Antimicrobial resistance (AMR) is a major threat to global health. Improving laboratory capacity for AMR detection is critically important for patient health outcomes and population level surveillance. We aimed to estimate the financial cost of setting up and running a microbiology laboratory for organism identification and antimicrobial susceptibility testing as part of an AMR surveillance programme. Financial costs for setting up and running a microbiology laboratory were estimated using a top-down approach based on resource and cost data obtained from three clinical laboratories in the Mahidol Oxford Tropical Medicine Research Unit network. Costs were calculated for twelve scenarios, considering three levels of automation, with equipment sourced from either of the two leading manufacturers, and at low and high specimen throughput. To inform the costs of detection of AMR in existing labs, the unit cost per specimen and per isolate were also calculated using a micro-costing approach. Establishing a laboratory with the capacity to process 10,000 specimens per year ranged from $254,000 to $660,000 while the cost for a laboratory processing 100,000 specimens ranged from $394,000 to $887,000. Excluding capital costs to set up the laboratory, the cost per specimen ranged from $22–31 (10,000 specimens) and $11–12 (100,000 specimens). The cost per isolate ranged from $215–304 (10,000 specimens) and $105–122 (100,000 specimens). This study provides a conservative estimate of the costs for setting up and running a microbiology laboratory for AMR surveillance from a healthcare provider perspective. In the absence of donor support, these costs may be prohibitive in many low- and middle- income country (LMIC) settings. With the increased focus on AMR detection and surveillance, the high laboratory costs highlight the need for more focus on developing cheaper and cost-effective equipment and reagents so that laboratories in LMICs have the potential to improve laboratory capacity and participate in AMR surveillance.
Background: Low- and middle-income countries (LMICs) have a growing and largely unaddressed neurosurgical burden. Cambodia has been an understudied country regarding the neurosurgical pathologies and case volume. Rapid infrastructure development with noncompliance of safety regulations has led to increased numbers of traumatic injuries. This study examines the neurosurgical caseload and pathologies of a single government institution implementing the first residency program in an effort to understand the neurosurgical needs of this population. Methods: This is a longitudinal descriptive study of all neurosurgical admissions at the Department of Neurosurgery at Preah Kossamak Hospital (PKH), a major government hospital, in Phnom Penh, Cambodia, between September 2013 and June 2018. Results: 5490 patients were admitted to PKH requiring neurosurgical evaluation and care. Most of these admissions were cranial injuries related to road traffic accidents primarily involving young men compared to women by approximately 4:1 ratio. Spinal pathologies were more evenly distributed in age and gender, with younger demographics more commonly presenting with traumatic injuries, while the older with degenerative conditions. Conclusions: Despite increased attention and efforts over the past decade, Cambodia’s neurosurgical burden mirrors that of other LMICs, with trauma affecting most patients either on the road or at the workplace. Currently, Cambodia has 34 neurosurgeons to address the growing burden of a country of 15 million with an increasing life expectancy of 69 years of age, stressing the importance of better public health policies and urgency for building capacity for safe and affordable neurosurgical care.
The International Standards for a Safe Practice of Anesthesia (ISSPA) were developed on behalf of the World Federation of Societies of Anaesthesiologists and the World Health Organization. It has been recommend as an assessment tool that allows anesthetic providers in developing countries to assess their compliance and needs. This study was performed to describe the anesthesia service in one main public hospital during an 8-month medical mission in Cambodia and evaluate its anesthetic safety issues according to the ISSPA. We conduct a retrospective study involving 1953 patients at the Preah Ket Mealea hospital. Patient demographics, anesthetic techniques, and complications were reviewed according to the registers of the anesthetic services and questionnaires. The inadequacies in personnel, facilities, equipment, medications, and conduct of anesthesia drugs were recorded using a checklist based on the ISSPA. A total of 1792 patients received general and regional anesthesia in the operating room, while 161 patients receiving sedation for gastroscopy. The patients’ mean age was 45.0 ± 16.6 years (range, 17-87 years). The three most common surgical procedures were abdominal (52.0%; confidence interval [CI], 49.3-54.7), orthopedic (27.6%; CI, 25.2-29.9), and urological surgery (14.7%; CI, 12.8-16.6). General anesthesia, spinal anesthesia, and brachial plexus block were performed in 54.3% (CI, 51.7-56.8), 28.2% (CI, 25.9-30.5), and 9.4% (CI, 7.9-10.9) of patients, respectively. One death occurred. Twenty-six items related to professional aspects, monitoring, and conduct of anesthesia did not meet the ISSPA-recommended standards. A lack of commonly used drugs and monitoring equipment was noted, posing major threats to the safety of anesthesia practice, especially in emergency situations. This study adds to the scarce literature on anesthesia practice in low- and middle-income countries such as Cambodia. Future medical assistance should help to strengthen these countries’ inadequacies, allowing for the adoption of international standards for the safe practice of anesthesia.
To determine the incidence of unintended pregnancy among female sex workers (FSWs) in low-income and middle-income countries (LMICs).We searched MEDLINE, PsychInfo, Embase and Popline for papers published in English between January 2000 and January 2016, and Web of Science and Proquest for conference abstracts. Meta-analysis was performed on the primary outcomes using random effects models, with subgroup analysis used to explore heterogeneity.Eligible studies targeted FSWs aged 15-49 years living or working in an LMIC.Studies were eligible if they provided data on one of two primary outcomes: incidence of unintended pregnancy and incidence of pregnancy where intention is undefined. Secondary outcomes were also extracted when they were reported in included studies: incidence of induced abortion; incidence of birth; and correlates/predictors of pregnancy or unintended pregnancy.Twenty-five eligible studies were identified from 3866 articles. Methodological quality was low overall. Unintended pregnancy incidence showed high heterogeneity (I²>95%), ranging from 7.2 to 59.6 per 100 person-years across 10 studies. Study design and duration were found to account for heterogeneity. On subgroup analysis, the three cohort studies in which no intervention was introduced had a pooled incidence of 27.1 per 100 person-years (95% CI 24.4 to 29.8; I2=0%). Incidence of pregnancy (intention undefined) was also highly heterogeneous, ranging from 2.0 to 23.4 per 100 person-years (15 studies).Of the many studies examining FSWs’ sexual and reproductive health in LMICs, very few measured pregnancy and fewer assessed pregnancy intention. Incidence varied widely, likely due to differences in study design, duration and baseline population risk, but was high in most studies, representing a considerable concern for this key population. Evidence-based approaches that place greater importance on unintended pregnancy prevention need to be incorporated into existing sexual and reproductive health programmes for FSWs.CRD42016029185.
This article reviews the burden of epilepsy in Asia, the challenges faced by people with epilepsy, and the management of epilepsy. Comparison is made with other parts of the world. For this narrative review, data were collected using specified search criteria. Articles investigating the epidemiology of epilepsy, diagnosis, comorbidities and associated mortality, stigmatization, and treatment were included. Epilepsy is a global health care issue affecting up to 70 million people worldwide. Nearly 80% of people with epilepsy live in low- and middle-income countries with limited resources. People with epilepsy are prone to physical and psychological comorbidities, including anxiety and depression, which can negatively impact their quality of life. Furthermore, people with epilepsy are at higher risk of premature death than people without epilepsy. Discrimination or stigmatization of people with epilepsy is common in Asia and can affect their education, work, and marriage opportunities. Access to epilepsy treatment varies throughout Asia. Although highly advanced treatment is available in some countries, up to 90% of people with epilepsy are not adequately treated or are not treated with conventional antiepileptic therapy in resource-limited countries. People in remote areas often do not receive any epilepsy care. First-generation antiepileptic drugs (AEDs) are available, but usually only in urban areas, and second-generation AEDs are not available in all countries. Newer AEDs tend to have more favorable safety profiles than first-generation AEDs and provide options to tailor therapy for individual patients, especially those with comorbidities. Active epilepsy surgery centers are present in some countries, although epilepsy surgery is often underutilized given the number of patients who could benefit. Further epidemiologic research is needed to provide accurate epilepsy data across the Asian region. Coordinated action is warranted to improve access to treatment and care.
Chronic suppurative otitis media is a massive public health problem in numerous low- and middle-income countries. Unfortunately, few low- and middle-income countries can offer surgical therapy.A six-month long programme in Cambodia focused on training local surgeons in type I tympanoplasty was instigated. Qualitative educational and quantitative surgical outcomes were evaluated in the 12 months following programme completion. A four-month long training programme in mastoidectomy and homograft ossiculoplasty was subsequently implemented, and the preliminary surgical and educational outcomes were reported.A total of 124 patients underwent tympanoplasty by the locally trained surgeons. Tympanic membrane closure at six weeks post-operation was 88.5 per cent. Pure tone audiometry at three months showed that 80.9 per cent of patients had improved hearing, with a mean gain of 17.1 dB. The trained surgeons reported high confidence in performing tympanoplasty. Early outcomes suggest the local surgeons can perform mastoidectomy and ossiculoplasty as safely as overseas-trained surgeons, with reported surgeon confidence reflecting these positive outcomes.The training programme has demonstrated success, as measured by surgeon confidence and operative outcomes. This approach can be emulated in other settings to help combat the global burden of chronic suppurative otitis media.
Access to cardiac surgery is limited in low-income settings, and data on patient outcomes are scarce.
To assess characteristics, surgical procedures and outcomes in patients undergoing open-heart surgery in low-income settings.
This was a cohort study (2001-2011) in two low-income countries, Cambodia and Mozambique, where cardiac surgery had been promoted by visiting non-governmental organizations.
In Cambodia and Mozambique, respectively, 1332 and 767 consecutive patients were included; 547 (41.16%) and 385 (50.20%) were men; median age at first surgery was 11 years (interquartile range [IQR] 4-14) and 11 years (IQR 3-18); rheumatic heart disease affected 490 (36.79%) and 268 (34.94%) patients; congenital heart disease (CHD) affected 834 (62.61%) and 390 (50.85%) patients, with increasingly more CHD patients over time (P<0.001); and the number of patients lost to follow-up reached 741 (55.63%) and 112 (14.6%) at 30 days. A total of 249 (32.46%) patients were lost to follow-up in Mozambique, remoteness being the only influencing factor (P<0.001). Among patients with known vital status, the early (<30 days) postoperative mortality rate was 6.10% (n=40) in Mozambique and 3.05% (n=18) in Cambodia. Overall, 109 (8.18%) patients in Cambodia and 94 (12.26%) patients in Mozambique underwent re-do surgery. In Mozambique, a further 50/518 (9.65%) patients died at a median of 23months (IQR 7-43); in Cambodia, a further 34/591 (5.75%) patients died at a median of 11.5months (IQR 6-54.5).
Cardiac surgery is feasible in low-income countries with acceptable in-hospital mortality and proof of capacity building. Patient outcomes after cardiac surgery in low-income countries remain unknown, given the strikingly high numbers of lost to follow-u
Initial report on establishment of a hip service in Phnom Penh, Cambodia at Children’s Surgical Centre. We describe indications for total hip replacement (THR) and initial results.
A database was established to collect data and track patients for follow up. Initial data collected included; diagnosis, implant used, post-operative complications. As the service developed, pre- and postoperative Harris hip scores were included.
High rate of avascular necrosis (AVN) as the initial diagnosis. Five years post initiation of the hip service, 95 patients have received 116 THRs; including 10 revisions, 12 bilateral procedures. Complications/failures requiring revision involved four prosthetic femoral neck fractures, two aseptic acetabular component, two late infections, one instability. One failure, a periprosthetic acetabular fracture, required removal of all prosthetics. Complications not requiring revision, included three post-op foot drops, three superficial wound infections, one Vancouver B1 periprosthetic femur fracture. Average age was 41. Overall implant survival is 85% at three years.
AVN was the most common indication for THR: many patients had a history of hip trauma, and/or prolonged steroids from traditional healers for pain. Problems with specific implants were addressed by the company. A different stem is now routinely used, no further fractures have been reported. Acetabular loosening, thought to be due to poor technique, has been addressed by focused training. Infection rate is monitored, and microbiology resources are improving.
Osteosarcoma (OS) is a serious disease affecting mainly children and young adults. In a resource poor setting the treatment options are limited and further obstacles can be found with respect to late presenting pathology, access to modern treatment modalities such as effective chemotherapy, and cultural reluctance to undergo certain treatments. Clinical outcome studies and epidemiology for this disease in developing countries are scarce.
We report on the outcomes of 30 patients treated by the CSC, a rehabilitative surgery centre in Cambodia, from 2002 to present. Enneking staging, location, and treatment protocols were evaluated. Outcome measures were months of survival, EDQ5S life quality scores and clinically relevant inquiries. Kaplan-Meier analysis estimates and the Wilcoxon chi-square test were used for statistical inferences.
We find a grim prognosis for patients diagnosed with OS in Cambodia, 53 % survive the first year after presentation and the five-year survival stands at 8 %. There is a higher mean age for presentation of OS compared to Western norms, namely, 18.8 years and 21.7 years for females and males, respectively.
Most patients opted for surgical treatment without adjuvant chemotherapy, which is not within the means of many Cambodian patients. Acceptance of amputation, earlier diagnosis, patient education, and access to standardized chemotherapy needs to be enhanced if Cambodian patients are to have a fighting chance.