of the GM-CSF transgene was confirmed in a patient with metastatic cancer, as was the recruitment of significant tumor-infiltrating lymphocytes (TILs). Taken together, these studies provide the first demonstrations of cytokine gene delivery to cancerous lesions following intravenous administration and extend the applications of cancer immunization in vivo.

Pediatric chloral hydrate poisonings and death following outpatient procedural sedation.

INTRODUCTION: Chloral hydrate has been used medicinally since the 1800 s as a sedative hypnotic, most commonly for procedural sedation. As it is administered orally and available in a liquid formulation, it is used almost exclusively in pediatric patients despite many safer and more effective alternative agents being available. CASE SERIES: We present three cases of pediatric chloral hydrate poisoning, all occurring following procedural sedation in outpatient clinic settings and presenting to the emergency department. The ages ranged from 15 months to 4 years of age and all required resuscitation. Unfortunately, the 4-year-old died. CONCLUSION: Choral hydrate is associated with significant adverse effects, including death, and safer alternatives for pediatric procedural sedation should be sought and utilized. There are a number of more effective sedative agents with more predictable pharmacokinetic and safety profiles than chloral hydrate including parenteral and oral agents. The practice of pre-procedure sedation should be performed only in a supervised setting where cardiorespiratory monitoring can occur in all cases.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Migration to the Heart Diagnosed by Emergency Department Ultrasound.

A 57-year-old man presented to our emergency department with altered mental status. He had a past medical history significant for cirrhosis and previous placement of a transjugular intrahepatic portosystemic shunt (TIPS). On cardiac auscultation, a new heart murmur and an unexpected degree of cardiac ectopy were noted. On the 12-lead electrocardiogram, the patient was noted to have multiple premature atrial contractions, corroborating the irregular heart rhythm on physical exam. A focused bedside emergency ultrasound of the heart was then performed. This exam revealed an apparent foreign body in the right atrium. It appeared as if the patient's TIPS had migrated from the heart into the right atrium. This case, as well as the literature describing this unusual complication of TIPS placement, is reviewed in this case report.