Variability in the use of pulse oximeters with children in Kenyan hospitals: A mixed-methods analysis.

BACKGROUND: Pulse oximetry, a relatively inexpensive technology, has the potential to improve health outcomes by reducing incorrect diagnoses and supporting appropriate treatment decisions. There is evidence that in low- and middle-income countries, even when available, widespread uptake of pulse oximeters has not occurred, and little research has examined why. We sought to determine when and with which children pulse oximeters are used in Kenyan hospitals, how pulse oximeter use impacts treatment provision, and the barriers to pulse oximeter use. METHODS AND FINDINGS: We analyzed admissions data recorded through Kenya's Clinical Information Network (CIN) between September 2013 and February 2016. We carried out multiple imputation and generated multivariable regression models in R. We also conducted interviews with 30 healthcare workers and staff from 14 Kenyan hospitals to examine pulse oximetry adoption. We adapted the Integrative Model of Behavioural Prediction to link the results from the multivariable regression analyses to the qualitative findings. We included 27,906 child admissions from 7 hospitals in the quantitative analyses. The median age of the children was 1 year, and 55% were male. Three-quarters had a fever, over half had a cough; other symptoms/signs were difficulty breathing (34%), difficulty feeding (34%), and indrawing (32%). The most common diagnoses were pneumonia, diarrhea, and malaria: 45%, 35%, and 28% of children, respectively, had these diagnoses. Half of the children obtained a pulse oximeter reading, and of these, 10% had an oxygen saturation level below 90%. Children were more likely to receive a pulse oximeter reading if they were not alert (odds ratio [OR]: 1.30, 95% confidence interval (CI): 1.09, 1.55, p = 0.003), had chest indrawing (OR: 1.28, 95% CI: 1.17, 1.40, p < 0.001), or a very high respiratory rate (OR: 1.27, 95% CI: 1.13, 1.43, p < 0.001), as were children admitted to certain hospitals, at later time periods, and when a Paediatric Admission Record (PAR) was used (OR PAR used compared with PAR not present: 2.41, 95% CI: 1.98, 2.94, p < 0.001). Children were more likely to be prescribed oxygen if a pulse oximeter reading was obtained (OR: 1.42, 95% CI:1.25, 1.62, p < 0.001) and if this reading was below 90% (OR: 3.29, 95% CI: 2.82, 3.84, p < 0.001). The interviews indicated that the main barriers to pulse oximeter use are inadequate supply, broken pulse oximeters, and insufficient training on how, when, and why to use pulse oximeters and interpret their results. According to the interviews, variation in pulse oximeter use between hospitals is because of differences in pulse oximeter availability and the leadership of senior doctors in advocating for pulse oximeter use, whereas variation within hospitals over time is due to repair delays. Pulse oximeter use increased over time, likely because of the CIN's feedback to hospitals. When pulse oximeters are used, they are sometimes used incorrectly and some healthcare workers lack confidence in readings that contradict clinical signs. The main limitations of the study are that children with high levels of missing data were not excluded, interview participants might not have been representative, and the interviews did not enable a detailed exploration of differences between counties or across senior management groups. CONCLUSIONS: There remain major challenges to implementing pulse oximetry-a cheap, decades old technology-into routine care in Kenya. Implementation requires efficient and transparent procurement and repair systems to ensure adequate availability. Periodic training, structured clinical records that include prompts, the promotion of pulse oximetry by senior doctors, and monitoring and feedback might also support pulse oximeter use. Our findings can inform strategies to support the use of pulse oximeters to guide prompt and effective treatment, in line with the Sustainable Development Goals. Without effective implementation, the potential benefits of pulse oximeters and possible hospital cost-savings by targeting oxygen therapy might not be realized

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Pulse oximetry in low-income settings: a case study of Kenyan hospitals

Pulse oximeters are low-cost, easy to use, and effective at detecting hypoxemia (low blood oxygen levels), a common complication of bronchiolitis, asthma, and pneumonia, the leading infectious cause of death in children worldwide. However, pulse oximeters are often unavailable in lowincome settings, and if available, often underused, yet little research investigates why. In this thesis, I examine pulse oximeter implementation in low-income settings, focusing on Kenyan hospitals as a case study, and using a mixed-methods approach. I conducted a systematic literature review, examining how pulse oximeter use with children at admission to hospital impacts health outcomes; I then conducted quantitative analyses of 28,000 children admitted to seven Kenyan hospitals to determine with which children pulse oximeters are used, and pulse oximetryâs impact on treatment provision; these analyses informed the qualitative research component, for which I conducted interviews with 30 healthcare workers (HCWs) and staff in 14 Kenyan hospitals and employed theoretical frameworks to determine how HCWs decide whether to use pulse oximeters, and the barriers to pulse oximetry. I found that pulse oximeter use varies substantially between and within Kenyan hospitals over time. After adjusting for case-mix and signs of illness severity, HCWs were most likely to use pulse oximeters with children with a very high respiratory rate, indrawing and/or who were not alert; children who obtained a pulse oximeter reading were more likely to be prescribed oxygen than if a pulse oximeter was not used; and children with a reading below 90% were more likely to be prescribed oxygen than those with higher readings, suggesting that HCW decision-making is influenced by international and national guidelines. However, HCWs sometimes cannot use pulse oximeters when they intend to, because of insufficient pulse oximeter availability, largely due to inefficient and confusing procurement processes and repair delays. Furthermore, HCWs sometimes use pulse oximeters incorrectly or misinterpret their results, because of insufficient training. Pulse oximeter promotion programme planners can use the recommendations I provide to effectively target barriers to pulse oximeter uptake in low-income settings. Increased pulse oximetry implementation could enable early detection of hypoxemia, improving accurate diagnosis, and supporting prompt, effective treatment, which could help reduce mortality in children needing oxygen, in line with Sustainable Development Goal 3. </p

Pulse oximetry in low-income settings: a case study of Kenyan hospitals

Pulse oximeters are low-cost, easy to use, and effective at detecting hypoxemia (low blood oxygen levels), a common complication of bronchiolitis, asthma, and pneumonia, the leading infectious cause of death in children worldwide. However, pulse oximeters are often unavailable in lowincome settings, and if available, often underused, yet little research investigates why. In this thesis, I examine pulse oximeter implementation in low-income settings, focusing on Kenyan hospitals as a case study, and using a mixed-methods approach. I conducted a systematic literature review, examining how pulse oximeter use with children at admission to hospital impacts health outcomes; I then conducted quantitative analyses of 28,000 children admitted to seven Kenyan hospitals to determine with which children pulse oximeters are used, and pulse oximetry’s impact on treatment provision; these analyses informed the qualitative research component, for which I conducted interviews with 30 healthcare workers (HCWs) and staff in 14 Kenyan hospitals and employed theoretical frameworks to determine how HCWs decide whether to use pulse oximeters, and the barriers to pulse oximetry. I found that pulse oximeter use varies substantially between and within Kenyan hospitals over time. After adjusting for case-mix and signs of illness severity, HCWs were most likely to use pulse oximeters with children with a very high respiratory rate, indrawing and/or who were not alert; children who obtained a pulse oximeter reading were more likely to be prescribed oxygen than if a pulse oximeter was not used; and children with a reading below 90% were more likely to be prescribed oxygen than those with higher readings, suggesting that HCW decision-making is influenced by international and national guidelines. However, HCWs sometimes cannot use pulse oximeters when they intend to, because of insufficient pulse oximeter availability, largely due to inefficient and confusing procurement processes and repair delays. Furthermore, HCWs sometimes use pulse oximeters incorrectly or misinterpret their results, because of insufficient training. Pulse oximeter promotion programme planners can use the recommendations I provide to effectively target barriers to pulse oximeter uptake in low-income settings. Increased pulse oximetry implementation could enable early detection of hypoxemia, improving accurate diagnosis, and supporting prompt, effective treatment, which could help reduce mortality in children needing oxygen, in line with Sustainable Development Goal 3. </p

Quantitative analysis of TALE-DNA interactions suggests polarity effects.

Transcription activator-like effectors (TALEs) have revolutionized the field of genome engineering. We present here a systematic assessment of TALE DNA recognition, using quantitative electrophoretic mobility shift assays and reporter gene activation assays. Within TALE proteins, tandem 34-amino acid repeats recognize one base pair each and direct sequence-specific DNA binding through repeat variable di-residues (RVDs). We found that RVD choice can affect affinity by four orders of magnitude, with the relative RVD contribution in the order NG &gt; HD ≈ NN &gt;&gt; NI &gt; NK. The NN repeat preferred the base G over A, whereas the NK repeat bound G with 10(3)-fold lower affinity. We compared AvrBs3, a naturally occurring TALE that recognizes its target using some atypical RVD-base combinations, with a designed TALE that precisely matches 'standard' RVDs with the target bases. This comparison revealed unexpected differences in sensitivity to substitutions of the invariant 5'-T. Another surprising observation was that base mismatches at the 5' end of the target site had more disruptive effects on affinity than those at the 3' end, particularly in designed TALEs. These results provide evidence that TALE-DNA recognition exhibits a hitherto un-described polarity effect, in which the N-terminal repeats contribute more to affinity than C-terminal ones

Quantitative analysis of TALE–DNA interactions suggests polarity effects

Transcription activator-like effectors (TALEs) have revolutionized the field of genome engineering. We present here a systematic assessment of TALE DNA recognition, using quantitative electrophoretic mobility shift assays and reporter gene activation assays. Within TALE proteins, tandem 34-amino acid repeats recognize one base pair each and direct sequence-specific DNA binding through repeat variable di-residues (RVDs). We found that RVD choice can affect affinity by four orders of magnitude, with the relative RVD contribution in the order NG > HD ∼ NN ≫ NI > NK. The NN repeat preferred the base G over A, whereas the NK repeat bound G with 10(3)-fold lower affinity. We compared AvrBs3, a naturally occurring TALE that recognizes its target using some atypical RVD-base combinations, with a designed TALE that precisely matches ‘standard’ RVDs with the target bases. This comparison revealed unexpected differences in sensitivity to substitutions of the invariant 5′-T. Another surprising observation was that base mismatches at the 5′ end of the target site had more disruptive effects on affinity than those at the 3′ end, particularly in designed TALEs. These results provide evidence that TALE–DNA recognition exhibits a hitherto un-described polarity effect, in which the N-terminal repeats contribute more to affinity than C-terminal ones