Cancer care delivery innovations, experiences and challenges during the COVID-19 pandemic: The Rwanda experience

Globally, cancer is the second leading cause of mortality. In 2018, 9.6 million lives were lost to cancer of which over 70% occurred in low and middle-income countries (LMICs) where limited access to cancer care and overwhelming late disease presentations negatively impact cancer related survival and quality of life [1]. Moreover, globally, new cancer cases are expected to increase from 18.1 million in 2018 to 21.4 million by 2030 [2]. In settings of poor health care systems and impoverished communities, the scarcity of and limited access to diagnostic and treatment modalities negatively impacts health outcomes and undermines achievement of the universal health care coverage (UHC) targets.

Over the past 20 years, Rwanda has recorded gains in key health indicators including increased life expectancy (from 48.6 in 2000 to 67.4 in 2015); declines in maternal mortality (from 1071 in 2000 to 210 per 100 000 live births in 2015) [3]. Concurrently, impressive gains were registered in the control of infectious diseases such as HIV, tuberculosis and malaria [3]. However, little gains have been recorded for the management of non-communicable diseases (NCDs) where age-standardized NCD mortality rates slightly decreased from 894.9 to 548.6 deaths per 100 000 people from 2000 to 2016 [4,5]. Anecdotally, plausible hindrances to the prevention and control of NCDs in Rwanda include low community awareness, lack of trained providers, limited access to diagnostic services and treatment capacity for complicated cases

Awake prone positioning for COVID-19 patients at Eka Kotebe General Hospital, Addis Ababa, Ethiopia: A prospective cohort study

OBJECTIVES:
The objectives of the study were to evaluate the benefit of awake prone positioning in COVID-19 patients hospitalized at Eka Kotebe General Hospital, Addis Ababa, Ethiopia.

MATERIALS AND METHODS:
Consecutive patients with COVID-19 who require supplemental oxygen to maintain oxygen saturation of ≥90% during the month of October 2020 were enrolled. Structured questionnaires were employed to collect data. Admission oxygen saturation was recorded for each patient before and after their first proning session. Analysis of descriptive and comparison statistics was done using SPSS version 25.

RESULTS:
A total of 61 patients were included in the study. The mean age (+SD) for the cohort was 55.4 (+16.9) years. The average duration of proning was 5+2.5 h/session and 8+6 h/day. The average oxygen saturation before proning was 89% (SD 5.2) and 93% (SD 2.8) 1 h after proning (P < 0.001); supplemental oxygen requirements significantly decreased with prone ventilation, before proning: FiO2 0.33 (+0.14) versus 1 h after prone ventilation: FiO2 0.31 (+0.13) (P < 0.001). Oxygen improvement with prone ventilation was not associated with duration of illness or total prone position hours. When assessed at 28 days after admission, 55.7% (n = 34) had been discharged home, 1.6% (n = 1) had died, and 42.6 (n = 26) were still hospitalized. CONCLUSION: Awake prone positioning demonstrated improved oxygen saturation in our oxygen requiring COVID-19 patients. Even though further studies are needed to support causality and determine the effect of proning on disease severity and mortality, early institution of prone ventilation in appropriate oxygen requiring COVID-19 patients should be encouraged.

Feasibility of the application of multimedia animations as preoperative guides for urgent abdominal surgeries in public hospitals in Brazi

Introduction: Preoperative education helps patients feel less anxious and improve self-care while decreasing hospitalization time and demand for postoperative analgesia. Health literacy, culture and language play vital roles in patients’ understanding of health issues and may influence treatment outcomes. Obstacles are more evident in low and middle income countries (LMICs), where inadequate patient education levels are higher and hospital resources lower. Methodology: This is a prospective pilot study assessing the feasibility of online preoperative multimedia animations as guides for surgical patients in an LMIC. Patients admitted to a public hospital in Brazil for acute cholecystitis or appendicitis were included. Feasibility was represented by acceptability rate and ease of integration with department protocols. Results: Thirty-four patients were included in the study. Twenty-six patients concluded the intervention (feasibility rate of 76.5%). Demographic factors seemed to affect results, indicated by higher acceptability from those with lower education levels, from younger patients and from women. No issues were reported regarding integration to local protocols. Discussion: Few studies have evaluated use of multimedia resources for preoperative patients. No studies assessed the use of animations and none analyzed digital patient education resources in an LMIC. This study demonstrated that the use of animations for patient education in LMICs is feasible. A step-based protocol approach is proposed by this study to aid the implementation of patient education digital interventions. Conclusion: The implementation of this tool is feasible and presents patients with easier access to appropriate and engaging information, allowing better surgical preparation and recovery. It can be offered online, allowing it to be sustainable while creating the foundations for a modern patient education culture in LMICs

The Novel Coronavirus (COVID-19) Pandemic and the Response in Low-to-Middle Income Countries

Purpose of Review
The COVID-19 pandemic has posed an unprecedented challenge to healthcare, particularly in resource-constrained low and middle-income countries (LMICs). We aim to summarize the challenges faced by LMICs in providing breast cancer care during the pandemic and their response during this crisis.

Recent Findings
Conversion of oncology centers into COVID-19 isolation centers and lack of LMIC applicable guidelines for breast cancer treatment worsened the challenge for providers. Few LMICs changed their management framework, taking steps like triaging patients, prioritizing care, therapeutic spacing, and a shift to telehealth.

Summary
Modified protocols where available have served LMICs well for resource allocation; however, effectiveness of these cannot be determined due to lack of outcomes reporting. This pandemic has underscored the importance of flexibility, prompt intervention, good communication, and reassessment to address unexpected healthcare challenges and has been a learning lesson to help tailor guidelines early in the future.

Increased complications in patients who test COVID-19 positive after elective surgery and implications for pre and postoperative screening

Background
The COVID-19 pandemic has necessitated the adoption of protocols to minimize risk of periprocedural complications associated with SARS-CoV-2 infection. This typically involves a preoperative symptom screen and nasal swab RT-PCR test for viral RNA. Asymptomatic patients with a negative COVID-19 test are cleared for surgery. However, little is known about the rate of postoperative COVID-19 positivity among elective surgical patients, risk factors for this group and rate of complications.
Methods
This prospective multicenter study included all patients undergoing elective surgery at 170 Veterans Health Administration (VA) hospitals across the United States. Patients were divided into groups based on first positive COVID-19 test within 30 days after surgery (COVID[-/+]), before surgery (COVID[+/−]) or negative throughout (COVID[−/−]). The cumulative incidence, risk factors for and complications of COVID[-/+], were estimated using univariate analysis, exact matching, and multivariable regression.
Results
Between March 1 and December 1, 2020 90,093 patients underwent elective surgery. Of these, 60,853 met inclusion criteria, of which 310 (0.5%) were in the COVID[-/+] group. Adjusted multivariable logistic regression identified female sex, end stage renal disease, chronic obstructive pulmonary disease, congestive heart failure, cancer, cirrhosis, and undergoing neurosurgical procedures as risk factors for being in the COVID[-/+] group. After matching on current procedural terminology code and month of procedure, multivariable Poisson regression estimated the complication rate ratio for the COVID[-/+] group vs. COVID[−/−] to be 8.4 (C.I. 4.9–14.4) for pulmonary complications, 3.0 (2.2, 4.1) for major complications, and 2.6 (1.9, 3.4) for any complication.
Discussion
Despite preoperative COVID-19 screening, there remains a risk of COVID infection within 30 days after elective surgery. This risk is increased for patients with a high comorbidity burden and those undergoing neurosurgical procedures. Higher intensity preoperative screening and closer postoperative monitoring is warranted in such patients because they have a significantly elevated risk of postoperative complications.

An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola

BACKGROUND:
The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014–2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country’s maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

METHODS:
Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible.

RESULTS:
Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1–3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided.

CONCLUSIONS:
Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.

Assessment of feasibility and acceptability of family-centered care implemented at a neonatal intensive care unit in India

Background
A family-centered care (FCC) parent participation program that ensures an infant is not separated from parents against their will was developed for the caring of their small or sick newborn at a neonatal intensive care unit (NICU) in Delhi, India. Healthcare provider sensitization training directed at psychosocial and tangible support and an audio-visual training tool for parent-attendants were developed that included: 1) handwashing, infection prevention, protocol for entry; 2) developmentally supportive care, breastfeeding, expression of breastmilk and assisted feeding; 3) kangaroo mother care; and 4) preparation for discharge and care at home. The study aimed to examine the feasibility and acceptability of the FCC model in a NICU in India.

Methods
A prospective cohort design collected quantitative data on each parent-attendant/infant dyad at enrollment, during the NICU stay, and at discharge. Feasibility of the FCC program was measured by assessing the participation of parent-attendants and healthcare providers, and whether training components were implemented as intended. Acceptability was measured by the proportion of parent-attendants who participated in the trainings and their ability to accurately complete program activities.

Results
Of 395 NICU admissions during the study period, eligible participants included 333 parent-attendant/infant dyads, 24 doctors, and 21 nurses. Of the 1242 planned parent-attendant training sessions, 939 (75.6%) were held, indicating that program fidelity was high, and the majority of trainings were implemented as intended. While 50% of parent-attendants completed all 4 FCC training sessions, 95% completed sessions 1 and 2; 60% of the total participating parent-attendants completed session 3, and 75% completed session 4. Compliance rates were over 96% for 5 of 10 FCC parent-attendant activities, and 60 to 78% for the remaining 5 activities.

Conclusions
FCC was feasible to implement in this setting and was acceptable to participating parent-attendants and healthcare providers. Parents participated in trainings conducted by NICU providers and engaged in essential care to their infants in the NICU. A standard care approach and behavior norms for healthcare providers directed psychosocial and tangible support to parent-attendants so that a child is not separated from his or her parents against their will while receiving advanced care in the NICU.

Did COVID-19 Pandemic change Anaesthesia Practices in India: A Multi-centre Cross-sectional Study

Introduction
The anaesthetic management for surgeries during the COVID-19 pandemic has posed unique challenges. Safety of all healthcare workers is an additional concern along with heightened risk to patients during General Anesthesia (GA). COVID-19 pneumonia and aerosol generation may be exacerbated during airway intervention and GA. We aimed to assess the change in the mode of anaesthesia due to the pandemic.

Methods
A research consortium led by WHO Collaboration Centre for Research in Surgical Care Delivery in Low and Middle Income countries, India, conducted this retrospective cross-sectional study in 12 hospitals across the country. We compared the anaesthesia preferences during pandemic (April 2020) to a corresponding pre pandemic period (April 2019)

Results
A total of 636 out of 2,162 (29.4%) and 156 out of 927 (16.8%) surgeries were performed under GA in April 2019 and April 2020 respectively, leading to a fall of 13% in usage of GA. A 5% reduction in GA and a 12% increase in the usage of regional anaesthesia was observed for cesarean sections. There was no significant change in anesthesia for laparotomies and fracture surgeries. However, 14% increase in GA usage was observed in surgeries for local soft tissue infections and necrotic tissues.

Conclusion
Though overall usage of GA reduced marginally, the change was mainly contributed by anesthesia for caesarean births. The insignificant change in anaesthesia for other surgeries may be attributed to the lack of facilities for spinal anaesthesia and may reflect the risk taking behaviour of healthcare professionals in COVID-19 pandemic.

Construction and Performance Testing of a Fast-Assembly COVID-19 (FALCON) Emergency Ventilator in a Model of Normal and Low-Pulmonary Compliance Conditions

Introduction: The COVID-19 pandemic has revealed an immense, unmet and international need for available ventilators. Both clinical and engineering groups around the globe have responded through the development of “homemade” or do-it-yourself (DIY) ventilators. Several designs have been prototyped, tested, and shared over the internet. However, many open source DIY ventilators require extensive familiarity with microcontroller programming and electronics assembly, which many healthcare providers may lack. In light of this, we designed and bench tested a low-cost, pressure-controlled mechanical ventilator that is “plug and play” by design, where no end-user microcontroller programming is required. This Fast-AssembLy COVID-Nineteen (FALCON) emergency prototype ventilator can be rapidly assembled and could be readily modified and improved upon to potentially provide a ventilatory option when no other is present, especially in low- and middle-income countries.

Hypothesis: We anticipated that a minimal component prototype ventilator could be easily assembled that could reproduce pressure/flow waveforms and tidal volumes similar to a hospital grade ventilator (Engström CarestationTM).

Materials and Methods: We benched-tested our prototype ventilator using an artificial test lung under 36 test conditions with varying respiratory rates, peak inspiratory pressures (PIP), positive end expiratory pressures (PEEP), and artificial lung compliances. Pressure and flow waveforms were recorded, and tidal volumes calculated with prototype ventilator performance compared to a hospital-grade ventilator (Engström CarestationTM) under identical test conditions.

Results: Pressure and flow waveforms produced by the prototype ventilator were highly similar to the CarestationTM. The ventilator generated consistent PIP/PEEP, with tidal volume ranges similar to the CarestationTM. The FALCON prototype was tested continuously for a 5-day period without failure or significant changes in delivered PIP/PEEP.

Conclusion: The FALCON prototype ventilator is an inexpensive and easily-assembled “plug and play” emergency ventilator design. The FALCON ventilator is currently a non-certified prototype that, following further appropriate validation and testing, might eventually be used as a life-saving emergency device in extraordinary circumstances when more sophisticated forms of ventilation are unavailable.

Respiratory complications after surgery in Vietnam: National estimates of the economic burden

Background
Estimating the cost of postoperative respiratory complications is crucial in developing appropriate strategies to mitigate the global and national economic burden. However, systematic analysis of the economic burden in low- and middle-income countries is lacking.

Methods
We used the nationwide database of the Vietnam Social Insurance agency and extracted data from January 2017 to September 2018. The data contain 1 241 893 surgical patients undergoing one of seven types of surgery. Propensity score matching method was used to match cases with and without complications. We used generalized gamma regressions to estimate the direct medical costs; logistic regressions to evaluate the impact of postoperative respiratory complications on re-hospitalization and outpatient visits.

Findings
Postoperative respiratory complications increased the odds of re-hospitalization and outpatient visits by 3·49 times (95% CI: 3·35–3·64) and 1·39 times (95% CI: 1·34–1·45) among surgical patients, respectively. The mean incremental cost associated with postoperative respiratory complications occurring within 30 days of the index admission was 1053·3 USD (95% CI: 940·7–1165·8) per procedure, which was equivalent to 41% of the GDP per capita of Vietnam in 2018. We estimated the national annual incremental cost due to respiratory complications occurring within 30 days after surgery was 13·87 million USD. Pneumonia contributed the greatest part of the annual cost burden of postoperative respiratory complications.

Interpretation
The economic burden of postoperative respiratory complications is substantial at both individual and national levels. Postoperative respiratory complications also increase the odds of re-hospitalization and outpatient visits and increase the length of hospital stay among surgical patients.