Child health and survival in the eastern mediterranean region

Most child deaths in the region are preventable and occur in just a few of the 22 countries in the region. The interventions are not expensive, but governments need to implement the

Measuring the patient safety culture at a tertiary care hospital in Pakistan using the hospital survey on patient safety culture (HSOPSC)

Background: Patient safety is a top priority for many healthcare organisations worldwide. However, most of the initiatives aimed at the measurement and improvement of patient safety culture have been undertaken in developed countries. The purpose of this study was to measure the patient safety culture at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC).Methods: The HSOPSC was used to measure the patient safety culture across 12 dimensions at Aga Khan University Hospital, Karachi. 2,959 individuals, who had been working at the hospital, were administered the HSOPSC in paper form between June and September 2019.Results: The response rate of the survey was 50%. In the past 12 months, 979 respondents (33.1%) had submitted at least one event report. Results showed that the personnel viewed the patient safety culture at their hospital favourably. Overall, respondents scored highest in the following dimensions: \u27feedback and communication on error\u27 (91%), \u27organisational learning and continuous improvement\u27 (85%), \u27teamwork within units\u27 (83%), \u27teamwork across units\u27 (76%). The dimensions with the lowest positive per cent scores included \u27staffing\u27 (40%) and \u27non-punitive response to error\u27 (41%). Only the reliability of the \u27handoffs and transitions\u27, \u27frequency of events reported\u27, \u27organisational learning\u27 and \u27teamwork within units\u27 was higher than Cronbach\u27s alpha of 0.7. Upon regression analysis of positive responses, physicians and nurses were found to have responded less favourably than the remaining professional groups for most dimensions.Conclusion: The measurement of safety culture is both feasible and informative in developing countries and could be broadly implemented to inform patient safety efforts. Current data suggest that it compares favourably with benchmarks from hospitals in the USA. Like the USA, high staff workload is a significant safety concern among staff. This study lays the foundation for further context-specific research on patient safety culture in developing countries

Outcome of allogeneic stem cell transplantation with a conditioning regimen of busulfan, cyclophosphamide and low-dose etoposide for children with myelodysplastic syndrome

BACKGROUND AND OBJECTIVESAllogeneic stem cell transplantation (SCT) offers the best chance of cure and long-term survival for children with myelodysplastic syndromes (MDS).DESIGN AND SETTINGRetrospective analysis of pediatric patients with primary MDS treated with allogeneic SCT at a single institution treated between January 1993 and December 2008.PATIENTS AND METHODSOf 16 consecutive children who received allogeneic SCT for treatment of MDS in our center, 14 patients met the criteria of MDS according WHO I and II criteria. The median age was 4.8years (range, 1-14 years) and 64% were male. The median time from diagnosis to transplant was 6 months. MDS stage was refractory cytopenia (RC) in 9, refractory anemia with excess blasts (RAEB) in 5. Monosomy 7 was present in 35% of the patients. The majority of patients (11/14) were conditioned with a busulfan-based myeloablative (MA) regimen with addition of low-dose of etoposide (30mg/kg). All but one received a bone marrow graft.RESULTSNine patients achieved complete remission (CR), and seven remain alive. At a median follow-up of 3 years (range, 2-14 years) the OS and EFS was 57% (95%CI, 0.28-0.78). Cumulative EFS at 1 0 years was 43% (95% CI: 0.14-0.70). Relapse-related mortality was 21.4%; nonrelapse mortality (NRM) was 28.57%. All the survivors had etoposide in their conditioning regimen. Patients younger than 1 0 years had better survival (P=.001).CONCLUSIONChildren with MDS achieve encouraging OS and EFS following allogeneic SCT. A busulfan-based regimen with a lower dose of etoposide is an effective and less toxic regimen. The outcomes are best in younger patients

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions

Hodgkin\u27s lymphoma in the young child

Primarily a disease of adults, Hodgkin\u27s lymphoma (HL) contributes significantly to pediatric malignant diseases, particularly in developing countries where the incidence is higher. The treatment has evolved and now most patients are treated with chemotherapy; the optimal use additional radiation therapy (XRT) is being questioned, and it is likely that XRT will be reserved for a subset of higher risk patients. Patients with advanced disease have lower outcomes, which have improved with chemotherapy intensification. This has the potential for increasing acute and long-term toxicity. Treatment strategies for HL should be risk and response stratified, aiming at reduction of toxic effects

Development and implementation of a distributed integrated data-management system for pediatric hematology/oncology service: A modular approach for a clinical outcome and research information system

Introduction: The role of a reliable data-management and information system in oncology services is well established. Being a specialized branch of medicine, outcome of the treatment efforts, besides other established risk factors, is also influenced by geographic and genetic makeup of the population being treated. This shapes the need for treatment modalities to be constantly updated in light of the outcome of previous cohorts of cases. Advances in diagnostic tools and identification of new risk factors also require a constant update of the data items being collected in such systems. Commercially available oncology data-management and information-processing systems are not always helpful in fulfilling the information needs of the health-care team and the hospital administrators. This eventually increases the maintenance cost of such systems through modifications and application of patches in some instances. We are reporting our experience of the successful development and implementation of a comprehensive, integrated, scalable, and robust data-management system for a pediatric hematology/oncology service. This can serve as a model for developing countries where cost of development and maintenance of information systems is still a significant factor contributing towards optimum patient care in pediatric hematology/oncology.Results: The simplicity and scalable nature of the design of the system make it possible for it to be used for other non-hematology/oncology services like pediatrics, cardiology, congenital defects registries, or registries of inborn errors of metabolism for their data-management and retrieval systems.Conclusion: In-house development of a large-scale data-management system for pediatric hematology/oncology service is efficient and cost effective in terms of development time and resources

Pediatric Hodgkin’s lymphoma: Changing concepts and moving points in radiation therapy

The classic treatment of Hodgkin\u27s lymphoma (HL) in children resulted in significant late toxicity in long-term survivors. Late treatment effects included skeletal, cardio- pulmonary, gonadal toxicities, and second malignant tumor (SMN). This has driven pediatric HL groups to adopt treatment strategies using less intense chemotherapy, less alkylating agents, reduced radiation dose and volume, and omission of radiation therapy in selected group of patients. In limited disease, the aim is to maintain a high cure rate with minimal side effects. Patients with advanced-stage HL have a lower outcome, and need treatment intensification. Dose-dense, risk and response-adapted treatment strategies are evolving aiming at improving outcome and reducing toxicity

Pediatric hodgkin lymphoma: Making progress

Hodgkin lymphoma (HL) is one of the more common cancers encountered among pediatric and adolescent patients; however, most HL occurs in adults, and children constitute only a small proportion of the total number of cases. Treatment outcomes for pediatric HL are excellent and current strategies focus on reduction of therapy-related toxicity while maintaining high survival. This has been achieved by identifying patient cohorts who are at a lower risk for relapse and can be successfully treated with reduced amounts of chemotherapeutic agents and radiation therapy. This identification has been assisted by better understanding of newer imaging modalities, in particular functional FDG–PET imaging. Patients who fail first-line therapy continue to have a chance of cure, and a variety of modalities are available for their treatment. New therapeutic agents, both traditional and biological, are under assessment

Global Immunization Crisis Amid the COVID-19 Pandemic: Implications for Pediatric Oncology

Declining herd immunity and severe manifestation of vaccine preventable infections underscores the need for vaccinations campaigns to urgently vaccinate children who missed their routine immunizations