Social media and global cardiovascular disparities

Social media have become pervasive in modern life, academic practice, and medicine, even more so in response to the COVID-19 pandemic. Ladeiras-Lopes et al.1 present a timely overview of social media in cardiovascular medicine, highlighting successes to date and opportunities to responsibly incorporate social media in clinicians’ and researchers’ toolbox. Indeed, the power and growth of social media cannot be disregarded. For professional platforms like Twitter, the reach of tweets can be as much as hundreds of thousands of unique users: a large and fast gain for minimal (280-character) effort. The potential of social media platforms has further been clear through its ability to foster social networks, remote mentorship, virtual journal clubs, post-publication peer review, and more.2 In today’s world, where virtual communication, education, and telemedicine are increasingly leveraged, opportunities arise to take existing social media tools beyond our immediate environments and seek to connect with and learn from peers and colleagues in low- and middle-income countries (LMICs) and remote areas.3

Disparities in cardiovascular medicine persist as 18 million people die each year from cardiovascular diseases, of which a vast majority takes place in LMICs.4 Six billion people lack access to safe, timely, and affordable cardiac surgical care,4 whereas little is known regarding the global distribution of non-surgical cardiac care providers. Nevertheless, many challenges, such as inefficient supply chains, limited training programmes, remote populations, lack of financial risk protection, and other barriers to care remain common across all cardiovascular disciplines. In addition, beyond health system disparities, language barriers contribute to the vast gap in country- or population-specific research in the global health and global surgery context. Moreover, this has commonly been skewed with anglophone predominance, requiring a paradigm shift to instill more equitable practices within today’s academic ecosystem.

Social media has shown vast potential in the realms of global health and global surgery, creating networks of clinicians, trainees, and researchers all the way to the last mile.5 While current social media engagement is focused largely on online dialogue, it is increasingly leveraged as a tool to foster global collaboration, community engagement, education, and awareness regarding global health issues.6 Importantly, social media have been used to facilitate telemedicine and teleconsult communication channels to gain expertise from colleagues remotely or to educate residents and fellows, especially in lower-resource or remote settings.7,8 The current pandemic further leverages such channels and networks to host virtual conferences and shift to virtual education, ranging from video-conference calls to online training modules and low-cost, low-to-high-fidelity virtual reality and simulators.3 Similar opportunities arise to utilize such networks, specifically with regards to social media, in the fields of global cardiology and global cardiac surgery.

Social media platforms aid in creating global networks that transcend borders and promote international collaboration. For example, the Global Cardiac Surgery Initiative brings together trainees and young surgeons in cardiac surgery from around the world to advance the field of global cardiac surgery, illustrating what can result from such networks in terms of mentorship, sponsorship, and support for trainees and early-career researchers.9 Education and research are no longer limited by distance or time zones, giving way to open-access information through low-cost or free-of-charge webinars and conferences. Experts in the field share evidence-based and experience-based education and advice, recordings of which are readily available for whenever needed. Cases, some one-of-a-kind as observed in the current pandemic, may be discussed among colleagues and how to best manage them considering available resources and training. Accordingly, social media facilitates virtual training, presenting a variety of topics directed to students, trainees, faculty, and even patients. Moreover, virtual coaching of the entire cardiac surgery team present in the operating room, including perfusionists, scrub technicians, and nurses, remains an area of opportunity to explore to truly leverage the heart team mentality at the core of our work and such online engagement.

During this pandemic, social media has proven to be an effective tool for rapidly disseminating novel information, guidelines, and recently published papers.10 This allows for global efforts to continue in a timely fashion despite known or unforeseen barriers, such as the COVID-19 pandemic. Therefore, recognizing and understanding such barriers constitutes an important aspect of global health. One may utilize such platforms to present ongoing projects and the difficulties they encounter along the way. Additionally, social media allows for increasing awareness regarding understudied and under-addressed topics, such as global cardiac surgery. It makes connecting and interacting with others dedicated to global health, as well as other medical and non-medical disciplines, amiable, and approachable. These are of importance to create a true interdisciplinary and intersectoral health system that aims to consider multiple points of views and cover all issues thoroughly, as opposed to conventional vertical-only global health interventions. It is time for governments, global organizations, and individuals to search for long-due solutions and implement radical changes, in which social media can be a fundamental tool. Global research collaborations allow for increased awareness of each countries’ disparities and ideas to dissipate them, as well as finding sponsor organizations and partners with similar goals, facilitating resource collection and allocation in a sustainable manner. Social media may provide an opportunity for generating international registries to better understand population-specific characteristics and differences in access to care. Finally, it serves as an invaluable tool to inspire and mentor trainees to pursue certain career options, at home and abroad. The impact on the formation of present and future cardiology and cardiac surgery leaders will continue to grant encouraging results, extending to all corners of the world.

Global cardiovascular disparities prevail and substantially impede progress towards the Sustainable Development Goals and countries’ paths towards universal health coverage. Social media is a tool that should be leveraged to foster awareness surrounding these global disparities and accelerate shared learning, network building, and knowledge generation and dissemination within global cardiovascular care.

Designing devices for global surgery: evaluation of participatory and frugal design methods

Introduction:
Most people living in low- and middle-income countries have no access to surgical care. Equipping under-resourced health care contexts with appropriate surgical equipment is thus critical. “Global” technologies must be designed specifically for these contexts. But while models, approaches and methods have been developed for the design of equipment for global surgery, few studies describe their implementation or evaluate their adequacy for this purpose.

Methods:
A multidisciplinary team applied participatory and frugal design methods to design a surgical device for gasless laparoscopy. The team employed a formal roadmap, devised to guide the development of global surgical equipment, to structure the design process into phases. Phases 0–1 comprised primary research with surgeons working in low-resource settings and forming collaborative partnerships with key stakeholders. These participated in phases 2–3 through design workshops and video events. To conclude, surgical stakeholders (n=13) evaluated a high-fidelity prototype in a cadaveric study.

Results:
The resulting design, “RAIS” (Retractor for Abdominal Insufflation-less Surgery), received positive feedback from rural surgeons keen to embrace and champion innovation as a result of the close collaboration and participatory design methods employed. The roadmap provided a valuable means to structure the design process but this evaluation highlighted the need for further development to detail specific methodology. The project outcomes were used to develop recommendations for innovators designing global surgical equipment.

To inform early phases in the design roadmap, engaging a variety of stakeholders to provide regular input is crucial. Effective communication is vital to elucidate clear functional design requirements and hence reveal opportunities for frugal innovation. Finally, responsible innovation must be embedded within the process of designing devices for global surgery.

Conclusion:
A community-wide effort is required to formally evaluate and optimize processes for designing global surgical devices and hence accelerate adoption of frugal surgical technologies in low-resource settings.

Estimated Impact of the COVID-19 Economic Recession on Under-5 Mortality Rates for 129 Countries

Background: This study estimates the potential loss of life in children under five years old attributable to the economic recessions of 2020. Multiple prior studies have shown a strong and independent effect of GDP per capita on child mortality in developing countries after controlling for health system effects, demography, politics, environment, and literacy.

Methods: Data were retrieved from the World Bank World Development Indicators database and the United Nations World Populations Prospects estimates for the years 1990-2020 for 129 countries with GDP per capita below 12,375 US$ (defined as low, lower-middle, and upper-middle income countries; LMICs). We used a multi-level, mixed effects, multivariate model to estimate the adjusted relationship between GDP per capita and the under-5 mortality rate (U5MR) specific to each country. The model’s country-specific parameters were used to simulate the impact on U5MR due to reductions in GDP per capita of 5%, 10%, and 15%.

Findings: In a conservative scenario, a 5% reduction in GDP per capita in 2020 is estimated to cause an additional 282,996 deaths in children under 5 in one year compared to a baseline of no economic recession. Recessions at 10% and 15% lead to higher losses of under-5 lives, increasing to 585,802 and 911,026 additional deaths, respectively. We estimate that nearly half of all the potential under-5 lives lost from economic recessions in LMICs are estimated to occur in Sub-Saharan Africa.

Interpretation: In developing countries, under-5 mortality rates are closely tied to national income. We estimate that the recessions of 2020 will lead to around 300,000 deaths in the under-5 population. Our results do not take into account the irreparable effects of economic deprivation on child development. We expect to see similar trends of child mortality in the next few years in the absence of sufficient SARS-CoV-2 vaccination or herd immunity.

Recommendations for the Management of COVID-19 in Low- and Middle-Income Countries

At the conclusion of its first year, the dynamics of the COVID-19 pandemic are still fluid. Today’s global and regional numbers on incidence and mortality are outdated just a few weeks later. Effective SARS-CoV-2 vaccines are becoming available, but the exact timeline of their availability, in particular in low- and middle-income countries (LMICs), is still unclear. What has become clear, albeit not completely understood, is that many poorer countries have been hit less by the pandemic than high-income countries (HICs), even when accounting for underreporting related to more limited testing capacity. Many LMICs need to be commended for their generally faster public health responses at much earlier stages in their epidemics than their HIC counterparts. Also, likely because of the relatively younger population in LMICs than HICs, the estimated COVID-19 infection/ fatality ratio is typically around two to three deaths per 1,000 infections in LMICs, contrasted to six to 10 deaths per 1,000 infections observed in HICs with older populations.

Broader health impacts of vertical responses to Covid-19 in low- and middle-income countries

The COVID-19 pandemic has undermined capacity and efforts to address other health needs that are just as pressing as the virus itself, particularly in low- and middle-income countries (LMICs). Pressure on governments to act on COVID-19 now to save “immediately identifiable lives” rather than “statistical lives at risk”1 has had and will continue to have harmful short- and long-term consequences for other areas of health. This paper reviews the effects of vertical responses to COVID-19 on health systems, services, and people’s access to and use of them in LMICs, where historic and ongoing under-investments heighten vulnerability to a multiplicity of health threats. We use the term ‘vertical response’ to describe decisions, measures and actions taken solely with the purpose of preventing and containing COVID-19, often without adequate consideration of how this affects the wider health system and pre-existing resource constraints. Through four main sections focused on 1) characterising vertical response, 2) the drivers of broader health impacts, 3) evidence of impacts, and finally 4) suggestions for mitigation, we provide insight for actors in government, agencies, organisations and communities to design and implement more proportionate, appropriate, comprehensive and socially just responses that address COVID-19 without compromising other aspects of health. Beyond immediate action, there is a need to re-evaluate priorities and approaches in global health, both in the context of COVID-19 and beyond. If the well-being of all people is truly valued, ‘whole of health’ approaches which account for health trade-offs of COVID-19 response in the short-term, and address the health needs of diverse populations in the medium- to long-term are crucial.

Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control

Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site–specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems’ capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.

The Rise of Inflow Cisternostomy in Resource-Limited Settings: Rationale, Limitations, and Future Challenges

Low- and middle-income countries (LMICs) bear most of the global burden of traumatic brain injury (TBI), but they lack the resources to address this public health crisis. For TBI guidelines and innovations to be effective, they must consider the context in LMICs; keeping this in mind, this article will focus on the history, pathophysiology, practice, evidence, and implications of cisternostomy. In this narrative review, the author discusses the history, pathophysiology, practice, evidence, and implications of cisternostomy. Cisternostomy for the management of TBI is an innovation developed in LMICs, primarily for LMICs. Its practice is based on the cerebrospinal fluid shift edema theory that attributes injury to increased pressure within the subarachnoid space due to subarachnoid hemorrhage and subsequent dysfunction of glymphatic drainage. Early reports of the technique report significant improvements in the Glasgow Outcome Scale, lower mortality rates, and shorter intensive care unit durations. Most reports are single-center studies with small sample sizes, and the technique requires experience and skill. These limitations have led to criticisms and slow adoption of the technique. Further research is needed to establish the effect of cisternostomy on TBI outcomes.

Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies

Secondary peritonitis and intra-abdominal sepsis are a global health problem. The life-threatening systemic insult that results from intra-abdominal sepsis has been extensively studied and remains somewhat poorly understood. While local surgical therapy for perforation of the abdominal viscera is an age-old therapy, systemic therapies to control the subsequent systemic inflammatory response are scarce. Advancements in critical care have led to improved outcomes in secondary peritonitis. The understanding of the effect of secondary peritonitis on the human microbiome is an evolving field and has yielded potential therapeutic targets. This review of secondary peritonitis discusses the history, classification, pathophysiology, diagnosis, treatment, and future directions of the management of secondary peritonitis. Ongoing clinical studies in the treatment of secondary peritonitis and the open abdomen are discussed

Point-of-Care Ultrasound: Applications in Low- and Middle-Income Countries

Purpose of Review
This review highlights the applications of point-of-care ultrasound in low- and middle-income countries and shows the diversity of ultrasound in the diagnosis and management of patients.

Recent Findings
There is a paucity of data on point-of-care ultrasound in anesthesiology in low- and middle-income countries. However, research has shown that point-of-care ultrasound can effectively help manage infectious diseases, as well as abdominal and pulmonary pathologies.

Summary
Point-of-care ultrasound is a low-cost imaging modality that can be used for the diagnosis and management of diseases that affect low- and middle-income countries. There is limited data on the use of ultrasound in anesthesiology, which provides clinicians and researchers opportunity to study its use during the perioperative period.

Double standards in healthcare innovations: the case of mosquito net mesh for hernia repair

With over two decades of evidence available including from randomised clinical trials, we explore whether the use of low-cost mosquito net mesh for inguinal hernia repair, common practice only in low-income and middle-income countries, represents a double standard in surgical care. We explore the clinical evidence, biomechanical properties and sterilisation requirements for mosquito net mesh for hernia repair and discuss the rationale for its use routinely in all settings, including in high-income settings. Considering that mosquito net mesh is as effective and safe as commercial mesh, and also with features that more closely resemble normal abdominal wall tissue, there is a strong case for its use in all settings, not just low-income and middle-income countries. In the healthcare sector specifically, either innovations should be acceptable for all contexts, or none at all. If such a double standard exists and worse, persists, it raises serious questions about the ethics of promoting healthcare innovations in some but not all contexts in terms of risks to health outcomes, equitable access, and barriers to learning.