Amid COVID-19 pandemic, are non-COVID patients left in the lurch?

Objectives: 1) To explore the possible impact of the pandemic on the health seeking behavior of the patients, 2) To explore the relation of socio-demographics on the utility of health-care facilities.

Methods: This cross-sectional study was conducted by enrolling all patients ≥15 years of age presenting to the Out-Patient-Department of three main public-hospitals after obtaining ethical committee approval. A questionnaire with validated Urdu translation was filled by each participant that included socio-demographic data, pre-Covid and Covid-19 era health seeking behaviors and the impact of the pandemic on the utilization of healthcare facilities. Data was analyzed using SPSS V.19.

Results: A total of 393 patients were enrolled with a male preponderance (72%) and a median age range of 31-45 years. Fifty-eight percent of the study population was unemployed and 47.3% were seeking follow up care. The frequency of ER and multiple (>4 times) OPD visits were significantly decreased in the Covid-19 times whereas, the laboratory and radiology services were largely unaffected. A significant number of patients were not satisfied with the current healthcare facilities that was seen irrespective of the socio-demographic status. Emergency Room and radiology services were largely unaffected whereas, elective procedures and laboratory facilities were reported to be severely affected or delayed in relation to socio-demographic variables.

Conclusions: Healthcare inequalities have widened and depression has shown a sharp rise during this pandemic. The over-burdened healthcare facilities at the verge of collapse may miss out on the chronic non-Covid patients which would ultimately lead to increased morbidity and mortality.

Neglected tropical diseases activities in Africa in the COVID-19 era: the need for a “hybrid” approach in COVID-endemic times

With the coronavirus disease 2019 (COVID-19) pandemic showing no signs of abating, resuming neglected tropical disease (NTD) activities, particularly mass drug administration (MDA), is vital. Failure to resume activities will not only enhance the risk of NTD transmission, but will fail to leverage behaviour change messaging on the importance of hand and face washing and improved sanitation—a common strategy for several NTDs that also reduces the risk of COVID-19 spread. This so-called “hybrid approach” will demonstrate best practices for mitigating the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by incorporating physical distancing, use of masks, and frequent hand-washing in the delivery of medicines to endemic communities and support action against the transmission of the virus through water, sanitation and hygiene interventions promoted by NTD programmes. Unless MDA and morbidity management activities resume, achievement of NTD targets as projected in the WHO/NTD Roadmap (2021–2030) will be deferred, the aspirational goal of NTD programmes to enhance universal health coverage jeopardised and the call to ‘leave no one behind’ a hollow one. We outline what implementing this hybrid approach, which aims to strengthen health systems, and facilitate integration and cross-sector collaboration, can achieve based on work undertaken in several African countries.

Organ Donation and Transplantation in Sub-Saharan Africa: Opportunities and Challenges

Sub-Saharan Africa (SSA), occupying about 80% of the African continent is a heterogeneous region with estimated population of 1.1 billion people in 47 countries. Most belong to the low resource countries (LRCs). The high prevalence of end-organ diseases of kidney, liver, lung and heart makes provision of organ donation and transplantation necessary. Although kidney and heart transplantations were performed in South Africa in the 1960s, transplant activity in SSA lags behind the developed world. Peculiar challenges militating against successful development of transplant programmes include high cost of treatment, low GDP of most countries, inadequate infrastructural and institutional support, absence of subsidy, poor knowledge of the disease condition, poor accessibility to health-care facilities, religious and trado-cultural practices. Many people in the region patronize alternative healthcare as first choice. Opportunities that if harnessed may alter the unfavorable landscape are: implementation of the 2007 WHO Regional Consultation recommendations for establishment of national legal framework and self-sufficient organ donation/transplantation in each country and adoption of their 2020 proposed actions for organ/transplantation for member states, national registries with sharing of data with GODT, prevention of transplant commercialization and tourism. Additionally, adapting some aspects of proven successful models in LRCs will improve transplantation programmes in SSA.

Surgical data strengthening in Ethiopia: results of a Kirkpatrick framework evaluation of a data quality intervention

Background: One key challenge in improving surgical care in resource-limited settings is the lack of high-quality and informative data. In Ethiopia, the Safe Surgery 2020 (SS2020) project developed surgical key performance indicators (KPIs) to evaluate surgical care within the country. New data collection methods were developed and piloted in 10 SS2020 intervention hospitals in the Amhara and Tigray regions of Ethiopia.

Objective: To assess the feasibility of collecting and reporting new surgical indicators and measure the impact of a surgical Data Quality Intervention (DQI) in rural Ethiopian hospitals.

Methods: An 8-week DQI was implemented to roll-out new data collection tools in SS2020 hospitals. The Kirkpatrick Method, a widely used mixed-method evaluation framework for training programs, was used to assess the impact of the DQI. Feedback surveys and focus groups at various timepoints evaluated the impact of the intervention on surgical data quality, the feasibility of a new data collection system, and the potential for national scale-up.

Results: Results of the evaluation are largely positive and promising. DQI participants reported knowledge gain, behavior change, and improved surgical data quality, as well as greater teamwork, communication, leadership, and accountability among surgical staff. Barriers remained in collection of high-quality data, such as lack of adequate human resources and electronic data reporting infrastructure.

Conclusions: Study results are largely positive and make evident that surgical data capture is feasible in low-resource settings and warrants more investment in global surgery efforts. This type of training and mentorship model can be successful in changing individual behavior and institutional culture regarding surgical data collection and reporting. Use of the Kirkpatrick Framework for evaluation of a surgical DQI is an innovative contribution to literature and can be easily adapted and expanded for use within global surgery.

The landscape of academic global surgery: a rapid review

Interest in academic global surgery, which comprises clinical, educational, and research collaborations to improve surgical care between academic surgeons in high-income countries and low- and middle-income countries (LMICs) and their corresponding academic institutions, has grown over the years. However, there is no collective knowledge of academic global surgery. Thus, this review aims to understand the current landscape of academic global surgery and discuss future directions. A rapid review, a streamlined approach, was conducted to identify and summarize emerging studies systematically. The keywords applied in the search strategy were “global surgery” and “academic programs”. The total number of retrieved articles in PubMed was 390, and after the investigation, 20 articles were extensively reviewed for the result section. According to the results, this study provided findings regarding: (I) perceptions of residents, faculty, and surgical program directors toward academic global surgery programs, (II) key program characteristics of implemented academic global surgery programs, and (III) evaluation results of available academic global surgery programs. We also drew lessons and challenges for a useful guide for future academic global surgery research and the development of optimal educational programs. This review identified a small but rich set of information on academic global surgery. Further research and discussion are needed on how to successfully incorporate the academic global surgery program into medical institutions

Radiologic-Pathologic Analysis of Increased Ethanol Localization and Ablative Extent Achieved by Ethyl Cellulose

Purpose
Ethanol provides a rapid, low-cost ablative solution for liver tumors with a small technological footprint but suffers from uncontrolled diffusion in target tissue, limiting treatment precision and accuracy. The authors demonstrate that incorporating the gel-forming polymer ethyl cellulose to ethanol localizes the distribution. This therapy may have a low barrier of entry for cancer care in low- and middle- income countries.

Materials and Methods
The relationship of radiodensity to ethanol concentration was characterized with water-ethanol surrogates. Ex vivo EC-ethanol ablations were performed to optimize the formulation (n=6). In vivo ablations were performed to compare the optimal EC-ethanol formulation to pure ethanol (n=6). Ablations were monitored with CT and ethanol distribution volume was quantified. Livers were explanted, sectioned and stained with NADH-diaphorase to determine the ablative extent.

Results
CT imaging of ethanol-water surrogates demonstrated the ethanol concentration-radiodensity relationship is approximately linear. A concentration of 12% EC in ethanol created the largest distribution volume, more than 8-fold that of pure ethanol, ex vivo. In vivo, 12% EC-ethanol was superior to pure ethanol, yielding a distribution volume 3 times greater and an ablation zone 6 times greater than pure ethanol.

Conclusions
EC-ethanol, a novel gel formulation injectable ablative injectate, safely increases distribution and necrosis compared to pure ethanol.

Healthcare providers’ and managers’ knowledge, attitudes and perceptions regarding international medical volunteering in Uganda: a qualitative study

Objectives The study sought to explore the knowledge, attitudes and perceptions of healthcare providers and health programme managers regarding the benefits, challenges and impact of international medical volunteers’ clinical placements. Views on how to better improve the work of international medical volunteers and the volunteer organisation Voluntary Service Overseas (VSO) for the benefit of local communities were also explored.

Settings Public healthcare facilities, VSO offices in Gulu and VSO offices in Kampala, Uganda.

Participants Ugandan healthcare providers (n=11) and health programme managers (n=6) who had worked with or managed international medical volunteers.

Interventions Data collection was conducted using key informant interviews. Transcribed interviews were coded by topic and grouped into categories. Thematic framework analysis using NVivo identified emerging themes.

Results Both healthcare providers and managers reported a beneficial impact of volunteers and working with the volunteer organisation (clinical service provision, multidisciplinary teamwork, patient-centred care, implementation of audits, improved quality of care, clinical teaching and mentoring for local healthcare providers); identified challenges of working with volunteers (language barriers and unrealistic expectations) and the organisation (lack of clear communication and feedback processes); and provided recommendations to improve volunteer placements and working partnership with the organisation (more local stakeholder input and longer placements). Most healthcare providers were positive and recommended that volunteers are enabled to continue to work in such settings if resources are available to do so.

Conclusions Healthcare providers based in a low-resource setting report positive experiences and impacts of working with international medical volunteers. Currently, there is lack of local feedback processes, and the establishment of such processes that consider local stakeholder reflections requires further strengthening. These would help gain a better understanding of what is needed to ensure optimal effectiveness and sustainable impact of international medical volunteer placements.

From short-term surgical missions towards sustainable partnerships. A survey among members of visiting teams

Introduction
An estimated five billion people lack access to safe surgical care across the globe. Traditionally, providing short-term surgical missions has been the main strategy for health professionals from high-income countries to support surgical care in low- and middle-income countries. However, traditional missions have come under criticism because evidence of their sustainable value is lacking, along with any robust documentation and application of recommendations by participants of ongoing surgical missions. Using survey data collection and analysis, this study aims to provide a framework on how to improve the use of visiting surgical teams to strengthen surgical services in resource-poor settings.

Method
An online survey was conducted among members of foreign teams to collect data on five specific areas: basic characteristics of the mission, main activities. follow-up and reporting, the local registration process and collaboration with local actors. The survey included 58 respondents from 13 countries, and representing 20 organizations.

Results
During surgical missions, training activities were considered most impactful, and reporting on outcome/s, along with long-term follow-up were strongly recommended. According to almost all participants (94 percent), the focus should be on establishing collaborative practices with local actors, and encourage strategic, long-term changes under their leadership.

Conclusion
Building sustainable partnerships within local healthcare systems is the way forward for foreign surgical parties that aim to improve surgical care in low- and- middle income countries. When foreign help is offered, local stakeholders should be in the lead.

The embodiment of low-field MRI for the diagnosis of infant hydrocephalus in Uganda

Compared to other parts of the world, theincidence of hydrocephalus in children is very high in subSaharan Africa. Magnetic resonance imaging (MRI) would be the
preferred diagnostic method for infant hydrocephaleus. However, in practice, MRI is seldom used in sub-Saharan Africa due to its high prize, low mobility, and high power consumption.
A low-cost MRI technology is under development by reducing the strength of the magnetic field and the use of alternative technologies to create the magnetic field. This paper describes the embodiment design process to match this new MRI technology under development with the specific characteristics of the healthcare system in Uganda.

A context exploration was performed to identify factors that may affect the design and implementation of the low-field MRI in Ugandan hospitals and Ugandan healthcare environment. The key-insights from the technology- and context-exploration were translated into requirements which were the starting point for the design process. The concept development did have a focus on Cost-effective design, Design for durability & reliability, and Design for repairability. The final design was validated by stakeholders from the Ugandan Healthcare context.

Frugal innovations that helped mission hospitals manage during the pandemic and further suggestions

The COVID-19 pandemic with the suddenly announced lockdown in India caused great stress to already resource-constrained rural mission hospitals. Frugal innovations helped some of the mission hospitals cope with the lockdown and resume regular work. Personal Protective Equipment was made locally and staff were trained to take care of the infected patients. Cell phones and the zoom app helped them with communications. The Gas Insufflation Less Laparoscopic surgical technique helped them perform safe surgeries and allow quicker turnover of patients. The innovative Laptop Cystoscope helped in follow up treatment of patients treated earlier by specialists and for emergency treatment. Empowering local mission hospital doctors and modern communication methods helped these hospitals maintain services during the pandemic.