Yamikani Chimalizeni

OBJECTIVES: To evaluate the feasibility, reliability, and diagnostic implications of performing the pediatric Rapid Ultrasound for Shock and Hypotension (p-RUSH) in children with undifferentiated shock upon hospital presentation in a low-resource setting (LRS). DESIGN: Prospective observational study from February 2019 to December 2019. SETTING: Pediatric emergency department (ED) of a large academic referral hospital in Blantyre, Malawi. PATIENTS: Children (2 mo to 16 yr old) with shock upon presentation to the pediatric ED. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty children with shock were enrolled, of whom 14 died. The p-RUSH was performed upon admission to the ED, before administration of an IV fluid bolus. The p-RUSH was performed within a median time of 11.5 minutes, and 92.3% of the image frames in 4-second video clips were interpretable. Images were scored by two independent reviewers and the qualitative and quantitative assessments were compared and showed positive correlations as follows: 1) qualitative assessments of cardiac performance vs. left ventricle ejection fraction and fractional shortening measurements (r = 0.684 and r = 0.616, respectively, both p < 0.05) and 2) qualitative assessment of inferior vena cava (IVC) collapsibility vs. IVC collapsibility index (r = 0.470; p < 0.05). The interobserver agreement between cardiac and IVC qualitative assessments yielded a kappa statistic of up to 0.850 (cardiac views) and 0.275 (IVC collapsibility). Both reviewers applied a novel algorithmic flow diagram to diagnose the shock phenotype. In 23 of 30 children, the flowchart could be completed, which suggested either hypovolemic or distributive shock as the most common phenotype. CONCLUSIONS: In a Malawian pediatric ED, the p-RUSH was feasible and qualitative assessments were reliable. This 2019 proof-of-concept test provides a basis for further external validation of the p-RUSH and our algorithm for identifying shock phenotypes, which may lead to individualizing care of children presenting with shock in LRSs.

: We convened an electroencephalography and epilepsy think tank in Blantyre, Malawi, bringing together American pediatric neurologist clinical researchers and Malawian clinicians. We worked with the aim of improving care for children with seizures and epilepsy in southern Malawi. By sharing and discussing ideas, six United States-based researchers and six Malawian end users developed consensus for directions of both current and future clinical research activities. Compared with our previous use of informal one-to-one discussions to generate research ideas, we found the structured think tank useful for generating ideas and better establishing links between clinical researchers and those who will eventually use the results of their work. We hope that these new interactions will lead to a self-sustaining environment integrating clinical care and research, leading to improvements in brain health for the children of Malawi and integrating technology in the places where it will be most clinically useful.

Pediatric critical care medicine (PCCM), as it is practiced in high-income countries, is focused on specialized medical care for the most vulnerable pediatric patient populations. However, best practices for provision of that care globally are lacking. Thus, PCCM research and education programming can potentially fill significant knowledge gaps by facilitating the development of evidence-based clinical guidelines that reduce child mortality on a global scale. Malaria remains a leading cause of pediatric mortality worldwide. The Blantyre Malaria Project (BMP) is a research and clinical care collaborative that has focused on reducing the public health burden of pediatric cerebral malaria in Malawi since 1986. In 2017, the requirements of a new research study led to the creation of PCCM services in Blantyre, creating the opportunity to establish a PCCM-Global Health Research Fellowship by BMP in collaboration with the University of Maryland School of Medicine. In this perspective piece, we reflect on the evolution of the PCCM-Global Health research fellowship. Although the specifics of this fellowship are out of the scope of this perspective, we discuss the context allowing for the development of this program and explore some early lessons learned to consider for future capacity-building efforts in the future of PCCM-Global Health research.