Crohn’s Disease Among the Poorest Billion: Burden of Crohn’s Disease in Low- and Lower-Middle-Income Countries

Background
To establish the epidemiology and patterns of care of Crohn’s Disease in low- and lower-middle-income countries.

Methods
A cross-sectional survey of gastroenterology providers in countries where the world’s poorest billion live was conducted to learn more about the state of diagnostic and treatment capacity for Crohn’s. Quantitative data were analyzed in R and Excel.

Results
A total of 46 survey responses from 15 countries were received, giving a response rate of 54.8%. All responses collected were from providers practicing in Africa and South Asia. The mean number of patients with Crohn’s cared for in the last year was 89.5 overall but ranged from 0 reported at one facility in Rwanda to 1000 reported at two different facilities in India. Overall, Crohn’s disease made up 20.6% of the inflammatory bowel disease diagnoses reported by survey respondents, with Africa exhibiting a larger proportion of Crohn’s compared to ulcerative colitis than Asia. Most providers reported that patients with Crohn’s have symptoms for 6–24 months prior to diagnosis and that 26–50% of their patients live in rural areas. The most reported diagnostic challenges are differentiating between Crohn’s and intestinal tuberculosis, poor disease awareness, and lack of trained pathologists. The most widely reported challenge in managing Crohn’s disease is patients’ inability to afford biologics, reported by 65% of providers.

Conclusion
Our study suggests there may be a greater burden of Crohn’s disease in low- and lower-middle-income countries than is indicated in prior literature. Respondents reported many challenges in diagnosing and treating Crohn’s disease.

Cost of open access publishing in otolaryngology-head and neck surgery

Objective
Open access (OA) publishing makes research more accessible but is associated with steep article processing charges (APCs). The study objective was to characterize the APCs of OA publishing in otolaryngology-head and neck surgery (OHNS) journals.

Methods
We conducted a cross-sectional analysis of published policies of 110 OHNS journals collated from three databases. The primary outcomes were the publishing model, APC for original research, and APC waiver policy.

Results
We identified 110 OHNS journals (57 fully OA, 47 hybrid, 2 subscription-only, 4 unknown model). After excluding 12 journals (2 subscription-only, 4 unknown model, 5 OA with unspecified APCs, and 1 OA that accepts publications only from society members), we analyzed 98 journals, 23 of which did not charge APCs. Among 75 journals with nonzero APCs, the mean and median APCs were $2452 and $2900 (interquartile range: $1082–3520). Twenty-five journals (33.3%) offered APC subsidies for authors in low- and middle-income countries (LMICs) and/or on a case-by-case basis. Eighty-five and 25 journals were based in high-income countries (HICs) and LMICs, respectively. The mean APC was higher among HIC journals than LMIC journals ($2606 vs. $958, p < 0.001).

Conclusion
APCs range from tens to thousands of dollars with limited waivers for authors in LMICs.

Second- and Third-Tier Therapies for Severe Traumatic Brain Injury

Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.

Abdominal Packing for Obstetric Surgical Uncontrollable Hemorrhage

Postpartum hemorrhage (PPH), which makes up the bulk of the 14 million occurrences of obstetric hemorrhage that happen yearly, is the most prevalent type. Obstetric emergencies must be promptly identified and treated because most PPH-related deaths occur within four hours of delivery and even after hysterectomy. This literature study tries to elucidate abdominal packing in reducing obstetrical bleeding in greater detail. Pads or roller gauze (sterile pads bound by suture threads, wrapped in a sterile bag, or stacked gauze) and balloon pack (Foley catheter or Bakri balloon), and abdominal packs retrieved within 24-48 hours, are two categories of abdominal packing techniques for controlling bleeding after hysterectomy. Due to its ease of use, minimal risk of complications, and usefulness in environments with limited resources, abdominal packing continues to be a valuable technique in the arsenal of the modern obstetrician.

Access to training in neurosurgery (Part 2): The costs of pursuing neurosurgical training

Introduction
Opportunities for in-country neurosurgical training are severely limited in LMICs, particularly due to rigorous educational requirements and prohibitive upfront costs.

Research question
This study aims to evaluate financial barriers aspiring neurosurgeons face in accessing and completing neurosurgical training, specifically in LMICs, in order to determine the barriers to equitable access to training.

Material and methods
In order to assess the financial costs of accessing and completing neurosurgery residency, an electronic survey was administered to those with the most recent experience with the process: aspiring neurosurgeons, neurosurgical trainees, and recent neurosurgery graduates. We attempted to include a broad representation of World Health Organization (WHO) geographic regions and World Bank income classifications in order to determine differences among regions and countries of different income levels.

Results
Our survey resulted in 198 unique responses (response rate 31.3%), of which 83% (n ​= ​165) were from LMICs. Cost data were reported for 48 individual countries, of which 26.2% were reported to require trainees to pay for their neurosurgical training. Payment amounts varied amongst countries, with multiple countries having costs that surpassed their annual gross national income as defined by the World Bank.

Discussion and conclusions
Opportunities for formal neurosurgical training are severely limited, especially in LMICs. Cost is an important barrier that can not only limit the capacity to train neurosurgeons but can also perpetuate inequitable access to training. Additional investment by governments and other stakeholders can help develop a sufficient workforce and reduce inequality for the next generation of neurosurgeons worldwide.

mHealth Interventions to Improve Cancer Screening and Early Detection: Scoping Review of Reviews

Background:
Cancer screening provision in resource-constrained settings tends to be opportunistic, and uptake tends to be low, leading to delayed presentation and treatment and poor survival.

Objective:
The aim of this study was to identify, review, map, and summarize findings from different types of literature reviews on the use of mobile health (mHealth) technologies to improve the uptake of cancer screening.

Methods:
The review methodology was guided by the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Ovid MEDLINE, PyscINFO, and Embase were searched from inception to May 2021. The eligible criteria included reviews that focused on studies of interventions that used mobile phone devices to promote and deliver cancer screening and described the effectiveness or implementation of mHealth intervention outcomes. Key data fields such as study aims, types of cancer, mHealth formats, and outcomes were extracted, and the data were analyzed to address the objective of the review.

Results:
Our initial search identified 1981 titles, of which 12 (0.61%) reviews met the inclusion criteria (systematic reviews: n=6, 50%; scoping reviews: n=4, 33%; rapid reviews: n=1, 8%; narrative reviews: n=1, 8%). Most (57/67, 85%) of the interventions targeted breast and cervical cancer awareness and screening uptake. The most commonly used mHealth technologies for increasing cancer screening uptake were SMS text messages and telephone calls. Overall, mHealth interventions increased knowledge about screening and had high acceptance among participants. The likelihood of achieving improved uptake-related outcomes increased when interventions used >1 mode of communication (telephone reminders, physical invitation letters, and educational pamphlets) together with mHealth.

Conclusions:
mHealth interventions increase cancer screening uptake, although multiple modes used in combination seem to be more effective.

J Med Internet Res 2022;24(8):e36316

Decolonizing Global Surgery

By bringing health professionals across a variety of disciplines together, we are able to share strategies and create solutions for improving surgical care to these under-serviced regions. The Bethune Round Table 2022 took place virtually, June 16 – 19 and was hosted by BGSC,in co-operation with the Canadian Network for International Surgery. The theme for the BRT 2022 was “Decolonizing Global Surgery”.

The conference program consisted of 28 panelists and speakers and 98 abstracts (46 podium presentations and 52 posters) touching upon diverse aspects of global surgery including women in surgery, indigenous health, and sustainability in global partnerships. All sessions were recorded, including abstracts. All the abstracts presented are contained within this document.

The Connection between Climate Change, Surgical Care and Neglected Tropical Diseases

The surgical burden of neglected tropical diseases (NTDs) is set to rise alongside average temperatures and drought. NTDs with surgical indications, including trachoma and lymphatic filariasis, predominantly affect people in low- and middle-income countries where the gravest effects of climate change are likely to be felt. Vectors sensitive to temperature and rainfall will likely expand their reach to previously nonendemic regions, while drought may exacerbate NTD burden in already resource-strained settings. Current NTD mitigation strategies, including mass drug administrations, were interrupted by COVID-19, demonstrating the vulnerability of NTD progress to global events. Without NTD programming that meshes with surgical systems strengthening, climate change may outpace current strategies to reduce the burden of these diseases.

Achieving Antimicrobial Stewardship on the Global Scale: Challenges and Opportunities

Antimicrobial resistance (AMR) has been clearly identified as a major global health challenge. It is a leading cause of human deaths and also has a toll on animals, plants, and the environment. Despite the considerable socio-economic impacts, the level of awareness of the problem remains woefully inadequate, and antimicrobials are not generally recognized as a global common good, one that everyone has a role and responsibility to conserve. It is imperative for antimicrobial stewardship to be more widely implemented to achieve better control of the AMR phenomenon. The Food and Agriculture Organization (FAO) of the United Nations plays an important role in promoting and facilitating antimicrobial stewardship. The specific needs to be addressed and barriers to be overcome, in particular, in low- and middle-income countries in order to implement antimicrobial stewardship practices in agrifood systems are being identified. As a global community, it is essential that we now move beyond discussing the AMR problem and focus on implementing solutions. Thus, FAO provides multi-pronged support for nations to improve antimicrobial stewardship through programs to strengthen governance, increase awareness, develop and enhance AMR surveillance, and implement best practices related to antimicrobial resistance in agrifood systems. For example, FAO is developing a platform to collect data on AMR in animals and antimicrobial use (AMU) in plants (InFARM), working on a campaign to reduce the need to use antimicrobials, studying the use of alternatives to the use of antimicrobials (especially those used for growth promotion) and actively promoting the implementation of the Codex Alimentarius AMR standards. Together, these will contribute to the control of AMR and also bring us closer to the achievement of multiple sustainable development goals.

Building power-ful health systems: the impacts of electrification on health outcomes in LMICs

Critical disparities threaten health care in developing countries and hinder progress towards global development commitments. Almost a billion people and thousands of public services are not yet connected to electricity – a majority in sub-Saharan Africa. In economically fragile settings, clinics and health services struggle to gain and maintain their access to the most basic energy infrastructure. Less than 30% of health facilities in LMICs report access to reliable energy sources, truncating health outcomes and endangering patients in critical conditions. While ‘universal health coverage’ and ‘sustainable energy for all’ are two distinct SDGs with their respective targets, this review challenges their disconnect and inspects their interdependence in LMICs. To evaluate the impact of electrification on healthcare facilities in LMICs, this systematic review analysed relevant publications up to March 2021, using MEDLINE, Embase, Scopus, CENTRAL, clinicaltrials.gov and CINAHL. Outcomes captured were in accordance with the WHO HHFA modules. A total of 5083 studies were identified, 12 fulfilled the inclusion criteria of this review – most were from Africa, with the exception of two studies from India and one from Fiji. Electrification was associated with improvements in the quality of antenatal care services, vaccination rates, emergency capabilities and primary health services; with many facilities reporting high-quality, reliable and continuous oxygen supplies, refrigeration and enhanced medical supply chains. Renewable energy sources were considered in six of the included studies, most highlighting their suitability for rural health facilities. Notably, solar-powered oxygen delivery systems reduced childhood mortality and length of hospital stay. Unavailable and unreliable electricity is a bottleneck to health service delivery in LMICs. Electrification was associated with increased service availability, readiness and quality of care – especially for women, children and those under critical care. This study indicates that stable and clean electrification allows new heights in achieving SDG 3 and SDG7 in LMICs.