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Robotic Living Donor Right Hepatectomy: A Systematic Review and Meta-Analysis
(2022) Lincango Naranjo, Eddy P; Garces-Delgado, Estefany; Siepmann, Timo; Mirow, Lutz; Solis-Pazmino, Paola; Alexander-Leon, Harold; Restrepo-Rodas, Gabriela; Mancero-Montalvo, Rafael; Ponce, Cristina J; Cadena-Semanate, Ramiro; Vargas-Cordova, Ronnal; Herrera-Cevallos, Glenda; Vallejo, Sebastian; Liu-Sanchez, Carolina; Prokop, Larry J; Ziogas, Ioannis A; Vailas, Michail G; Guerron, Alfredo D; Visser, Brendan C; Ponce, Oscar J; Barbas, Andrew S; Moris, Dimitrios
The introduction of robotics in living donor liver transplantation has been revolutionary. We aimed to examine the safety of robotic living donor right hepatectomy (RLDRH) compared to open (ODRH) and laparoscopic (LADRH) approaches. A systematic review was carried out in Medline and six additional databases following PRISMA guidelines. Data on morbidity, postoperative liver function, and pain in donors and recipients were extracted from studies comparing RLDRH, ODRH, and LADRH published up to September 2020; PROSPERO (CRD42020214313). Dichotomous variables were pooled as risk ratios and continuous variables as weighted mean differences. Four studies with a total of 517 patients were included. In living donors, the postoperative total bilirubin level (MD: −0.7 95%CI −1.0, −0.4), length of hospital stay (MD: −0.8 95%CI −1.4, −0.3), Clavien–Dindo complications I–II (RR: 0.5 95%CI 0.2, 0.9), and pain score at day > 3 (MD: −0.6 95%CI −1.6, 0.4) were lower following RLDRH compared to ODRH. Furthermore, the pain score at day > 3 (MD: −0.4 95%CI −0.8, −0.09) was lower after RLDRH when compared to LADRH. In recipients, the postoperative AST level was lower (MD: −0.5 95%CI −0.9, −0.1) following RLDRH compared to ODRH. Moreover, the length of stay (MD: −6.4 95%CI −11.3, −1.5) was lower after RLDRH when compared to LADRH. In summary, we identified low- to unclear-quality evidence that RLDRH seems to be safe and feasible for adult living donor liver transplantation compared to the conventional approaches. No postoperative deaths were reported. Keywords: liver transplantation, robot, systematic review, meta-analysis
The Role of Parathyroid Hormone Level as a Predictor of Hypocalcemia After Total Thyroidectomy for Thyroid Cancer: A Cross-Sectional Study
(2025) Semanate, Fernando; Tarupi, Wilmer; Fernandez Trokhimtchouk, Tatiana; Palacios, Christian; Jaramillo, Oscar
This study aimed to investigate the utility of measuring parathyroid hormone (PTH) levels as a predictor of hypocalcemia in a population of patients undergoing total thyroidectomy for thyroid cancer between 2016 and 2019. We conducted an observational, analytical, descriptive, cross-sectional investigation, assessing PTH levels as a predictor of hypocalcemia following thyroidectomy. Among patients with hypoparathyroidism, 25.5% experienced hypocalcemia, while 74.5% had normal serum calcium levels. The likelihood of hypocalcemia was five times higher in patients with hypoparathyroidism (OR: 5.43; 95% CI: 1.89-15.6), a statistically significant finding (p < 0.05). Additionally, PTH values at 24 hours post-surgery averaged 28.9 pg/mL (SD: 30.8 pg/mL), ranging from 0.01 to 235 pg/mL. Serum calcium levels averaged 8.31 mg/dL (SD: 0.74), with values ranging from 6.5 to 10.6 mg/dL. The study demonstrates a statistically significant association between PTH levels and post-surgical serum calcium levels, albeit with moderate predictive power. These findings support the utility of PTH measurement in predicting hypocalcemia following thyroidectomy, underscoring its potential clinical relevance in patient management. Keywords: low calcium; open thyroidectomy; parathyroid level; postoperative parathyroid hormone (pth); thyroid cancer surgery; thyroidectomy complications.
Trends in traffic accident mortality and social inequalities in Ecuador from 2011 to 2022
(2024) Holguín-Carvajal, Juan Pablo; Otzen, Tamara; Sanhueza, Antonio; Castillo, Álvaro; Manterola, Carlos; Muñoz, Georgina; García-Aguilera, Fernanda; Salgado-Castillo, Fernanda
Background: Traffic accidents (TA) remain a significant global public health concern, impacting low-and middle-income countries. This study aimed to describe the trend in TA mortality and inequalities in Ecuador for 2011-2022, distributed by year, gender, age group, geographical location, type of accident, and social inequalities. Methods: An ecological study was conducted using INEC national-level data on TA fatalities in Ecuador. Mortality rates were calculated per 100,000 population and analyzed by year, gender, age group, geographic region, and accident type. Annual percentage variation (APV) was determined using linear regression models. Inequality analyses examined associations between TA mortality and socioeconomic factors like per capita income and literacy rates. Complex measures such as the Slope Inequality Index (SII) were calculated to assess the magnitude of inequalities. Results: There were 38,355 TA fatalities in Ecuador from 2011 to 2022, with an overall mortality rate of 19.4 per 100,000 inhabitants. The rate showed a non-significant decreasing trend (APV - 0.4%, p = 0.280). Males had significantly higher mortality rates than females (31.99 vs. 7.19 per 100,000), with the gender gap widening over time (APV 0.85%, p = 0.003). The Amazon region had the highest rate (24.4 per 100,000), followed by the Coast (20.4 per 100,000). Adults aged ≥ 60 years had the highest mortality (31.0 per 100,000), followed by those aged 25-40 years (28.6 per 100,000). The ≥ 60 age group showed the most significant rate decrease over time (APV - 2.25%, p < 0.001). Pedestrians were the most affected group after excluding unspecified accidents, with a notable decreasing trend (APV - 5.68%, p < 0.001). Motorcyclist fatalities showed an increasing trend, ranking third in TA-related deaths. Lower literacy rates and per capita income were associated with higher TA mortality risks. Inequality in TA mortality between provinces with the highest and lowest per capita income increased by 247.7% from 2011 to 2019, as measured by the SII. Conclusion: While overall TA mortality slightly decreased in Ecuador, significant disparities persist across demographic groups and geographic regions. Older adults, males, pedestrians, and economically disadvantaged populations face disproportionately higher risks. The increasing trend in motorcycle-related fatalities and widening socioeconomic inequalities are particularly concerning. Keywords: Ecuador; Mortality; Traffic accidents; Trends.
Risk factors for COVID-19 and their association with mortality in Ecuadorian patients admitted to the ICU A retrospective cohort multicentric study
(2024) Fuenmayor-González, Luis; Vera-Ormaza, Jair; Shen, Hua; Corella-Ortega, Belén; Fajardo-Loaiza, Thalía; Borja-Pérez, Cristina; Ochoa-Godoy, Nancy; Vásquez-Barzallo, Sebastián; Díaz-Rodríguez, Juan; María Díaz, Ana; García, Fernanda; Ramírez, Vanessa; Sánchez, Hernán; Barberán, José Luis; Paredes, Juan Pablo; Cevallos, Mónica; Montenegro, Francisco; Puertas, Soraya; Briones, Killen; Martínez, Marlon; Vélez-Páez, Jorge; Montalvo-Villagómez, Mario; Herrera, Luis; Garrido, Santiago; Sisa, Ivan; Jibaja, Manuel
Effect of High Altitude on the Survival of COVID-19 Patients in Intensive Care Unit: A Cohort Study
(2022) Jibaja, Manuel; Roldan-Vasquez, Estefania; Rello, Jordi; Shen, Hua; Maldonado, Nelson; Grunauer, Michelle; Díaz, Ana María; García, Fernanda; Ramírez, Vanessa; Sánchez, Hernán; Barberán, José Luis; Paredes, Juan Pablo; Cevallos, Mónica; Montenegro, Francisco; Puertas, Soraya; Briones, Killen; Martínez, Marlon; Vélez-Páez, Jorge; Montalvo-Villagómez, Mario; Herrera, Luis; Garrido, Santiago; Sisa, Ivan
Purpose: The effect of high altitude ( ≥ 1500 m) and its potential association with mortality by COVID-19 remains controversial. We assessed the effect of high altitude on the survival/discharge of COVID-19 patients requiring intensive care unit (ICU) admission for mechanical ventilation compared to individuals treated at sea level. Methods: A retrospective cohort multi-center study of consecutive adults patients with a positive RT-PCR test for COVID-19 who were mechanically ventilated between March and November 2020. Data were collected from two sea-level hospitals and four high-altitude hospitals in Ecuador. The primary outcome was ICU and hospital survival/discharge. Survival analysis was conducted using semi-parametric Cox proportional hazards models. Results: Of the study population (n = 670), 35.2% were female with a mean age of 58.3 ± 12.6 years. On admission, high-altitude patients were more likely to be younger (57.2 vs. 60.5 years old), presented with less comorbidities such as hypertension (25.9% vs. 54.9% with p-value <.001) and diabetes mellitus (20.5% vs. 37.2% with p-value <.001), less probability of having a capillary refill time > 3 sec (13.7% vs. 30.1%, p-value <.001), and less severity-of-illness condition (APACHE II score, 17.5 ± 8.1 vs. 20 ± 8.2, p < .01). After adjusting for key confounders high altitude is associated with significant higher probabilities of ICU survival/discharge (HR: 1.74 [95% CI: 1.46-2.08]) and hospital survival/discharge (HR: 1.35 [95% CI: 1.18-1.55]) than patients treated at sea level. Conclusions: Patients treated at high altitude at any time point during the study period were 74% more likely to experience ICU survival/discharge and 35% more likely to experience hospital survival/discharge than to the sea-level group. Possible reasons for these findings are genetic and physiological adaptations due to exposure to chronic hypoxia. Keywords: COVID-19; ICU; SARS-CoV-2; high altitude; sea level; survival.
Clinical characteristics, systemic complications, and in-hospital outcomes for patients with COVID-19 in Latin America. LIVEN-Covid-19 study: A prospective, multicenter, multinational, cohort study
(2022) Reyes, Luis F; Bastidas, Alirio; Narváez, Paula O; Parra-Tanoux, Daniela; Fuentes, Yuli V; Serrano-Mayorga, Cristian C; Ortíz, Valentina; Caceres, Eder L; Ospina-Tascon, Gustavo; Díaz, Ana M; Jibaja, Manuel; Vera, Magdalena; Silva, Edwin; Gorordo-Delsol, Luis Antonio; Maraschin, Francesca; Varón-Vega, Fabio; Buitrago, Ricardo; Poveda, Marcela; Saucedo, Lina M; Estenssoro, Elisa; Ortíz, Guillermo; Nin, Nicolás; Calderón, Luis E; Montaño, Gina S; Chaar, Aldair J; García, Fernanda; Ramírez, Vanessa; Picoita, Fabricio; Peláez, Cristian; Unigarro, Luis; Friedman, Gilberto; Cucunubo, Laura; Bruhn, Alejandro; Hernández, Glenn; Martin-Loeches, Ignacio
Purpose: The COVID-19 pandemic has spread worldwide, and almost 396 million people have been infected around the globe. Latin American countries have been deeply affected, and there is a lack of data in this regard. This study aims to identify the clinical characteristics, in-hospital outcomes, and factors associated with ICU admission due to COVID-19. Furthermore, to describe the functional status of patients at hospital discharge after the acute episode of COVID-19. Material and methods: This was a prospective, multicenter, multinational observational cohort study of subjects admitted to 22 hospitals within Latin America. Data were collected prospectively. Descriptive statistics were used to characterize patients, and multivariate regression was carried out to identify factors associated with severe COVID-19. Results: A total of 3008 patients were included in the study. A total of 64.3% of patients had severe COVID-19 and were admitted to the ICU. Patients admitted to the ICU had a higher mean (SD) 4C score (10 [3] vs. 7 [3)], p<0.001). The risk factors independently associated with progression to ICU admission were age, shortness of breath, and obesity. In-hospital mortality was 24.1%, whereas the ICU mortality rate was 35.1%. Most patients had equal self-care ability at discharge 43.8%; however, ICU patients had worse self-care ability at hospital discharge (25.7% [497/1934] vs. 3.7% [40/1074], p<0.001). Conclusions: This study confirms that patients with SARS CoV-2 in the Latin American population had a lower mortality rate than previously reported. Systemic complications are frequent in patients admitted to the ICU due to COVID-19, as previously described in high-income countries.
Hospital Mortality and Effect of Adjusting PaO2/FiO2 According to Altitude Above the Sea Level in Acclimatized Patients Undergoing Invasive Mechanical Ventilation. A Multicenter Study
(2019) Jibaja, Manuel; Ortiz-Ruiz, Guillermo; García, Fernanda; Garay-Fernández, Manuel; Montelongo, Felipe de Jesús; Martinez, Jorge; Viruez, José Antonio; Baez-Pravia, Orville; Salazar, Santiago; Villacorta-Cordova, Francisco; Morales, Freddy; Tinoco-Solórzano, Amilcar; Ibañez Guzmán, Carlos; Valle Pinheiro, Bruno; Zubia-Olaskoaga, Felix; Dueñas, Carmelo; Lara Garcia, Antonio; Cardinal-Fernández, Pablo
Objective: (i) Analyze the effect of altitude above the sea level on the mortality rate in patients undergoing invasive mechanical ventilation. (ii) Validate the traditional equation for adjusting PaO2/FiO2 according to the altitude. Design: A prospective, observational, multicenter and international study conducted during August 2016. Patients: Inclusion criteria: (i) age between 18 and 90 years old, (ii) admitted to intensive care unit (ICU) situated at the same altitude above the sea level (AASL) in which the patients has stayed, at least, during the previous 40 days and (iii) received invasive MV for at least 12h. Material and methods: All variables were registered the day of intubation (day 0). Patients were followed until death, ICU discharge or day 28. PaO2/FiO2 ratio was adjusted by the AASL according to: PaO2/FiO2*(barometric pressure/760). Categorical variables were compared with χ2 and Cochran-Mantel-Haenszel test. Continuous variables with Mann-Whitney. Correlation between continuous variables was analyzed graphically and analytically. Logistic regression model was constructed to identify factors associated to mortality. Kapplan-Meier method was used to estimate the probability of survival according to the altitude. A 2-side p value <0.05 was consider significant. Results: 249 patients (<1500m n=55; 1500 to <2500m n=20; 2500 to <3500m n=155 and ≥3500m n=19) were included. Adjusted and non-adjusted PaO2/FiO2 were correlated with several respiratory and non respiratory variables. None discordances between non adjusted and adjusted PaO2/FiO2 were identified. However, several correlations were appreciated only in patients situated <1500m or in >1500m. Seventy-nine patients died during the ICU stayed (32%). The mortality curve was not affected by the altitude above the sea level. Variables independently associated to mortality are: PEEP, age, systolic arterial blood pressure, and platelet count. Auroc: 0.72. Conclusion: In acclimatized patients undergoing invasive mechanical ventilation, the traditional equation for adjusting PaO2/FiO2 according the elevation above the sea level seems to be inaccurate and the altitude above the sea level does not affect the mortality risk. Keywords: Altitud; Altitud elevada; Altitude; Fallo respiratorio; High altitude; Mechanical ventilation; Mortalidad; Mortality; Respiratory failure; Ventilación mecánica.
Early rise in central venous pressure during a spontaneous breathing trial: A promising test to identify patients at high risk of weaning failure?
(2019) Dubo, Sebastián; Valenzuela, Emilio Daniel; Aquevedo, Andrés; Jibaja, Manuel; Berrutti, Dolores; Labra, Christian; Lagos, Rossana; García, María Fernanda; Ramírez, Vanessa; Tobar, Milton; Picoita, Fabricio; Peláez, Cristian; Carpio, David; Alegría, Leyla; Hidalgo, Carolina; Godoy, Karen; Bruhn, Alejandro; Hernández, Glenn; Bakker, Jan; Castro, Ricardo
Background The spontaneous breathing trial (SBT) assesses the risk of weaning failure by evaluating some physiological responses to the massive venous return increase imposed by discontinuing positive pressure ventilation. This trial can be very demanding for some critically ill patients, inducing excessive physical and cardiovascular stress, including muscle fatigue, heart ischemia and eventually cardiac dysfunction. Extubation failure with emergency reintubation is a serious adverse consequence of a failed weaning process. Some data suggest that as many as 50% of patients that fail weaning do so because of cardiac dysfunction. Unfortunately, monitoring cardiovascular function at the time of the SBT is complex. The aim of our study was to explore if central venous pressure (CVP) changes were related to weaning failure after starting an SBT. We hypothesized that an early rise on CVP could signal a cardiac failure when handling a massive increase on venous return following a discontinuation of positive pressure ventilation. This CVP rise could identify a subset of patients at high risk for extubation failure. Methods Two-hundred and four mechanically ventilated patients in whom an SBT was decided were subjected to a monitoring protocol that included blinded assessment of CVP at baseline, and at 2 minutes after starting the trial (CVP-test). Weaning failure was defined as reintubation within 48-hours following extubation. Comparisons between two parametric or non-parametric variables were performed with student T test or Mann Whitney U test, respectively. A logistic multivariate regression was performed to determine the predictive value on extubation failure of usual clinical variables and CVP at 2-min after starting the SBT. Results One-hundred and sixty-five patients were extubated after the SBT, 11 of whom were reintubated within 48h. Absolute CVP values at 2-minutes, and the change from baseline (dCVP) were significantly higher in patients with extubation failure as compared to those successfully weaned. dCVP was an early predictor for reintubation (OR: 1.70 [1.31,2.19], p<0.001). Conclusions An early rise in CVP after starting an SBT was associated with an increased risk of extubation failure. This might represent a warning signal not captured by usual SBT monitoring and could have relevant clinical implications.
Prevalence of cardiovascular instability during hemodialysis therapy in hospitalized patients: A systematic review and meta-analysis
(2024) Arcentales-Vera, Karla; Vera-Mendoza, María Fernanda; Cevallos-Salas, Cristian; García-Aguilera, María Fernanda; Fuenmayor-González, Luis
Background: Intradialytic hypotension (IDH) is a common and serious complication in renal replacement therapy, especially in hospitalized patients. The absence of a standardized definition complicates data synthesis and the development of evidence-based guidelines. Current definitions vary, including different blood pressure thresholds, clinical symptoms, and the need for medical intervention during dialysis. IDH is linked to increased mortality and cardiovascular morbidity and may impede renal recovery in patients with acute kidney injury and chronic kidney disease. Methods: A systematic review was conducted using MEDLINE via PubMed, Embase, and Web of Science to identify studies reporting IDH prevalence. A meta-analysis of proportions was performed to determine the global prevalence of IDH, with subgroup analyses to explore heterogeneity. The Joanna Briggs Institute's checklist was used to assess the risk of bias in prevalence studies. The PRISMA guidelines were followed to report the results of this study, PROSPERO registration number CRD42024500622. Results: The meta-analysis found a global IDH prevalence of 31% (95% CI 0.18-0.44) across nine studies. Significant heterogeneity was observed (I²: 97.87%; p < 0.01), with prevalence rates ranging from 10.7% to 64% based on patient demographics and session characteristics. Sensitivity analysis suggested prevalence could range between 27% and 33% depending on study criteria. Conclusions: IDH is a significant complication during hospital-based renal replacement therapy, with a global prevalence of 31%. These findings highlight the need for a standardized, evidence-based definition of IDH to improve diagnostic consistency and clinical outcomes through more accurate diagnosis, better treatment strategies, and tailored patient management. Keywords: Dialysis; cardiovascular instability; intradialytic hypotension; proportions meta-analysis; systematic review.
Evaluation of DNA damage through cytogenetic approach in smokers and vapers with and without nicotine compared with control group
(2024) Paz-y-Miño, César; Ocampo, Ligia; Sánchez, María-Eugenia; Leone, Paola E
The use of tobacco and electronic cigarettes is harmful to health and can cause genetic damage, increasing the risk of cancer and other serious diseases. Although e-cigarettes contain fewer toxic chemicals than conventional tobacco, recent studies have shown that the vapor caused by burning produced by e-cigarettes can also be toxic and carcinogenic. Various studies have found that those exposed to tobacco and vaping have significantly higher levels of damage to their DNA in different types of cells and tissues. Evidence has accumulated that e-cigarette vaping can alter cellular functions and DNA itself, increasing the risk of cancer and aging. The present work evaluates the cytogenetic damage in individuals exposed to conventional cigarette vapors by burning with nicotine and vapors without nicotine, compared with a non-smoking population. The study included participants with an average age of 30 years (+/-10), with a majority of men representing 70% of the sample. The Chi-square test found no significant statistical differences between the men and women exposed (p<0.05). The results of chromosomal fragility found in the four groups studied (control group, conventional smokers, vapers with nicotine and vapers without nicotine) showed breaks and gaps in one or both of the chromatids in all exposed individuals, with highly significant statistical differences (p<0.001) compared to the unexposed control group. No statistically significant differences were found between the group of conventional smokers and the vapers with and without nicotine, nor between the two types of vapers (p>0.05). In conclusion, cytogenetic evidence of DNA damage produced by vaping is shown in the same proportions as a normal cigarette. This will significantly impact public health, which must be considered in preventive actions.
Variable patterns of retrotransposition in different HeLa strains provide mechanistic insights into SINE RNA mobilization processes
(2024) Moldovan, John B; Kopera, Huira C; Liu, Ying; Garcia-Canadas, Marta; Catalina, Purificacion; Leone, Paola E; Sanchez, Laura; Kitzman, Jacob O; Kidd, Jeffrey M; Garcia-Perez, Jose Luis; Moran, John V
Alu elements are non-autonomous Short INterspersed Elements (SINEs) derived from the 7SL RNA gene that are present at over one million copies in human genomic DNA. Alu mobilizes by a mechanism known as retrotransposition, which requires the Long INterspersed Element-1 (LINE-1) ORF2-encoded protein (ORF2p). Here, we demonstrate that HeLa strains differ in their capacity to support Alu retrotransposition. Human Alu elements retrotranspose efficiently in HeLa-HA and HeLa-CCL2 (Alu-permissive) strains, but not in HeLa-JVM or HeLa-H1 (Alu-nonpermissive) strains. A similar pattern of retrotransposition was observed for other 7SL RNA-derived SINEs and tRNA-derived SINEs. In contrast, mammalian LINE-1s, a zebrafish LINE, a human SINE-VNTR-Alu (SVA) element, and an L1 ORF1-containing mRNA can retrotranspose in all four HeLa strains. Using an in vitro reverse transcriptase-based assay, we show that Alu RNAs associate with ORF2p and are converted into cDNAs in both Alu-permissive and Alu-nonpermissive HeLa strains, suggesting that 7SL- and tRNA-derived SINEs use strategies to 'hijack' L1 ORF2p that are distinct from those used by SVA elements and ORF1-containing mRNAs. These data further suggest ORF2p associates with the Alu RNA poly(A) tract in both Alu-permissive and Alu-nonpermissive HeLa strains, but that Alu retrotransposition is blocked after this critical step in Alu-nonpermissive HeLa strains.
Recomendaciones generales e informe de la situación de impacto del SARSCoV2 en niños con cáncer en Latinoamérica
(0000) Sociedad Latinoamericana de Cuidados Intensivos Pediátricos (SLACIP)
Quality and capacity indicators for hospitalized pediatric oncology patients with critical illness: A modified delphi consensus
(2020) Arias, Anita V; Garza, Marcela; Murthy, Srinivas; Cardenas, Adolfo; Diaz, Franco; Montalvo, Erika; Nielsen, Katie R; Kortz, Teresa; Sharara-Chami, Rana; Friedrich, Paola; McArthur, Jennifer; Agulnik, Asya
Background Hospitalized pediatric hematology‐oncology (PHO) patients are at high risk for critical illness, especially in resource‐limited settings. Unfortunately, there are no established quality indicators to guide institutional improvement for these patients. The objective of this study was to identify quality indicators to include in PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), an assessment tool to evaluate the capacity and quality of pediatric critical care services offered to PHO patients. Methods A comprehensive literature review identified relevant indicators in the areas of structure, performance, and outcomes. An international focus group sorted potential indicators using the framework of domains and subdomains. A modified, three‐round Delphi was conducted among 36 international experts with diverse experience in PHO and critical care in high‐resource and resource‐limited settings. Quality indicators were ranked on relevance and actionability via electronically distributed surveys. Results PROACTIVE contains 119 indicators among eight domains and 22 subdomains, with high‐median importance (≥7) in both relevance and actionability, and ≥80% evaluator agreement. The top five indicators were: (a) A designated PICU area; (b) Availability of a pediatric intensivist; (c) A PHO physician as part of the primary team caring for critically ill PHO patients; (d) Trained nursing staff in pediatric critical care; and (e) Timely PICU transfer of hospitalized PHO patients requiring escalation of care. Conclusions PROACTIVE is a consensus‐derived tool to assess the capacity and quality of pediatric onco‐critical care in resource‐limited settings. Future endeavors include validation of PROACTIVE by correlating the proposed indicators to clinical outcomes and its implementation to identify service delivery gaps amenable to improvement. Keywords: clinical cancer research, pediatric cancer, translational research
Multilevel impacts of a pediatric early warning system in resource-limited pediatric oncology hospitals
(2022) Mirochnick, Emily; Graetz, Dylan E; Ferrara, Gia; Puerto-Torres, Maria; Gillipelli, Srinithya R; Elish, Paul; Muniz-Talavera, Hilmarie; Gonzalez-Ruiz, Alejandra; Armenta, Miriam; Barra, Camila; Diaz-Coronado, Rosdali; Hernandez, Cinthia; Juarez, Susana; Loeza, Jose de Jesus; Mendez, Alejandra; Montalvo, Erika; Penafiel, Eulalia; Pineda, Estuardo; Agulnik, Asya
Background: Pediatric Early Warning Systems (PEWS) reduce clinical deterioration, improve interdisciplinary communication, and provide cost savings; however, little is known about how these impacts are achieved or related. This study evaluates the multi-level impacts of PEWS in resource-limited pediatric oncology centers. Methods: We conducted 71 semi-structured interviews including physicians (45%), nurses (45%), and administrators (10%) from 5 resource-limited pediatric oncology centers in 4 Latin American countries. Interviews were conducted in Spanish, transcribed, and translated into English. A code book was developed using a priori and inductively derived codes. Transcripts were independently coded by 2 coders, achieving a kappa of 0.8-0.9. Thematic content analysis explored perceived impacts of PEWS at the level of the patient, clinician, healthcare team, and institution. Results: PEWS improved the quality of attention for patients, reducing morbidity and mortality. Clinicians felt more knowledgeable, confident, and empowered providing patient care, resulting in greater job satisfaction. PEWS affected team dynamics by improving interdisciplinary (ward and intensive care unit) and interprofessional (physicians and nurses) relationships and communication. This ultimately led to institutional culture change with emphasis on patient safety, collaboration with other centers, and receipt of institutional awards. Together, these impacts led to hospital-wide support of ongoing PEWS use. Conclusions: In resource-limited hospitals, PEWS use results in multi-level positive impacts on patients, clinicians, teams, and institutions, creating a feedback loop that further supports ongoing PEWS use. These findings can guide advocacy for PEWS to various stakeholders, improve PEWS effectiveness, and inform assessment of other interventions to improve childhood cancer outcomes. Keywords: Latin America; Pediatric Early Warning System (PEWS); global health; pediatric critical care; pediatric oncology; quality improvement; resource-limited. Copyright © 2022 Mirochnick, Graetz, Ferrara, Puerto-Torres, Gillipelli, Elish, Muniz-Talavera, Gonzalez-Ruiz, Armenta, Barra, Diaz-Coronado, Hernandez, Juarez, Loeza, Mendez, Montalvo, Penafiel, Pineda and Agulnik.
Stages of change: Strategies to promote use of a Pediatric Early Warning System in resource‐limited pediatric oncology centers
(2023) Woo, Marisa Cristin; Ferrara, Gia; Puerto-Torres, Maria; Gillipelli, Srinithya R; Elish, Paul; Muniz-Talavera, Hilmarie; Gonzalez-Ruiz, Alejandra; Armenta, Miriam; Barra, Camila; Diaz-Coronado, Rosdali; Hernandez, Cinthia; Juarez, Susana; Loeza, José; Mendez, Alejandra; Montalvo, Erika; Peñafiel, Eulalia; Pineda, Estuardo; Graetz, Dylan E; Kortz, Teresa; Agulnik, Asya
Background Pediatric Early Warning Systems (PEWS) assist early detection of clinical deterioration in hospitalized children with cancer. Relevant to successful PEWS implementation, the “stages of change” model characterizes stakeholder support for PEWS based on willingness and effort to adopt the new practice. Methods At five resource‐limited pediatric oncology centers in Latin America, semi‐structured interviews were conducted with 71 hospital staff involved in PEWS implementation. Purposive sampling was used to select centers requiring variable time to complete PEWS implementation, with low‐barrier centers (3–4 months) and high‐barrier centers (10–11 months). Interviews were conducted in Spanish, professionally transcribed, and translated into English. Thematic content analysis explored “stage of change” with constant comparative analysis across stakeholder types and study sites. Results Participants identified six interventions (training, incentives, participation, evidence, persuasion, and modeling) and two policies (environmental planning and mandates) as effective strategies used by implementation leaders to promote stakeholder progression through stages of change. Key approaches involved presentation of evidence demonstrating PEWS effectiveness, persuasion and incentives addressing specific stakeholder interests, enthusiastic individuals serving as models for others, and policies enforced by hospital directors facilitating habitual PEWS use. Effective engagement targeted hospital directors during early implementation phases to provide programmatic legitimacy for clinical staff. Conclusion This study identifies strategies to promote adoption and maintained use of PEWS, highlighting the importance of tailoring implementation strategies to the motivations of each stakeholder type. These findings can guide efforts to implement PEWS and other evidence‐based practices that improve childhood cancer outcomes in resource‐limited hospitals. Keywords: behavioral science, clinical cancer research, clinical management, implementation science, pediatric cancer, Pediatric Early Warning Systems, resource‐limited, stages of change, transtheoretical model
The COVID‐19 Pandemic's impact on sustainability and expansion of a Pediatric Early Warning System in resource‐limited hospitals
(2023) Wiphatphumiprates, Parima P; Graetz, Dylan E; Ferrara, Gia; Puerto-Torres, Maria; Gillipelli, Srinithya R; Elish, Paul; Muniz-Talavera, Hilmarie; Gonzalez-Ruiz, Alejandra; Armenta, Miriam; Barra, Camila; Carpio, Zulma; Hernandez, Cinthia; Juarez, Susana; de Jesus Loeza, Jose; Mendez, Alejandra; Montalvo, Erika; Penafiel, Eulalia; Pineda, Estuardo; McKay, Virginia; Agulnik, Asya
Background: The COVID-19 pandemic impacted healthcare delivery worldwide, including pediatric cancer care, with a disproportionate effect in resource-limited settings. This study evaluates its impact on existing quality improvement (QI) programs. Methods: We conducted 71 semi-structured interviews of key stakeholders at five resource-limited pediatric oncology centers participating in a collaborative to implement Pediatric Early Warning System (PEWS). Interviews were conducted virtually using a structured interview guide, recorded, transcribed, and translated into English. Two coders developed a codebook of a priori and inductive codes and independently coded all transcripts, achieving a kappa of 0.8-0.9. Thematic analysis explored the impact of the pandemic on PEWS. Results: All hospitals reported limitations in material resources, reduction in staffing, and impacts on patient care due to the pandemic. However, the impact on PEWS varied across centers. Identified factors that promoted or limited ongoing PEWS use included the availability of material resources needed for PEWS, staff turnover, PEWS training for staff, and the willingness of staff and hospital leaders to prioritize PEWS. Consequently, some hospitals were able to sustain PEWS; others halted or reduced PEWS use to prioritize other work. Similarly, the pandemic delayed plans at all hospitals to expand PEWS to other units. Several participants were hopeful for future expansion of PEWS post-pandemic. Conclusion: The COVID-19 pandemic created challenges for sustainability and scale of PEWS, an ongoing QI program, in these resource-limited pediatric oncology centers. Several factors mitigated these challenges and promoted ongoing PEWS use. These results can guide strategies to sustain effective QI interventions during future health crises. Keywords: COVID-19; Latin America; PEWS; implementation science; pediatric early warning system; pediatric oncology; quality improvement collaborative; resource-limited.
Clinical and organizational risk factors for mortality during deterioration events among pediatric oncology patients in Latin America: A multicenter prospective cohort
(2021) Agulnik, Asya; Cárdenas, Adolfo; Carrillo, Angela K; Bulsara, Purva; Garza, Marcela; Alfonso Carreras, Yvania; Alvarado, Manuel; Calderón, Patricia; Díaz, Rosdali; de León, Claudia; Del Real, Claudia; Huitz, Tania; Martínez, Angélica; Miralda, Scheybi; Montalvo, Erika; Negrín, Octavia; Osuna, Alejandra; Perez Fermin, Clara Krystal; Pineda, Estuardo; Soberanis, Dora; Juárez Tobias, Maria Susana; Lu, Zhaohua; Rodriguez-Galindo, Carlos; EVAT Study Group
Background Hospitalized pediatric hematology‐oncology (PHO) patients have frequent clinical deterioration events (CDE) requiring intensive care unit (ICU) admission, particularly in resource‐limited settings. The objective of this study was to describe CDEs in hospitalized PHO patients in Latin America and to identify event‐level and center‐level risk factors for mortality. Methods In 2017, the authors implemented a prospective registry of CDEs, defined as unplanned transfers to a higher level of care, use of ICU‐level interventions on the floor, or nonpalliative floor deaths, in 16 PHO centers in 10 countries. PHO hospital admissions and hospital inpatient days were also reported. This study analyzes the first year of registry data (June 2017 to May 2018). Results Among 16 centers, 553 CDEs were reported in PHO patients during 11,536 admissions and 119,414 inpatient days (4.63 per 1000 inpatient days). Event mortality was 29% (1.33 per 1000 inpatient days) but ranged widely across centers (11%‐79% or 0.36‐5.80 per 1000 inpatient days). Significant risk factors for event mortality included requiring any ICU‐level intervention on the floor and not being transferred to a higher level of care. Events with organ dysfunction, a higher severity of illness, and a requirement for ICU intervention had higher mortality. In center‐level analysis, hospitals with a higher volume of PHO patients, less floor use of ICU intervention, lower severity of illness on transfer, and lower rates of floor cardiopulmonary arrest had lower event mortality. Conclusions Hospitalized PHO patients who experience CDEs in resource‐limited settings frequently require floor‐based ICU interventions and have high mortality. Modifiable hospital practices around the escalation of care for these high‐risk patients may contribute to poor outcomes. Earlier recognition of critical illness and timely ICU transfer may improve survival in hospitalized children with cancer. Keywords: clinical deterioration, intensive care, Latin America, pediatric oncology, Pediatric Early Warning Systems (PEWS), resource‐limited settings
Essential Emergency and Critical Care: a consensus among global clinical experts
(2021) Schell, Carl Otto; Khalid, Karima; Wharton-Smith, Alexandra; Oliwa, Jacquie; Sawe, Hendry R; Roy, Nobhojit; Sanga, Alex; Marshall, John C; Rylance, Jamie; Hanson, Claudia; Kayambankadzanja, Raphael K; Wallis, Lee A; Jirwe, Maria; Baker, Tim; EECC Collaborators; EECC Collaborators*
Background: Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. Methods: In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements. Results: The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19. Conclusion: The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide. Keywords: COVID-19; health policy; health services research; health systems; surgery.
Reliability and validity of a Spanish-language measure assessing clinical capacity to sustain Paediatric Early Warning Systems (PEWS) in resource-limited hospitals
(2021) Agulnik, Asya; Malone, Sara; Puerto-Torres, Maria; Gonzalez-Ruiz, Alejandra; Vedaraju, Yuvanesh; Wang, Huiqi; Graetz, Dylan; Prewitt, Kim; Villegas, Cesar; Cardenas-Aguierre, Adolfo; Acuna, Carlos; Arana, Ana Edith; Díaz, Rosdali; Espinoza, Silvana; Guerrero, Karla; Martínez, Angélica; Mendez, Alejandra; Montalvo, Erika; Soberanis, Dora; Torelli, Antonella; Quelal, Janeth; Villanueva, Erika; Devidas, Meenakshi; Luke, Douglas; McKay, Virginia; EVAT Study Group
Background: Paediatric Early Warning Systems (PEWSs) improve identification of deterioration, however, their sustainability has not been studied. Sustainability is critical to maximise impact of interventions like PEWS, particularly in low-resource settings. This study establishes the reliability and validity of a Spanish-language Clinical Sustainability Assessment Tool (CSAT) to assess clinical capacity to sustain interventions in resource-limited hospitals. Methods: Participants included PEWS implementation leadership teams of 29 paediatric cancer centres in Latin America involved in a collaborative to implement PEWS. The CSAT, a sustainability assessment tool validated in high-resource settings, was translated into Spanish and distributed to participants as an anonymous electronic survey. Psychometric, confirmatory factor analysis (CFA), and multivariate analyses were preformed to assess reliability, structure and initial validity. Focus groups were conducted after participants reviewed CSAT reports to assess their interpretation and utility. Results: The CSAT survey achieved an 80% response rate (n=169) with a mean score of 4.4 (of 5; 3.8-4.8 among centres). The CSAT had good reliability with an average internal consistency of 0.77 (95% CI 0.71 to 0.81); and CFAs supported the seven-domain structure. CSAT results were associated with respondents' perceptions of the evidence for PEWS, its implementation and use in their centre, and their assessment of the hospital culture and implementation climate. The mean CSAT score was higher among respondents at centres with longer time using PEWS (p<0.001). Focus group participants noted the CSAT report helped assess their centre's clinical capacity to sustain PEWS and provided constructive feedback for improvement. Conclusions: We present information supporting the reliability and validity of the CSAT tool, the first Spanish-language instrument to assess clinical capacity to sustain evidence-based interventions in hospitals of variable resource levels. This assessment demonstrates a high capacity to sustain PEWS in these resource-limited centres with improvement over time from PEWS implementation. Keywords: paediatric intensive & critical care; paediatric oncology; paediatrics; quality in health care; statistics & research methods.
Assessment of Barriers and Enablers to Implementation of a Pediatric Early Warning System in Resource-Limited Settings
(2022) Agulnik, Asya; Ferrara, Gia; Puerto-Torres, Maria; Gillipelli, Srinithya R; Elish, Paul; Muniz-Talavera, Hilmarie; Gonzalez-Ruiz, Alejandra; Armenta, Miriam; Barra, Camila; Diaz, Rosdali; Hernandez, Cinthia; Juárez Tobias, Susana; de Jesus Loeza, Jose; Mendez, Alejandra; Montalvo, Erika; Penafiel, Eulalia; Pineda, Estuardo; Graetz, Dylan E
Importance: Pediatric early warning systems (PEWS) aid with early identification of clinical deterioration and improve outcomes in children with cancer hospitalized in resource-limited settings; however, there may be barriers to implementation. Objective: To evaluate stakeholder-reported barriers and enablers to PEWS implementation in resource-limited hospitals. Design, setting, and participants: In this qualitative study, semistructured stakeholder interviews were conducted at 5 resource-limited pediatric oncology centers in 4 countries in Latin America. Hospitals participating in a multicenter collaborative to implement PEWS were purposefully sampled based on time required for implementation (fast vs slow), and stakeholders interviewed included physicians, nurses, and administrators, involved in PEWS implementation. An interview guide was developed using the Consolidated Framework for Implementation Research (CFIR). Interviews were conducted virtually in Spanish, audiorecorded, and professionally transcribed and translated into English. A codebook was developed a priori using the CFIR and supplemented with codes inductively derived from transcript review. Two coders independently analyzed all transcripts, achieving a κ of 0.8 to 0.9. The study was conducted from June 1 to August 31, 2020. Main outcomes and measures: Thematic analysis was conducted based on CFIR domains (inner setting, characteristics of individuals, outer setting, intervention characteristics, and implementation process) to identify barriers and enablers to PEWS implementation. Results: Seventy-one staff involved in PEWS implementation were interviewed, including 32 physicians (45%), 32 nurses (45%), and 7 administrators (10%). Of these, 50 were women (70%). Components of the 5 CFIR domains were mentioned by participants as barriers and enablers to PEWS implementation at both fast- and slow-implementing centers. Participants emphasized barriers at the level of the clinical staff, hospital, external factors, and PEWS intervention. These barriers included staff resistance to change, inadequate resources, components of health systems, and the perceived origin and complexity of PEWS. At all centers, most barriers were successfully converted to enablers during the implementation process through targeted strategies, such as early stakeholder engagement and adaptation, including adapting PEWS to better fit the local context and changing the hospital setting to support ongoing use of PEWS. Conclusions and relevance: To date, this is the first multicenter, multinational study describing barriers and enablers to PEWS implementation in resource-limited settings. Findings suggest that many barriers are not immutable and can be converted to enablers during the implementation process. This work can serve as a guide for clinicians looking to implement evidence-based interventions to reduce global disparities in patient outcomes.

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