Objective.
The DoTT (Decreasing Time to Therapy) project aimed to minimize the interval between fever onset and medical interventions for children with febrile neutropenia. The objective of this ...study was to determine the effect of implementing the DoTT project on the hospital time to antibiotic (TTA) and patient time to arrival (PTA) at the hospital in children with febrile neutropenia admitted to the emergency department.
Methods.
The DoTT project was implemented at a Peruvian hospital and followed the World Health Organization (WHO) multimodal improvement strategy model. Components included creating a healthcare delivery bundle and antibiotic selection pathways, training users of the bundle and pathways, monitoring patient outcomes and obtaining user feedback, encouraging use of the new system, and promoting the integration of DoTT into the institutional culture. Emergency room providers were trained in the care delivery for children with cancer and fever and taught to use the bundle and pathways. DoTT was promoted via pamphlets and posters, with a view to institutionalizing the concept and disseminating it to other hospital services.
Results.
Admission data for 129 eligible patients in our registry were analyzed. The TTA and PTA were compared before and after the DoTT intervention. The median TTA was 146 minutes (interquartile range IQR 97–265 minutes) before the intervention in 99 patients, and 69 minutes (IQR 50–120 minutes) afterwards in 30 patients (
p
<0.01). The median PTA was reduced from 1483 minutes at baseline to 660 minutes after the intervention (
p
<0.01).
Conclusions.
Applying the WHO multimodal improvement strategy model to the care of children with febrile neutropenia arriving at the hospital had a positive impact on the PTA and TTA, thus potentially increasing the survival of these patients.
Background
Pediatric early warning systems (PEWS) aid in the early identification of deterioration in hospitalized children with cancer; however, they are under‐used in resource‐limited settings. The ...authors use the knowledge‐to‐action framework to describe the implementation strategy for Proyecto Escala de Valoracion de Alerta Temprana (EVAT), a multicenter quality‐improvement collaborative, to scale‐up PEWS in pediatric oncology centers in Latin America.
Methods
Proyecto EVAT mentored participating centers through an adaptable implementation strategy to: (1) monitor clinical deterioration in children with cancer, (2) contextually adapt PEWS, (3) assess barriers to using PEWS, (4) pilot and implement PEWS, (5) monitor the use of PEWS, (6) evaluate outcomes, and (7) sustain PEWS. The implementation outcomes assessed included the quality of PEWS use, the time required for implementation, and global program impact.
Results
From April 2017 to October 2021, 36 diverse Proyecto EVAT hospitals from 13 countries in Latin America collectively managing more than 4100 annual new pediatric cancer diagnoses successfully implemented PEWS. The time to complete all program phases varied among centers, averaging 7 months (range, 3–13 months) from PEWS pilot to implementation completion. All centers ultimately implemented PEWS and maintained high‐quality PEWS use for up to 18 months after implementation. Across the 36 centers, more than 11,100 clinicians were trained in PEWS, and more than 41,000 pediatric hospital admissions had PEWS used in their care.
Conclusions
Evidence‐based interventions like PEWS can be successfully scaled‐up regionally basis using a systematic approach that includes a collaborative network, an adaptable implementation strategy, and regional mentorship. Lessons learned can guide future programs to promote the widespread adoption of effective interventions and reduce global disparities in childhood cancer outcomes.
Lay summary
Pediatric early warning systems (PEWS) are clinical tools used to identify deterioration in hospitalized children with cancer; however, implementation challenges limit their use in resource‐limited settings.
Proyecto EVAT is a multicenter quality‐improvement collaborative to implement PEWS in 36 pediatric oncology centers in Latin America.
This is the first multicenter, multinational study reporting a successful implementation strategy (Proyecto EVAT) to regionally scale‐up PEWS.
The lessons learned from Proyecto EVAT can inform future programs to promote the adoption of clinical interventions to globally improve childhood cancer outcomes.
Précis
Proyecto EVAT is a multicenter, multinational quality‐improvement collaborative that supported successful regional implementation and scale‐up of an evidence‐based intervention—a pediatric early warning system—at 36 pediatric oncology hospitals in Latin America. The knowledge‐to‐action framework was used to explain the project’s implementation strategy and to assess implementation outcomes, including the quality, the time required, and the global impact.
Paediatric early warning systems (PEWS) aid in the early identification of clinical deterioration events in children admitted to hospital. We aimed to investigate the effect of PEWS implementation on ...mortality due to clinical deterioration in children with cancer in 32 resource-limited hospitals across Latin America.
Proyecto Escala de Valoración de Alerta Temprana (Proyecto EVAT) is a quality improvement collaborative to implement PEWS in hospitals providing childhood cancer care. In this prospective, multicentre cohort study, centres joining Proyecto EVAT and completing PEWS implementation between April 1, 2017, and May 31, 2021, prospectively tracked clinical deterioration events and monthly inpatient-days in children admitted to hospital with cancer. De-identified registry data reported between April 17, 2017, and Nov 30, 2021, from all hospitals were included in analyses; children with limitations on escalation of care were excluded. The primary outcome was clinical deterioration event mortality. Incidence rate ratios (IRRs) were used to compare clinical deterioration event mortality before and after PEWS implementation; multivariable analyses assessed the correlation between clinical deterioration event mortality and centre characteristics.
Between April 1, 2017, and May 31, 2021, 32 paediatric oncology centres from 11 countries in Latin America successfully implemented PEWS through Proyecto EVAT; these centres documented 2020 clinical deterioration events in 1651 patients over 556 400 inpatient-days. Overall clinical deterioration event mortality was 32·9% (664 of 2020 events). The median age of patients with clinical deterioration events was 8·5 years (IQR 3·9–13·2), and 1095 (54·2%) of 2020 clinical deterioration events were reported in male patients; data on race or ethnicity were not collected. Data were reported per centre for a median of 12 months (IQR 10–13) before PEWS implementation and 18 months (16–18) after PEWS implementation. The mortality rate due to a clinical deterioration event was 1·33 events per 1000 patient-days before PEWS implementation and 1·09 events per 1000 patient-days after PEWS implementation (IRR 0·82 95% CI 0·69–0·97; p=0·021). In the multivariable analysis of centre characteristics, higher clinical deterioration event mortality rates before PEWS implementation (IRR 1·32 95% CI 1·22–1·43; p<0·0001), being a teaching hospital (1·18 1·09–1·27; p<0·0001), not having a separate paediatric haematology-oncology unit (1·38 1·21–1·57; p<0·0001), and having fewer PEWS omissions (0·95 0·92–0·99; p=0·0091) were associated with a greater reduction in clinical deterioration event mortality after PEWS implementation; no association was found with country income level (IRR 0·86 95% CI 0·68–1·09; p=0·22) or clinical deterioration event rates before PEWS implementation (1·04 0·97–1·12; p=0·29).
PEWS implementation was associated with reduced clinical deterioration event mortality in paediatric patients with cancer across 32 resource-limited hospitals in Latin America. These data support the use of PEWS as an effective evidence-based intervention to reduce disparities in global survival for children with cancer.
American Lebanese Syrian Associated Charities, US National Institutes of Health, and Conquer Cancer Foundation.
For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.
Background
Pediatric early warning systems (PEWS) aid in the early identification of deterioration in hospitalized children with cancer; however, they are under‐used in resource‐limited settings. The ...authors use the knowledge‐to‐action framework to describe the implementation strategy for Proyecto Escala de Valoracion de Alerta Temprana (EVAT), a multicenter quality‐improvement collaborative, to scale‐up PEWS in pediatric oncology centers in Latin America.
Methods
Proyecto EVAT mentored participating centers through an adaptable implementation strategy to: (1) monitor clinical deterioration in children with cancer, (2) contextually adapt PEWS, (3) assess barriers to using PEWS, (4) pilot and implement PEWS, (5) monitor the use of PEWS, (6) evaluate outcomes, and (7) sustain PEWS. The implementation outcomes assessed included the quality of PEWS use, the time required for implementation, and global program impact.
Results
From April 2017 to October 2021, 36 diverse Proyecto EVAT hospitals from 13 countries in Latin America collectively managing more than 4100 annual new pediatric cancer diagnoses successfully implemented PEWS. The time to complete all program phases varied among centers, averaging 7 months (range, 3–13 months) from PEWS pilot to implementation completion. All centers ultimately implemented PEWS and maintained high‐quality PEWS use for up to 18 months after implementation. Across the 36 centers, more than 11,100 clinicians were trained in PEWS, and more than 41,000 pediatric hospital admissions had PEWS used in their care.
Conclusions
Evidence‐based interventions like PEWS can be successfully scaled‐up regionally basis using a systematic approach that includes a collaborative network, an adaptable implementation strategy, and regional mentorship. Lessons learned can guide future programs to promote the widespread adoption of effective interventions and reduce global disparities in childhood cancer outcomes.
Lay summary
Pediatric early warning systems (PEWS) are clinical tools used to identify deterioration in hospitalized children with cancer; however, implementation challenges limit their use in resource‐limited settings.
Proyecto EVAT is a multicenter quality‐improvement collaborative to implement PEWS in 36 pediatric oncology centers in Latin America.
This is the first multicenter, multinational study reporting a successful implementation strategy (Proyecto EVAT) to regionally scale‐up PEWS.
The lessons learned from Proyecto EVAT can inform future programs to promote the adoption of clinical interventions to globally improve childhood cancer outcomes.
Précis
Proyecto EVAT is a multicenter, multinational quality‐improvement collaborative that supported successful regional implementation and scale‐up of an evidence‐based intervention—a pediatric early warning system—at 36 pediatric oncology hospitals in Latin America. The knowledge‐to‐action framework was used to explain the project’s implementation strategy and to assess implementation outcomes, including the quality, the time required, and the global impact.
This thesis comprises three studies of interactions among arbuscular mycorrhizal (AM) fungi, coffee cultivars (Coffea arabica L.) and a foliar pathogen (Cercospora coffeicola Berk. & Cooke). The ...first part compares the extent of extraradical mycorrhizal hyphae among three coffee cultivars. The second part is a study of the effects of AM colonization on leaf spots caused by C. coffeicola in coffee seedlings. The third part determines under controlled conditions if the mycorrhizal symbiosis increases the development of leaf spots caused by C. coffeicola and the effects of C. coffeicola inoculation on AM root colonization. The results showed that coffee cultivars responded differently to arbuscular mycorrhizal fungi although they were generally associated with the same morphotypes of AM fungi in their rhizospheres. Furthermore, some AM fungi present in roots of different cultivars had identical DNA sequences. Differences in extrametrical hyphae among cultivars may contribute to differences in their responses to fertilization. Comparison of paired diseased and healthy seedlings showed that C. coffeicola and percent AM colonization were significantly positively associated. Furthermore, percent AM colonization and percent leaf area diseased were positively correlated among diseased seedlings, though little variation was explained. These results suggest AM colonization may increase susceptibility of seedlings to Cercospora infection. However, results of the inoculation experiment in Chapter 3 showed that Cercospora infection increased AM colonization, which could have contributed to the positive correlation found in Chapter 2. Inoculation with AM fungi slowed the development of C. coffeicola lesions in older plants. Interactions between arbuscular mycorrhizal fungi and a leaf pathogen in coffee were complex, but should allow for the development of integrated crop management systems incorporating AM fungi with further research. The results presented here provide a basis for Puerto Rican farmers to use arbuscular mycorrhizal management in coffee as an alternative to application of inorganic fertilization and promote sustainable farming. Such an approach may have added benefits such as slowing the development of Cercospora leaf spot. Additional studies would be needed to fully develop integrated crop management systems for coffee incorporating AM fungi because of the complexity of the interactions between pathogens, cultivars, nutrient levels and AM fungi.
Objetivo. Identificar la infección natural de caracoles de agua dulce con Fasciola hepatica en una localidad del altiplano de Guatemala. Materiales y métodos. Se colectaron caracoles de agua dulce en ...una aldea endémica de fascioliasis, en la localidad de Paquix, en el departamento de Huehuetenango, ubicado a ~3.300 msnm. La identificación de la especie de caracol se basó en las características morfológicas observadas por estereoscopio usando una clave de identificación. La búsqueda de fases del trematodo se realizó mediante la inspección visual externa con fuente de luz y la disección e inspección visual dentro del molusco bajo estereoscopio y microscopio. Resultados. 260 caracoles fueron encontrados e identificados como Pseudosuccinea columella. Se examinaron los especímenes colectados y se encontraron dos caracoles infectados de forma natural con fases larvarias de F. hepatica. Conclusiones. Este es el primer reporte de este hospedero intermediario portando formas de F. hepatica en Guatemala. Es necesario aumentar los reportes de este parásito y de sus interacciones ecológicas en otras áreas no estudiadas de Guatemala y Centro América, debido al riesgo latente de infección para poblaciones de animales herbívoros y humanos.
Objetivo. Identificar la infección natural de caracoles de agua dulce con Fasciolahepatica en una localidad del altiplano de Guatemala. Materiales y métodos. Se colectaron caracoles de agua dulce en ...una aldea endémica de fascioliasis, en la localidad de Paquix, en el departamento de Huehuetenango, ubicado a ~3.300 msnm. La identificación de la especie de caracol se basó en las características morfológicas observadas por estereoscopio usando una clave de identificación. La búsqueda de fases del trematodo se realizó mediante la inspección visual externa con fuente de luz y la disección e inspección visual dentro del molusco bajo estereoscopio y microscopio. Resultados. 260 caracoles fueron encontrados e identificados como Pseudosuccinea columella. Se examinaron los especímenes colectados y se encontraron dos caracoles infectados de forma natural con fases larvarias de F. hepatica. Conclusiones. Este es el primer reporte de este hospedero intermediario portando formas de F. hepatica en Guatemala. Es necesario aumentar los reportes de este parásito y de sus interacciones ecológicas en otras áreas no estudiadas de Guatemala y Centro América, debido al riesgo latente de infección para poblaciones de animales herbívoros y humanos.
Objective. Identify the natural infection of freshwater snails as an intermediate host of Fasciola hepatica in Guatemala. Materials and methods. Freshwater snails were collected in a highaltitude ...village (3.000 mamsl) from Huehuetenango department, where fasciolasis is endemic. The identification of the snail species was based on the morphological characteristics observed under the stereoscope using an identification key. The trematode phases were searched externally by visual inspection using a light source, and internally by dissection and visual inspection of the tissues under a stereoscope and microscope. Results. 260 snails were found and identified as Pseudosuccinea columella. Two of them were found naturally infected with larval phases of F. hepatica. Conclusions. This is the first report of P. columella carrying phases of F. hepatica in the highlands of Guatemala. It is necessary to increase the research of the ecology of this parasite in other understudied areas in Guatemala and Central America, due to the latent risk of infection for populations of herbivorous animals and humans.
La región latinoamericana ha sido pionera en la implementación del etiquetado frontal de advertencia nutricional (EFAN), mismo que ha demostrado su eficacia y efectividad para identificar ...correctamente cuando un producto contiene cantidades excesivas de nutrientes asociados a Enfermedades no transmisibles (ENT). Sin embargo, ningún país del Sistema de la Integración Centroamericana (SICA); que incluye a Belice, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panamá y República Dominicana, lo ha adoptado. Por esta razón, el Instituto de Nutrición de Centro América y Panamá, convocó a un grupo de expertos de la academia y la sociedad civil con el objetivo de establecer una postura técnica, basada en la mejor evidencia científica, en relación al etiquetado frontal para los nutrientes críticos de alimentos y bebidas pre- envasados en la región centroamericana. Se presenta evidencia específica de la región del SICA que demuestran la superioridad del EFAN frente a otros etiquetados como las Guías Diarias de Alimentación (GDA), el semáforo y el Nutriscore para seleccionar opciones más saludables. Dentro del marco de los derechos de la niñez y de los consumidores, se brindan argumentos y se hace un llamado a los gobiernos para la pronta adopción del EFAN como una política costo-efectiva para la prevención de ENT. Además, se proveen recomendaciones para su monitoreo y evaluación, así como recomendaciones de otras políticas costo-efectivas como la regulación de la publicidad de alimentos no saludables dirigido a la niñez y adolescencia, entre otros, para la prevención de las ENT y la creación de ambientes y sistemas alimentarios más saludables y sostenibles.
Salmonellosis is a relevant public health threat worldwide. Reptiles are commonly involved in cases in humans. A microbiological survey was conducted from August to October 2018 to isolate Salmonella ...bacteria and look for antibiotic-resistant isolates in pet turtles of five species (Kinosternon sp., Rhinoclemmys sp., Staurotypus sp., Trachemys scripta y T. venusta) in Guatemala City and San Lucas Sacatepéquez. Cloacal swabs were taken from 63 turtle individuals and cultivated in the Microbiology Laboratory at the Veterinary Medicine Faculty, University of San Carlos of Guatemala. Three samples were positive to the presence of Salmonella sp. One of these isolates (from Trachemys scripta) was resistant to Gentamicin, Penicillin and Amikacin, other isolate (from T. scripta) was partially resistant to Amoxicilin+Clavulanic Acid and Penicillin and other (from T. venusta) to Penicillin. These findings highlight the need for better biosecurity practices and show the capacity of bacteria to develop survival strategies that involve resistance to harmful substances like antibiotics. Key words: Salmonellosis, public health, epidemiology, zoonoses, multiresistant gram negative bacteria.
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