Challenges and priorities for pediatric critical care clinician-researchers in low- and middle-income countries

IntroductionThere is need for more data on critical care outcomes and interventions from low- and middle-income countries (LMIC). Global research collaborations could help improve health-care delivery for critically ill children in LMIC where child mortality rates remain high.Materials and methodsTo inform the role of collaborative research in health-care delivery for critically ill children in LMIC, an anonymous online survey of pediatric critical care (PCC) physicians from LMIC was conducted to assess priorities, major challenges, and potential solutions to PCC research. A convenience sample of 56 clinician-researchers taking care of critically ill children in LMIC was targeted. In addition, the survey was made available on a Latin American PCC website. Descriptive statistics were used for data analysis.ResultsThe majority of the 47 survey respondents worked at urban, public teaching hospitals in LMIC. Respondents stated their primary PCC research motivations were to improve clinical care and establish guidelines to standardize care. Top challenges to conducting research were lack of funding, high clinical workload, and limited research support staff. Respondent-proposed solutions to these challenges included increasing research funding options for LMIC, better access to mentors from high-income countries, research training and networks, and higher quality medical record documentation.ConclusionLMIC clinician-researchers must be better empowered and resourced to lead and influence the local and global health research agenda for critically ill children. Increased funding options, access to training and mentorship in research methodology, and improved data collection systems for LMIC PCC researchers were recognized as key needs for success

Non–housestaff medicine services in academic centers: Models and challenges

Non–housestaff medicine services are growing rapidly in academic medical centers (AMCs), partly driven by efforts to comply with resident duty hour restrictions. Hospitalists have emerged as a solution to providing these services given their commitment to delivering efficient and high-quality care and the field's rapid growth. However, limited evidence is available on designing these services, including the similarities and differences of existing ones. We describe non–housestaff medicine services at 5 AMCs in order to share our experiences and outline important considerations in service development. We discuss common challenges in building and sustaining these models along with local institutional factors that affect decision making. Keys to success include ensuring an equitable system for scheduling and staffing, fostering opportunities for scholarly activities and academic promotion (defining the “academic hospitalist”), and providing compensation that supports recruitment and retention of hospitalists. With further work hour restrictions expected in the future and increased requests for surgical comanagement, the relationship between AMCs and hospitalists will continue to evolve. To succeed in developing hospitalist faculty who follow long careers in hospital medicine, academic leadership must carefully plan for and evaluate the methods of providing these clinical services while expanding on our academic mission. Journal of Hospital Medicine 2008;3:247–255. © 2008 Society of Hospital Medicine.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/60235/1/311_ftp.pd

Urethral catheters: can we reduce use?

<p>Abstract</p> <p>Background</p> <p>Indwelling urinary catheters are the main cause of healthcare-associated urinary tract infections. It can be expected that reduction of the use of urinary catheters will lead to decreased numbers of urinary tract infection.</p> <p>Methods</p> <p>The efficacy of an intervention programme to improve adherence to recommendations to reduce the use of urethral catheters was studied in a before-after comparison in ten Dutch hospitals. The programme detected barriers and facilitators and each individual facility was supported with developing their own intervention strategy. Outcome was evaluated by the prevalence of catheters, alternatives such as diapers, numbers of urinary tract infections, the percentage of correct indications and the duration of catheterization. The costs of the implementation as well as the catheterization were evaluated.</p> <p>Results</p> <p>Of a population of 16,495 hospitalized patients 3335 patients of whom 2943 were evaluable for the study, had a urethral catheter. The prevalence of urethral catheters decreased insignificantly in neurology (OR 0.93; 95% CI 0.77 - 1.13) and internal medicine wards (OR 0.97; 95% CI 0.83 - 1.13), decreased significantly in surgical wards (OR 0.84; 95% CI 0.75 - 0.96), but increased significantly in intensive care (IC) and coronary care (CC) units (OR 1.48; 95% CI 1.01 - 2.17). The use of alternatives was limited and remained so after the intervention. Duration of catheterization decreased insignificantly in IC/CC units (ratio after/before 0.95; 95% CI 0.78 - 1.16) and neurology (ratio 0.97; 95% CI 0.80 - 1.18) and significantly in internal medicine (ratio 0.81; 95% CI 0.69 - 0.96) and surgery wards (ratio 0.80; 95% CI 0.71 - 0.90). The percentage of correct indications on the day of inclusion increased from 50 to 67% (p < 0.0001). The prevalence of urinary tract infections in catheterized patients did not change. The mean cost saved per 100 patients was € 537.</p> <p>Conclusion</p> <p>Targeted implementation of recommendations from an existing guideline can lead to better adherence and cost savings. Especially, hospitals which use a lot of urethral catheters or where catheterization is prolonged, can expect important improvements.</p

The association of academic tracking to depressive symptoms among adolescents in three Caribbean countries

<p>Abstract</p> <p>Background</p> <p>Students who are tracked into low performing schools or classrooms that limit their life chances may report increased depressive symptoms. Limited research has been conducted on academic tracking and its association with depressive symptoms among high school students in the Caribbean. This project examines levels of depressive symptoms among tenth grade students tracked within and between high schools in Jamaica, St. Vincent and St. Kitts and Nevis.</p> <p>Methods</p> <p>Students enrolled in grade ten of the 2006/2007 academic year in Jamaica, St. Kitts and Nevis and St. Vincent were administered the Beck Depression Inventory II (BDI-II). In Jamaica and St. Vincent, academic tracking was operationalized using data provided by the local Ministries of Education. These Ministries ranked ordered schools according to students' performance on Caribbean school leaving examinations. In St. Kitts and Nevis tracking was operationalized by classroom assignments within schools whereby students were grouped into classrooms according to their levels of academic achievement. Multiple regression analyses were conducted to examine the relationships between academic tracking and BDI-II depression scores.</p> <p>Results</p> <p>A wide cross-section of 4^thform students in each nation was sampled (n = 1738; 278 from Jamaica, 737 St. Kitts and Nevis, 716 from St. Vincent; 52% females, 46.2% males and 1.8% no gender reported; age 12 to 19 years, mean = 15.4 yrs, sd = .9 yr). Roughly half (53%) of the students reported some symptoms of depression with 19.2% reporting moderate and 10.7% reporting severe symptoms of depression. Students in Jamaica reported significantly higher depression scores than those in either St. Kitts and Nevis or St. Vincent (p < .01). Students assigned to a higher academic track reported significantly lower BDI-II scores than students who were assigned to the lower academic track (p < .01).</p> <p>Conclusions</p> <p>There appears to be an association between academic tracking and depressive symptoms that is differentially manifested across the islands of Jamaica, St. Kitts and Nevis and St. Vincent.</p

Systematics of Marionina (Annelida: Clitellata: Enchytraeidae)

This thesis is about species of segmented worms that previously were placed in the genus Marionina Michaelsen, 1890, within the family Enchytraeidae, class Clitellata and phylum Annelida. These species are closely related to earthworms, but are much smaller and many of them are found between the sand grains in marine beaches. Species within Marionina have long been suspected to be a non-monophyletic assemblage of only distantly related species, since they lack unique and consistent morphological characters that unify them as a group and distinguish them from other enchytraeids. The main aim of this thesis has been to revise the systematics of Marionina, to obtain a classification that is congruent with the phylogenetic relationships of this assemblage. To clarify the complex taxonomical history of Marionina, a nomenclatural review is conducted, and the type species Pachydrilus georgianus Michaelsen, 1888 is re-described. Based on morphological characters it is concluded that a majority of the species bearing the generic name Marionina are only distantly related to this type species. Within my thesis, DNA sequences from three mitochondrial (12S, 16S, COI) and tree nuclear genes (16S, 18S, ITS) were studied, from different specimens. Molecular analyses confirmed that Marionina is a non-monophyletic taxon, and revealed, e.g., a monophyletic sub-group of almost 50 species that have a pharyngeal bifurcation of the dorsal blood vessel. This feature is shared with the type species of Michaelsena Ude, 1896 and is likely to be an autapomorphy (a derived, unique character) for this group. Michaelsena, which was earlier synonymised with Marionina, was thereby restored as a genus, and proposed to include these nearly 50 species. Seven other former Marionina species form a monophyletic group together with the type species of another genus, Enchytronia parva Nielsen & Christensen, 1959, and they are thus relocated into Enchytronia Nielsen & Christensen, 1959, which is the sister group to Michaelsena. The majority of species within Michaelsena are marine, while Enchytronia species are exclusively terrestrial. Two additional nominal species of Marionina appear to be closely related to, respectively, Bryodrilus and Oconnorella, which are only distantly related to Michaelsena and Enchytronia. The remaining species of Marionina not dealt with in this thesis, may form a non-monophyletic group and their correct phylogenetic position and taxonomy are not yet solved. In several cases within Michaelsena, the molecular variation is large within groups of taxa that are difficult or impossible to separate morphologically. One example is studied in detail: the Marionina achaeta complex, which comprises at least nine separate species that all lack chaetae. Some of these species are impossible to distinguish morphologically and are therefore referred to as cryptic species. A new species, Michaelsena triplex (Matamoros et al., 2007) from the Black Sea has been formally described within this thesis