PDFs


1. Determinants of survival in children with cancer in Johannesburg, South Africa

SA Journal of Oncology


Authors: Nadia Beringer, Kate G. Bennett, Janet E. Poole, Jennifer A. Geel
Region / country: Southern Africa – South Africa
Speciality: Paediatric surgery, Surgical oncology

Background: Childhood cancer, although rare, remains an important cause of death worldwide. The outcomes of children with all cancer types in South Africa are not well-documented.

Aim: The aim of the article was to determine local childhood cancer survival rates and establish determinants of survival.

Setting: The study was conducted at a state and a private hospital in South Africa.

Methods: This retrospective cohort study consecutively included all children with a proven malignancy from 01 January 2012 to 31 December 2016. Univariable and multivariable analyses were used to establish which factors significantly impacted overall survival (OS).

Results: Of a total of 677 study participants, 71% were black South Africans. The estimated 5-year overall survival (OS) was 57% (95% confidence interval [CI]: 53-61%) and significant determinants of OS on the multivariable analysis included: ethnicity, cancer-type and nutritional status. White and Indian patients had higher OS compared to black patients (hazard ration [HR] (95% CI) 0.46 (0.30-0.69) p = 0.0002 and HR (95%) 0.38 (0.19-0.78) p = 0.0087, respectively). Underweight patients had inferior survival (HR (95% CI) 1.78 (1.28-2.47)) p = 0.0006. Patients with neuroblastoma had an increased risk of dying compared to those with leukaemia (HR [95% CI] 1.78 [1.08-2.94]) p = 0.025. Progression of disease was the most common cause of death, followed by disease relapse.

Conclusion: The childhood cancer survival rate obtained in this study can be used as a baseline to facilitate improvement. Non-modifiable prognostic factors included ethnicity and cancer-type whilst modifiable risk factors included undernutrition. Undernutrition should be addressed on a national and local level to improve survival.


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2. Epidemiology of surgery in a protracted humanitarian setting: a 20-year retrospective study of Nyarugusu Refugee Camp, Kigoma, Western Tanzania

BMC Surgery


Authors: Sarah Rapaport, Hilary Ngude, Amber Lekey, Mohamed Abbas, Peter J. Winch, Kent Stevens, Zachary Obinna Enumah
Region / country: Eastern Africa – Tanzania
Speciality: General surgery, Health policy

Background
There are 80 million forcibly displaced persons worldwide, 26.3 million of whom are refugees. Many refugees live in camps and have complex health needs, including a high burden of non-communicable disease. It is estimated that 3 million procedures are needed for refugees worldwide, yet very few studies exist on surgery in refugee camps, particularly protracted refugee settings. This study utilizes a 20-year dataset, the longest dataset of surgery in a refugee setting to be published to date, to assess surgical output in a setting of protracted displacement.

Methods
A retrospective review of surgeries performed in Nyarugusu Camp was conducted using paper logbooks containing entries between November 2000 and September 2020 inclusive. Abstracted data were digitized into standard electronic form and included date, patient nationality, sex, age, indication, procedure performed, and anesthesia used. A second reviewer checked 10% of entries for accuracy. Entries illegible to both reviewers were excluded. Demographics, indication for surgery, procedures performed, and type of anesthesia were standardized for descriptive analysis, which was performed in STATA.

Results
There were 10,799 operations performed over the 20-year period. Tanzanians underwent a quarter of the operations while refugees underwent the remaining 75%. Ninety percent of patients were female and 88% were 18 years of age or older. Caesarean sections were the most common performed procedure followed by herniorrhaphies, tubal ligations, exploratory laparotomies, hysterectomies, appendectomies, and repairs. The most common indications for laparotomy procedures were ectopic pregnancy, uterine rupture, and acute abdomen. Spinal anesthesia was the most common anesthesia type used. Although there was a consistent increase in procedural volume over the study period, this is largely explained by an increase in overall camp population and an increase in caesarean sections rather than increases in other, specific surgical procedures.

Conclusion
There is significant surgical volume in Nyarugusu Camp, performed by staff physicians and visiting surgeons. Both refugees and the host population utilize these surgical services. This work provides context to the surgical training these settings require, but further study is needed to assess the burden of surgical disease and the extent to which it is met in this setting and others.


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3. The Impact of COVID-19 on Hospital Admissions for Twelve High-Burden Diseases and Five Common Procedures in the Philippines: A National Health Insurance Database Study 2019-2020

The Lancet Regional Health – Western Pacific


Authors: Jhanna Uy, Vanessa T. Siy Van, Valerie Gilbert Ulep, Diana Beatriz Bayani, Damian Walker
Region / country: South-eastern Asia – Philippines
Speciality: Health policy

Background
The Philippines has the highest cumulative COVID-19 cases and deaths in the Western-Pacific. To explore the broader health impacts of the pandemic, we assessed the magnitude and duration of changes in hospital admissions for 12 high-burden diseases and the utilization of five common procedures by lockdown stringency, hospital level, and equity in patient access.

Methods
Our analysis used Philippine social health insurance data filed by 1,295 hospitals in 2019 and 2020. We calculated three descriptive statistics of percent change comparing 2020 to the same periods in 2019: (1) year-on-year, (2) same-month-prior-year, and (3) lockdown periods.

Findings
Disease admissions declined (-54%) while procedures increased (13%) in 2020 versus 2019. The increase in procedures was caused by hemodialysis surpassing its 2019 utilization levels in 2020 by 25%, overshadowing declines for C-section (-5%) and vaginal delivery (-18%). Comparing months in 2020 to the same months in 2019, the declines in admissions and procedures occurred at pandemic onset (March-April 2020), with some recovery starting May, but were generally not reversed by the end of 2020. Non-urgent procedures and respiratory diseases faced the largest declines in April 2020 versus April 2019 (range: -60% to -70%), followed by diseases requiring regular follow-up (-50% to -56%), then urgent conditions (-4% to -40%). During the strictest (April-May 2020) and relaxed (May-December 2020) lockdown periods compared to the same periods in 2019, the declines among the poorest (-21%, -39%) were three-times greater than in direct contributors (-7%, -12%) and two-times more in the south (-16%, -32%) than the richer north (-8%, -10%). Year-on-year admission declines across the 12 diseases and procedures (except for hemodialysis) was highest for level three hospitals. Compared to public hospitals, private hospitals had smaller year-on-year declines for procedures, because of increases in utilization in lower level private hospitals.

Interpretation
COVID-19’s prolonged impact on the utilization of hospital services in the Philippines suggests a looming public health crisis in countries with frail health systems. Through the periodic waves of COVID-19 and lockdowns, policymakers must employ a whole-of-health strategy considering all conditions, service delivery networks, and access for the most vulnerable.


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4. Low-cost peer-taught virtual research workshops for medical students in Pakistan: a creative, scalable, and sustainable solution for student research

BMC Medical Education


Authors: Ronika Devi Ukrani, Ayesha Niaz Shaikh, Russell Seth Martins, Syeda Sadia Fatima, Hamna Amir Naseem & Mishall Ahmed Baig
Region / country: Southern Asia – Pakistan
Speciality: Health policy, Surgical Education

Background
Pakistan has not been a major contributor to medical research, mainly because of the lack of learning opportunities to medical students. With the increase in online learning systems during COVID-19, research related skills can be taught to medical students via low-cost peer taught virtual research workshops.

Aim of the Study
To assess the effectiveness of a comprehensive low-cost peer-taught virtual research workshops amongst medical students in Pakistan.

Methods
This quasi-experimental study assessed the effectiveness of five virtual research workshops (RWs) in improving core research skills. RWs for medical students from across Pakistan were conducted over Zoom by medical students (peer-teachers) at the Aga Khan University, Pakistan, with minimal associated costs. The content of the workshops included types of research, ethical approval and research protocols, data collection and analysis, manuscript writing, and improving networking skills for research. Improvement was assessed via pre-and post-quizzes for each RW, self-efficacy scores across 16 domains, and feedback forms. Minimum criteria for completion of the RW series was attending at least 4/5 RWs and filling the post-RW series feedback form. A 6-month post-RW series follow-up survey was also emailed to the participants.

Results
Four hundred medical students from 36 (/117; 30.8%) different medical colleges in Pakistan were enrolled in the RWs. However, only 307/400 (76.75%) medical students met the minimum requirement for completion of the RW series. 56.4% of the participants belonged to the pre-clinical years while the rest were currently to clinical years. The cohort demonstrated significant improvement in pre-and post-quiz scores for all 5 RWs (p <  0.001) with the greatest improvement in Data Collection and Analysis (+ 34.65%), and in self-efficacy scores across all domains (p <  0.001). 166/307 (54.1%) participants responded to the 6 months post-RWs follow-up survey. Compared to pre-RWs, Research involvement increased from 40.4 to 62.8% (p <  0.001) while proportion of participants with peer-reviewed publications increased from 8.4 to 15.8% (p = 0.043).

Conclusion
Virtual RWs allow for a wide outreach while effectively improving research-related knowledge and skills, with minimal associated costs. In lower-middle-income countries, virtual RWs are a creative and cost-effective use of web-based technologies to facilitate medical students to contribute to the local and global healthcare research community.


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5. Effect of Door-to-Door Screening and Awareness Generation Activities in the Catchment Areas of Vision Centers on Service Use: Protocol for a Randomized Experimental Study

JMIR Research Protocol


Authors: Shalinder Sabherwal, Anand Chinnakaran, Ishaana Sood, Gaurav K Garg, Birendra P Singh, Rajan Shukla, Priya A Reddy, Suzanne Gilbert, Ken Bassett, Gudlavalleti V S Murthy, Operational Research Capacity Building Study Group
Region / country: Southern Asia – India
Speciality: Ophthalmology

Background:
A vision center (VC) is a significant eye care service model to strengthen primary eye care services. VCs have been set up at the block level, covering a population of 150,000-250,000 in rural areas in North India. Inadequate use by rural communities is a major challenge to sustainability of these VCs. This not only reduces the community’s vision improvement potential but also impacts self-sustainability and limits expansion of services in rural areas. The current literature reports a lack of awareness regarding eye diseases and the need for care, social stigmas, low priority being given to eye problems, prevailing gender discrimination, cost, and dependence on caregivers as factors preventing the use of primary eye care.

Objective:
Our organization is planning an awareness-cum-engagement intervention—door-to-door basic eye checkup and visual acuity screening in VCs coverage areas—to connect with the community and improve the rational use of VCs.

Methods:
In this randomized, parallel-group experimental study, we will select 2 VCs each for the intervention arm and the control arm from among poor, low-performing VCs (ie, walk-in of ≤10 patients/day) in our 2 operational regions (Vrindavan, Mathura District, and Mohammadi, Kheri District) of Uttar Pradesh. Intervention will include door-to-door screening and awareness generation in 8-12 villages surrounding the VCs, and control VCs will follow existing practices of awareness generation through community activities and health talks. Data will be collected from each VC for 4 months of intervention. Primary outcomes will be an increase in the number of walk-in patients, spectacle advise and uptake, referral and uptake for cataract and specialty surgery, and operational expenses. Secondary outcomes will be uptake of refraction correction and referrals for cataract and other eye conditions. Differences in the number of walk-in patients, referrals, uptake of services, and cost involved will be analyzed.

Results:
Background work involved planning of interventions and selection of VCs has been completed. Participant recruitment has begun and is currently in progress.

Conclusions:
Through this study, we will analyze whether our door-to-door intervention is effective in increasing the number of visits to a VC and, thus, overall sustainability. We will also study the cost-effectiveness of this intervention to recommend its scalability.


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6. Health facility delivery among women of reproductive age in Nigeria: Does age at first birth matter?

Plos one


Authors: Obasanjo Afolabi Bolarinwa, Effiong Fortune, Richard Gyan Aboagye, Abdul-Aziz Seidu, Olalekan Seun Olagunju, Ugochinyere Ijeoma Nwagbara, Edward Kwabena Ameyaw, Bright Opoku Ahinkorah
Region / country: Western Africa – Nigeria
Speciality: Obstetrics and Gynaecology

Background
High maternal mortality ratio in sub-Saharan Africa (SSA) has been linked to inadequate medical care for pregnant women due to limited health facility delivery utilization. Thus, this study, examined the association between age at first childbirth and health facility delivery among women of reproductive age in Nigeria.

Methods
The study used the most recent secondary dataset from Nigeria’s Demographic and Health Survey (NDHS) conducted in 2018. Only women aged15-49 were considered for the study (N = 34,193). Bi-variate and multivariable logistic regression models were used to examine the association between age at first birth and place of delivery. The results were presented as crude odds ratios and adjusted odds ratios (aOR) with corresponding 95% confidence intervals (CIs). Statistical significance was set at p<0.05.

Results
The results showed that the prevalence of health facility deliveries was 41% in Nigeria. Women who had their first birth below age 20 [aOR = 0.82; 95%(CI = 0.74–0.90)] were less likely to give birth at health facilities compared to those who had their first birth at age 20 and above.

Conclusion
Our findings suggest the need to design interventions that will encourage women of reproductive age in Nigeria who are younger than 20 years to give birth in health facilities to avoid the risks of maternal complications associated with home delivery. Such interventions should include male involvement in antenatal care visits and the education of both partners and young women on the importance of health facility delivery.


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7. WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

World Journal of Emergency Surgery


Authors: Massimo Sartelli, Federico Coccolini, Yoram Kluger, Ervis Agastra, Fikri M. Abu-Zidan, Ashraf El Sayed Abbas, Luca Ansaloni, Abdulrashid Kayode Adesunkanmi, Boyko Atanasov, Goran Augustin, Miklosh Bala, Oussama Baraket, Suman Baral, Walter L. Biffl, Marja A. Boermeester, Marco Ceresoli, Elisabetta Cerutti, Osvaldo Chiara, Enrico Cicuttin , Massimo Chiarugi , Raul Coimbra, Elif Colak, Daniela Corsi, Francesco Cortese, Yunfeng Cui, Dimitris Damaskos, Nicola de’ Angelis, Samir Delibegovic, Zaza Demetrashvili, Belinda De Simone, Stijn W. de Jonge, Sameer Dhingra, Stefano Di Bella, Francesco Di Marzo, Salomone Di Saverio, Agron Dogjani, Therese M. Duane, Mushira Abdulaziz Enani, Paola Fugazzola , Joseph M. Galante, Mahir Gachabayov, Wagih Ghnnam, George Gkiokas, Carlos Augusto Gomes, Ewen A. Griffiths, Timothy C. Hardcastle, Andreas Hecker, Torsten Herzog, Syed Mohammad Umar Kabir, Aleksandar Karamarkovic, Vladimir Khokha, Peter K. Kim, Jae Il Kim, Andrew W. Kirkpatrick, Victor Kong, Renol M. Koshy, Igor A. Kryvoruchko, Kenji Inaba, Arda Isik, Katia Iskandar, Rao Ivatury, Francesco M. Labricciosa, Yeong Yeh Lee, Ari Leppäniemi, Andrey Litvin, Davide Luppi, Gustavo M. Machain, Ronald V. Maier, Athanasios Marinis, Cristina Marmorale, Sanjay Marwah, Cristian Mesina, Ernest E. Moore, Frederick A. Moore, Ionut Negoi, Iyiade Olaoye, Carlos A. Ordoñez, Mouaqit Ouadii, Andrew B. Peitzman, Gennaro Perrone, Manos Pikoulis, Tadeja Pintar, Giuseppe Pipitone, Mauro Podda, Kemal Raşa, Julival Ribeiro, Gabriel Rodrigues, Ines Rubio-Perez, Ibrahima Sall, Norio Sato, Robert G. Sawyer, Helmut Segovia Lohse, Gabriele Sganga, Vishal G. Shelat, Ian Stephens, Michael Sugrue, Antonio Tarasconi, Joel Noutakdie Tochie, Matti Tolonen, Gia Tomadze, Jan Ulrych, Andras Vereczkei, Bruno Viaggi, Chiara Gurioli, Claudio Casella, Leonardo Pagani, Gian Luca Baiocchi, Fausto Catena
Region / country: Global
Speciality: Emergency surgery, General surgery

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language.
The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs


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8. Breast Cancer Patients’ Experience about Involvement in Health Care: A Qualitative Study

Journal of high institute of public health


Authors: Eman El-Sayed, Ensaf Abdelgawad, Nabil L. Dowidar, Azza A. Mehanna
Region / country: Northern Africa – Egypt
Speciality: Other, Surgical oncology

Background: Patient involvement in health care is a basic patient’s right. Effective communication between the health care professional and the patient is associated with improved psychological functioning of the patient, adherence to treatment, and higher quality of life. Objective(s): This study aims to explore qualitatively breast cancer patients’ experience and satisfaction with their involvement in cancer care. Methods: This study was carried out among 30 women in different breast cancer care stages through in depth-interviews. The patients were purposively selected from surgery and oncology outpatient clinics and surgery inpatient wards in Medical Research Institute Hospital- Alexandria University, and in Ayadi El-Mostakbal Cancer Care Center – Ayadi El-Mostakbal Charity Foundation, Alexandria, Egypt. Results: Some patients mentioned that they did not know their diagnosis until late, others complained of the harsh non-empathetic way of breaking the news of their disease. Patients, generally, reported a little understanding of their treatment plan, they just followed physician’s instructions without receiving enough explanation. Patients on chemotherapy and radiotherapy expressed their unsatisfied need for information. Patients’ source of information was mainly other patients who suffered from the same disease. Patients, in general, were not familiar with the concept of giving feedback, it was perceived by the majority of them as equivalent to complaining. Some patients believed that complaining could put them in trouble such as receiving harsh blame or even delaying their medication. Conclusion: Patients’ narratives revealed poor involvement in health care and showed dissatisfaction of the majority of patients with their level of involvement.


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9. Hydatid brain cyst: A delayed diagnosis in a rural setting during COVID-19

South African Medical Journal


Authors: C J Opperman, J M N Enslin, J Nuttall, A J Brink, S P da Fonseca, H D Tootla
Region / country: Southern Africa – South Africa
Speciality: Neurosurgery

A previously healthy 10-year-old girl, living in a sheep-farming community in South Africa with exposure to dogs, presented to her local hospital with generalised tonic-clonic seizures. The initial clinical assessment and laboratory work-up were unremarkable. When she presented with further seizures 6 months later, attempts to arrange neuroimaging and specialist assessment were unsuccessful owing to restrictions on routine healthcare services during the SARS-CoV-2 nationwide lockdown. Subsequently, 11 months after her first presentation, she developed focal neurological signs suggestive of raised intracranial pressure. A brain computed tomography scan revealed a left-sided cerebral cyst and imminent tonsillar herniation. An emergency burr-hole procedure was performed to relieve the raised intracranial pressure, followed by definitive neurosurgical excision of cysts. Hydatid protoscolices and hooklets were seen on microscopy of cyst fluid, and treatment with albendazole and praziquantel was initiated. While her infection was treated successfully, long-term sequelae including permanent blindness and hemiparesis could potentially have been prevented with early neuroimaging and surgical intervention.


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10. Aetiology and outcomes of operatively managed acute abdomen in adults, at Moi Teaching and Referral Hospital

Moi University Digital Repository


Authors: Okoth Philip B.
Region / country: Eastern Africa – Kenya
Speciality: General surgery

Background: Acute abdomen is responsible for up to 50% of surgical emergencies. Its aetiological patterns are thought to be changing in Africa. Despite its frequent occurrence, the aetiology and outcomes of operatively managed acute abdomen, in adults, is yet to be described at Moi Teaching and Referral Hospital (MTRH). This description of will be informative to clinical practitioners and improve care of patients Objective: To determine the aetiology and outcomes of operatively managed acute abdominal conditions, in adults at Moi Teaching and Referral Hospital MTRH. Methods: A prospective descriptive study was carried out in the general surgical and gynaecology wards. Fischer‟s statistical formula was used to determine sample size, and consecutive sampling was done until the sample size was achieved. A sample of 203 adult patients, 18 years and older, operated on for an acute abdomen between 29th March 2018 to 29th March 2019, were studied. Patients with abdominal trauma causing acute abdomen were excluded. A data sheet was used to record the aetiology and outcomes (early complications, mortality and duration of stay). Descriptive statistical analysis such as frequencies and percentages were used for categorical variables. Measures of central tendency such as mean and interquartile ranges were used for continuous variables. Univariate analysis was used to assess association between the outcome and the aetiology. Results: 203 patients with a median age of 29 years (IQR 23, 35.5) were studied. One hundred and twenty-one (59.6%) were female and eighty-two (40.4%) were male. The most common causes of operative acute abdomen included: ectopic pregnancy 72(35.5%), intestinal obstruction 46(22.7%) and appendicitis 37(18. 7%). Three (1.5%) patients died. Postoperative complication rate was 20.7%. Wound dehiscence (8.4%), surgical site infection (7.9%), pneumonia (3.4%), then sepsis (2.5%) were the most encountered complications. A majority of patients 124(63.5%) were discharged within a week of admission. Aetiology was found to be associated with likelihood of developing wound dehiscence (p 0.003) and surgical site infection (p 0.004) postoperatively. Conclusion: Ectopic pregnancy is the most frequently encountered cause of operative acute abdomen at MTRH. It is followed by intestinal obstruction, appendicitis, then bowel perforations in that order. Wound complications, pneumonia then sepsis are the commonly encountered complications. Recommendation: A 5-10 yearly review of acute abdominal aetiology should be carried out at MTRH to allow us to monitor for any future changes. Studies should be carried out on perioperative factors affecting wound dehiscence with the aim of reducing its occurrence.


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11. The Progress of Global Antimicrobial Resistance Governance and Its Implication to China: A Review

Antibiotics


Authors: Jia Yin, Yu Wang, Xueran Xu ,Yinqi Liu, Lu Yao, Qiang Sun
Region / country: Eastern Asia – China
Speciality: Health policy, Other

China has great potential for engaging in global actions on antimicrobial resistance (AMR) control. This study aims to summarize the process of global AMR governance and provide relevant policy recommendations on how China could take more initiative in the global AMR governance. We searched for academic articles and official document published or issued before December 2020 in e-journal databases, official websites of major organizations, and the relevant national ministries. This review revealed that global action on AMR control has experienced three stages: (1) The beginning stage (1980s and 1990s) when actions were mainly sponsored by high-income countries and AMR surveillance was focused on hospitals; (2) The rapid development stage (2000–2010) when global AMR governance began to concentrate on joint actions in multi-sectors, and developing countries were gradually involved in global actions; (3) The comprehensive stage (2011 to present) when global actions on AMR have covered various fields in different countries. China’s AMR governance has fallen behind at the beginning but recently began to catch up with the global trend. The central government should take a far-fetched view, act decisively and positively towards the global efforts of addressing AMR to play a more active and greater role on the international stage. View Full-Text


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12. OneHealth Approaches Contribute Towards Antimicrobial Resistance: Malaysian Perspective

Frontiers in Microbiology


Authors: Vanitha Mariappan, Kumutha Malar Vellasamy, Nor Alia Mohamad, Sreeramanan Subramaniam, Jamuna Vadivelu
Region / country: South-eastern Asia – Malaysia
Speciality: Health policy, Other

On a global scale, antimicrobial resistance (AMR) is recognized as a One Health challenge due to the continual and increased development and distribution of resistant microbes and genes among humans, animals, and the environment. These sectors contribute to the increase in AMR, as antibiotics are widely used in healthcare to treat or prevent bacterial infection; as growth enhancers, therapeutics and metaphylactics in animal husbandry; and transmitted in the environment through irrigation using wastewater or inappropriate disposal and treatment of human and agricultural waste. However, there is a major drawback in terms of the lack of research assessing the coexistence of AMR in these sectors. Extensive research highlighted food–animal manufacture structures that are likely to harbor reservoirs or promote transmission of AMR, in addition to increasing human colonization with AMR commensal bacteria. Numerous antibiotic stewardship policies have been designed and implemented in medical practices and animal husbandry in high- and middle-income countries. However, research concentrating on high-income settings, attitudes, emotions, and beliefs on the utilization of antimicrobials remain underexplored in lower- and middle-income countries such as Malaysia. Microbiological, epidemiological, and social science exploration are required at community and farming across the One Health range to fill huge gaps in information and knowledge of AMR. Manipulating human activities and character associated with antibiotics is a multifaceted progression that includes elements like knowledge, social behavior, attitudes, approaches, social standards, socioeconomic settings, peer pressure, experiences, and biophysical environment. Therefore, understanding these aspects in the utilization of antimicrobial drugs among the different sectors is essential to develop and implement policies to curb AMR development and transmission that overarch all sectors within the One Health consortium in Malaysia.


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13. Burden of Road Traffic Injuries in Tanzania: One-Year Prospective Study of Consecutive Patients in 13 Multilevel Health Facilities

Emergency Medicine International


Authors: Hendry R. Sawe, Sveta Milusheva, Kevin Croke, Saahil Karpe, Meyhar Mohammed, Juma A. Mfinanga
Region / country: Eastern Africa – Tanzania
Speciality: Emergency surgery, Trauma surgery

Background. Road traffic injuries (RTIs) pose a severe public health crisis in Sub-Saharan Africa (SSA) and specifically in Tanzania, where the mortality due to RTIs is nearly double the global rate. There is a paucity of RTI data in Tanzania to inform evidence-based interventions to reduce the incidence and improve care outcomes. A trauma registry was implemented at 13 health facilities of diverse administrative levels in Tanzania. In this study, we characterize the burden of RTIs seen at these health facilities. Methods. This was a one-year prospective descriptive study utilizing trauma registry data from 13 multilevel health facilities in Tanzania from 1 October 2019 to 30 September 2020. We provide descriptive statistics on patient demographics; location; share of injury; nature, type, and circumstances of RTI; injury severity; disposition; and outcomes. Results. Among 18,553 trauma patients seen in 13 health facilities, 7,416 (40%) had RTIs. The overall median age was 28 years (IQR 22–38 years), and 79.3% were male. Most road traffic crashes (RTC) occurred in urban settings (68.7%), involving motorcycles (68.3%). Motorcyclists (32.9%) were the most affected road users; only 37% of motorcyclists wore helmets at the time of the crash. The majority (88.2%) of patients arrived directly from the site, and 49.0% used motorized (two- or three-) wheelers to travel to the health facility. Patients were more likely to be admitted to the ward, taken to operating theatre, died at emergency unit (EU), or referred versus being discharged if they had intracranial injuries (27.8% vs. 3.7%; ), fracture of the lower leg (18.9% vs. 6.4%; ), or femur fracture (12.9% vs. 0.4%; ). Overall, 36.1% of patients were admitted, 10.6% transferred to other facilities, and mortality was 2%. Conclusions. RTCs are the main cause of trauma in this setting, affecting mostly working-age males. These RTCs result in severe injuries requiring hospital admission or referral for almost half of the victims. Motorcyclists are the most affected group, in alignment with prior studies. These findings demonstrate the burden of RTCs as a public health concern in Tanzania and the need for targeted interventions with a focus on motorcyclists.


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14. Decarbonising healthcare in low and middle income countries: potential pathways to net zero emissions

BMJ


Authors: Fawzia N Rasheed, Jerome Baddley, Poornima Prabhakaran, Enrique Falceto De Barros, K Srinath Reddy, Nelzair Araujo Vianna, Robert Marten
Region / country: Global
Speciality: Health policy, Other

Healthcare in low and middle income countries has a high carbon footprint. Reducing emissions should be integral to plans for universal health coverage, say Fawzia Rasheed and colleagues

Considerable attention has been paid to the role that healthcare systems have in combating climate change.1 Recent analysis has calculated the global carbon footprint of healthcare as equivalent to 2-2.4 Gt of CO2, about 4-5% of total global emissions.23

The focus is often on reducing emissions in high income countries (HICs) and adaptation in low and middle income countries (LMICs).4 Few LMICs are included in studies on carbon emissions from healthcare.

This imbalance is understandable, given the greater relative contribution to greenhouse gas emissions from health systems in HICs and the disproportionate burden of climate change impacts on LMICs.56 Nevertheless, healthcare in LMICs is a carbon intensive activity and likely to grow with the delivery of commitments to universal health coverage (UN Sustainable Development Goal 3.8).


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15. Midwives’ knowledge and practices regarding the screening for and management of chorioamnionitis: A qualitative study

Health SA Gesondheid


Authors: Allison H. du Plessis, Dalena van Rooyen, Wilma ten Ham-Baloyi
Region / country: Southern Africa – South Africa
Speciality: Obstetrics and Gynaecology

Background: Screening for chorioamnionitis, or the risk thereof, by midwives is largely lacking during antenatal care and no best practice guidelines for chorioamnionitis in South Africa was noted.

Aim: To explore and describe midwives’ knowledge and practices related to the screening and management of women who are at risk of or diagnosed with chorioamnionitis.

Setting: Public healthcare institutions in a health district in the Eastern Cape province of South Africa.

Methods: A qualitative, exploratory, descriptive and contextual research design was used. Ten midwives were purposively included in this study, and semi-structured interviews were conducted with them. The data were analysed using an adapted version of Tesch’s eight steps for data analysis.

Results: The main theme revealed that midwives lack knowledge regarding chorioamnionitis, resulting in incorrect practices including a lack of screening, misdiagnosis and mismanagement of the infectious condition.

Conclusions: Findings of this research showed that midwives lacked knowledge regarding the screening and management of women with chorioamnionitis resulting in incorrect practices in this regard. There is thus a need for midwives to update their knowledge regarding the screening and management of chorioamnionitis and training (e.g. through a short learning programme).

Contribution: Findings of this study could be used by midwives to update their knowledge regarding screening and managing women with chorioamnionitis, which is expected to translate to better practices. Moreover, study findings were synthesised with the results of a literature review study to form the basis for the development of a best practice guideline for screening and managing women with chorioamnionitis


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16. The accountability of the private sector towards citizens in times of crisis: vaccines, medicines and equipment

European Journal of Public Health


Authors: Elena Petelos, Dimitra Lingri, Jinane Ghattas, Silvia M A A Evers, Dineke Zeegers Paget, Chiara de Waure
Region / country: Global
Speciality: Health policy, Other

In this article, we examine what the role of the private sector in times of crises is and whether the private sector is, and can be held to be, accountable. COVID-19 has amplified the difficulties with public–private partnerships and this article addresses several aspects concerning business enterprises, in particular transnational corporations, human rights and health sector activities, highlighting the key aspects to understand and address accountability issues. The article also explores accountability for the private sector, the processes to ensure accountability, and the relevance of regulation and self-regulation.


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17. Distribution of the workforce involved in cancer care: a systematic review of the literature

ESMO Open


Authors: D. Trapani, S. S. Murthy , M. Boniol, C. Booth, V. C. Simensen, M. K. Kasumba, R. Giuliani, G. Curigliano, A. M. Ilbawi
Region / country: Global
Speciality: Surgical oncology

Background
A skilled health workforce is instrumental for the delivery of multidisciplinary cancer care and in turn a critical component of the health systems. There is, however, a paucity of data on the vast inequalities in cancer workforce distribution, globally. The aim of this study is to describe the global distribution and density of the health care workforce involved in multidisciplinary cancer management.

Methods
We carried out a systematic review of the literature to determine ratios of health workers in each occupation involved in cancer care per 100 000 population and per 100 cancer patients (PROSPERO: protocol CRD42018095414).

Results
We identified 33 eligible papers; a majority were cross-sectional surveys (n = 16). The analysis of the ratios of health providers per population and per patients revealed deep gaps across the income areas, with gradients of workforce density, highest in high-income countries versus low-income areas. Benchmark estimates of optimal workforce availability were provided in a secondary research analysis: mainly high-income countries reported workforce capacities closer to benchmark estimates. A paucity of literature was defined for critical health providers, including for pediatric oncology, surgical oncology, and cancer nurses.

Conclusion
The availability and distribution of the cancer workforce is heterogeneous, and wide gaps are described worldwide. This is the first systematic review on this topic. These results can inform policy formulation and modelling for capacity building and scaleup.


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18. Financial risk of road traffic trauma care in public and private hospitals in Addis Ababa, Ethiopia: a cross-sectional observational study

Injury


Authors: Hailu Tamiru Dhufera, Abdulrahman Jbaily, Stephane Verguet, Mieraf Taddesse Tolla, Kjell Arne Johansson, Solomon Tessema Memirie
Region / country: Eastern Africa – Ethiopia
Speciality: Health policy, Trauma surgery

Background: Road traffic injuries are among the most important causes of morbidity and mortality and cause substantial economic loss to households in Ethiopia. This study estimates the financial risks of seeking trauma care due to road traffic injuries in Addis Ababa, Ethiopia.

Methods: This is a cross-sectional survey on out-of-pocket (OOP) expenditures related to trauma care in three public and one private hospital in Addis Ababa from December 2018 to February 2019. Direct medical and non-medical costs (2018 USD) were collected from 452 trauma cases. Catastrophic health expenditures were defined as OOP health expenditures of 10% or more of total household expenditures. Additionally, we investigated the impoverishment effect of OOP expenditures using the international poverty line of $1.90 per day per person (adjusted for Purchasing Power Parity).

Results: Trauma care seeking after road traffic injuries generate catastrophic health expenditures for 67% of households and push 24% of households below the international poverty line. On average, the medical OOP expenditures per patient seeking care were $256 for outpatient visits and $690 for inpatient visits per road traffic injury. Patients paid more for trauma care in private hospitals, and OOP expenditures were six times higher in private than in public hospitals. Transport to facilities and caregiver costs were the two major cost drivers, amounting to $96 and $68 per patient, respectively.

Conclusion: Seeking trauma care after a road traffic injury poses a substantial financial threat to Ethiopian households due to lack of strong financial risk protection mechanisms. Ethiopia’s government should enact multisectoral interventions for increasing the prevention of road traffic injuries and implement universal public finance of trauma care.


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19. Integrative oncology: Addressing the global challenges of cancer prevention and treatment

CA: A Cancer Journal for Clinicians


Authors: Jun J. Mao, Geetha Gopalakrishna Pillai, Carlos Jose Andrade, Jennifer A. Ligibel, Partha Basu, Lorenzo Cohen, Ikhlas A. Khan, Karen M. Mustian, Rammanohar Puthiyedath, Kartar Singh Dhiman, Lixing Lao, Ricardo Ghelman , Paulo Cáceres Guido , Gabriel Lopez , Daniel F. Gallego-Perez, Luis Alejandro Salicrup
Region / country: Global
Speciality: Surgical oncology

The increase in cancer incidence and mortality is challenging current cancer care delivery globally, disproportionally affecting low- and middle-income countries (LMICs) when it comes to receiving evidence-based cancer prevention, treatment, and palliative and survivorship care. Patients in LMICs often rely on traditional, complementary, and integrative medicine (TCIM) that is more familiar, less costly, and widely available. However, spheres of influence and tensions between conventional medicine and TCIM can further disrupt efforts in evidence-based cancer care. Integrative oncology provides a framework to research and integrate safe, effective TCIM alongside conventional cancer treatment and can help bridge health care gaps in delivering evidence-informed, patient-centered care. This growing field uses lifestyle modifications, mind and body therapies (eg, acupuncture, massage, meditation, and yoga), and natural products to improve symptom management and quality of life among patients with cancer. On the basis of this review of the global challenges of cancer control and the current status of integrative oncology, the authors recommend: 1) educating and integrating TCIM providers into the cancer control workforce to promote risk reduction and culturally salient healthy life styles; 2) developing and testing TCIM interventions to address cancer symptoms or treatment-related adverse effects (eg, pain, insomnia, fatigue); and 3) disseminating and implementing evidence-based TCIM interventions as part of comprehensive palliative and survivorship care so patients from all cultures can live with or beyond cancer with respect, dignity, and vitality. With conventional medicine and TCIM united under a cohesive framework, integrative oncology may provide citizens of the world with access to safe, effective, evidence-informed, and culturally sensitive cancer care.


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20. Screening Programs for Common Maternal Mental Health Disorders Among Perinatal Women: Report of the Systematic Review of Evidence

Research Square


Authors: Ahmed Waqas, Ahmreen Kokab, Hafsa Meraj, Tarun Dua, Neerja Chowdhary, Batool Fatima, Atif Rahman
Region / country: Global
Speciality: Health policy, Obstetrics and Gynaecology

Postpartum depression and anxiety are highly prevalent worldwide. Fisher et al., estimated the prevalence of depression and anxiety at 15.6% during the antenatal and 19.8% during the postpartum period. Their impact on maternal and child health is well-recognized among the public health community, accounting for high societal costs. The public health impact of these conditions has highlighted the need to focus on the development and provision of effective prevention and treatment strategies.

In recent decades, some advances have been made in development of effective universal and targeted screening programmes for perinatal depression and anxiety disorders. Recent research has shown potential benefits of universal and targeted screening for perinatal depression, to identify and treat undiagnosed cases, and help thwart its deleterious consequences. Ethical implications, however, for these screening programmes, without the provision of treatment have often been emphasized.

The present mixed-methods systematic review and meta-analysis was conducted to collate evidence pertaining to screening programmes for perinatal depression and anxiety. It aims to answer following questions, in a global context: For women in the perinatal period, do screening programmes for perinatal depression and anxiety compared with no screening improve maternal mental health and infant outcomes?

A series of meta-analyses reveal a reduction in perinatal depression and anxiety among perinatal women undergoing screening programmes. For the outcome of depressive disorder, meta-analysis indicates a positive impact in favour of the intervention group (OR = 0.55, 95% CI: 0.45 to 0.66, n = 9,009), with a moderate quality of evidence. A significant improvement (high quality) was also observed in symptoms of anxiety among perinatal women (SMD= -0.18, 95% CI: -0.25 to -0.12, n = 3654).


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21. Gastrointestinal endoscopy capacity in Eastern Africa

Endoscopy International Open


Authors: Michael Mwachiro, Hillary M. Topazian‡, Violet Kayamba, Gift Mulima, Elly Ogutu, Mengistu Erkie, Gome Lenga, Thomas Mutie, Eva Mukhwana, Hailemichael Desalegn, Rezene Berhe, Berhane Redae Meshesha, Bongani Kaimila, Paul Kelly, David Fleischer, Sanford M. Dawsey, Mark D. Topazian
Region / country: Eastern Africa – Ethiopia, Kenya, Malawi, Zambia
Speciality: General surgery

Background and study aims Limited evidence suggests that endoscopy capacity in sub-Saharan Africa is insufficient to meet the levels of gastrointestinal disease. We aimed to quantify the human and material resources for endoscopy services in eastern African countries, and to identify barriers to expanding endoscopy capacity.

Patients and methods In partnership with national professional societies, digestive healthcare professionals in participating countries were invited to complete an online survey between August 2018 and August 2020.

Results Of 344 digestive healthcare professionals in Ethiopia, Kenya, Malawi, and Zambia, 87 (25.3 %) completed the survey, reporting data for 91 healthcare facilities and identifying 20 additional facilities. Most respondents (73.6 %) perform endoscopy and 59.8 % perform at least one therapeutic modality. Facilities have a median of two functioning gastroscopes and one functioning colonoscope each. Overall endoscopy capacity, adjusted for non-response and additional facilities, includes 0.12 endoscopists, 0.12 gastroscopes, and 0.09 colonoscopes per 100,000 population in the participating countries. Adjusted maximum upper gastrointestinal and lower gastrointestinal endoscopic capacity were 106 and 45 procedures per 100,000 persons per year, respectively. These values are 1 % to 10 % of those reported from resource-rich countries. Most respondents identified a lack of endoscopic equipment, lack of trained endoscopists and costs as barriers to provision of endoscopy services.

Conclusions Endoscopy capacity is severely limited in eastern sub-Saharan Africa, despite a high burden of gastrointestinal disease. Expanding capacity requires investment in additional human and material resources, and technological innovations that improve the cost and sustainability of endoscopic services.


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22. From Theory to Implementation: Adaptations to a Quality Improvement Initiative According to Implementation Context

Qualitative Health Research


Authors: Abimbola A. Olaniran, Modupe Oludipe, Zelee Hill, Adedoyin Ogunyemi, Nasir Umar, Kelechi Ohiri, Joanna Schellenberg, Tanya Marchant
Region / country: Western Africa – Nigeria
Speciality: Health policy

As countries continue to invest in quality improvement (QI) initiatives in health facilities, it is important to acknowledge the role of context in implementation. We conducted a qualitative study between February 2019 and January 2020 to explore how a QI initiative was adapted to enable implementation in three facility types: primary health centres, public hospitals and private facilities in Lagos State, Nigeria.

Despite a common theory of change, implementation of the initiative needed to be adapted to accommodate the local needs, priorities and organisational culture of each facility type. Across facility types, inadequate human and capital resources constrained implementation and necessitated an extension of the initiative’s duration. In public facilities, the local governance structure was adapted to facilitate coordination, but similar adaptations to governance were not possible for private facilities. Our findings highlight the importance of anticipating and planning for the local adaptation of QI initiatives according to implementation environment


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23. Assessing the global burden of hemorrhage: The global blood supply, deficits, and potential solutions

SAGE Open Medicine


Authors: Nakul P. Raykar, Jennifer Makin, Monty Khajanchi, Bernard Olayo, Alejandro Munoz Valencia, Nobhojit Roy, Pablo Ottolino, Analia Zinco, Jana MacLeod, Mark Yazer, Jayant Rajgopal, Bo Zeng, Hyo Kyung Lee, Bopaya Bidanda, Pratap Kumar, Juan Carlos Puyana, Kristina Rudd
Region / country: Global
Speciality: Emergency surgery, Health policy

There is a critical shortage of blood available for transfusion in many low- and middle-income countries. The consequences of this scarcity are dire, resulting in uncounted morbidity and mortality from trauma, obstetric hemorrhage, and pediatric anemias, among numerous other conditions. The process of collecting blood from a donor to administering it to a patient involves many facets from donor availability to blood processing to blood delivery. Each step faces particular challenges in low- and middle-income countries. Optimizing existing strategies and introducing new approaches will be imperative to ensure a safe and sufficient blood supply worldwide.


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24. Rapid assessment of the civil registration and vital statistics performance of health facilities in the five districts of Zambia: A cross-sectional study

Heliyon


Authors: Yuta Yokobori, Jun Matsuura, Hiromi Obara, Yasuo Sugiura, Tomomi Kitamura, Crispin Moyo, Chomba Mwango, Motoyuki Yuasa
Region / country: Southern Africa – Zambia
Speciality: Health policy

Background
Civil registration and vital statistics (CRVS) are essential administrative tools for accurate statistical data on vital events. However, civil registration coverage is particularly poor in low- and middle-income countries. Currently, CRVS are attracting global attention, as their improvement is considered a priority. While health facility is one of the important actors involved in the management of quality CRVS, its function in CRVS remains unclear. Therefore, this work aims to investigate the CRVS performance of the health facility in Zambia, a low-income country, and identify the gaps for effective policy-making.

Methods
To assess the health facilities’ CRVS performance, a questionnaire was developed based on existing assessment tools for the whole CRVS; this comprised 21 multiple-choice questions in 10 areas with four choices awarded between 0 and 3 points according to performance. These questionnaire-based interviews were conducted by information officers in all health facilities per first, secondary, and tertiary-level in five target districts of Zambia, selected via socioeconomic and geographic features. The average points were calculated in each area by each level of healthcare system and summarized in a single chart.

Results
The results indicated low scores in the following areas: staff compliance with standard reporting procedures, infrastructure, capacity of coding based on International Classification of Diseases among health personnel, documentation of the cause of death in medical records, and absence of a system to identify the cause of death of brought-in-dead cases.

Conclusion
The tool developed in this work to evaluate the CRVS performance of health facilities was useful for identifying the gaps that need to be overcome to ensure the quality of CRVS in Zambia. However, its validity should be further investigated in other areas in Zambia as well as in other countries.


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25. Patterns, Predictors and Outcome of Time to Presentation Among Critically ill Paediatric Patients at Emergency Department of Muhimbili National Hospital, Dar es Salaam, Tanzania

Research Square


Authors: Alphonce N Simbila, Said S. Kilindimo, Hendry R. Sawe, Zawadi E. Kalezi, Amne O. Yussuf, Hussein K. Manji, Germana Leyna, Juma A. Mfinanga, Ellen J. Weber
Region / country: Eastern Africa – Tanzania
Speciality: Emergency surgery, Paediatric surgery

Background: Mortality among under-five children in Tanzania remains high. While early presentation for treatment increases likelihood of survival, delays to care are common and factors causing delay to presentation among critically ill children are unknown.

Methodology: This was a prospective cohort study of critically ill children aged 28days to 14 years attending emergency department (ED) at Muhimbili National Hospital in Tanzania from September 2019 to January 2020. We documented demographics, time to ED presentation, ED interventions and 30-day outcome. The primary outcome was delay (>48 hours) from the onset of illness to ED presentation. Logistic regression and relative risk were calculated to measure the strength of the predictor and relationship between delay and mortality respectively.

Results: We enrolled 440 (59.1%) critically ill children, their median age was 12 [IQR =9-60] months and 63.9% were males. The median time to ED arrival was 3 days [IQR=1-5] and more than half (56.6%) of critically ill children presented to ED in > 48 hours where by being an infant, self-referral and belonging to poor family were independent predictors of delay. Infants and those referred from other facilities had 2.2 (95% CI 1.3-3.8) and 1.7 (95% CI 1.1-2.7) times increased odds of presenting late to the ED respectively. The overall 30-day in-hospital mortality was 26.5% in which those who presented late were 1.3 more likely to die than those who presented early (RR=1.3, CI: 0.9-1.9). Majority died >24 hours of ED arrival (P-value=0.021).

Conclusion: Delayed ED presentation of more than 48 hours from onset of illness was associated with in-hospital mortality. A larger study is needed to evaluate the care pathway of critically ill paediatric patients to identify preventable course of delay to tertiary care facility


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26. Association between triage level and outcomes at Médecins Sans Frontières trauma hospital in Kunduz, Afghanistan, 2015

Emergency Medicine Journal


Authors: Hadjer Latif Daebes, Linnea Latifa Tounsi, Maximilian Nerlander, Martin Gerdin Wärnberg, Momer Jaweed, Bashir Ahmad Mamozai, Masood Nasim, Miguel Trelles, Johan von Schreeb
Region / country: Southern Asia – Afghanistan
Speciality: Emergency surgery, Trauma surgery

Background Five million people die annually due to injuries; an increasing part is due to armed conflict in low-income and middle-income countries, demanding resolute emergency trauma care. In Afghanistan, a low-income country that has experienced conflict for over 35 years, conflict related trauma is a significant public health problem. To address this, the non-governmental organisation Médecins Sans Frontières (MSF) set up a trauma centre in Kunduz (Kunduz Trauma Centre (KTC)). MSF’s standardised emergency operating procedures include the South African Triage Scale (SATS). To date, there are few studies that assess how triage levels correspond with outcome in low-resource conflict settings

Aim This study aims to assess to what extent SATS triage levels correlated to outcomes in terms of hospital admission, intensive care unit (ICU) admission and mortality for patients treated at KTC.

Method and materials This retrospective study used routinely collected data from KTC registries. A total of 17 970 patients were included. The outcomes were hospital admission, ICU admission and mortality. The explanatory variable was triage level. Covariates including age, gender and delay to arrival were used. Logistic regression was used to study the correlation between triage level and outcomes.

Results Out of all patients seeking care, 28.7% were triaged as red or orange. The overall mortality was 0.6%. In total, 90% of those that died and 79% of ICU-admitted patients were triaged as red.

Conclusion The risk of positive and negative outcomes correlated with triage level. None of the patients triaged as green died or were admitted to the ICU whereas 90% of patients who died were triaged as red.


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27. Do health policies address the availability, accessibility, acceptability, and quality of human resources for health? Analysis over three decades of National Health Policy of India

Human Resources for Health


Authors: Sweta Dubey, Jeel Vasa, Siddhesh Zadey
Region / country: Southern Asia – India
Speciality: Health policy

Background
Human Resources for Health (HRH) are crucial for improving health services coverage and population health outcomes. The World Health Organisation (WHO) promotes countries to formulate holistic policies that focus on four HRH dimensions—availability, accessibility, acceptability, and quality (AAAQ). The status of these dimensions and their incorporation in the National Health Policies of India (NHPIs) are not well known.

Methods
We created a multilevel framework of strategies and actions directed to improve AAAQ HRH dimensions. HRH-related recommendations of NHPI—1983, 2002, and 2017 were classified according to targeted dimensions and cadres using the framework. We identified the dimensions and cadres focussed by NHPIs using the number of mentions. Furthermore, we introduce a family of dimensionwise deficit indices formulated to assess situational HRH deficiencies for census years (1981, 2001, and 2011) and over-year trends. Finally, we evaluated whether or not the HRH recommendations in NHPIs addressed the deficient cadres and dimensions of the pre-NHPI census years.

Results
NHPIs focused more on HRH availability and quality compared to accessibility and acceptability. Doctors were prioritized over auxiliary nurses-midwives and pharmacists in terms of total recommendations. AAAQ indices showed deficits in all dimensions for almost all HRH cadres over the years. All deficit indices show a general decreasing trend from 1981 to 2011 except for the accessibility deficit. The recommendations in NHPIs did not correspond to the situational deficits in many instances indicating a policy priority mismatch.

Conclusion
India needs to incorporate AAAQ dimensions in its policies and monitor their progress. The framework and indices-based approach can help identify the gaps between targeted and needed dimensions and cadres for effective HRH strengthening. At the global level, the application of framework and indices will allow a comparison of the strengths and weaknesses of HRH-related policies of various nations.


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28. The 4-Year Experience with Implementation and Routine Use of Pathogen Reduction in a Brazilian Hospital

Pathogens


Authors: Roberta Maria Fachini, Rita Fontão-Wendel, Ruth Achkar, Patrícia Scuracchio, Mayra Brito, Marcelo Amaral, Silvano Wendel
Region / country: South America – Brazil
Speciality: Health policy, Other

(1) Background: We reviewed the logistics of the implementation of pathogen reduction (PR) using the INTERCEPT Blood System™ for platelets and the experience with routine use and clinical outcomes in the patient population at the Sírio-Libanês Hospital of São Paulo, Brazil. (2) Methods: Platelet concentrate (PC), including pathogen reduced (PR-PC) production, inventory management, discard rates, blood utilization, and clinical outcomes were analyzed over the 40 months before and after PR implementation. Age distribution and wastage rates were compared over the 10 months before and after approval for PR-PC to be stored for up to seven days. (3) Results: A 100% PR-PC inventory was achieved by increasing double apheresis collections and production of double doses using pools of two single apheresis units. Discard rates decreased from 6% to 3% after PR implementation and further decreased to 1.2% after seven-day storage extension for PR-PCs. The blood utilization remained stable, with no increase in component utilization. A significant decrease in adverse transfusion events was observed after the PR implementation. (4) Conclusion: Our experience demonstrates the feasibility for Brazilian blood centers to achieve a 100% PR-PC inventory. All patients at our hospital received PR-PC and showed no increase in blood component utilization and decreased rates of adverse transfusion reactions


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29. A Cybersecurity Model for the Health Sector: A Case Study of Hospitals in Nairobi, Kenya

United States International University – Africa – Digital repository


Authors: Raburu Eugene Emmanuel
Region / country: Eastern Africa – Kenya
Speciality: Digital health, Health policy

Internet crime is perceived to be an advanced type of crime that has not yet infiltrated third world countries like Kenya. Cybercrime is growing in all parts of the world, and most users of the internet have fallen victims at one point in time. Most victims suffer and do not speak out especially healthcare institutions due to the fear of backlash from the general public. Moreover, the cybercrimes threats to healthcare equipment, electronic healthcare technology is prevalent worldwide and creates enormous potential to improve clinical outcomes and transform the delivery of care. Overall, this study strived to come up with a cyber-security framework for fighting cybercrime in the health sector in Kenya. Specifically, this research project sought to outline the major cyber threats and vulnerabilities, develop a cyber-security framework and validate it for adoption within health sector in Kenya. A descriptive research design was adopted in the study. The population of the study consisted of Mediheal group of hospitals staff. The study focused on top and mid-level IT and other departmental heads that work for Mediheal group of hospitals in Nairobi Kenya. The hospital had a total of 206 staff in Nairobi. This study used convenience sampling. Based on the Yamane formula, the study sampled 135 employees from all departments of Mediheal group of hospitals. Primary data was gathered by use of a questionnaire. Frequency tables and percentages were used to present the findings. Correlation and simple regression analysis were used to indicate simple relationships between individual constructs with the dependent variable. For model evaluation, Structural Equation Modelling (SEM) was used. The study found that top management commitment had a moderate influence on cybersecurity (r = .338, p = .000), organizational factors had a strong influence on cybersecurity (r = .604, p = .000), IT policies had a weak influence on cybersecurity (r = .209, p = .028), and IT literacy had a strong influence on cybersecurity (r = .642, p = .000). From SEM analysis, the study confirmed that the path coefficients were positive for top management commitment, organizational factors and IT literacy with cybersecurity. The paths coefficients were, however, negative for IT policies and threats and vulnerabilities with cybersecurity. The study recommends that monitoring of the performance of cybersecurity as well as continuous awareness and training programs on cyber security for all employees are needed.


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30. Health care equity in urban India

Azim Premji University Publication Repository


Authors: Mishra Arima, Seshadri Shreelata Rao, Pradyumna Adithya, Pinto Edward Premdas, Bhattacharya Aruna, Saligram Prasanna
Region / country: Southern Asia – India
Speciality: Health policy

The report is based on the data drawn from detailed interactions with civil society organisations working on urban health in different cities and town across geographies including Mumbai, Bengaluru, Surat, Lucknow, Guwahati, Ranchi, Delhi etc., inputs from health officials in select cities, analysis of select data bases including NFHS, Census of India, government websites and secondary literature on urban health. The report focuses on a) understanding the health vulnerabilities of the urban poor b) the availability, accessibility, cost and quality of health care facilities and challenges therein c) and to propose possible pathways towards fixing the gaps in urban health care governance and provisioning. It also outlines the detailed provision and governance of health care in four different cities and towns including Bengaluru (Tier I), Thiruvananthapuram (Tier II), Raipur (Tier III) and Davanagere (Tier III).


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31. Analysis of reasons for loss to follow up in a prospective study in Chandigarh, India and impact from telecom changes

BMC Research Notes


Authors: Joseph L. Mathew, Pooja N. Patel, Abram L. Wagner, Vanita Suri, Bhavneet Bharti, Bradley F. Carlson & Matthew L. Boulton
Region / country: Southern Asia – India
Speciality: Digital health, Health policy

Objective
Mobile phones are used in research studies, to enroll and follow-up participants, collect data, and implement mHealth initiatives. We conducted a longitudinal study in a birth cohort, where infants were required to make four scheduled visits by 12 months of age. Families of those failing to attend scheduled follow-up visits, were contacted telephonically to ascertain the reasons, which were categorized as: not interested to continue participating, migrated, phone disconnected due to telecom change, or other reason.

Results
A total of 413 mother-infant dyads were enrolled. The overall attrition was 56%, with majority occurring at the first follow-up visit. This temporally coincided with a telecom service provider announcing strong incentives to switch providers. Attrition monotonically decreased at subsequent visits. The reasons were: moved away (13%), no longer interested (8%), phone disconnected (7%), and multiple other reasons (28%), the majority of whom had unreachable phones. Those who remained in the study and those lost to follow-up were similar on most demographic variables. Among common reasons for attrition in cohort studies, we experienced a new dimension introduced by telecom changes. These findings underscore the need to consider unexpected reasons for attrition in longitudinal studies, and design more robust methods to follow-up participants.


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32. Restrictive abortion laws, COVID-19, telehealth, and medication abortion in the SDG era

the lancet global health


Authors: Ibraheem O Awowole, Omotade A Ijarotimi
Region / country: Global
Speciality: Obstetrics and Gynaecology

Annual worldwide abortion rates reportedly increased from 55·7 million between 2010 and 2014, to 73·3 million in 2015–19.1, 2 About 4·7–13·2% of maternal deaths annually are abortion-related, with the highest burden in Asia and Africa.3 Elimination of unsafe abortion, defined by WHO4 as “an abortion that is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both”, is therefore a critical step towards achieving the UN Sustainable Development Goal (SDG) target of reducing the global maternal mortality ratio to less than 70 per 100 000 livebirths (SDG 3.1) and ensuring universal access to sexual and reproductive health-care services by 2030 (SDG 3.7). Some of the relevant factors that might impact positively on abortion-related morbidity and mortality are discussed here.
Asia, Latin America, and Africa have some of the most legally restrictive abortion laws, yet these regions account for 97% of the global burden of unsafe abortions.1, 3 Abortion rates in settings with restrictive laws are not necessarily lower than in regions with permissive laws. In fact, almost 62% of all abortion-related deaths are recorded in Africa alone.3 These predominantly restrictive abortion laws lead to delayed decisions to seek care until advanced gestational ages, when the abortion becomes more difficult to undertake, and care is often sought from clandestine sources to circumvent the law. Nigeria and Argentina, which were selected by Heidi Moseson and colleagues5 for their research, are countries with some of the highest rates of unsafe abortion. Therefore, the findings of this research are relevant to many other countries with similar prevailing circumstances.
The American College of Obstetrics and Gynaecology defines telehealth as “the technology-enhanced health care framework that includes services such as virtual visits, remote patient monitoring, and mobile health care”.6 With the COVID-19 pandemic, use of telehealth has become widespread in many aspects of health-care delivery systems. Specifically, with respect to abortion, telehealth not only facilitates access for women seeking abortion services, but also provides the additional benefits of confidentiality and avoidance of stigmatisation, with similar clinical outcomes to facility-based management.7, 8 However, in low-income and middle-income countries (LMICs), such as Nigeria, termination for any reason apart from saving maternal life is not only illegal, but the provider of such medications and services is liable to 14 years imprisonment. Such laws might significantly impede the optimal use of telehealth for abortion services across various regions of the world.
Medication abortion has been in use for at least two decades, with current regimens including misoprostol alone and misoprostol and mifepristone in combination. Evidence supports the effectiveness and efficiency of medication abortion, especially in pregnancies of less than 10 weeks, which was further affirmed by the findings from Moseson and colleagues.5 Medication abortion is also associated with lower risks of cervical injuries, uterine perforations, and post-abortion sepsis than is surgical abortion, and might therefore reduce abortion-related morbidity and maternal mortality.9, 10 However, conventional medication abortion is physician supervised, and initially involves hospital admission. The cost of health facility visits can be prohibitive in LMICs, where people pay out-of-pocket for health care and might be living on less than US$1 per day.
Apart from the social stigma associated with abortion, women cannot seek health care without the permission and accompaniment of a male relative in some cultural and religious settings. Moseson and colleagues5 showed that self-managed medication abortion is highly effective at early gestational ages, obviating the need for health facility visits. The study also showed that home-managed abortion with accompaniment support by trained, non-medical personnel was non-inferior to historical controls who underwent physician-supervised, facility-based management. These findings might influence access to and safe management of abortion, thereby facilitating reproductive health decision making by women, with more efficient use of resources through telemedicine and task shifting. However, such benefits might remain impossible to explore in settings with restrictive abortion laws.
There is also a need to balance these benefits against the possibility of abuse, exploitation, and forced abortions by male partners at home, especially in settings where women are less empowered to make decisions concerning their reproductive health. Further qualitative research is needed for strategic planning towards SDG targets 3.1 and 3.7. Although this can be achieved without hindrance in some settings, it is unclear how much data might be obtainable from regions within restrictive abortion jurisdictions, where the line between legality and illegality could easily be crossed by researchers unless laws are revised.
We declare no competing interests.


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33. Infection control

Southern African Journal of Anaesthesia and Analgesia


Authors: M Fourtounas
Region / country: Southern Africa – South Africa
Speciality: Health policy, Other

Despite healthcare-associated infections (HAIs) being preventable, the incidence is increasing, leading to morbidity, mortality and increased healthcare costs. The aim of infection control practices is to prevent the transmission of infections between patients and healthcare providers. The earliest published infection control reference in anaesthesia was in 1873.

Infection prevention and control involves every corner of the hospital. From environmental and equipment cleaning and decontamination to infection control precautions when managing infectious patients to the most basic of effective interventions, hand hygiene. There are additional sources of risk in anaesthesia practice; injection and drug administration practices, the insertion of invasive lines, surgical antibiotic prophylaxis and the performance of regional and neuraxial anaesthesia. Anaesthetists should endeavour to be part of the solution and not part of the problem.

Modest changes in our daily infection control practices, such as appropriate and adequate hand hygiene; surface, environmental and equipment decontamination; correct handling and use of drugs, fluids, intravenous administration sets; and meticulous care to sterility and cleanliness when performing invasive procedures can have a significant impact on patient outcomes. Knowledge of local infection prevention and control guidelines is the first step to adherence and building the central pillars to minimise the risk of HAIs.

HAIs increase morbidity, mortality and healthcare expenses. These infections are avoidable and yet the incidence is increasing. Surgical site infections (SSIs) are the most common HAIs with the highest expenditure, increasing hospital stay by up to 11 days.1 The World Health Organization (WHO)2 reports that 3.5–12% of hospitalised patients in developed countries will develop an HAI and this is almost doubled in developing countries at 5.7–19.1%. The GlobalSurg Collaborative3 found the prevalence of SSIs in lower-and-middle income countries (LMICs) to be 2–20 times higher than in higher income countries (HICs). In South Africa, one in seven patients is at risk of developing an HAI.


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34. Resource Use, Availability and Cost in the Provision of Critical Care in Tanzania: A Systematic Review

Research Square


Authors: Joseph Kazibwe, Hiral A. Shah, August Kuwawenaruwa, Carl Otto Schell, Karima Khalid, Phuong Bich Tran, Srobana Ghosh, Tim Baker, Lorna Guinness
Region / country: Eastern Africa – Tanzania
Speciality: Critical care, Health policy

Introduction

Critical care is essential in saving lives of critically ill patients, however, provision of critical care across lower resource settings can be costly, fragmented and heterogenous. Despite the urgent need to scale-up the provision of critical care, little is known about its availability and cost. Here, we aim to systematically review and identify reported resource use, availability and costs for the provision of critical care and the nature of critical care provision in Tanzania.

Methods

The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; PROSPERO registration number: CRD42020221923. We searched Medline, Embase and global health databases. We included studies that reported on provision of critical care, cost and availability of resources used in the provision of critical care published after 2010. Costs were adjusted and reported in 2019 USD and TZS using the world bank GDP deflators.

Results

A total 31 studies were found to fulfil the inclusion and exclusion criteria. Critical care identified in Tanzania was categorised into: ICU delivered critical care and non-ICU critical care. The availability of ICU delivered critical care was limited to urban settings whereas non-ICU critical care was found in rural and urban settings. 15 studies reported on the costs of services related to critical care yet no study reported an average or unit cost of critical care. Costs of medication, equipment (e.g. oxygen, PPE), services, and human resources were identified as inputs to specific critical care services in Tanzania.

Conclusion

There is limited evidence on the resource use, availability and costs of critical care in Tanzania. There is a strong need for further empirical research on critical care resources availability, utilization and costs across specialties and hospitals of different level in LMICs like Tanzania to inform planning, priority setting and budgeting for critical care services.


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35. Breast Conservative Surgery for Breast Cancer: Indian Surgeon’s Preferences and Factors Influencing Them

Research Square


Authors: Rohini Dutta, Sargun Virk, Priti Patil, Geetu Bhandoria, Bhakti Sarang, Anshul Mahajan, Monty Khajanchi, Samarvir Jain, Lovenish Bains, Prashant Bhandarkar, Shamita Chatterjee, Nobhojit Roy, Anita Gadgil
Region / country: Southern Asia – India
Speciality: General surgery, Surgical oncology

Background: It is well established that disease-free survival and overall survival after breast conservation surgery (BCS) followed by radiotherapy are equivalent to that after mastectomy. However, in Asian countries, the rate of BCS continues to remain low. The cause may be multifactorial including the patient’s choice, availability and accessibility of infrastructure and surgeon’s choice. We aimed to elucidate the Indian surgeons’ perspective while choosing between BCS and mastectomy, in women oncologically eligible for BCS.

Methods: We conducted a survey-based cross-sectional study over 3 weeks between January-February 2021. Indian surgeons with general surgical or specialised onco-surgical training, who consented to participate were included in the study. Multinomial logistic regression was performed to assess the effect of study variables on offering mastectomy or BCS to an eligible patient.

Results: A total of 347 responses were included. The mean age of the participants was 43(11) years. 63% of the surgeons were in the 25-44 years age group with the majority (80%) being males. 66.4% of surgeons ‘almost always’ offered BCS to oncologically eligible patients. Surgeons who had undergone specialised training in oncosurgery or breast conservation surgery were 35 times more likely to offer BCS (p<0.01). Surgeons working in hospitals with in-house radiation oncology facilities were 9 times more likely to offer BCS (p<0.05). Surgeons’ years of practice, age, sex and hospital setting did not influence the surgery offered.

Conclusion: Our study found that two-thirds of Indian surgeons preferred BCS over mastectomy. Lack of radiotherapy facilities and specialised surgical training were deterrents to offering BCS to eligible women.


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36. The prevalence and risk factors of chronic low back pain among adults in KwaZulu-Natal, South Africa: an observational cross-sectional hospital-based study

BMC Musculoskeletal Disorders


Authors: Morris Kahere, Themba Ginindza
Region / country: Southern Africa – South Africa
Speciality: Trauma and orthopaedic surgery

Background
Globally, chronic low back pain (CLBP) is the leading cause of disability associated with economic costs. However, it has received little attention in low-and-middle-income countries. This study estimated the prevalence and risk factors of CLBP among adults presenting at selected hospitals in KwaZulu-Natal.

Methodology
This cross-sectional study was conducted among adults aged ≥18 years who attended the selected hospitals in KwaZulu-Natal during the study period. A self-administered questionnaire was used to collect data on socio-demographic, work-related factors, and information about CLBP. The SPSS version 24.0 (IBM SPSS Inc) was used for data analysis. Descriptive statistics were used for demographic characteristics of participants. CLBP risk factors were assessed using multivariate logistic regression analysis. A p-value of ≤0.05 was deemed statistically significant.

Results
A total of 678 adults participated in this study. The overall prevalence of CLBP was 18.1% (95% CI: 15.3 – 21.3) with females having a higher prevalence than males, 19.8% (95% CI: 16.0 – 24.1) and 15.85% (95% CI: 11.8 – 20.6), respectively. Using multivariate regression analysis, the following risk factors were identified: overweight (aOR: 3.7, 95% CI: 1.1 – 12.3, p = 0.032), no formal education (aOR: 6.1, 95% CI: 2.1 – 18.1, p = 0.001), lack of regular physical exercises (aOR: 2.2, 95% CI: 1.0 – 4.8, p = 0.044), smoking 1 to 10 (aOR: 4.5, 95% CI: 2.0 – 10.2, p < 0.001) and more than 11 cigarettes per day (aOR: 25.3, 95% CI: 10.4 – 61.2, p < 0.001), occasional and frequent consumption of alcohol, aOR: 2.5, 95% CI: 1.1 – 5.9, p < 0.001 and aOR: 11.3, 95% CI: 4.9 – 25.8, p < 0.001, respectively, a sedentary lifestyle (aOR: 31.8, 95% CI: 11.2 – 90.2, p < 0.001), manual work (aOR: 26.2, 95% CI: 10.1 – 68.4, p < 0.001) and a stooped sitting posture (aOR: 6.0, 95% CI: 2.0 – 17.6, p = 0.001).

Conclusion
This study concluded that the prevalence of CLBP in KwaZulu-Natal is higher than in other regions, and that it is predicted by a lack of formal education, overweight, lack of regular physical exercises, smoking, alcohol consumption, sedentary lifestyle, manual work, and a stooped posture.


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37. A practical approach to perioperative risk optimisation for non-cardiac surgery

Southern African Journal of Anaesthesia and Analgesia


Authors: I Cassimjee
Region / country: Southern Africa – South Africa
Speciality: Cardiothoracic surgery

The combination of careful perioperative considerations, less invasive surgeries and the liberal use of neuro-axial techniques has decreased perioperative major adverse cardiac events (MACE) and overall mortality in vascular surgical patients.

Despite this, the recently published ASOS-2 study still demonstrated a 1% mortality even with intensive postoperative monitoring for a range of patients and procedures in lower-middle income countries (LMICs).1 As surgeons, our outcome measures are sometimes different to other perioperative physicians (primarily anaesthesiologists and cardiologists). Our outcomes are not limited to the myocardial function or the safe awakening after anaesthesia, but also incorporates medium term outcomes such as postoperative infections, wound healing, returns to the operating theatre and restoration of pre-morbid functional capacity.


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38. Hearing screening program for school going children in India: necessity, justification, and suggested approaches

The Egyptian Journal of Otolaryngology


Authors: Mohammad Shamim Ansari
Region / country: Southern Asia – India
Speciality: ENT surgery

Background
It is estimated that about 15% of students have transient hearing loss worldwide sufficient enough to interfere with communication, psychosocial relationship, and learning resulting in poor educational achievement and poverty. However, these conditions are reversible through timely detection and effective interventions. India is home to the largest number of school age children with hearing impairment, and majority of them remain undetected and untreated due to the absence of any dedicated hearing screening program. Therefore, this paper attempts to convince all stakeholders for planning and implementing early detection and intervention program for children with hearing impairment in school settings.

Methods
Recent literature estimates that children between the ages 0 and 14 years contribute 25.9% of the total Indian population. As per the global estimates of the prevalence of hearing impairment, India houses the largest number of school age children with hearing impairment. Many of them either remain out of school or perform poorly in school curriculum.

Results
The children in educational programs are readily and easily available for applying hearing screening procedures to detect hearing impairment and instituting audiological and educational remedial measures. But unfortunately, India has not yet envisaged any dedicated early detection and intervention program for school-going children consequently majority of children with hearing impairment undetected and untreated in the classroom.

Conclusion
Hearing impairment is a serious health concern among school age children which can adversely impact on communication, educational achievement, and vocational options. However, screening approaches for early identification in school age children across the world which are simple, effective, and cost-efficient can be considered for countries like India to reverse the ill effects of hearing impairment.

Potential implication
The paper may heighten the awareness among school personnel, educational administrators, and policymakers to consider planning and implementation of early detection and intervention program for children with hearing impairment in school settings.


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39. Rheumatic Heart Disease is Missing from the Global Health Agenda

annals of global health


Authors: Wubishet Belay, Muktar H. Aliyu
Region / country: Global
Speciality: Cardiothoracic surgery

Rheumatic heart disease (RHD) is a complication of untreated throat infection by Group A beta-hemolytic streptococcus with a high prevalence among socioeconomically disadvantaged populations. Despite its high incidence and prevalence, RHD prevention is not a priority in major global health discussions. The reasons for the apparent neglect are multifactorial, including underestimated morbidity and mortality burden, underappreciated economic burden, lack of public awareness, and lack of sustainable investment. In this review, we recommend multisectoral collaboration to tackle the burden of RHD by engaging the public, health experts, and policymakers; augmenting funding for clinical care; improving distribution channels for prophylaxis, and increasing research and innovation as critical interventions to save millions of people from preventable morbidity and mortality.


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40. Assessing the Rates and Reasons of Elective Surgical Cancellations on the Day of Surgery: A Multicentre Study from Urban Indian Hospitals

World Journal of Surgery


Authors: Bhakti Sarang, Geetu Bhandoria, Priti Patil, Anita Gadgil, Lovenish Bains, Monty Khajanchi, Deepa Kizhakke Veetil, Rohini Dutta, Priyansh Shah, Prashant Bhandarkar, Lileswar Kaman, Dhruva Ghosh, Kavita Mandrelle, Ashwani Kumar, Akshay Bahadur, Sunil Krishna, Kamal Kishore Gautam, Ya Dev, Manisha Aggarwal, Neil Thivalapill & Nobhojit Roy On Behalf of the IndSurg Collaboration
Region / country: Southern Asia – India
Speciality: Health policy

Background
Cancellations of elective surgeries on the day of surgery (DOS) can lead to added financial burden and wastage of resources for healthcare facilities; as well as social and emotional problems to patients. These cancellations act as barriers to delivering efficient surgical services. Optimal utilisation of the available resources is necessary for resource-constrained low-and-middle-income countries (LMIC). This study investigates the rate and causes of cancellations of elective surgeries on the DOS in various surgical departments across ten hospitals in India.

Methods
A research consortium ‘IndSurg’ led by World Health Organisation Collaboration Centre (WHOCC) for Research in Surgical Care Delivery in LMICs, India conducted this multicentre retrospective cross-sectional study to analyse the cancellations of elective/planned surgical operations on DOS across urban secondary and tertiary level hospitals. We audited surgical records of a pre-decided period of six weeks for cancellations, documented relevant demographic information and reasons for cancellations.

Results
We analysed records from the participating hospitals, with an overall cancellation rate of 9.7% (508/5231) on the DOS for elective surgical operations. Of these, 74% were avoidable cancellations. A majority (30%) of these 508 cancellations were attributed to insufficient resources, 28% due to patient’s refusal or failure to show-up, and 22% due to change in patient’s medical status.

Conclusion
We saw a preponderance of avoidable reasons for elective surgery cancellations. A multidisciplinary approach with adequate preoperative patient counselling, timely communication between the patients and caregivers, adequate preoperative anaesthetic assessment, and planning by the surgical team may help reduce the cancellation rate.


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41. Barriers and facilitators to adherence to national drug policies on antibiotic prescribing and dispensing in Bangladesh

Journal of Pharmaceutical Policy and Practice


Authors: Fosiul Alam Nizame, Dewan Muhammad Shoaib, Emily K. Rousham, Salma Akter, Mohammad Aminul Islam, Afsana Alamgir Khan, Mahbubur Rahman, Leanne Unicomb
Region / country: Southern Asia – Bangladesh
Speciality: Health policy, Other

Background
The National Drug Policy in Bangladesh prohibits the sale and distribution of antibiotics without prescription from a registered physician. Compliance with this policy is poor; prescribing antibiotics by unqualified practitioners is common and over-the-counter dispensing widespread. In Bangladesh, unqualified practitioners such as drug shop operators are a major source of healthcare for the poor and disadvantaged. This paper reports on policy awareness among drug shop operators and their customers and identifies current dispensing practices, barriers and facilitators to policy adherence.

Methods
We conducted a qualitative study in rural and urban Bangladesh from June 2019 to August 2020. This included co-design workshops (n = 4) and in-depth interviews (n = 24) with drug shop operators and customers/household members, key informant interviews (n = 12) with key personnel involved in aspects of the antibiotic supply chain including pharmaceutical company representatives, and model drug shop operators; and a group discussion with stakeholders representing key actors in informal market systems namely: representatives from the government, private sector, not-for-profit sector and membership organizations.

Results
Barriers to policy compliance among drug shop operators included limited knowledge of government drug policies, or the government-led Bangladesh Pharmacy Model Initiative (BPMI), a national guideline piloted to regulate drug sales. Drug shop operators had no clear knowledge of different antibiotic generations, how and for what diseases antibiotics work contributing to inappropriate antibiotic dispensing. Nonetheless, drug shop operators wanted the right to prescribe antibiotics based on having completed related training. Drug shop customers cited poor healthcare facilities and inadequate numbers of attending physician as a barrier to obtaining prescriptions and they described difficulties differentiating between qualified and unqualified providers.

Conclusion
Awareness of the National Drug Policy and the BPMI was limited among urban and rural drug shop operators. Poor antibiotic prescribing practice is additionally hampered by a shortage of qualified physicians; cultural and economic barriers to accessing qualified physicians, and poor implementation of regulations. Increasing qualified physician access and increasing training and certification of drug shop operators could improve the alignment of practices with national policy.


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42. Performance in mortality prediction of SAPS 3 And MPM-III scores among adult patients admitted to the ICU of a private tertiary referral hospital in Tanzania: a retrospective cohort study

peer journal


Authors: Nadeem Kassam​, Eric Aghan, Samina Somji, Omar Aziz, James Orwa, Salim R. Surani
Region / country: Eastern Africa – Tanzania
Speciality: Critical care

Background
Illness predictive scoring systems are significant and meaningful adjuncts of patient management in the Intensive Care Unit (ICU). They assist in predicting patient outcomes, improve clinical decision making and provide insight into the effectiveness of care and management of patients while optimizing the use of hospital resources. We evaluated mortality predictive performance of Simplified Acute Physiology Score (SAPS 3) and Mortality Probability Models (MPM0-III) and compared their performance in predicting outcome as well as identifying disease pattern and factors associated with increased mortality.

Methods
This was a retrospective cohort study of adult patients admitted to the ICU of the Aga Khan Hospital, Dar- es- Salaam, Tanzania between August 2018 and April 2020. Demographics, clinical characteristics, outcomes, source of admission, primary admission category, length of stay and the support provided with the worst physiological data within the first hour of ICU admission were extracted. SAPS 3 and MPM0-III scores were calculated using an online web-based calculator. The performance of each model was assessed by discrimination and calibration. Discrimination between survivors and non–survivors was assessed by the area under the receiver operator characteristic curve (ROC) and calibration was estimated using the Hosmer-Lemeshow goodness-of-fit test.

Results
A total of 331 patients were enrolled in the study with a median age of 58 years (IQR 43-71), most of whom were male (n = 208, 62.8%), of African origin (n = 178, 53.8%) and admitted from the emergency department (n = 306, 92.4%). In- hospital mortality of critically ill patients was 16.1%. Discrimination was very good for all models, the area under the receiver-operating characteristic (ROC) curve for SAPS 3 and MPM0-III was 0.89 (95% CI [0.844–0.935]) and 0.90 (95% CI [0.864–0.944]) respectively. Calibration as calculated by Hosmer-Lemeshow goodness-of-fit test showed good calibration for SAPS 3 and MPM0-III with Chi- square values of 4.61 and 5.08 respectively and P–Value > 0.05.

Conclusion
Both SAPS 3 and MPM0-III performed well in predicting mortality and outcome in our cohort of patients admitted to the intensive care unit of a private tertiary hospital. The in-hospital mortality of critically ill patients was lower compared to studies done in other intensive care units in tertiary referral hospitals within Tanzania.


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43. Engagement of non-governmental organisations in moving towards universal health coverage: a scoping review

Globalization and Health


Authors: Arman Sanadgol, Leila Doshmangir, Reza Majdzadeh, Vladimir Sergeevich Gordeev
Region / country: Global
Speciality: Health policy

Background
Developing essential health services through non-governmental organisations (NGOs) is an important strategy for progressing towards Universal Health Coverage (UHC), especially in low- and middle-income countries. It is crucial to understand NGOs’ role in reaching UHC and the best way to engage them.

Objective
This study reviewed the role of NGOs and their engagement strategies in progress toward UHC.

Method
We systematically reviewed studies from five databases (PubMed, Web of Science (ISI), ProQuest, EMBASE and Scopus) that investigated NGOs interventions in public health-related activities. The quality of the selected studies was assessed using the mixed methods appraisal tool. PRISMA reporting guidelines were followed.

Findings
Seventy-eight studies met the eligibility criteria. NGOs main activities related to service and population coverage and used different strategies to progress towards UHC. To ensure services coverage, NGOs provided adequate and competent human resources, necessary health equipment and facilities, and provided public health and health care services strategies. To achieve population coverage, they provided services to vulnerable groups through community participation. Most studies were conducted in middle-income countries. Overall, the quality of the reported evidence was good. The main funding sources of NGOs were self-financing and grants from the government, international organisations, and donors.

Conclusion
NGOs can play a significant role in the country’s progress towards UHC along with the government and other key health players. The government should use strategies and interventions in supporting NGOs, accelerating their movement toward UHC.


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44. Health-Related Suffering and Palliative Care in Breast Cancer

Current Breast Cancer Reports


Authors: M. M. Sunilkumar, Charles G. Finni, A. S. Lijimol & M. R. Rajagopal
Region / country: Global
Speciality: Surgical oncology

Purpose of Review
Breast cancer continues to be the most frequently diagnosed cancer in women and the leading cause of cancer death worldwide. By the suffering that it causes in various domains of life, breast cancer seriously impacts the quality of life of affected individuals and causes a major burden of suffering in the community. The objectives of the review were to understand the health-related suffering in patients with breast cancer and to identify the scope of palliative care in improving the quality of life of patients with breast cancer.

Recent Findings
Breast cancer causes suffering in physical, psychological, social, financial, and spiritual domains of the lives of the patient and family. Management of breast cancer with surgery, chemotherapy, and radiation could have adverse effects, such as pain, nausea and vomiting, fatigue, shortness of breath, depression, and constipation. Both cancer and its treatment can impact the psychosocial and spiritual well-being of the patient and family members. Integrating palliative care into existing breast cancer treatment programs seems to be the best approach to diminish these sufferings.

Summary
In addition to pain and other physical symptoms, breast cancer can cause major psychological, social, and spiritual suffering. In the context of developing countries, out-of-pocket expenditure can cause major financial destruction which can impact generations. Integration of palliative care to breast cancer treatment is essential.


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45. Impact of COVID-19 pandemic on global burn care

Burns


Authors: Pompermaier Laura, Adorno José, Allorto Nikki, Altarrah Khaled, Juan P Barret, Carter Jeffery, Chamania Shobha, Chong Si Jack, Corlew Scott, Depetris Nadia, Elmasry Moustafa, Junlin Liao, Haik Josef, Horwath Briana, Keswani Sunil, Kiyozumi Tetsuro, Leon-Villapalos Jorge, Luo Gaoxing, Matsumura Hajime, Miranda-Altamirano Rodolfo, Moiemen Naiem, Nakarmi Kiran, Nawar Ahmed, Ntirenganya Faustin, Olekwu Anthony, Potokar Tom, Qiao Liang, Rai Shankar Man, Steinvall Ingrid, Tanveer Ahmed, Vana Luiz Philipe Molina, Wall Shelley, Fisher Mark
Region / country: Global
Speciality: Plastic surgery, Trauma surgery

Background
Worldwide, different strategies have been chosen to face the COVID-19-patient surge, often affecting access to health care for other patients. This observational study aimed to investigate whether the standard of burn care changed globally during the pandemic, and whether country´s income, geographical location, COVID-19-transmission pattern, and levels of specialization of the burn units affected reallocation of resources and access to burn care.

Methods
The Burn Care Survey is a questionnaire developed to collect information on the capacity to provide burn care by burn units around the world, before and during the pandemic. The survey was distributed between September and October 2020. McNemar`s test analyzed differences between services provided before and during the pandemic, χ2 or Fisher’s exact test differences between groups. Multivariable logistic regression analyzed the independent effect of different factors on keeping the burn units open during the pandemic.

Results
The survey was completed by 234 burn units in 43 countries. During the pandemic, presence of burn surgeons did not change (p=0.06), while that of anesthetists and dedicated nursing staff was reduced (<0.01), and so did the capacity to manage patients in all age groups (p=0.04). Use of telemedicine was implemented (p<0.01), collaboration between burn centers was not. Burn units in LMICs and LICs were more likely to be closed, after adjustment for other factors.

Conclusions
During the pandemic, most burn units were open, although availability of standard resources diminished worldwide. The use of telemedicine increased, suggesting the implementation of new strategies to manage burns. Low income was independently associated with reduced access to burn care.


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46. Burn injury prevention in low- and middle- income countries: scoping systematic review

Burns and trauma


Authors: Kate Price, Kwang Chear Lee, Katherine E. Woolley, Henry Falk, Michael Peck, Richard Lilford, Naiem Moiemen
Region / country: Global
Speciality: Plastic surgery, Trauma surgery

Background
Burn injuries are a leading cause of morbidity and disability, with the burden of disease being disproportionately higher in low- and middle-income countries (LMIC). Burn prevention programmes have led to significant reductions in the incidence of burns in high-income countries. However, a previous systematic review published in 2015 highlighted that implementation and evaluation of similar programmes has been limited in LMIC. The objective of this scoping review and narrative synthesis was to summarise and understand the initiatives that have been carried out to reduce burn injuries in LMIC and their effectiveness.

Methods
We aimed to identify publications that described studies of effectiveness of burn prevention interventions applied to any population within a LMIC and measured burn incidence or burns-related outcomes. Suitable publications were identified from three sources. Firstly, data was extracted from manuscripts identified in the systematic review published by Rybarczyk et al. We then performed a search for manuscripts on burn prevention interventions published between January 2015 and September 2020. Finally, we extracted data from two systematic reviews where burn evidence was not the primary outcome, which were identified by senior authors. A quality assessment and narrative synthesis of included manuscripts were performed.

Results
In total, 24 manuscripts were identified and categorized according to intervention type. The majority of manuscripts (n = 16) described education-based interventions. Four manuscripts focused on environmental modification interventions and four adopted a mixed-methods approach. All of the education-based initiatives demonstrated improvements in knowledge relating to burn safety or first aid, however few measured the impact of their intervention on burn incidence. Four manuscripts described population-based educational interventions and noted reductions in burn incidence. Only one of the four manuscripts describing environmental modification interventions reported burns as a primary outcome measure, noting a reduction in burn incidence. All mixed-method interventions demonstrated some positive improvements in either burn incidence or burns-related safety practices.

Conclusion
There is a lack of published literature describing large-scale burn prevention programmes in LMIC that can demonstrate sustained reductions in burn incidence. Population-level, collaborative projects are necessary to drive forward burn prevention through specific environmental or legislative changes and supplementary educational programmes.


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47. Surgical Capacity in Rural Southeast Nigeria: Barriers and New Opportunities

annals of global health


Authors: Aloysius U. Ogbuanya, Stanley Nnamdi C. Anyanwu, Akuma Ajah, Onyeyirichi Otuu, Nonyelum Benedett Ugwu, Emmanuel A. Boladuro, Williams Otu Nandi
Region / country: Western Africa – Nigeria
Speciality: Anaesthesia, General surgery, Health policy, Obstetrics and Gynaecology

Background: Remarkable gains have been made in global health with respect to provision of essential and emergency surgical and anesthesia care. At the same time, little has been written about the state of surgical care, or the potential strategies for scale-up of surgical services in sub-Saharan Africa, southeast Nigeria inclusive.

Objective: The aim was to document the state of surgical care at district hospitals in southeast Nigeria.

Methods: We surveyed 13 district hospitals using the World Health Organization (WHO) tool for situational analysis developed by the “Lancet Commission on Global Surgery” initiative to assess surgical care in rural Southeast Nigeria. A systematic literature review of scientific literatures and policy documents was performed. Extraction was performed for all articles relating to the five National Surgical, Obstetric and Anesthesia Plans (NSOAPs) domains: infrastructure, service delivery, workforce, information management and financing.

Findings: Of the 13 facilities investigated, there were six private, four mission and three public hospitals. Though all the facilities were connected to the national power grid, all equally suffered electricity interruption ranging from 10–22 hours daily. Only 15.4% and 38.5% of the 13 hospitals had running water and blood bank services, respectively. Only two general surgeon and two orthopedic surgeons covered all the facilities. Though most of the general surgical procedures were performed in private and mission hospitals, the majority of the public hospitals had limited ability to do the same. Orthopedic procedures were practically non-existent in public hospitals. None of the facilities offered inhalational anesthetic technique. There was no designated record unit in 53.8% of facilities and 69.2% had no trained health record officer.

Conclusion: Important deficits were observed in infrastructure, service delivery, workforce and information management. There were indirect indices of gross inadequacies in financing as well


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48. High HIV Detection in a Tertiary Facility in Liberia: Implications and Opportunities

annals of global health


Authors: Onyema Ogbuagu, Ian Wachekwa, Faiza Yasin, Cecilia Nuta, Sean Donato, Julia Toomey, Mukhtar Adeiza, Lydia Aoun Barakat
Region / country: Western Africa – Liberia
Speciality: Health policy, Other

Background: HIV/AIDS remains one of the world’s most significant public health challenges; sub-Saharan Africa accounts for 71% of the global burden of HIV. Testing for HIV is pivotal to achieving UNAIDS 95-95-95 target towards bringing an end to the epidemic.

Objective: The study assessed five-year HIV testing data from the largest tertiary hospital in Monrovia, Liberia and highlights risk groups that would benefit from targeted testing and prevention interventions.

Methods: This was a single-center academic hospital-based retrospective analysis of HIV testing data from January 2014 to December 2018 obtained from all testing sites at John F. Kennedy Medical Center in Monrovia, Liberia. Pooled HIV testing data during the study period were analyzed using descriptive statistics and stratified by age, gender and pregnancy status. Annual diagnoses rates were reported as proportion of individuals tested within a specified category (age [=25 years], gender, and pregnancy status) that had a positive HIV test. Five-year trends were analyzed.

Results: Over the study period, 41,343 non-pregnant individuals were screened for HIV. In addition, the antenatal clinic performed 24,913 tests. Of non-pregnant individuals tested, 4,066 (10%) were diagnosed with HIV ranging from 7% (909/12821) in 2018 to 13% (678/5079) in 2014. Case detection rates for individuals aged 15–24 were 7%, 5%, 4%, 6% and 3% for years 2014, 2015, 2016, 2017 and 2018 respectively. Annually, 2–3% of all pregnant women tested were diagnosed with HIV. While HIV detection rates decreased over time overall, children less than 15 years of age showed an annual increase from 6.7% in 2014 to 12.3% in 2018.

Conclusion: A large five-year dataset from the largest tertiary facility in Liberia shows broad HIV detection rates that are much higher than national prevalence estimates. Ramping up HIV testing and prevention interventions including pre-exposure prophylaxis are sorely needed.


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49. Neonatal Resuscitation Research Priorities in Low- and Middle-Income Countries

International Journal of Pediatrics


Authors: Vivek V. Shukla, Somashekhar M. Nimbalkar
Region / country: Global
Speciality: Paediatric surgery

Several critical physiological changes occur during birth. Optimal and timely resuscitation is essential to avoid morbidity and mortality. The International Liaison Committee on Resuscitation (ILCOR) is a multinational committee that publishes evidence-based consensus and treatment recommendations for resuscitation in various scenarios including that for neonatal resuscitation. The majority of perinatal deaths occur in low- and middle-income countries (LMICs); however, there is limited research output from LMICs to generate evidence-based practice recommendations specific for LMICs. The current review identifies key areas of neonatal resuscitation-related research needed from LMICs to inform evidence-based resuscitation of neonates in LMICs.


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50. Challenges Affecting Health Referral Systems in Low-And Middle-Income Countries: A Systematic Literature Review

European Journal of Health Sciences


Authors: Mildred Nakayuki, Annabella H.D Basaza, Hasifah K. Namatovu
Region / country: Global
Speciality: Health policy

Aims: Low and middle-income countries are still facing challenges of dysfunctional referral systems which have impaired health service provision. This review aimed at investigating these challenges to understand their nature, cause, and the impacts they have on health service provision.

Methods: Database search was made in Google scholar, ACM Library, PubMed health, and BMC public health, and a total of 123 papers were generated. Only 14 fitted the inclusion criteria. Inclusion criteria included studies that were both quantitative and qualitative addressing challenges facing referral systems or health referral systems, studies describing the barriers to effective referral systems, and studies describing factors that affect referral systems. The review only included studies conducted in LMICs and included literature between January 2010 and February 2021.

Findings: Results revealed that human resource and financial constraints, non-compliance, and communication are the key challenges affecting referral systems in LMICs.

Recommendation: Countries that are facing these challenges need to overhaul the system and improve end-to-end communication between hospitals, improve capacity specifically in referral and emergency units, and sensitizing patients on the adherence to emergency protocols.


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51. The role of community health workers in the surgical cascade: a scoping review

Human Resources for Health


Authors: Helen W. Li, Michael L. Scanlon, Nicholas Kisilu & Debra K. Litzelman
Region / country: Global
Speciality: Health policy, Other

Background
Community health workers (CHWs) can increase access to various primary healthcare services; however, their potential for improving surgical care is under-explored. We sought to assess the role of CHWs in the surgical cascade, defined as disease screening, linkage to operative care, and post-operative care. Given the well-described literature on CHWs and screening, we focused on the latter two steps of the surgical cascade.

Methods
We conducted a scoping review of the peer-reviewed literature. We searched for studies published in any language from January 1, 2000 to May 1, 2020 using electronic literature databases including Pubmed/MEDLINE, Web of Science, SCOPUS, and Google Scholar. We included articles on CHW involvement in linkage to operative care and/or post-operative surgical care. Narrative and descriptive methods were used to analyze the data.

Results
The initial search identified 145 articles relevant to steps in the surgical cascade. Ten studies met our inclusion criteria and were included for review. In linkage to care, CHWs helped increase surgical enrollment, provide resources for vulnerable patients, and build trust in healthcare services. Post-operatively, CHWs acted as effective monitors for surgical-site infections and provided socially isolated patients with support and linkage to additional services. The complex and wide-ranging needs of surgical patients illustrated the need to view surgical care as a continuum rather than a singular operative event.

Conclusion
While the current literature is limited, CHWs were able to maneuver complex medical, cultural, and social barriers to surgical care by linking patients to counseling, education, and community resources, as well as post-operative infection prevention services. Future studies would benefit from more rigorous study designs and larger sample sizes to further elucidate the role CHWs can serve in the surgical cascade.


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52. The Chiranjeevi Yojana (CY) : a public-private-partnership to promote institutional births in Gujarat, India : studies of providers and users

Karolinksa Institutet open archive


Authors: Iyer Veena
Region / country: Southern Asia – India
Speciality: Emergency surgery, Health policy, Obstetrics and Gynaecology

Introduction: National, regional and local governments, particularly in lower middleincome countries, are encouraged to pursue partnerships with the pool of private providers available to them, in order to achieve the Sustainable Development Goal for maternal health. The state of Gujarat in India (population 60 million) has been a pioneer in designing a large-scale Public-Private-Partnership (PPP), the Chiranjeevi Yojana (CY), for emergency obstetric care (EmOC) for vulnerable women through qualified obstetricians. The program was instituted in 2006-07 and 865 obstetricians partnered with the state at the time.

Methodology: The papers in this thesis examine this CY program through three quantitative and one qualitative study. The studies were conducted in three districts of Gujarat state, Sabarkantha, Surendranagar and Dahod. The methods included two crosssectional surveys (i.e., a facility survey and a facility-based survey of women who gave birth) and in-depth interviews.

These four studies elucidate characteristics of CY providers and CY beneficiaries, as well as outcomes in the health system environment and the population. In order to synthesise these results coherently, I adapted the Anderson’s theoretical model to synthesise, explain and discuss the findings in my studies. In the adapted model, I present my findings in three clear and linked domains – (1) Environment – Health system and population environment in which the CY program was implemented (2) Enabler – Characteristics of the health system and population that were enabled, i.e., made eligible, as per program criteria to participate in the CY program and (3) Outcomes – in the health system and population environment, examined through (a) Health system and provider behaviours (b) Users’ behaviours (c) Health status of the mothers and (d) Financial status of households with respect to using obstetric services.

Results: The CY program influenced the health system’s environment towards increasing the availability of free CEmOC by 10 times, from 0.32 to 3.65 per 500,000 population, but actual performance of notionally free CEmOC functions was only 2 per 500,000 population (Study I). Providers’ behaviour was reflected in the en masse participation or non-participation of providers in ten out of seventeen urban centres. The facilities that participated in the CY program had a significantly higher likelihood, independently, of being general facilities (PR 1.9, 95% CI 1.3–2.9), or conducting lower proportion of caesarean births (PR 2.1, 95% CI 1.2–3.5) or having obstetricians new in private practice (PR 1.9, 95% CI 1.2–3.1) or being less expensive (PR 1.8, 95% CI 1.1–3.0) (Study II). The CY program criteria influenced the population environment by enabling mothers to become eligible for CY benefit. These mothers were significantly more likely to be vulnerable – rural, multiparous, scheduled tribe, and less educated. Users’ behaviours showed that eligible mothers had significantly less prevalence of ante-natal visits, as well as shorter hospital stay after birth. The evaluated health status showed low caesarean rates among eligible vulnerable mothers (6%) and high caesarean (40%) and episiotomy (63%) rates among ineligible mothers (Study III). The perceived health status of the population was reflected in the fact that most mothers and families were very happy with the care they had received and none reported any preferential treatment of paying mothers over CY beneficiary mothers. However, a few mothers who experienced instances of poor quality of care or rude behaviour, reflected back on their experience and still reported it as a “good (sari) delivery”. The financial status of the population showed only 15% of eligible mothers were CY beneficiaries, and only 4 % of them received a completely cashless birth. The median degree of subsidy for women in CY who birthed vaginally was 85% and by caesarean section was 71 % compared to out-of-pocket expenditure sustained by non-beneficiaries in the private health sector. Mothers without formal education were significantly less likely (OR 0.4, 95% CI 0.3–0.7) to receive CY benefit. Only having CY program knowledge (OR 4.7, 95% CI 2.6–8.4) and showing proof of poverty (OR 2.6, 95% CI 1.3–5.4) increased the likelihood of receiving the benefit. (Study III).

Discussion: Although the CY program increased the availability of free emergency obstetric care to 10 times more than the UN standards, their actual performance increased by only twice. This indicated poor management mechanisms within the state authorities. Although the CY program criteria recognised vulnerable mothers adequately accurately, their behaviours, health status and financial status showed mixed outcomes. Vulnerable populations behaviours to ensure improved maternal health and access to the CY program were varied, despite the program being in effect for seven years before our study. The health status of the vulnerable population, in terms of low caesarean rates, were below established norms in the literature, and among the non-vulnerable populations was much higher. The financial status of the eligible population was not much eased by the program since 85% of them did not receive the CY benefit. However, the highest median expenditure in our study (INR 7224) was well below the mean cost in private facilities across the nation (INR 15000) thus indicating a possible partial protection from out-of-pocket cost due to the CY program activity in the region.

Conclusion: The recently established Prime Minister’s People’s Health Program in India depends on PPPs for secondary and tertiary care all over the country. As revealed in this thesis, improved, adequate and effective health systems through PPPs requires better contract designing and managing capacities within in the state system. The health status and users’ behaviours could be assisted by the ongoing digitization of health systems such that (a) maternal health data is collected by both public and private sectors in enough detail to be able to categorise it by Robson’s criteria and thus monitor BEmOC and CEmOC performance, ante-natal visits, length of stay in hospital and other relevant variables (b) user feed-back is collected in a manner that captures actual experiences of women during birth, and that of their families during their interactions with the health system.


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53. Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study

Lancet Oncology


Authors: COVIDSurg Collaborative
Region / country: Global
Speciality: Surgical oncology

Background
Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.

Methods
This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.

Findings
Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays.

Interpretation
Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services.

Funding
National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.


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54. Malignant Extracranial Germ Cell Tumours: A First Report by the South African Children’s Cancer Study Group

authorea


Authors: Marc Hendricks,Annibale Cois,Jennifer Geel,Jan du Plessis,Mairi Bassingthwaighte,Gita Naidu,Biance Rowe,Ane Buchner,Fareed Omar,Karla Thomas,Ronelle Uys,Anel van Zyl,Jaques van Heerden,Ngoakoana Mahlachana,Johani Vermeulen,Alan Davidson,Lindsay Frazier,Kirsty Donald,Mariana Kruger
Region / country: Southern Africa – South Africa
Speciality: Paediatric surgery, Surgical oncology

OBJECTIVE To determine the overall survival (OS) and prognostic factors influencing outcomes in children and adolescents with malignant extracranial germ cell tumours (MEGCTs) in preparation for the development of a harmonised national treatment protocol. METHODS A retrospective folder review was undertaken at nine South African paediatric oncology units to document patient profiles, tumour and treatment-related data and outcomes. RESULTS Between 1 January 2000 and 31 December 2015, 218 patients were diagnosed with MEGCTs. Female sex (OR 2.26; p=0.037) and higher socio-economic status (SES) (HR 0.071; p=0.039) were associated with a significantly lower risk of death. Advanced clinical stage at diagnosis significantly affected 5-year OS: stage I -96%; stage II – 94.3%; stage III -75.5%; (p=0.017) and stage IV (60.1%; p<0.001). There was a significant association between earlier stage at presentation and higher SES (p=0.03). Patients with a serum AFP level of more than 33,000 ng/ml at diagnosis had significantly poorer outcomes (p=0.002). The use of chemotherapy significantly improved survival, irrespective of the regimen used (p33,000ng/ml were independently predictive of outcome. The relationship between SES and outcome is important as the implementation of a new national protocol aims to standardise care across the socio-economic divide.


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55. Resource constrained innovation in a technology intensive sector: Frugal medical devices from manufacturing firms in South Africa

Technovation


Authors: Sanghamitra Chakravarty
Region / country: Southern Africa – South Africa
Speciality: Health policy, Other

Most medical devices are designed by western firms from efficient innovation systems with a focus on their home markets. A disproportionately high percentage of imported medical devices in low resource settings become non-functional. Despite interest from global health and innovation studies, little is known about firms in emerging markets appreciative of challenges in their home environments. Using empirical evidence from innovative manufacturing firms in South Africa, this study investigates frugal orientation and mechanisms to innovate under resource constraints, in a technology intensive sector typically under the purview of western firms. Systematic analysis of six devices by adapting a global health lens reveals that while some innovations specifically address health challenges of low resource, others are more affordable technological innovations with universal relevance and some frugal elements. Resource constrained innovation strategies involved building advanced internal manufacturing capabilities to overcome institutional voids while forging multiple knowledge collaborations to complement inhouse capabilities. This drives frugality around design, engineering and manufacturing processes. Innovation delivery strategies are complementary to these processes. The evidence suggests fundamentally new products were designed in collaborative bottom up processes. The role of the state and global non-profits in harnessing frugal innovations for public health was found to be critical.


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56. The impact of the COVID-19 pandemic on international reconstructive collaborations in Africa

European Journal of Plastic Surgery


Authors: Calum S. Honeyman, Vinod Patel, Abdelwakeel Bakhiet, Daniel R. Bradley, Fernando Almas, Dominique Martin & Mark McGurk
Region / country: Eastern Africa – Ethiopia, Tanzania
Speciality: Plastic surgery, Trauma surgery

Background
The SARS-CoV-2 (COVID-19) pandemic has catalysed a widespread humanitarian crisis in many low- and middle-income countries around the world, with many African nations significantly impacted. The aim of this study was to quantify the impact of the COVID-19 pandemic on the planning and provision of international reconstructive collaborations in Africa.

Methods
An anonymous, 14-question, multiple choice questionnaire was sent to 27 non-governmental organisations who regularly perform reconstructive surgery in Africa. The survey was open to responses for four weeks, closing on the 7th of March 2021. A single reminder was sent out at 2 weeks. The survey covered four key domains: (1) NGO demographics; (2) the impact of COVID-19 on patient follow-up; (3) barriers to the safe provision of international surgical collaborations during COVID-19; (4) the impact of COVID-19 on NGO funding.

Results
A total of ten reconstructive NGOs completed the survey (response rate, 37%). Ethiopia (n = 5) and Tanzania (n = 4) were the countries where most collaborations took place. Plastic, reconstructive and burns surgery was the most common sub-speciality (n = 7). For NGOs that did not have a year-round presence in country (n = 8), only one NGO was able to perform reconstructive surgery in Africa during the pandemic. The most common barrier identified was travel restrictions (within country, n = 8 or country entry-exit, n = 7). Pre-pandemic, 1547 to ≥ 1800 patients received reconstructive surgery on international surgical collaborations. After the outbreak, 70% of NGOs surveyed had treated no patients, with approximately 1405 to ≥ 1640 patients left untreated over the last year.

Conclusions
The COVID-19 pandemic has placed huge pressures on health services and their delivery across the globe. This theme has extended into international surgical collaborations leading to increased unmet surgical needs in low- and middle-income countries.


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57. Mind the gap: Patterns of red blood cell product usage in South Africa, 2014 – 2019

South African Medical Journal


Authors: L Bolton, K van den Berg, R Swanevelder, J R C Pulliam
Region / country: Southern Africa – South Africa
Speciality: Health policy

Background. A key component of any successful healthcare system is the availability of sufficient, safe blood products delivered in an equitable manner. South Africa (SA) has a two-tiered healthcare system with public and privately funded sectors. Blood utilisation data for both sectors are lacking. Evaluation of blood utilisation patterns in each healthcare sector will enable implementation of systems to bring about more equality.

Objectives. To conduct a critical evaluation of red blood cell (RBC) product utilisation patterns at the South African National Blood Service (SANBS).

Methods. Operationally collected data from RBC requests submitted to SANBS blood banks for the period 1 January 2014 – 31 March 2019 were used to determine temporal RBC product utilisation patterns by healthcare sector. Demographic patterns were determined, and per capita RBC utilisation trends calculated.

Results. Of the 2 356 441 transfusion events, 65.9% occurred in the public and 34.1% in the private sector. Public sector patients were younger (median (interquartile range (IQR)) 33 (22 – 49) years) than in the private sector (median (IQR) 54 (37 – 68) years), and mainly female in both sectors (66.2% in the public sector and 53.4% in the private sector). Between 2014 and 2018, per capita RBC utilisation decreased from 11.9 to 11.0/1 000 population in the public sector, but increased from 34.8 to 38.2/1 000 population in the private sector.

Conclusions. We confirmed distinctly different RBC utilisation patterns between the healthcare sectors in SA. Possible drivers for these differences may be healthcare access, differing patient populations and prescriber habits. Better understanding of these drivers may help inform equitable public health policy.


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58. Training facilitated by inter-institutional collaboration and telemedicine: An alternative for improving results in the placenta accreta spectrum

AJOG Global Reports


Authors: Albaro José NIETO-CALVACHE, José Miguel PALACIOS-JARAQUEMADA, Lina María VERGARA-GALLIADI, Alejandro Solo NIETO-CALVACHE, Maria Andrea ZAMBRANO, Juan Manuel BURGOS-LUNA
Region / country: South America – Colombia
Speciality: Digital health, Obstetrics and Gynaecology, Surgical Education

Background
Placenta accreta spectrum (PAS) is a severe condition that requires trained interdisciplinary group participation. However, achieving that specific training is difficult without academic programs or hospitals dedicated to teaching PAS skills.

Objectives
We describe an interinstitutional collaboration process focused on improving PAS treatment and facilitated by telemedicine. Finally, we propose a replicable model for other centres

Study Design
This was a retrospective, descriptive study including PAS patients treated over 10-years in a low-middle income country (LMIC) hospital (local hospital [LH]). We evaluated the clinical results and impact of interinstitutional collaboration with a PAS expert group (EG) at another LMIC. Virtual strategies of continuous communication between the LH and EG were used, such as telemedicine, teleradiology and telepresence during surgeries.

Results
Eighty-nine PAS patients were included. We observed a progressive improvement in clinical results (intraoperative bleeding, transfusion frequency, postoperative length of stay and frequency of complications) as the LH fixed interdisciplinary group gained experience by treating more cases.

Conclusions
Interinstitutional collaboration (through telemedicine and remote supervision) and PAS team formation, were related to the best results in the most recent years of observation. Thus, ongoing PAS team training, facilitated by inter-institutional collaboration and telemedicine, is a valid strategy for improving clinical outcomes in PAS.


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59. The impact of the COVID-19 pandemic on global neurosurgical education: a systematic review

Neurosurgical Review


Authors: Raunak Jain, Raquel Alencastro Veiga Domingues Carneiro, Anca-Mihaela Vasilica, Wen Li Chia, Abner Lucas Balduino de Souza, Jack Wellington & Niraj S. Kumar
Region / country: Global
Speciality: Neurosurgery, Surgical Education

The COVID-19 pandemic has disrupted neurosurgical training worldwide, with the shutdown of academic institutions and the reduction of elective surgical procedures. This impact has disproportionately affected LMICs (lower- and/or middle-income countries), already burdened by a lack of neurosurgical resources. Thus, a systematic review was conducted to examine these challenges and innovations developed to adapt effective teaching and learning for medical students and neurosurgical trainees. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and The Cochrane Handbook of Systematic Reviews of Interventions. MEDLINE, PubMed, Embase and Cochrane databases were accessed, searching and screening literature from December 2019 to 5th December 2020 with set inclusion and exclusion criteria. Screening identified 1254 articles of which 26 were included, providing data from 96 countries. Twenty-three studies reported transition to online learning, with 8 studies also mentioned redeployment into COVID wards with 2 studies mentioning missed surgical exposure as a consequence. Of 7 studies conducted in LMICs, 3 reported residents suffering financial insecurities from reduced surgical caseload and recession. Significant global disruption in neurosurgical teaching and training has arisen from the COVID-19 pandemic. Decreased surgical exposure has negatively impacted educational provision. However, advancements in virtual technology have allowed for more affordable, accessible training especially in LMICs. Using this, initiatives to reduce physical and mental stress experienced by trainees should be paramount.


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60. Functional recovery after cesarean delivery: a prospective cohort study in rural Rwanda

BMC Pregnancy and Childbirth


Authors: Anne Niyigena, Saidath Gato, Barnabas Alayande, Elizabeth Miranda, Bethany Hedt-Gauthier, Andrea S. Goodman, Theoneste Nkurunziza, Christian Mazimpaka, Sadoscar Hakizimana, Patient Ngamije, Fredrick Kateera, Robert Riviello, Adeline A. Boatin
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Obstetrics and Gynaecology

Background
Women who deliver via cesarean section (c-section) experience short- and long-term complications that may affect their physical health and their ability to function normally. While physical health outcomes are routinely assessed and monitored, postpartum functional outcomes are not well understood from a patient’s perspective or characterized by clinicians. In Rwanda, 11% of rural women deliver via c-section. This study explores the functional recovery of rural Rwandan women after c-section and assesses factors that predict poor functionality at postoperative day (POD) 30.

Methods
Data were collected prospectively on POD 3, 11, and 30 from women delivering at Kirehe District Hospital between October 2019 and March 2020. Functionality was measured by self-reported overall health, energy level, mobility, self-care ability, and ability to perform usual activities. We computed composite mean scores with a maximum score of 4.0 and scores ≤ 2.0 reflected poor functionality. We assessed functionality with descriptive statistics and logistic regression.

Results
Of 617 patients, 54.0%, 25.9%, and 26.8% reported poor functional status at POD3, POD11, and POD30, respectively. At POD30, the most self-reported poor functionality dimensions were poor or very poor overall health (48.1%), and inability to perform usual activities (15.6%). In the adjusted model, women whose surgery lasted 30–45 minutes had higher odds of poor functionality (aOR = 1.85, p = 0.01), as did women who experienced intraoperative complications (aOR = 4.12, p = 0.037). High income patients had incrementally lower significant odds of poor functionality (aOR = 0.62 for every US$100 increase in monthly income, p = 0.04).

Conclusion
We found a high proportion of poor functionality 30 days post-c-section and while surgery lasting > 30 minutes and experiencing intra-operative complications was associated with poor functionality, a reported higher income status was associated with lower odds of poor functionality. Functional status assessments, monitoring and support should be included in post-partum care for women who delivered via c-section. Effective risk mitigating intervention should be implemented to recover functionality after c-section, particularly among low-income women and those undergoing longer surgical procedures or those with intraoperative complications.


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61. Applying the Workload Indicators of Staffing Needs Method in Nursing Health Workforce Planning: Evidences from Four Hospitals in Vietnam

Human Resources for Health


Authors: Nguyen Thi Hoai Thu, Phung Thanh Hung, My Anh Bui
Region / country: South-eastern Asia – Vietnam
Speciality: Health policy

Background: Vietnam has encountered difficulties in ensuring an adequate and equitable distribution of health workforce. The traditional staffing norms stated in the Circular 08/TT-BYT issued in 2007 based solely on population or institutional size and do not adequately take into consideration the variations of need such as population density, mortality and morbidity patterns. To address this problem, more rigorous approaches are needed to determine the number of personnel in health facilities. One such approach is Workload Indicators of Staffing Need (WISN) developed by the World Health Organization (WHO), a facility-based workforce planning method that assists managers in defining the responsibilities of different workforce categories and improving the appropriateness and efficiency of a staff mix.

Methods: This study applied the WISN approach and was employed in 22 clinical departments at four hospitals in Vietnam between 2015 and 2018. 22 targeted group discussions involving nurses were conducted. Hospital personnel records have been retrieved. The data were analyzed according to WISN instructions.

Results: Of the 22 departments, there was a shortage of 1 to 2 nurses in 10 departments, with WISN ratios ranging between 0.88 and 0.95. Only 01 clinical colleges at Can Tho Hospital lacked 05 nurses, facing a high workload with a WISN ratio of 0.78. Administrative time represented 20-40% of the total work time of a nurse. In comparison, nurses at Can Tho Hospital spent time on administration from 24 onwards. 5% to 41.7% of their working time while nurses at Thanh Hoa Hospital spent 21% to 33%.

Conclusion: The application of the WISN enabled health managers to analyze the workload of nurses, calculate staffing needs, and thus effectively contribute to the workforce planning process. It is expected that the results of this research will encourage the use of the WISN tool in other hospitals and health facilities across the health system. At provincial and national levels, this study provides important evidence to help policy makers develop guidelines for personnel norms for health facilities in the context of limited resources, while the existing regulation is no longer appropriate


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62. Maternal knowledge and attitudes to childhood hearing loss and hearing services in the Pacific Islands: A cross-sectional survey protocol for urban and rural/remote Samoa

Public Health in Practice


Authors: Annette Kaspar, Sione Pifeleti, Carlie Driscoll
Region / country: Polynesia – Pacific Islands, Samoa
Speciality: ENT surgery, Health policy

Introduction
The successful implementation of ear and hearing health services for children depends on the support and engagement of primary caregivers. The World Health Organization recommends childhood hearing screening programs for all member states to enable early detection and intervention for children with hearing loss. Ear and hearing specialists are limited in the Pacific Islands, a region with one of the highest global rates of ear disease and hearing loss. Given that a significant proportion of childhood hearing loss is preventable through public health measures, collaboration with health promotion activities is recommended to improve primary caregiver knowledge of avoidable ear and hearing disorders among infants and young children. Previous work has examined the knowledge and attitudes of parents in an urban Pacific Island settings, and this study will investigate for differences between urban and rural/remote Pacific Island populations.

Study design
Cross-sectional survey.

Methods
Questionnaire administered to mothers attending immunization clinics with their infants in urban (Apia) and rural/remote (Savai’i) Samoa. A 25-item questionnaire was formally translated from the original English into Samoan by an accredited translator in collaboration with an Ear, Nose and Throat registered nurse. It will be administered in a semi-structured interview style by a Health Promotion Officer in Samoan. The participating mothers are required to respond with ‘yes,’ ‘no,’ or ‘unsure.’ The questions assess knowledge of biomedical etiology of hearing impairment (9 questions), beliefs regarding non-biomedical etiology of hearing impairment (2 questions), knowledge of otitis media and its risk factors (5 questions), knowledge of hearing loss identification and intervention (4 questions), and attitudes towards hearing services for children (6 questions).

Results
Not applicable. Data to be collected.

Conclusion
We publish these protocols to facilitate similar studies in other Low- and Middle-Income Countries, and especially among our Pacific Island neighbours.


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63. Think global, act local: Burn care in a resource-limited setting

VU Research Portal


Authors: Hendriks, Thomas Charles Cecile
Region / country: Global
Speciality: Health policy, Neurosurgery, Plastic surgery, Trauma surgery

The burden of burn injuries remains a major global health issue.1,2 Worldwide,millions of people suffer from burns and burn-related disabilities and deformities. Every year over 8 million people require medical attention due to burns. Burns cause an estimated loss of 8.5 million disability-adjusted life years (DALYs) each year due to premature death and disability.3 Five per cent of all injury-related deaths are caused by burns, which amounts to an estimated 120,000 deaths annually.4 Non-fatal burns are a leading cause of disability, which cause long-term physical and psychological problems.5,6 There are large differences in burn care worldwide.1 In high-income countries (HICs) major progress has been made in acute burn care over the past decades. With advancements made in the prevention of burns and treatments of wounds, the incidence of burns has decreased and the survival rate of patients has increased. The current mortality reported by HICs is 1.5%.7 This is in stark contrast to low- and middle-income countries (LMICs). In these countries the burden of burn incidence, mortality and morbidity remains high.1,8,9 The vast majority of all burns globally occur in LMICs. This is because people use open fires in daily life, for example for cooking, heating and agriculture. The incidence of burns in these countries is estimated to be 1.3 per 100,000 people, compared to 0.14 per 100,000 people in HICs.8,10 The few existing studies from LMICs show that poor populations are most at risk of sustaining burns, and that the majority of patients are children.1,2,9,11,12 The higher morbidity and mortality is a consequence of the fact that geographically isolated and economically disadvantaged populations have limited access to safe and timely burn care.2 Due to this lack of care, 95% of all fatal fire-related cases of mortality due to burns occurs in LMICs. Studies have estimated that the risk of child mortality due to burns is currently over seven times
higher in LMICs compared to HICs


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64. Factors associated with hospital outcomes of patients with penetrating craniocerebral injuries in armed conflict areas of the Democratic Republic of the Congo: a retrospective series

BMC Emergency Medicine


Authors: Paterne Safari Mudekereza, Gauthier Bahizire Murhula, Charles Kachungunu, Amani Mudekereza, Fabrice Cikomola, Leon-Emmanuel Mukengeshai Mubenga, Patrick Birindwa Balungwe, Paul Munguakonkwa Budema, Christian Molima, Erick Namegabe Mugabo & Hervé Monka Lekuya
Region / country: Central Africa – Democratic Republic of the Congo
Speciality: Neurosurgery, Trauma surgery

Introduction
Penetrating craniocerebral injuries (PCCI) are types of open head injuries caused by sharp objects or missiles, resulting in communication between the cranial cavity and the external environment. This condition is deemed to be more prevalent in armed conflict regions where both civilians and military are frequently assaulted on the head, but paradoxically their hospital outcomes are under-reported. We aimed to identify factors associated with poor hospital outcomes of patients with PCCI.

Methods
This was a retrospective series of patients admitted at the Regional Hospital of Bukavu, DRC, from 2010 to 2020. We retrieved medical records of patients with PCCI operated in the surgical departments. A multivariate logistic regression model was performed to find associations between patients’ admission clinico-radiological parameters and hospital outcomes. Poor outcome was defined as a Glasgow Outcomes Score below 4.

Results
The prevalence of PCCI was 9.1% (91/858 cases) among admitted TBI patients. More than one-third (36.2%) of patients were admitted with GCS < 13, and 40.6% of them were unstable hemodynamic. Hemiplegia was found in 23.1% on admission. Eight patients had an intracerebral hemorrhage. Among the 69 operated patients, complications, mainly infectious, occurred in half (50.7%) of patients. Poor hospital outcomes were observed in 30.4% and associated with an admission GCS < 13, hemodynamic instability, intracerebral hemorrhage, and hemiplegia (p < 0.05).

Conclusion
The hospital poor outcomes are observed when patients present with hemodynamic instability, an admission GCS < 13, intracerebral hemorrhage, and hemiplegia. There is a need for optimizing the initial care of patients with PCCI in armed conflict regions.


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65. Knowledge of Palestinian women about cervical cancer warning signs: a national cross- sectional study

BMC Public Health


Authors: Mohamedraed Elshami , Ibrahim Al-Slaibi , Hanan Abukmail , Mohammed Alser , Afnan Radaydeh , Alaa Alfuqaha , Mariam Thalji , Salma Khader , Lana Khatib , Nour Fannoun , Bisan Ahmad, Lina Kassab , Hiba Khrishi , Deniz Elhussaini, Nour Abed , Aya Nammari , Tumodir Abdallah , Zaina Alqudwa, Shahd Idais , Ghaid Tanbouz , Ma’alem Hajajreh, Hala Abu Selmiyh , Zakia Abo-Hajouj, Haya Hebi , Manar Zamel , Refqa Skaik, Lama Hammoud , Siba Rjoub , Hadeel Ayesh , Toqa Rjoub , Rawan Zakout , Amany Alser, Nasser Abu-El-Noor, Bettina Bottcher
Region / country: Middle East – Palestinian Territories
Speciality: Obstetrics and Gynaecology, Surgical oncology

Background
Timely presentation and diagnosis of cervical cancer (CC) are crucial to decrease its mortality especially in low- and middle-income countries like Palestine. This study aimed to evaluate the knowledge of Palestinian women about CC warning signs and determine the factors associated with good knowledge.

Methods
This was a national cross-sectional study conducted between July 2019 and March 2020 in Palestine. Stratified convenience sampling was used to recruit adult women from hospitals, primary healthcare centers, and public spaces of 11 governorates. A translated-into-Arabic version of the validated CC awareness measure (CeCAM) was used to assess women’s knowledge of 12 CC warning signs.

Results
Of 8086 approached, 7223 participants completed the CeCAM (response rate = 89.3%). A total of 7058 questionnaires were included in the analysis: 2655 from the Gaza Strip and 4403 from the West Bank and Jerusalem (WBJ). The median age [interquartile range] for all participants was 34.0 [24.0, 42.0] years. Participants recruited from the WBJ were older, getting higher monthly income, and having more chronic diseases than those recruited from the Gaza Strip.

The most frequently identified warning sign was ‘vaginal bleeding after menopause’ (n = 5028, 71.2%) followed by ‘extreme generalized fatigue’ (n = 4601, 65.2%) and ‘unexplained weight loss’ (n = 4578, 64.9%). Only 1934 participants (27.4%) demonstrated good knowledge of CC warning signs. Participants from the Gaza Strip were slightly more likely than participants from the WBJ to have a good level of knowledge. Factors associated with having good knowledge included having a bachelor or postgraduate degree, being married, divorced, or widowed as well as knowing someone with cancer.

Conclusion
The overall awareness of CC warning signs was low. Educational interventions are needed to increase Palestinian women’s awareness of CC warning signs.


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66. Improving antimicrobial use through antimicrobial stewardship in a lower-middle income setting: a mixed-methods study in a network of acute-care hospitals in Viet Nam

Journal of Global Antimicrobial Resistance


Authors: Vu Thi Lan Huong , Ta Thi Dieu Ngan , Huynh Phuong Thao , Nguyen Thi Cam Tu , Truong Anh Quan , Behzad Nadjm , Thomas Kesteman , Nguyen Van Kinh , H Rogier van Doorn
Region / country: South-eastern Asia – Vietnam
Speciality: Health policy, Other

Objectives
This study aimed to analyze the current state of antimicrobial stewardship (AMS) in hospitals in Viet Nam, a lower middle-income country, to identify factors determining success in AMS implementation and associated challenges to inform planning and design of future programs.

Methods
We conducted a mixed-methods study in seven acute-care hospitals in the antimicrobial resistance (AMR) surveillance network in Viet Nam. Data collection included seven focus-group discussions, forty in-depth interviews and a self-administered quantitative survey of staff on AMR and AMS programs. We summarized qualitative data by reporting the most common themes according to the core AMS elements and analyzed quantitative data using proportions and a linear mixed-effects model.

Results
The findings reveal a complex picture of factors and actors involved in the AMS implementation from the national level to the departmental and individual level within each hospital. The level of implementation varied, starting from the formation of an AMS committee and with or without an active delivery of specific interventions. Development of treatment guidelines, pre-authorization of antimicrobial drug classes, and post-prescription audit and feedback to doctors at selected clinical departments were the main interventions reported. A higher level of leadership support and commitment to AMS led to a higher level of engagement with AMS activities from the AMS team and effective collaboration between departments involved.

Conclusions
Establishing country-specific guidelines on AMS staffing and adapting standards for AMS education and training from international resources are needed to support capacity building to implement AMS programs effectively in LMICs like Viet Nam.


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67. The availability of psychological support following road travel injuries in Namibia: A qualitative study

plos one


Authors: Mitchel Chatukuta ,Nora Groce,Jenny Mindell,Maria Kett
Region / country: Southern Africa – Namibia
Speciality: Emergency surgery, Other, Trauma surgery

Road traffic injuries (RTIs) are a major problem worldwide with a high burden of mental health problems and the importance of psychological support following road injury is well documented. However, globally there has been very little research on the accessibility of psychological services following road injury. Namibia is one of the countries most affected by RTIs but no previous studies have been done on this. In this qualitative study we investigated the availability of psychological services to RTI injured in Namibia. Our study findings are in line with those of other global studies in showing inadequate access to psychological support for injury survivors and we discuss the reasons. It is hoped these findings will help policymakers develop ways of enhancing access to psychological support for the many people injured in RTIs in Namibia. The models they develop may also be of use to other LMICs countries with high RTI rates.


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68. Design Approaches to Developing Technologies for Global Surgery

White Rose eTheses Online


Authors: Marriott Webb, Millie Jane
Region / country: Southern Asia – India
Speciality: General surgery, Health policy

Surgical care is a fundamental component of an effective healthcare system, yet most people living in low and middle-income countries have no access to it. Critical to addressing this is the ability to equip low-resource healthcare contexts with appropriate surgical technologies. An estimated 40% of healthcare equipment is unused in these contexts, and there is increasing recognition that new technologies must be designed specifically for them, to provide Affordable, Available, Accessible, Appropriate and Quality solutions. For this, researchers suggest conventional approaches to medical device design are not appropriate, but recommended alternative approaches are in early development stages, and since their use is rarely reported in the literature, little evidence exists with which to improve them. This thesis addresses this paucity of evidence, and describes the integration, implementation, and evaluation of recommended approaches to designing technologies for low-resource healthcare contexts. A design roadmap, and the principles of frugal innovation and participatory design are applied to design a device for gasless laparoscopy in rural hospitals in Northeast India. The evaluation of these approaches considers their influence on the development of the design through a review of the design history of the device and uses an exploratory qualitative study to understand whether the participatory approach was beneficial to the clinical stakeholders, who were participants. The design roadmap provided appropriate structure and advice for the design process but requires further development. A thorough understanding of the use context, local stakeholder participation and ability to maintain quality are important for innovating frugally, but specific methods to guide frugal innovation are required. Clinical stakeholders benefited from participating throughout the design process and supported the process by revealing potential barriers to collaboration as well as potential solutions to them. The results highlight the value and potential for using these approaches to increase global access to surgical care.


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69. Health system and patient-level factors serving as facilitators and barriers to rheumatic heart disease care in Sudan

Global Health Research and Policy


Authors: Jeffrey G. Edwards, Michele Barry, Dary Essam, Mohammed Elsayed, Mohamed Abdulkarim, Basamat M. A. Elhossein, Zahia H. A. Mohammed, Abdelmunim Elnogomi, Amna S. E. Elfaki, Ahmed Elsayed & Andrew Y. Chang
Region / country: Eastern Africa – Sudan
Speciality: Cardiothoracic surgery

Background
Rheumatic heart disease (RHD) remains a leading cause of morbidity and mortality in Sub-Saharan Africa despite widely available preventive therapies such as prophylactic benzathine penicillin G (BPG). In this study, we sought to characterize facilitators and barriers to optimal RHD treatment with BPG in Sudan.

Methods
We conducted a mixed-methods study, collecting survey data from 397 patients who were enrolled in a national RHD registry between July and November 2017. The cross-sectional surveys included information on demographics, healthcare access, and patient perspectives on treatment barriers and facilitators. Factors associated with increased likelihood of RHD treatment adherence to prophylactic BPG were assessed by using adjusted logistic regression. These data were enhanced by focus group discussions with 20 participants, to further explore health system factors impacting RHD care.

Results
Our quantitative analysis revealed that only 32% of the study cohort reported optimal prophylaxis adherence. Younger age, reduced primary RHD healthcare facility wait time, perception of adequate health facility staffing, increased treatment costs, and high patient knowledge about RHD were significantly associated with increased odds of treatment adherence. Qualitative data revealed significant barriers to RHD treatment arising from health services factors at the health system level, including lack of access due to inadequate healthcare staffing, lack of faith in local healthcare systems, poor ancillary services, and patient lack of understanding of disease. Facilitators of RHD treatment included strong interpersonal support.

Conclusions
Multiple patient and system-level barriers to RHD prophylaxis adherence were identified in Khartoum, Sudan. These included patient self-efficacy and participant perception of healthcare facility quality. Strengthening local health system infrastructure, while enhancing RHD patient education, may help to improve treatment adherence in this vulnerable population.


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70. Access to burn care in low-and middle-income countries: An assessment of timeliness, surgical capacity, and affordability in a regional referral hospital in Tanzania

Journal of Burn Care & Research


Authors: Matthijs Botman, Thom C C Hendriks, Louise de Haas, Grayson Mtui, Joost Binnerts, Emanuel Nuwass, Anuschka S Niemeijer, Mariëlle E H Jaspers, Hay A H Winters, Marianne K Nieuwenhuis, Paul P M van Zuijlen
Region / country: Eastern Africa – Tanzania
Speciality: Health policy, Plastic surgery, Trauma surgery

This study investigates patients’ access to surgical care for burns in a low-and-middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50 percent reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within three weeks for 74 percent in this group. Of contracture patients, seventy four percent, had sought healthcare after the acute burn injury. Of the same group, only 4 percent had been treated with skin grafts beforehand, and 70 percent never received surgical care or a referral. Combined, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively impacting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socio-economic factors that determine patient mortality and disability.


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71. The True Costs of Cesarean Sections for Patients in Rural Rwanda: Accounting for Post-Discharge Expenses in Estimated Health Expenditures

Research Square


Authors: Anne Niyigena, Barnabas Alayande, Laban Bikorimana, Elizabeth Miranda, Niclas Rudolfson, Deogratias Ndagijimana, Fredrick Kateera, Robert Riviello, Bethany Hedt-Gauthier
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Emergency surgery, Health policy, Obstetrics and Gynaecology

Introduction: While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda.

Methods: We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs.

Results: Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs.

Conclusion: Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.


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72. Fatal and nonfatal firearm injuries in the eastern Democratic Republic of Congo: a hospital-based retrospective descriptive cohort study assessing correlates of adult mortality

BMC Emergency Medicine


Authors: Paul Munguakonkwa Budema, Roméo Bujiriri Murhega, Tshibambe Nathanael Tshimbombu, Georges Kuyigwa Toha, Fabrice Gulimwentuga Cikomola, Paterne Safari Mudekereza, Léon-Emmanuel Mubenga, Ghislain Maheshe-Balemba, Darck Cubaka Badesire & Ulrick Sidney Kanmounye
Region / country: Central Africa – Democratic Republic of the Congo
Speciality: Health policy

Introduction
The Eastern Democratic Republic of Congo (DRC) has been the battleground for multiple armed conflicts, resulting in many fatal and nonfatal firearm injuries (F&NFFIs). Chronic insecurity has stressed the health system’s resources and created barriers to seeking, reaching, and receiving timely care further increasing the F&NFFI burden. Our institution is the largest trauma center in the region and receives the bulk of F&NFFI cases. We aimed to identify correlates of mortality in Congolese F&NFFI patients.

Methods
We included all F&NFFI patients admitted to our institution between 2017 and 2020. We extracted data from patient charts and admission logs. We identified mortality correlates using the two-sample t-test, Chi-square test, and multivariable regression analysis. A P-value of less than 0.05 was considered statistically significant.

Results
This study included 814 adult patients, mostly male (86%) with an average age of 34.5 years and living 154.4 km away from the hospital on average. The most affected anatomical sites were the lower limbs (48.2%) and upper limbs (23.2%). The median length of stay was 34.0 days, and the in-hospital mortality rate was 3.6%. In addition, mortality was negatively correlated with diastolic blood pressure (P = 0.01), SaO2 (P < 0.001), and hemoglobin concentration (P = 0.002).

Conclusion
F&NFFIs cause an enormous burden in the region, and mortality is correlated with some clinical and biological variables. Thus, the study findings will inform F&NFFI referral, triage, and management in low-resource and mass casualty settings.


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73. Anemia prevalence in women of reproductive age in low- and middle-income countries between 2000 and 2018

Nature Medicine


Authors: Damaris Kinyoki, Aaron E. Osgood-Zimmerman, Natalia V. Bhattacharjee, Local Burden of Disease Anaemia Collaborators, Nicholas J. Kassebaum & Simon I. Hay
Region / country: Global
Speciality: Health policy, Obstetrics and Gynaecology

Anemia is a globally widespread condition in women and is associated with reduced economic productivity and increased mortality worldwide. Here we map annual 2000–2018 geospatial estimates of anemia prevalence in women of reproductive age (15–49 years) across 82 low- and middle-income countries (LMICs), stratify anemia by severity and aggregate results to policy-relevant administrative and national levels. Additionally, we provide subnational disparity analyses to provide a comprehensive overview of anemia prevalence inequalities within these countries and predict progress toward the World Health Organization’s Global Nutrition Target (WHO GNT) to reduce anemia by half by 2030. Our results demonstrate widespread moderate improvements in overall anemia prevalence but identify only three LMICs with a high probability of achieving the WHO GNT by 2030 at a national scale, and no LMIC is expected to achieve the target in all their subnational administrative units. Our maps show where large within-country disparities occur, as well as areas likely to fall short of the WHO GNT, offering precision public health tools so that adequate resource allocation and subsequent interventions can be targeted to the most vulnerable populations.


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74. Identification and Evaluation of Methodologies to Assess the Quality of Mobile Health Apps in High-, Low-, and Middle-Income Countries: Rapid Review

JMIR Mhealth Uhealth


Authors: Fionn Woulfe, Kayode Philip Fadahunsi, Simon Smith, Griphin Baxter Chirambo, Emma Larsson, Patrick Henn, Mala Mawkin, John O’ Donoghue
Region / country: Global
Speciality: Digital health

Background:
In recent years, there has been rapid growth in the availability and use of mobile health (mHealth) apps around the world. A consensus regarding an accepted standard to assess the quality of such apps has yet to be reached. A factor that exacerbates the challenge of mHealth app quality assessment is variations in the interpretation of quality and its subdimensions. Consequently, it has become increasingly difficult for health care professionals worldwide to distinguish apps of high quality from those of lower quality. This exposes both patients and health care professionals to unnecessary risks. Despite progress, limited understanding of the contributions of researchers in low- and middle-income countries (LMICs) exists on this topic. Furthermore, the applicability of quality assessment methodologies in LMIC settings remains relatively unexplored.

Objective:
This rapid review aims to identify current methodologies in the literature to assess the quality of mHealth apps, understand what aspects of quality these methodologies address, determine what input has been made by authors from LMICs, and examine the applicability of such methodologies in LMICs.

Methods:
This review was registered with PROSPERO (International Prospective Register of Systematic Reviews). A search of PubMed, EMBASE, Web of Science, and Scopus was performed for papers related to mHealth app quality assessment methodologies, which were published in English between 2005 and 2020. By taking a rapid review approach, a thematic and descriptive analysis of the papers was performed.

Results:
Electronic database searches identified 841 papers. After the screening process, 52 papers remained for inclusion. Of the 52 papers, 5 (10%) proposed novel methodologies that could be used to evaluate mHealth apps of diverse medical areas of interest, 8 (15%) proposed methodologies that could be used to assess apps concerned with a specific medical focus, and 39 (75%) used methodologies developed by other published authors to evaluate the quality of various groups of mHealth apps. The authors in 6% (3/52) of papers were solely affiliated to institutes in LMICs. A further 15% (8/52) of papers had at least one coauthor affiliated to an institute in an LMIC.

Conclusions:
Quality assessment of mHealth apps is complex in nature and at times subjective. Despite growing research on this topic, to date, an all-encompassing appropriate means for evaluating the quality of mHealth apps does not exist. There has been engagement with authors affiliated to institutes across LMICs; however, limited consideration of current generic methodologies for application in LMIC settings has been identified.


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75. Antimicrobial resistance detection in Southeast Asian hospitals is critically important from both patient and societal perspectives, but what is its cost?

plos global public health


Authors: Tamalee Roberts, Nantasit Luangasanatip, Clare L. Ling, Jill Hopkins, Risara Jaksuwan, Yoel Lubell, Manivanh Vongsouvath, H. Rogier van Doorn, Elizabeth A. Ashley, Paul Turner
Region / country: Southern Asia – Cambodia, Laos, Thailand
Speciality: Health policy, Other

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.


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76. Mobile health intervention for promotion of eye health literacy

ploos global public health


Authors: Indra Prasad Sharma, Monica Chaudhry, Dhanapati Sharma, Raju Kaiti
Region / country: Southern Asia – India
Speciality: Digital health, Ophthalmology

Purpose
Improving eye health awareness in the underserved population is a universal eye health priority. The ubiquity of cell phones and internet usage provides new and innovative opportunities for health promotion. This study evaluated the effect of mobile health intervention (text message link) to promote eye health literacy (EHL) of priority ocular morbidities.

Methods
This study was an intervention evaluation and employed a two-armed pre-test post-test approach. Baseline assessment on EHL was performed on 424 university students. Participants were categorised into intervention and control groups, using the 1:1 allocation ratio. The intervention and control group received a text message alone and text message with a link, respectively. EHL was assessed via a self-administered questionnaire. The primary outcome measures were changes in EHL scores between baseline and one month post-intervention. Descriptive analysis was performed to assess the cost-effectiveness of the intervention.

Results
With low attrition and a response rate of 95.6%, 409 responses were eligible for analysis. The mean age of the participants (49.4% males and 50.6% of females) was 19.9±1.68 years. Baseline EHL scores were low, and there was no correlation with a demographic profile (all p<0.05, CI 95%). The demographic characteristics were similar between the two groups (for all, P <0.05, CI 95%) at baseline. The EHL scores improved in both groups between the pre-and post-test assessment; however, improvements were statistically significant only in the control group. The one-month post-intervention EHL scores were also higher in the intervention group compared to the control (p≤0.001, CI 95% for all). The total cost incurred for the intervention used was 11.5 USD.

Conclusion
Text message link demonstrated effectiveness for improving the EHL scores; the low baseline EHL scores substantially improved with intervention. The text message link intervention is a cost-effective method and could be considered in advocating for eye health in developing countries, particularly during global emergencies.


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77. Chronic wounds in Sierra Leone: Searching for Buruli ulcer, a NTD caused by Mycobacterium ulcerans, at Masanga Hospital

plos neglected tropical diseases


Authors: Helen R. Please ,Jonathan H. Vas Nunes,Rashida Patel,Gerd Pluschke,Mohamed Tholley,Marie-Therésè Ruf,William Bolton,Julian A. Scott,Martin P. Grobusch,Håkon A. Bolkan,Julia M. Brown,David G. Jayne
Region / country: Western Africa – Sierra Leone
Speciality: General surgery, Other

Background
Chronic wounds pose a significant healthcare burden in low- and middle-income countries. Buruli ulcer (BU), caused by Mycobacterium ulcerans infection, causes wounds with high morbidity and financial burden. Although highly endemic in West and Central Africa, the presence of BU in Sierra Leone is not well described. This study aimed to confirm or exclude BU in suspected cases of chronic wounds presenting to Masanga Hospital, Sierra Leone.

Methodology
Demographics, baseline clinical data, and quality of life scores were collected from patients with wounds suspected to be BU. Wound tissue samples were acquired and transported to the Swiss Tropical and Public Health Institute, Switzerland, for analysis to detect Mycobacterium ulcerans using qPCR, microscopic smear examination, and histopathology, as per World Health Organization (WHO) recommendations.

Findings
Twenty-one participants with wounds suspected to be BU were enrolled over 4-weeks (Feb-March 2019). Participants were predominantly young working males (62% male, 38% female, mean 35yrs, 90% employed in an occupation or as a student) with large, single, ulcerating wounds (mean diameter 9.4cm, 86% single wound) exclusively of the lower limbs (60% foot, 40% lower leg) present for a mean 15 months. The majority reported frequent exposure to water outdoors (76%). Self-reports of over-the-counter antibiotic use prior to presentation was high (81%), as was history of trauma (38%) and surgical interventions prior to enrolment (48%). Regarding laboratory investigation, all samples were negative for BU by microscopy, histopathology, and qPCR. Histopathology analysis revealed heavy bacterial load in many of the samples. The study had excellent participant recruitment, however follow-up proved difficult.

Conclusions
BU was not confirmed as a cause of chronic ulceration in our cohort of suspected cases, as judged by laboratory analysis according to WHO standards. This does not exclude the presence of BU in the region, and the definitive cause of these treatment-resistance chronic wounds is uncertain.

Author summary
Chronic wounds constitute a significant surgical burden to low- and middle-income countries; however, their aetiology often remains poorly understood. This study improves our understanding of wound aetiology through tissue analysis of chronic leg wounds suspected to be caused by Buruli ulcer (BU). BU is a neglected tropical disease caused by infection with Mycobacterium ulcerans, and remains severely under-researched. There is a lack of testing facilities in regions surrounding endemic countries which makes prevalence difficult to determine, with a particular paucity of data from Sierra Leone (SL). This study identified twenty-one patients with wounds suspected to be caused by BU who presented to Masanga Hospital (Tonkonili District, Sierra Leone) between February and March 2019. Tissue samples were acquired from the wounds and transported to a European tropical health laboratory for analysis. Significant bacterial loads were demonstrated in the samples. However, the gold-standard molecular tests recommended by World Health Organisation (WHO) revealed no cases of BU. These results suggest that BU is not a major cause of chronic wounds in the Northern Province of Sierra Leone. Our conclusions cannot necessarily be generalised to other regions of Sierra Leone, therefore further studies in other geographical districts are required.


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78. Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study

global heart journal


Authors: Anish Keepanasseril, Ajith Ananthakrishna Pillai, Jyoti Baghel, Swaraj Nandini Pande, Nivedita Mondal, Hemachandren Munuswamy, Pankaj Kundra, Rohan D’Souza
Region / country: Southern Asia – India
Speciality: Cardiothoracic surgery, Obstetrics and Gynaecology

Objective: To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country.

Methods: We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitamin K antagonists (VKAs) throughout pregnancy versus sequential anticoagulation (heparins in the first trimester and peripartum period and VKAs for the remainder of pregnancy), at a tertiary centre in South India, from January 2011 to August 2020.

Results: We identified 138 pregnancies in 121 women, of whom 32 received VKAs while 106 were on sequential anticoagulation. There were no differences between groups with regard to maternal deaths [0 vs. 6 (5.7%), p = 0.34], thromboembolic events [2 (6.3%) vs. 15 (14.2%), p = 0.36], haemorrhagic complications [4 (12.5%) vs. 12 (11.3%), p = 0.85], cardiac events [1 (3.1% vs. 17 (16%), p = 0.07], spontaneous miscarriages [5 (15.6%) vs. 13 (12.3%), p = 0.62], stillbirths [0 vs. 5 (5.4%), p = 0.581] or neonatal deaths [2 (8.7%) vs. 1 (1.1%), p = 0.11]. Both cases of warfarin embryopathy received >5 mg warfarin in the first trimester. Thromboembolic events were associated with subtherapeutic doses of heparin in the first and third trimesters and the early postpartum period. Fetal growth restriction and preterm birth complicated 34 (29.3%) and 26 (22.4%) pregnancies respectively.

Conclusion: Pregnancy complications associated with MHVs in middle-income countries may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if daily doses >5 mg and ensuring therapeutic levels of heparin during bridging in the first and third trimesters and peripartum period. Administration of low-dose aspirin should be considered as this may prevent placentally-mediated complications of pregnancy.

Highlights:
Pregnancy complications associated with MHVs in LMICs may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if the daily dose is >5 mg, ensuring therapeutic levels of heparin in the first trimester and peripartum period.
Placentally-mediated complications of pregnancy can be prevented by administering low-dose aspirin.
Vitamin K antagonists or sequential regimen can be used as suitable alternatives to LMWH for anticoagulation in pregnant women with MHVs.


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79. Systematic media review: A novel method to assess mass-trauma epidemiology in absence of databases—A pilot-study in Rwanda

plos one


Authors: Lotta Velin, Mbonyintwari Donatien, Andreas Wladis, Menelas Nkeshimana, Robert Riviello, Jean-Marie Uwitonze, Jean-Claude Byiringiro, Faustin Ntirenganya, Laura Pompermaier
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Health policy, Trauma surgery

Objective
Surge capacity refers to preparedness of health systems to face sudden patient inflows, such as mass-casualty incidents (MCI). To strengthen surge capacity, it is essential to understand MCI epidemiology, which is poorly studied in low- and middle-income countries lacking trauma databases. We propose a novel approach, the “systematic media review”, to analyze mass-trauma epidemiology; here piloted in Rwanda.

Methods
A systematic media review of non-academic publications of MCIs in Rwanda between January 1st, 2010, and September 1st, 2020 was conducted using NexisUni, an academic database for news, business, and legal sources previously used in sociolegal research. All articles identified by the search strategy were screened using eligibility criteria. Data were extracted in a RedCap form and analyzed using descriptive statistics.

Findings
Of 3187 articles identified, 247 met inclusion criteria. In total, 117 MCIs were described, of which 73 (62.4%) were road-traffic accidents, 23 (19.7%) natural hazards, 20 (17.1%) acts of violence/terrorism, and 1 (0.09%) boat collision. Of Rwanda’s 30 Districts, 29 were affected by mass-trauma, with the rural Western province most frequently affected. Road-traffic accidents was the leading MCI until 2017 when natural hazards became most common. The median number of injured persons per event was 11 (IQR 5–18), and median on-site deaths was 2 (IQR 1–6); with natural hazards having the highest median deaths (6 [IQR 2–18]).

Conclusion
In Rwanda, MCIs have decreased, although landslides/floods are increasing, preventing a decrease in trauma-related mortality. By training journalists in “mass-casualty reporting”, the potential of the “systematic media review” could be further enhanced, as a way to collect MCI data in settings without databases.


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80. Integration of mHealth Information and Communication Technologies Into the Clinical Settings of Hospitals in Sub-Saharan Africa: Qualitative Study

JMIR Mhealth Uhealth


Authors: Oluwamayowa Oaikhena Ogundaini, Retha de la Harpe , Nyx McLean
Region / country: Southern Africa, Western Africa – Nigeria, South Africa
Speciality: Digital health

Background:
There is a rapid uptake of mobile-enabled technologies in lower- and upper-middle–income countries because of its portability, ability to reduce mobility, and facilitation of communication. However, there is limited empirical evidence on the usefulness of mobile health (mHealth) information and communication technologies (ICTs) to address constraints associated with the work activities of health care professionals at points of care in hospital settings.

Objective:
This study aims to explore opportunities for integrating mHealth ICTs into the work activities of health care professionals at points of care in clinical settings of hospitals in Sub-Saharan Africa. Thus, the research question is, “How can mHealth ICTs be integrated into the work activities of health care professionals at points of care in hospital settings?”

Methods:
A qualitative approach was adopted to understand the work activities and points at which mHealth ICTs could be integrated to support health care professionals. The techniques of inquiry were semistructured interviews and co-design activities. These techniques were used to ensure the participation of frontline end users and determine how mHealth ICTs could be integrated into the point of care in hospital settings. Purposive and snowball sampling techniques were used to select tertiary hospitals and participants for this study from South Africa and Nigeria. A total of 19 participants, including physicians, nurses, and hospital managers, were engaged in the study. Ethical clearance was granted by the University research committee and the respective hospitals. The data collected were sorted and interpreted using thematic analysis and Activity Analysis and Development model.

Results:
The findings show that mHealth ICTs are suitable at points where health care professionals consult with patients in the hospital clinics, remote communication is needed, and management of referrals and report writing are required. It was inferred that mHealth ICTs could be negatively disruptive, and some participants perceived the use of mobile devices while engaging with patients as unprofessional. These findings were informed by the outcomes of the interplay between human attributes and technology capabilities during the transformation of the motives of work activity into the intended goal, which is enhanced service delivery.

Conclusions:
The opportunities to integrate mHealth ICTs into clinical settings depend on the inefficiencies of interaction moments experienced by health care professionals at points of care during patient consultation, remote communication, referrals, and report writing. Thus, the timeliness of mHealth ICTs to address constraints experienced by health care professionals during work activities should take into consideration the type of work activity and the contextual factors that may result in contradictions in relation to technology features. This study contributes toward the design of mHealth ICTs by industry vendors and its usability evaluation for the work activity outcomes of health care professionals.


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81. Measuring socioeconomic outcomes in trauma patients up to one year post-discharge: A systematic review and meta-analysis

Injury


Authors: Siddarth Daniels Davida, Anna Aroke, Nobhojit Roya, Harris Solomond, Cecilia Stålsby Lundborga, Martin Gerdin Wärnberg
Region / country: Global
Speciality: Health policy, Trauma surgery

Introduction
Trauma accounts for nearly one-tenth of the global disability-adjusted life-years, a large proportion of which is seen in low- and middle-income countries (LMICs). Trauma can affect employment opportunities, reduce social participation, be influenced by social support, and significantly reduce the quality of life (QOL) among survivors. Research typically focuses on specific trauma sub-groups. This dispersed knowledge results in limited understanding of these outcomes in trauma patients as a whole across different populations and settings. We aimed to assess and provide a systematic overview of current knowledge about return-to-work (RTW), participation, social support, and QOL in trauma patients up to one year after discharge.

Methods
We undertook a systematic review of the literature published since 2010 on RTW, participation, social support, and QOL in adult trauma populations, up to one year from discharge, utilizing the most commonly used measurement tools from three databases: MEDLINE, EMBASE, and the Cochrane Library. We performed a meta-analysis based on the type of outcome, tool for measurement, and the specific effect measure as well as assessed the methodological quality of the included studies.

Results
A total of 43 articles were included. More than one-third (36%) of patients had not returned to work even a year after discharge. Those who did return to work took more than 3 months to do so. Trauma patients reported receiving moderate social support. There were no studies reporting social participation among trauma patients using the inclusion criteria. The QOL scores of the trauma patients did not reach the population norms or pre-injury levels even a year after discharge. Older adults and females tended to have poorer outcomes. Elderly individuals and females were under-represented in the studies. More than three-quarters of the included studies were from high-income countries (HICs) and had higher methodological quality.

Conclusion
RTW and QOL are affected by trauma even a year after discharge and the social support received was moderate, especially among elderly and female patients. Future studies should move towards building more high-quality evidence from LMICs on long-term socioeconomic outcomes including social support, participation and unpaid work.


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82. Exploring the experiences of National Health Insurance Scheme subscribers and non-subscribers in accessing healthcare within the Accra Metropolitan Area

bergen open research archive


Authors: Bannerman-Agbeshie, Isaac-Glover
Region / country: Western Africa – Ghana
Speciality: Health policy

Maintaining the health and wellbeing of a nation largely depends on the state of health care policies and programs that guarantees citizens access to health care. Policies and social intervention programs such as the National Health Insurance Scheme (NHIS) should create an enabling operational environment for health institutions. The study examines the experiences of subscribers and non-subscribers of the National Health Insurance Scheme in accessing health care in the Accra Metropolitan Area (AMA) in Ghana. It identifies the challenges in accessing health care, the resources available to individuals and the other strategies individuals employ in accessing health care. A combination of primary and secondary sources was used to collect data for the study. Using a qualitative research design, twelve participants were sampled using a stratified sampling technique. Interviews conducted revealed that many participants had negative experiences in accessing health care with the National Health Insurance Scheme (NHIS). Delays in registration processes, long queuing systems at health centres and delays in reimbursement of health centres by the government were some of the core challenges that led to these negative experiences in accessing health care. As a result, many people resort to alternative means to cater for their health needs. The study further revealed that some people utilized the formal health care facilities only in critical conditions due to past negative experiences and perceptions around accessing health care with the National Health Insurance Scheme (NHIS). However, the NHIS was seen or perceived as an important mechanism for removing financial barrier to achieving equitable access to health care for all citizens in Ghana. The results further showed that the NHIS has improved access and benefits to maternal and child health services. The study concluded by advocating for an improvement and a rebalance of efforts by decision makers to inculcate more health promotion approaches or concepts in making policies concerning public health.


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83. Obstetric neonatal emergency simulation workshops in remote and regional South India: a qualitative evaluation

Advances in Simulation


Authors: Bella Zhong, Mahbub Sarkar, Nandakumar Menon, Shylaja Devi, Jayaram K. Budanoor, Naresh Beerappa, Atul Malhotra & Arunaz Kumar
Region / country: Southern Asia – India
Speciality: Obstetrics and Gynaecology, Surgical Education

Background
Healthcare facilities in remote locations with poor access to a referral centre have a high likelihood of health workers needing to manage emergencies with limited support. Obstetric and neonatal clinical training opportunities to manage childbirth emergencies are scant in these locations, especially in low- and middle-income countries.

Objectives
This study aimed to explore the factors, which influenced healthcare worker experience of attending birth emergencies in remote and regional areas of South India, and the perceived impact of attending the Obstetric and Neonatal Emergency Simulation (ONE-Sim) workshop on these factors.

Design
Qualitative descriptive study using pre- and post-workshop qualitative surveys.

Settings
Primary healthcare facilities in remote/regional settings in three states of South India.

Participants
A total of 125 healthcare workers attended the workshops, with 85 participants completing the pre- and post-workshop surveys included in this study. Participants consisted of medical and nursing staff and other health professionals involved in care at childbirth.

Methods
ONE-Sim workshops (with a learner-centred approach) were conducted across three different locations for interprofessional teams caring for birthing women and their newborns, using simulation equipment and immersive scenarios. Thematic analysis was employed to the free-text responses obtained from the surveys consisting of open-ended questions.

Results
Participants identified their relationship with the patient, the support provided by other health professionals, identifying their gaps in knowledge and experience, and the scarcity of resources as factors that influenced their experience of birth emergencies. Following the workshops, participant learning centred on improving team and personal performance and approaching future emergencies with greater confidence.

Conclusions
Challenges experienced by healthcare workers across sites in remote and regional South India were generally around patient experience, senior health professional support and resources. The technical and interpersonal skills introduced through the ONE-Sim workshop may help to address some of these factors in practice.


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84. Patterns, travel to care and factors influencing obstetric referral: Evidence from Nigeria’s most urbanised state

Social Science & Medicine


Authors: Aduragbemi Banke-Thomas, Cephas Avoka, Abimbola Olaniran, Mobolanle Balogun, Ololade Wright, Olabode Ekerin, Lenka Benova
Region / country: Western Africa – Nigeria
Speciality: Health policy, Obstetrics and Gynaecology

The criticality of referral makes it imperative to study its patterns and factors influencing it at a health systems level. This study of referral in Lagos, Nigeria is based on health records of 4181 pregnant women who presented with obstetric emergencies at one of the 24 comprehensive emergency obstetric care (EmOC) facilities in the state between November 2018 and October 2019 complemented with distance and time data extracted from Google Maps. Univariate, bivariate, and multivariate analyses were conducted. About a quarter of pregnant women who presented with obstetric emergencies were referred. Most referrals were from primary health centres (41.9 %), private (23.5 %) and public (16.2 %) hospitals. Apart from the expected low-level to high-level referral pattern, there were other patterns observed including non-formal, multiple, and post-delivery referrals. Travel time and distance to facilities that could provide needed care increased two-fold on account of referrals compared to scenarios of going directly to the final facility, mostly travelling to these facilities by private cars/taxis (72.8 %). Prolonged/obstructed labour was the commonest obstetric indication for referral, with majority of referred pregnant women delivered via caesarean section (52.9 %). After adjustment, being married, not being registered for antenatal care at facility of care, presenting at night or with a foetus in distress increased the odds of referral. However, parity, presentation in the months following the commissioning of a new comprehensive EmOC facility or with abortion reduced the likelihood of being referred. Our findings underscore the need for health systems strengthening interventions that support women during referral and the importance of antenatal care and early booking to aid identification of potential pregnancy complications whilst establishing robust birth preparedness plans that can minimise the need for referral in the event of emergencies. Indeed, there are context-specific influences that need to be addressed if effective referral systems are to be designed.


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85. Wilms tumour

Nature Reviews Disease Primers


Authors: Filippo Spreafico, Conrad V. Fernandez, Jesper Brok, Kayo Nakata, Gordan Vujanic, James I. Geller, Manfred Gessler, Mariana Maschietto, Sam Behjati, Angela Polanco, Vivian Paintsil, Sandra Luna-Fineman & Kathy Pritchard-Jones
Region / country: Global
Speciality: Paediatric surgery, Surgical oncology, Urology surgery

Wilms tumour (WT) is a childhood embryonal tumour that is paradigmatic of the intersection between disrupted organogenesis and tumorigenesis. Many WT genes play a critical (non-redundant) role in early nephrogenesis. Improving patient outcomes requires advances in understanding and targeting of the multiple genes and cellular control pathways now identified as active in WT development. Decades of clinical and basic research have helped to gradually optimize clinical care. Curative therapy is achievable in 90% of affected children, even those with disseminated disease, yet survival disparities within and between countries exist and deserve commitment to change. Updated epidemiological studies have also provided novel insights into global incidence variations. Introduction of biology-driven approaches to risk stratification and new drug development has been slower in WT than in other childhood tumours. Current prognostic classification for children with WT is grounded in clinical and pathological findings and in dedicated protocols on molecular alterations. Treatment includes conventional cytotoxic chemotherapy and surgery, and radiation therapy in some cases. Advanced imaging to capture tumour composition, optimizing irradiation techniques to reduce target volumes, and evaluation of newer surgical procedures are key areas for future research.


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86. Predictors of immediate neonatal outcome after cesarean section in Uganda

Internal Journal of obstetrics And gynaecology


Authors: Erica Båvenäs, Christoffer Möller, Prashant Bhandarkar, Jude Mulowooza, Jenny Löfgren
Region / country: Eastern Africa – Uganda
Speciality: Obstetrics and Gynaecology

Objective
Child mortality rates are high in sub-Saharan Africa and the proportion of early neonatal death is rising. Cesarean section is an effective way to prevent some neonatal deaths and also stillbirths. The present aim was to identify predictors of low Apgar score, immediate neonatal death, and stillbirth after cesarean section in Uganda.

Methods
Records of cesarean sections performed at all 14 regional referral hospitals and also 14 first-level (district) hospitals in Uganda were reviewed. Both elective and emergency cases were included. Data comprised mother’s age, indication, type of anesthesia, and immediate outcome of the newborn. To evaluate the relation of the predictor variables to outcome, regression analysis was performed.

Results
37 585 cesarean sections were recorded. The indications for cesarean section which led to the highest neonatal mortality and stillbirth rates and lowest mean Apgar score were uterine rupture and hemorrhage. Emergency surgery and general anesthesia had worse neonatal outcomes than elective surgery and spinal anesthesia. Compared to general anesthesia, spinal anesthesia was favorable for neonatal outcomes.

Conclusion
Elective surgical planning and scale-up of the use of spinal anesthesia may potentially reduce stillbirths and immediate neonatal deaths.


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87. Retrospective review of Google Trends to gauge the popularity of global surgery worldwide: A cross-sectional study

Annals of Medicine and Surgery


Authors: Lorraine Arabang Sebopelo, Alexandre Jose Bourcier, Olaoluwa Ezekiel Dada, Gideon Adegboyega, Daniel Safari Nteranya, Ulrick Sidney Kanmounye
Region / country: Global – Australia, Canada, Germany, India, New Zealand, Nigeria, South Africa, United Kingdom, United States of America
Speciality: Health policy

Introduction
Global surgery is a growing movement worldwide, but its expansion has not been quantified. Google Search is the most popular search engine worldwide, and Google Trends analyzes its queries to determine popularity trends. We used Google Trends to analyze the regional and temporal popularity of global surgery (GS). Furthermore, we compared GS with global health (GH) to understand if the two were correlated.

Methods
This is a retrospective cross-sectional study examining Google Trends of GS and GH. We searched the terms “global surgery” and “global health” on Google Trends (Google Inc., CA, USA) from January 2004 to May 2021. We identified time trends and compared the two search terms using SPSS v26 (IBM, WA, USA) to run summary descriptive analyses and Wilcoxon rank-sum tests.

Results
The ten countries most interested in GS were India (5.0%), the United Kingdom (5.0%), Ireland (4.0%), the United States (4.0%), Australia (3.0%), Canada (3.0%), New Zealand (3.0%), Germany (2.0%), South Africa (2.0%), and Nigeria (1.0%). GS became more popular after 2015 (2.3% vs. 1.3%, P < 0.001) and was consistently less popular than GH (1.6% vs. 45.3%, P = 0.04). The difference between GS and GH interest levels increased after 2015 (45.4% vs. 42.9%, P = 0.04).

Conclusion
GS is less popular than GH, more popular in high-income countries, and has become more popular after 2015 when the Lancet Commission on Global Surgery published its seminal report. The World Health Organization passed resolution WHA 68.15. Future advocacy efforts should target low- and middle-income countries primarily.


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88. Rheumatic heart disease in The Gambia: clinical and valvular aspects at presentation and evolution under penicillin prophylaxis

BMC Cardiovascular Disorders


Authors: Lamin E. S. Jaiteh, Lamin Drammeh, Suzanne T. Anderson, John Mendy, Samba Ceesay, Umberto D’Alessandro, Jonathan Carapetis, Mariana Mirabel & Annette Erhart
Region / country: Western Africa – Gambia
Speciality: Cardiothoracic surgery

Background
Rheumatic heart disease (RHD) remains the leading cause of cardiac-related deaths and disability in children and young adults worldwide. In The Gambia, the RHD burden is thought to be high although no data are available and no control programme is yet implemented. We conducted a pilot study to generate baseline data on the clinical and valvular characteristics of RHD patients at first presentation, adherence to penicillin prophylaxis and the evolution of lesions over time.

Methods
All patients registered with acute rheumatic fever (ARF) or RHD at two Gambian referral hospitals were invited for a clinical review that included echocardiography. In addition, patients were interviewed about potential risk factors, disease history, and treatment adherence. All clinical and echocardiography information at first presentation and during follow-up was retrieved from medical records.

Results
Among 255 registered RHD patients, 35 had died, 127 were examined, and 111 confirmed RHD patients were enrolled, 64% of them females. The case fatality rate in 2017 was estimated at 19.6%. At first presentation, median age was 13 years (IQR [9; 18]), 57% patients had late stage heart failure, and 84.1% a pathological heart murmur. Although 53.2% of them reported history of recurrent sore throat, only 32.2% of them had sought medical treatment. A history suggestive of ARF was reported by 48.7% patients out of whom only 15.8% were adequately treated. Two third of the patients (65.5%) to whom it was prescribed were fully adherent to penicillin prophylaxis. Progressive worsening and repeated hospitalisation was experienced by 46.8% of the patients. 17 patients had cardiac surgery, but they represented only 18.1% of the 94 patients estimated eligible for cardiac surgery.

Conclusion
This study highlights for the first time in The Gambia the devastating consequences of RHD on the health of adolescents and young adults. Our findings suggest a high burden of disease that remains largely undetected and without appropriate secondary prophylaxis. There is a need for the urgent implementation of an effective national RHD control programto decrease the unacceptably high mortality rate, improve case detection and management, and increase community awareness of this disease.


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89. Harnessing the power of artificial intelligence to transform hearing healthcare and research

Nature Machine Intelligence


Authors: Nicholas A. Lesica, Nishchay Mehta, Joseph G. Manjaly, Li Deng, Blake S. Wilson , Fan-Gang Zeng
Region / country: Global
Speciality: Digital health, ENT surgery

The advances in artificial intelligence that are transforming many fields have yet to make an impact in hearing. Hearing healthcare continues to rely on a labour-intensive service model that fails to provide access to the majority of those in need, while hearing research suffers from a lack of computational tools with the capacity to match the complexities of auditory processing. This Perspective is a call for the artificial intelligence and hearing communities to come together to bring about a technological revolution in hearing. We describe opportunities for rapid clinical impact through the application of existing technologies and propose directions for the development of new technologies to create true artificial auditory systems. There is an urgent need to push hearing towards a future in which artificial intelligence provides critical support for the testing of hypotheses, the development of therapies and the effective delivery of care worldwide.


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90. Effect of the Procurement Function on the Utilisation of Medical Devices in Public Level Five Hospitals in Kenya

USIU-A Digital Repository


Authors: Nyokabi Pityfaith
Region / country: Eastern Africa – Kenya
Speciality: Health policy

The purpose of the study was to investigate effect of procurement function on the utilization of medical devices in level five hospital in Kenya. More specifically, the study set to answer three key questions namely: What is the effect of procurement practices on utilization of medical devices in public Level Five Hospitals in Kenya? What is the effect of Human capital considerations during procurement on Utilization of Medical Devices? How has maintenance and technical support considerations during procurement affected utilization of medical devices in public Level Five Hospitals in Kenya? With respect to methodological approach, the study was guided by descriptive research design, with a focus on 12 public Level Five Hospitals in Kenya and a study sample size of 138 respondents who were staffs. Stratified sampling techniques was used in selecting respondents, and data collected using self-administered questionnaires, and subsequently analyzed using Statistical Package for Social Sciences (SPSS) version 25. The findings revealed that there were glaring inadequacies in roped to maintenance and technical support of medical devices, human capital considerations during procurement and procurement practices that should otherwise enhance the utilization of medical devices. The findings on procurement practices revealed that there no collaboration while making procurement decisions and this would have resulted to poor utilization of medical devices. The findings further indicate that there was a gap in human capacity and skills and this hindered effective utilization of medical devices. On maintenance and technical support, the findings revealed procured medical devices were not properly maintained due to factors like inadequate skilled workforce responsible for maintenance of medical devices. The results revealed that the relationship between medical device utilization and procurement practices. r (98) =.179, p=.03, maintenance and technical support, r (98) =239, p=.045, and human capital considerations were fairly weak, r (98) =.231, p=.015. The study concludes that there exists fundamental gaps and practices within the procurement function in general that is aiding the effective utilization of medical devices in level five hospitals. The study recommends that human capacity and skills improvement that relate to the users of medical equipment should be a continuous operational function whose cost should be part and parcel of the procurement process as a whole. Secondly, medical equipment maintenance and technical support should be considered as a strategic procurement imperative when any buying decision processes are been done. Lastly, there is need to examine, or to evaluate whether public healthcare services would be more effective as a devolved function or managed by the national government, just like education. The study further concludes there is need for all the departments to work together to have optimal utilization of medical devices that is the procurement division work together with the human resource and the maintenance department to ensure the require medical devices are procured, staff are well trained and there is proper maintenance and if this is properly collaborated there will be optimal utilization of medical devices.


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91. Universal Eye Health and its relation to Digital Health: A Systematic Analysis

Yonsei University Medical Library


Authors: Maria Ezzat Azer Mikhail
Region / country: Global
Speciality: Digital health, Ophthalmology

Background Despite the vigorous efforts of different Global public health sectors regarding eye health. It became now available, but not yet to everyone. From here appeared the urge of the development of Universal Eye Health (UEH) to ensure reducing social inequality in eye health services delivery and improving eye services’ coverage. Digital Health has also become an important frontier in health care services delivery nowadays. This research aims to study the availability and accessibility of UEH and the role of Digital Health as an additive factor in improving it. Methods This is an observational retrospective study. 2 methods where used for in-depth study of current situation of digital eye health in LMICs; Country profiles of the studied countries from different WHO regions and systematic analysis. Literatures have been searched at three search engines: PubMed, Google Scholar, and Cochrane Library. An overview of review articles was conducted using patient, intervention, comparison, and outcome (PICO) framework. Search keywords were; “Digital health”, “Smart health”, “eye health”, “Cataract”, and etc. Our 37 publications were identified as suitable regarding the three expected categories of outcomes. Results Digital health was found to be an important factor in the attainment of UEH in the studied countries. Three categories of outcomes representing the effect of digital health were found in the systematic analysis which helped in improving the eye health system: quality of life of patients with ocular diseases, quality of eye health services and access to the eye health services. Implication of these results on digital eye health in Egypt was identified as well. Conclusion Digital health was found to be an important additive factor in the attainment and expansion of UEH in many of the studied countries. Portable screening devices, Fundus photography, and retinal diagnostics AI innovations and Teleophthalmology have become the black horse of the eye field nowadays but still used in a limited range in many countries in need of such technologies. Using EHRs in research and gathering data for cataract surgical indicators still also used in a very narrow scope which needed to broaden. As it is strongly needed to monitor UEH indicators to be able to have a real assessment of the countries’ progress in their national eye plans and improve access and quality of eye services and of patient life, especially in LMICs.


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92. Diagnosis and Management of Traumatic Subarachnoid Hemorrhage: Protocol for a Scoping Review

JMIR Research Protocols


Authors: Dylan P Griswold, Laura Fernandez, A M Rubiano
Region / country: Global
Speciality: Neurosurgery, Trauma surgery

Background:
Globally, 69 million people suffer from traumatic brain injury (TBI) each year and TBI is the most common cause of subarachnoid hemorrhage (SAH). Traumatic SAH (TSAH) has been described as an adverse prognostic factor leading to progressive neurological deterioration and an increase in morbidity and mortality, but there are a limited number of studies which evaluate recent trends in the diagnostic and management of SAH in the context of trauma.

Objective:
The objective of this scoping review was to understand the extent and type of evidence in relation to the diagnostic criteria and management of TSAH.

Methods:
This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. A 3-step search strategy (an initial limited search in PubMed and Scopus databases; a main search of EMBASE, Web of Science, EBSCO, MEDLINE; and manual searches of reference lists of included articles) will be utilized. The search will be limited to studies with human participants and published in English, Spanish, and French between 2005 and 2020. This review will consider studies of adolescent and adult patients with SAH secondary to trauma. Study selection will be performed by 2 authors (DG and LF) in a 2-phase process; if any disagreement arises, a third author (AR) will be consulted. Data to be extracted from each study will include population, intervention, comparator and outcome measures, and a summary of findings. Citation screening, full-text review, risk of bias assessment, and extraction of study characteristics and outcomes will be carried out using a web-based software platform that streamlines the production of scoping reviews.

Results:
Ethics approval is not required for this systematic review, as there will be no patient involvement. The search for this systematic review commenced in December 2020, and we expect to publish the findings in early 2021. The plan for dissemination is to publish review findings in a peer-reviewed journal and present findings at conferences that engage the most pertinent stakeholders.

Conclusions:
This scoping review will serve as an initial step in providing more evidence for health care professionals, economists, and policymakers so that they might devote more resources toward this significant problem affecting both health and economic outcomes worldwide.


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93. The 4MOTHERS trial of the impact of a mobile money-based intervention on maternal and neonatal health outcomes in Madagascar: study protocol of a cluster-randomized hybrid effectiveness-implementation trial

Trials


Authors: Etienne Lacroze, Till Bärnighausen, Jan Walter De Neve, Sebastian Vollmer, Rolland Marie Ratsimbazafy, Peter Martin Ferdinand Emmrich, Nadine Muller, Elsa Rajemison, Zavaniarivo Rampanjato, Diana Ratsiambakaina, Samuel Knauss & Julius Valentin Emmrich
Region / country: Eastern Africa – Madagascar
Speciality: Health policy, Other

Background
Mobile money—a service enabling users to receive, store, and send electronic money using mobile phones—has been widely adopted across low- and middle-income economies to pay for a variety of services, including healthcare. However, evidence on its effects on healthcare access and health outcomes are scarce and the possible implications of using mobile money for financing and payment of maternal healthcare services—which generally require large one-time out-of-pocket payments—have not yet been systematically assessed in low-resource settings. The aim of this study is to determine the impact on health outcomes, cost-effectiveness, feasibility, acceptability, and usefulness of mobile phone-based savings and payment service, the Mobile Maternal Health Wallet (MMHW), for skilled healthcare during pregnancy and delivery among women in Madagascar.

Methods
This is a hybrid effectiveness-implementation type-1 trial, determining the effectiveness of the intervention while evaluating the context of its implementation in Madagascar’s Analamanga region, containing the capital, Antananarivo. Using a stratified cluster randomized design, 61 public-sector primary-care health facilities were randomized within 6 strata to either receive the intervention or not (29 intervention vs. 32 control facilities). The strata were defined by a health facility’s antenatal care visit volume and its capacity to offer facility-based deliveries. The registered pre-specified primary outcomes are (i) delivery at a health facility, (ii) antenatal care visits, and (iii) total healthcare expenditure during pregnancy, delivery, and neonatal period. The registered pre-specified secondary outcomes include additional health outcomes, economic outcomes, and measurements of user experience and satisfaction. Our estimated enrolment number is 4600 women, who completed their pregnancy between July 1, 2020, and December 31, 2021. A series of nested mixed-methods studies will elucidate client and provider perceptions on feasibility, acceptability, and usefulness of the intervention to inform future implementation efforts.

Discussion
A cluster-randomized, hybrid effectiveness-implementation design allows for a robust approach to determine whether the MMHW is a feasible and beneficial intervention in a resource-restricted public healthcare environment. We expect the results of our study to guide future initiatives and health policy decisions related to maternal and neonatal health and universal healthcare coverage through technology in Madagascar and other countries in sub-Saharan Africa.

Trial registration
This trial was registered on March 12, 2021: Deutsches Register Klinischer Studien (German Clinical Trials Register), identifier: DRKS00014928. For World Health Organization Trial Registration Data Set see Additional file 1.


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94. Caesarean Sections in Sierra Leone explored: a literature review from the last 20 years

ntnu open


Authors: Egeland Emilie, Ingels Ingrid
Region / country: Western Africa – Sierra Leone
Speciality: Obstetrics and Gynaecology

AIM: The aim of this study is to describe the main trends and use of caesarean section (CS) over the last 20 years in Sierra Leone. Further exploration of CS rates, indications for CS, patient outcomes, the effect of the Ebola outbreak on CS and task sharing and its effect on CS are main focus areas in this study. METHODS: The design of the study is a semi-systematic literature review. The main literature for the thesis was identified by conducting a systematic search in PubMed, MEDLINE, SCOPUS and Google Scholar. Additional Demographic and Health Survey (DHS) reports and Maternal Death Surveillance and Response (MDSR) reports were included alongside the database search results. The literature retrieval resulted in 51 works of literature which were read by both authors, and sorted by main focus areas as well as sub themes. A selection of key articles for the results were based on relevancy for each focus area. RESULTS: The key findings of the selected articles were summarized in the results. The result section includes an overview on the findings of the literature for each focus area (CS rates, patient outcomes, indications for CS, Ebola and its effect on CS and task sharing and its effect on CS). 13 articles were used for the CS rate results, seven articles and six reports were used for the patient outcome results, three articles were used for the indications for CS results, three articles were used for the task sharing results and five were used for the Ebola section of results. CONCLUSION: Findings in literature suggest there has been a development in maternal health care services in Sierra Leone over the last 20 years, resulting in increased CS rates and decreased maternal and perinatal mortality and morbidity. However, CS access is still below the recommendations, and increased investment, research and governmental commitment to improve obstetric care is needed in Sierra Leone


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95. Reducing surgical site infections in low-income and middle-income countries (FALCON): a pragmatic, multicentre, stratified, randomised controlled trial

the lancet


Authors: NIHR Global Research Health Unit on Global Surgery
Region / country: Global
Speciality: Health policy, Other

Background
Surgical site infection (SSI) is the most common postoperative complication worldwide. WHO guidelines to prevent SSI recommend alcoholic chlorhexidine skin preparation and fascial closure using triclosan-coated sutures, but called for assessment of both interventions in low-resource settings. This study aimed to test both interventions in low-income and middle-income countries.

Methods
FALCON was a 2 × 2 factorial, randomised controlled trial stratified by whether surgery was clean-contaminated, or contaminated or dirty, including patients undergoing abdominal surgery with a skin incision of 5 cm or greater. This trial was undertaken in 54 hospitals in seven countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). Patients were computer randomised 1:1:1:1 to: (1) 2% alcoholic chlorhexidine and non-coated suture, (2) 2% alcoholic chlorhexidine and triclosan-coated suture, (3) 10% aqueous povidone–iodine and non-coated suture, or (4) 10% aqueous povidone–iodine and triclosan-coated suture. Patients and outcome assessors were masked to intervention allocation. The primary outcome was SSI, reported by trained outcome assessors, and presented using adjusted relative risks and 95% CIs. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03700749.

Findings
Between Dec 10, 2018, and Sept 7, 2020, 5788 patients (3091 in clean-contaminated stratum, 2697 in contaminated or dirty stratum) were randomised (1446 to alcoholic chlorhexidine and non-coated suture, 1446 to alcoholic chlorhexidine and triclosan-coated suture, 1447 to aqueous povidone–iodine and non-coated suture, and 1449 to aqueous povidone–iodine and triclosan-coated suture). 14·0% (810/5788) of patients were children and 66·9% (3873/5788) had emergency surgery. The overall SSI rate was 22·0% (1163/5284; clean-contaminated stratum 15·5% [454/2923], contaminated or dirty stratum 30·0% [709/2361]). For both strata, there was no evidence of a difference in the risk of SSI with alcoholic chlorhexidine versus povidone–iodine (clean-contaminated stratum 15·3% [223/1455] vs 15·7% [231/1468], relative risk 0·97 [95% CI 0·82–1·14]; contaminated or dirty stratum 28·3% [338/1194] vs 31·8% [371/1167], relative risk 0·91 [95% CI 0·81–1·02]), or with triclosan-coated sutures versus non-coated sutures (clean-contaminated stratum 14·7% [215/1459] vs 16·3% [239/1464], relative risk 0·90 [95% CI 0·77–1·06]; contaminated or dirty stratum 29·4% [347/1181] vs 30·7% [362/1180], relative risk 0·98 [95% CI 0·87–1·10]). With both strata combined, there were no differences using alcoholic chlorhexidine or triclosan-coated sutures.

Interpretation
This trial did not show benefit from 2% alcoholic chlorhexidine skin preparation compared with povidone–iodine, or with triclosan-coated sutures compared with non-coated sutures, in preventing SSI in clean-contaminated or contaminated or dirty surgical wounds. Both interventions are more expensive than alternatives, and these findings do not support recommendations for routine use.


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96. Implementation of the World Health Organization Global Antimicrobial Resistance Surveillance System in Uganda, 2015-2020: Mixed-Methods Study Using National Surveillance Data

JMIR Public Health Surveillance


Authors: Susan Nabadda, Francis Kakooza, Reuben Kiggundu, Richard Walwema, Joel Bazira, Jonathan Mayito, Ibrahimm Mugerwa, Musa Sekamatte, Andrew Kambugu, Mohammed Lamorde, Henry Kajumbula, Henry Mwebasa
Region / country: Eastern Africa – Uganda
Speciality: Health policy, Other

Background:
Antimicrobial resistance (AMR) is an emerging public health crisis in Uganda. The World Health Organization (WHO) Global Action Plan recommends that countries should develop and implement National Action Plans for AMR. We describe the establishment of the national AMR program in Uganda and present the early microbial sensitivity results from the program.

Objective:
The aim of this study is to describe a national surveillance program that was developed to perform the systematic and continuous collection, analysis, and interpretation of AMR data.

Methods:
A systematic qualitative description of the process and progress made in the establishment of the national AMR program is provided, detailing the progress made from 2015 to 2020. This is followed by a report of the findings of the isolates that were collected from AMR surveillance sites. Identification and antimicrobial susceptibility testing (AST) of the bacterial isolates were performed using standard methods at both the surveillance sites and the reference laboratory.

Results:
Remarkable progress has been achieved in the establishment of the national AMR program, which is guided by the WHO Global Laboratory AMR Surveillance System (GLASS) in Uganda. A functional national coordinating center for AMR has been established with a supporting designated reference laboratory. WHONET software for AMR data management has been installed in the surveillance sites and laboratory staff trained on data quality assurance. Uganda has progressively submitted data to the WHO GLASS reporting system. Of the 19,216 isolates from WHO GLASS priority specimens collected from October 2015 to June 2020, 22.95% (n=4411) had community-acquired infections, 9.46% (n=1818) had hospital-acquired infections, and 68.57% (n=12,987) had infections of unknown origin. The highest proportion of the specimens was blood (12,398/19,216, 64.52%), followed by urine (5278/19,216, 27.47%) and stool (1266/19,216, 6.59%), whereas the lowest proportion was urogenital swabs (274/19,216, 1.4%). The mean age was 19.1 (SD 19.8 years), whereas the median age was 13 years (IQR 28). Approximately 49.13% (9440/19,216) of the participants were female and 50.51% (9706/19,216) were male. Participants with community-acquired infections were older (mean age 28, SD 18.6 years; median age 26, IQR 20.5 years) than those with hospital-acquired infections (mean age 17.3, SD 20.9 years; median age 8, IQR 26 years). All gram-negative (Escherichia coli, Klebsiella pneumoniae, and Neisseria gonorrhoeae) and gram-positive (Staphylococcus aureus and Enterococcus sp) bacteria with AST showed resistance to each of the tested antibiotics.

Conclusions:
Uganda is the first African country to implement a structured national AMR surveillance program in alignment with the WHO GLASS. The reported AST data indicate very high resistance to the recommended and prescribed antibiotics for treatment of infections. More effort is required regarding quality assurance of laboratory testing methodologies to ensure optimal adherence to WHO GLASS–recommended pathogen-antimicrobial combinations. The current AMR data will inform the development of treatment algorithms and clinical guidelines


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97. Trauma Care in Low- and Middle-Income Countries

thieme


Authors: Dhurka Shanthakumar, Anna Payne, Trish Leitch, Maryam Alfa-Wali
Region / country: Global
Speciality: Trauma surgery

Background Trauma-related injury causes higher mortality than a combination of prevalent infectious diseases. Mortality secondary to trauma is higher in low- and middle-income countries (LMICs) than high-income countries. This review outlines common issues, and potential solutions for those issues, identified in trauma care in LMICs that contribute to poorer outcomes.

Methods A literature search was performed on PubMed and Google Scholar using the search terms “trauma,” “injuries,” and “developing countries.” Articles conducted in a trauma setting in low-income countries (according to the World Bank classification) that discussed problems with management of trauma or consolidated treatment and educational solutions regarding trauma care were included.

Results Forty-five studies were included. The problem areas broadly identified with trauma care in LMICs were infrastructure, education, and operational measures. We provided some solutions to these areas including algorithm-driven patient management and use of technology that can be adopted in LMICs.

Conclusion Sustainable methods for the provision of trauma care are essential in LMICs. Improvements in infrastructure and education and training would produce a more robust health care system and likely a reduction in mortality in trauma-related injuries.


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98. Leadership development for orthopaedic trauma surgeons in Latin America: opportunities for and barriers to skill acquisition

OTA Journal


Authors: MacKechnie Madeline, MacKechnie Michael, Lieshout Esther, Verhofstad Michael, Quintero Jose Eduardo, Padilla Rojas Luis G. , Tabares Neyra Horacio, Russo Bibiana Dello, Giordano Vincenzo, Vilensky Eduardo, Fuehrer Sheryl L., Miclau Theodore, ACTUAR Study Group
Region / country: Central America, South America
Speciality: Health policy, Trauma and orthopaedic surgery

Introduction:
There is growing interest in leadership courses for physicians. Few opportunities are available in global regions with limited resources. This study describes orthopaedic trauma surgeons’ desired leadership skill acquisition, opportunities, and barriers to course participation in Latin America.

Methods:
Latin American orthopaedic trauma surgeons from the Asociación de Cirujanos Traumatólogos de las Americas (ACTUAR) network were surveyed. This survey solicited and gauged the surgeons’ level of interest in leadership topics and their relative importance utilizing a 5-point Likert-scale. Additionally, comparisons were calculated between middle-income countries (MICs) and high-income countries (HICs) to ascertain if needs were different between groups. The survey included demographic information, nationality, level of training, years in practice, leadership position, needs assessment, and perceived barriers for leadership educational opportunities.

Results:
One hundred forty-four orthopaedic surgeons completed the survey, representing 18 countries across Latin America; 15 MICs and 3 HICs. Participants had more than 20 years in practice (49%) and held leadership positions (81%) in hospital settings (62%), national orthopaedic societies (45%), and/or clinical settings (40%). Sixty-three percent had never attended a leadership course due to lack of opportunities/invitations (69%), difficulty missing work (24%), and costs (21%). Ninety-seven percent expressed interest in attending a leadership course. No difference in needs was determined between respondents from MICs and HICs. Professional Ethics, Crisis Management/Organizational Change Management, and High Performing Team-Building were identified as the most important leadership topics.

Conclusion:
Orthopaedic surgeons in Latin America demonstrate an interest in acquiring additional leadership skills but have few opportunities. Identifying interests, knowledge gaps, and core competencies can guide the development of such opportunities.


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99. Road Traffic Injuries in Malawi with special focus on the role of alcohol

Norwegian Institute of Public Health


Authors: Asbjørg S. Christophersen, Stig Tore Bogstrand, Hallvard Gjerde, Mads Sundet ,Elin H. Wyller
Region / country: Southern Africa – Malawi
Speciality: Health policy, Trauma and orthopaedic surgery

Driving under the influence of alcohol is one of the principal causes of road traffic crashes (RTCs) [1]. The use of alcohol is also a risk factor for other road users, such as pedestrians and bicyclists. The association of alcohol in injurious and fatal RTCs has been well documented in most high-income countries, but data for low- and middle-income countries is scarce, particularly for African countries [2]. The study was a collaborative effort between Kamuzu Central Hospital (KCH), the Norwegian Institute of Public Health (NIPH) and Oslo University Hospital (OUH), with the financial support of UK Aid through the Global Road Safety Facility (GRSF) hosted by the World Bank, the International Council on Alcohol Drugs and Traffic Safety (ICADTS) and the Norwegian Council for Road Safety (Trygg Trafikk). The objective of the study was to generate new knowledge about road traffic injuries in Malawi and the extent of traffic accidents related to alcohol use, to increase capacity to conduct alcohol testing, and develop a database for the findings, which in turn will form the basis for future policymaking to reduce traffic accidents.
The objectives were achieved through collecting data on patients who sought treatment after road traffic crashes and admitted to the Emergency Department at KCH in Lilongwe, Malawi. A questionnaire was developed for data collection in cooperation between the project groups in Norway and Malawi. The data included basic information about the patients, alcohol use before the injury, and information about accident circumstances, including types of road users and vehicles involved. Participation was voluntary and anonymous. All weekdays, weekends and nights were covered. Alcohol was measured using a breathalyzer or saliva test for those who were not able to blow. Knowledge and training of local KCH employees to perform alcohol testing and record data were an important aspect of this study.
The project was approved by the National Health Science Research Committee (NHSRC) in Malawi. The Regional Committee for Medical and Health Research Ethics in Norway was consulted, and their conclusion was that no formal application was needed, with reference to the Norwegian Health Research Act Section, §2 and 4a. A Data Protection Impact Assessment was performed as required by NIPH. There were 1251 patients in the study, representing nearly 95 per cent of those who were asked to participate. The results show a rather high prevalence of alcohol use among several injured road user groups (totally about 25 percent), particularly among those injured during weekend nights and evenings, but also during weekday evenings and nights. It was estimated that about 15 per cent of injured motor vehicle drivers and riders had BACs above the legal limit of 0.8 grams/L at the time of the crash. The findings also show that it is important to focus on bus/minibus/lorry drivers who often carry passengers, where about one out of five tested positive for alcohol. It is worth noting that pedestrians had the highest prevalence of alcohol use before being injured. They constitute a vulnerable group; they often walk in the dark with no road lighting, no pavements, walkways or safe places to cross
the road. Combined with alcohol use their injury risk is even higher. The collected data can contribute to future road traffic safety procedures and measures. The long-term goal is to contribute to sustainable development goal 3, target 3.6, to reduce by half the number of global RTC deaths and injuries. Road Traffic Inuries in Malawi • Norwegian Institute of Public Health This study shows the importance of collecting adequate and relevant data for health authorities particularly in low- and middle-income countries in battling the challenge of alcohol-related road traffic crashes, deaths and injuries. Due to the COVID-19 pandemic, a
number of recommendations were presented to Malawian authorities at a virtual seminar held in autumn 2020.


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100. The effect of a new maternity unit on maternal outcomes in rural Haiti: an interrupted time series study

BMC Pregnancy and Childbirth


Authors: Tonya MacDonald, Olès Dorcely, Joycelyne E. Ewusie, Elizabeth K. Darling, Sandra Moll , Lawrence Mbuagbaw
Region / country: Caribbean – Haiti
Speciality: Obstetrics and Gynaecology

Background
In Haiti where there are high rates of maternal and neonatal mortality, efforts to reduce mortality and improve maternal newborn child health (MNCH) must be tracked and monitored to measure their success. At a rural Haitian hospital, local surveillance efforts allowed for the capture of MNCH indicators. In March 2018, a new stand-alone maternity unit was opened, with increased staff, personnel, and physical space. We aimed to determine if the new maternity unit brought about improvements in maternal and neonatal outcomes.

Methods
We conducted an interrupted time series analysis using data collected between July 2016 and October 2019 including 20 months before the opening of the maternity unit and 20 months after. We examined maternal-neonatal outcomes such as physiological (vaginal) births, caesarean birth, postpartum hemorrhage (PPH), maternal deaths, stillbirths and undesirable outcomes (eclampsia, PPH, perineal laceration, postpartum infection, maternal death or stillbirth).

Results
Immediately after the opening of the new maternity, the number of physiological births decreased by 7.0% (β = − 0.070; 95% CI: − 0.110 to − 0.029; p = 0.001) and there was an increase of 6.7% in caesarean births (β = 0.067; 95% CI: 0.026 to 0.107; p = 0.002). For all undesirable outcomes, preintervention there was an increasing trend of 1.8% (β = 0.018; 95% CI: 0.013 to 0.024; p < 0.001), an immediate 14.4% decrease after the intervention (β = − 0.144; 95% CI: − 0.255 to − 0.033; p = 0.012), and a decreasing trend of 1.8% through the postintervention period (β = − 0.018; 95% CI: − 0.026 to − 0.009; p < 0.001). No other significant level or trend changes were noted.

Conclusions
The new maternity unit led to an upward trend in caesarean births yet an overall reduction in all undesirable maternal and neonatal outcomes. The new maternity unit at this rural Haitian hospital positively impacted and improved maternal and neonatal outcomes.


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101. Treating Children With Advanced Rheumatic Heart Disease in Sub-Saharan Africa: The NGO EMERGENCY’s Project at the Salam Centre for Cardiac Surgery in Sudan

Frontiers in Pediatrics


Authors: Rossella Miccio, Maria Quattrociocchi , Lorenzo Valgoi , Liliane Chatenoud , Salvatore Lentini , Elena Giovanella , Luca Rolla , Nicoletta Erba, Sofia Gatti , Daniela Rocchi , Manahel Badr Saad , Alessandro Salvati , Martin Langer , Gina Portella, Gino Strada
Region / country: Eastern Africa – Sudan
Speciality: Cardiothoracic surgery, Emergency surgery, Paediatric surgery

Rheumatic heart disease is endemic in Sub-Saharan Africa and while efforts are under way to boost prophylaxis and early diagnosis, access to cardiac surgery is rarely affordable. In this article, we report on a humanitarian project by the NGO EMERGENCY, to build and run the Salam Centre for Cardiac Surgery in Sudan. This hospital is a center of excellence offering free-of-charge, high-quality treatment to patients needing open-heart surgery for advanced rheumatic and congenital heart disease. Since it opened in 2007, more than 8,000 patients have undergone surgery there; most of them Sudanese, but ~20% were admitted from other countries, an example of inter-African cooperation. The program is not limited to surgical procedures. It guarantees long-term follow-up and anticoagulant treatment, where necessary. By way of example, we report clinical features and outcome data for the pediatric cohort: 1,318 children under the age of 15, operated on for advanced rheumatic heart disease between 2007 and 2019. The overall 5-year survival rate was 85.0% (95% CI 82.7–87.3). The outcomes for patients with mitral valves repaired and with mitral valves replaced are not statistically different. Nevertheless, observing the trend of patients undergoing valve repair, a better outcome for this category might be assumed. RHD in children is an indicator of poor socio-economic conditions and an inadequate health system, which clearly will not be cured by cardiac surgery alone. Nevertheless, the results achieved by EMERGENCY, with the crucial involvement and participation of the Sudanese government over the years, show that building a hospital, introducing free cardiac surgery, and offering long-term post-operative care may help spread belief in positive change in the future.


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102. Needs-led human resource planning for Sierra Leone in support of oral health

Human Resources for Health volume


Authors: Swapnil Gajendra Ghotane, Patric Don-Davis, David Kamara, Paul R. Harper, Stephen J. Challacombe , Jennifer E. Gallagher
Region / country: Western Africa – Sierra Leone
Speciality: Maxillofacial and oral surgery, Other

Background
In Sierra Leone (SL), a low-income country in West Africa, dental care is very limited, largely private, and with services focused in the capital Freetown. There is no formal dental education. Ten dentists supported by a similar number of dental care professionals (DCPs) serve a population of over 7.5 million people. The objective of this research was to estimate needs-led requirements for dental care and human resources for oral health to inform capacity building, based on a national survey of oral health in SL.

Methods
A dedicated operational research (OR) decision tool was constructed in Microsoft Excel to support this project. First, total treatment needs were estimated from our national epidemiological survey data for three key ages (6, 12 and 15 years), collected using the ‘International Caries Classification and Management System (ICCMS)’ tool. Second, oral health needs were extrapolated to whole population levels for each year-group, based on census demographic data. Third, full time equivalent (FTE) workforce capacity needs were estimated for mid-level providers in the form of Dental Therapists (DTs) and non-dental personnel based on current oral disease management approaches and clinical timings for treatment procedures. Fourth, informed by an expert panel, three oral disease management scenarios were explored for the national population: (1) Conventional care (CC): comprising oral health promotion (including prevention), restorations and tooth extraction; (2) Surgical and Preventive care (S5&6P and S6P): comprising oral health promotion (inc. prevention) and tooth extraction (D5 and D6 together, & at D6 level only); and (3) Prevention only (P): consisting of oral health promotion (inc. prevention). Fifth, the findings were extrapolated to the whole population based on demography, assuming similar levels of treatment need.

Results
To meet the needs of a single year-group of childrens’ needs, an average of 163 DTs (range: 133–188) would be required to deliver Conventional care (CC); 39 DTs (range: 30–45) to deliver basic Surgical and Preventive care (S6P); 54 DTs for more extended Surgical and Preventive care (S5&6P) (range 38–68); and 27 DTs (range: 25–32) to deliver Prevention only (P). When scaled up to the total population, an estimated 6,147 DTs (range: 5,565–6,870) would be required to deliver Conventional care (CC); 1,413 DTs (range: 1255–1438 DTs) to deliver basic Surgical and Preventive care (S6P); 2,000 DTs (range 1590–2236) for more extended Surgical and Preventive care (S5&6P) (range 1590–2236); and 1,028 DTs to deliver Prevention only (P) (range: 1016–1046). Furthermore, if oral health promotion activities, including individualised prevention, could be delivered by non-dental personnel, then the remaining surgical care could be delivered by 385 DTs (range: 251–488) for the S6P scenario which was deemed as the minimum basic baseline service involving extracting all teeth with extensive caries into dentine. More realistically, 972 DTs (range: 586–1179) would be needed for the S5&6P scenario in which all teeth with distinctive and extensive caries into dentine are extracted.

Conclusion
The study demonstrates the huge dental workforce needs required to deliver even minimal oral health care to the Sierra Leone population. The gap between the current workforce and the oral health needs of the population is stark and requires urgent action. The study also demonstrates the potential for contemporary epidemiological tools to predict dental treatment needs and inform workforce capacity building in a low-income country, exploring a range of solutions involving mid-level providers and non-dental personnel.


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103. Intersectional social-economic inequalities in breast cancer screening in India: analysis of the National Family Health Survey

BMC Women’s Health


Authors: Jyotsna Negi , Devaki Nambiar
Region / country: Southern Asia – India
Speciality: General surgery, Surgical oncology

Background
Breast cancer incidence rates are increasing in developing countries including India. With 1.3 million new cases of cancer been diagnosed annually, breast cancer is the most common women’s cancer in India. India’s National Family Health Survey (NFHS-4) data 2015–2016 shows that only 9.8% of women between the ages of 15 and 49 had ever undergone breast examination (BE). Further, access to screening and treatment is unequally distributed, with inequalities by socio-economic status. It is unclear, however, if socio-economic inequalities in breast examination are similar across population subgroups.

Methods
We compared BE coverage in population sub-groups categorised by place of residence, religion, caste/tribal groups, education levels, age, marital status, and employment status in their intersection with economic status in India. We analysed data for 699,686 women aged 15–49 using the NFHS-4 data set conducted during 2015–2016. Descriptive (mean, standard errors, and confidence intervals) of women undergoing BE disaggregated by dimensions of inequality (education, caste/tribal groups, religion, place of residence) and their intersections with wealth were computed with national weights using STATA 12. Chi-square tests were performed to assess the association between socio-demographic factors and breast screening. Additionally, the World Health Organisation’s Health Equity Assessment Toolkit Plus was used to compute summary measures of inequality: Slope index for inequality (SII) and Relative Concentration Indices (RCI) for each intersecting dimension.

Results
BE coverage was concentrated among wealthier groups regardless of other intersecting population subgroups. Wealth-related inequalities in BE coverage were most pronounced among Christians (SII; 20.6, 95% CI: 18.5–22.7), married (SII; 14.1, 95% CI: 13.8–14.4), employed (SII: 14.6, 95%CI: 13.9, 15.3), and rural women (SII; 10.8, 95% CI: 10.5–11.1). Overall, relative summary measures (RCI) were consistent with our absolute summary measures (SII).

Conclusions
Breast examination coverage in India is concentrated among wealthier populations across population groups defined by place of residence, religion, age, employment, and marital status. Apart from this national analysis, subnational analyses may also help identify strategies for programme rollout and ensure equity in women’s cancer screening.


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104. Clinical Profile and Predictors of Mortality in Neonates Born With Non-Immune Hydrops Fetalis: Experience From a Lower-Middle-Income Country

cureus


Authors: Vinod K. Hasija, Adnan Mirza, Waqar H. Khowaja, Sidra Asif, Muhammad Sohail Salat, Shabina Ariff, Khalil Ahmad
Region / country: Southern Asia – Pakistan
Speciality: Critical care, Obstetrics and Gynaecology, Paediatric surgery

Introduction
Hydrops fetalis (HF) is a life-threatening condition in which a fetus has an abnormal collection of fluid in the tissue around the lungs, heart, abdomen, or under the skin. Based on its pathophysiology, it is classified into immune and non-immune types. With the widespread use of anti-D immunoglobulin, non-immune HF has become more common, with an incidence of one in 1,700-3,000 live births. A multitude of fetal diseases with various causes can lead to non-immune HF. Due to the recent advances in prenatal diagnostic and therapeutic interventions together with improved neonatal intensive care, the diagnosis and subsequent management of HF have been refined. However, HF is still associated with a high mortality rate. A recent assessment of the literature found that there is a lack of data on prognostic variables in neonates with HF from low- and middle-income countries. In light of this, we sought to establish the etiologic causes, predictors of mortality, and eventual fate of newborns born non-immune HF at the Aga Khan University Hospital, Karachi during the 10-year period spanning January 2009-December 2019 in this retrospective analysis.

Methodology
For this study, we collected data from the computerized database and patient record files at the hospital on all infants with non-immune HF. Demographic data, postnatal interventions, clinical and laboratory findings, outcomes, and the results of comparison between HF patients who died and those who survived were analyzed.

Results
The incidence of non-immune HF at our hospital was 0.62/1,000 live births during the period under study, with 33 newborn babies diagnosed with non-immune HF from a total of 53,033 live-born deliveries. An etiologic factor was discovered in 17 (51.5%) neonates with non-immune HF while 16 (48.4%) were classified as those with unidentified etiology. The most common causes were cardiovascular and genetic syndromes, which resulted in 100% mortality. The overall mortality rate was 67%. The need for mechanical ventilation, surfactant therapy, and prolonged hospitalization were identified as independent risk factors of mortality.

Conclusion
Our study proves that the need for mechanical ventilation [moderate to severe hypoxic respiratory failure (HRF)] and prolonged hospitalization are strong predictors of poor outcomes in neonates with non-immune HF. Therefore, severe hydrops causing significant mortality can be anticipated based on the patients’ respiratory status and the need for escalated oxygen support.


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105. Job Satisfaction and Its Determinants among Nurse Anesthetists in Clinical Practice: The Botswana Experience

Anesthesiology Research and Practice


Authors: Mamo Woldu Kassa , Alemayehu Ginbo Bedada
Region / country: Southern Africa – Botswana
Speciality: Anaesthesia, Health policy

Job satisfaction (JS) correlates positively with patients’ satisfaction and outcomes and employees’ well-being. In Botswana, the level of job satisfaction and its determinants among nurse anesthetists were not investigated. A cross-sectional study was conducted from January 2020 to June 2020 encompassing all nurse anesthetists in clinical practice in Botswana. A self-administered questionnaire was used that incorporated demographic data, reasons to stay on or leave their job, and a validated 20-item short form of the Minnesota Satisfaction Questionnaire which was pretested on five of our nurse anesthetists. Percentage is used to describe the data. The independence of categorical variables was examined using chi-square or Fisher’s exact test. value <0.05 was considered statistically significant. In Botswana, a total of 76 nurse anesthetists were in clinical practice during the study period. Sixty-six (86.9%) responded to the survey. Gender distribution was even, 50.0%. The overall JS was 36.4%. Males had significantly higher JS than females, . Significantly higher job satisfaction was found in married nurse anesthetists (), expatriate nurse anesthetists (), nurse anesthetists in non-referral hospitals (), and nurse anesthetists with ≥10 years’ experience (). Nurse anesthetists were satisfied with security, social service, authority, ability utilization, and responsibility in ≥60.0% of the cases. They were not satisfied in compensation, working condition, and advancement in a similar percentage. The main reason to stay on their job was to serve the public in 68.2%. In Botswana, employers should make an effort to address the working conditions, compensation, and advancement of nurse anesthetists in clinical practice.


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106. Protocol for a systematic review of outcomes from microsurgical free-tissue transfer performed on short-term collaborative surgical trips in low-income and middle-income countries

Systematic Reviews


Authors: Henry T. de Berker, Urška Čebron, Daniel Bradley, Vinod Patel, Meklit Berhane, Fernando Almas, Gary Walton, Mekonen Eshete, Mark McGurk, Dominique Martin & Calum Honeyman
Region / country: Global
Speciality: Plastic surgery

Background
In many units around the world, microsurgical free-tissue transfer represents the gold standard for reconstruction of significant soft tissue defects following cancer, trauma or infection. However, many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources, infrastructure or training required to perform any microsurgical procedures. Long-term international collaborations have been formed with annual short-term reconstructive missions conducting microsurgery. In the first instance, these provide reconstructive surgery to those who need it. In the longer-term, they offer an opportunity for teaching and the development of sustainable local services.

Methods
A PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive, predetermined search strategy will be applied to the MEDLINE and Embase electronic databases from inception to August 2021. All clinical studies presenting sufficient data on free-tissue transfer performed on short-term collaborative surgical trips (STCSTs) in LMICs will be eligible for inclusion. The primary outcomes are rate of free flap failure, rate of emergency return to theatre for free flap salvage and successful salvage rate. The secondary outcomes include postoperative complications, cost effectiveness, impact on training, burden of disease, legacy and any functional or patient reported outcome measures. Screening of studies, data extraction and assessments of study quality and bias will be conducted by two authors. Individual study quality will be assessed according to the Oxford Evidence-based Medicine Scales of Evidence 2, and risk of bias using either the ‘Revised Cochrane risk of bias tool for randomized trials’ (Rob2), the ‘Risk of bias in non-randomized studies of interventions’ (ROBINS-I) tool, or the National Institute for Health Quality Assessment tool for Case Series. Overall strength of evidence will be assessed according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

Discussion
To-date the outcomes of microsurgical procedures performed on STCSTs to LMICs are largely unknown. Improved education, funding and allocation of resources are needed to support surgeons in LMICs to perform free-tissue transfer. STCSTs provide a vehicle for sustainable collaboration and training. Disseminating microsurgical skills could improve the care received by patients living with reconstructive pathology in LMICs, but this is poorly established. This study sets out a robust protocol for a systematic review designed to critically analyse outcomes.


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107. Improving knowledge about breast cancer and breast self examination in female Nigerian adolescents using peer education: a pre-post interventional study

BMC Women’s Health


Authors: Ayebo E. Sadoh, Clement Osime, Damian U. Nwaneri, Bamidele C. Ogboghodo, Charles O. Eregie , Osawaru Oviawe
Region / country: Western Africa – Nigeria
Speciality: Obstetrics and Gynaecology, Surgical Education, Surgical oncology

Background
Prevention of BC of which the cornerstone is creating awareness and early detection is important in adolescents and young women because of their worse outcomes. Early detection strategies such as mammography are currently beyond the reach of most women in sub-Saharan Africa.. Lack of awareness and late presentation contribute to the poor outcomes. Awareness creation among adolescents may result in modification of some risk factors for BC with adoption of healthy life styles including accessing early detection activities. This study determined the effect of peer education as a strategy to create awareness on BC and breast self examination (BSE) among in-school female adolescents in Benin City.

Methods
This was a pre-post interventional study carried out in October –December 2016 on female students of four secondary schools in Benin City. Pre-peer training, using a pre-tested self-administered questionnaire, knowledge about BC and BSE was assessed in about 30% of each school population. This was followed by training of 124 students selected from the schools (one student per class) as peer trainers. The peer trainers provided training on BC and BSE (the intervention) for their classmates. Within two weeks of peer training knowledge about BC and BSE was reassessed in 30% of each school population. Selection of students for assessment pre and post intervention was by systematic sampling. Correct knowledge was scored and presented as percentages. Chi square test, student t test and ANOVA were used to assess associations and test differences with level of significance set at p < 0.05.

Results
There were 1337 and 1201 students who responded to the pre and post-training questionnaires respectively. The mean BC knowledge score (20.61 ± 13.4) prior to training was low and it statistically significantly improved to 55.93 ± 10.86 following training p < 0.0001 Following peer training, statistically significant improvement (p 0.037- < 0.001) occurred in most knowledge domains apart from symptomatology. Pre-peer training 906(67.8%) students knew about BSE but only 67(4.8%). Significantly more students 1134(94.7%) knew about BSE following peer training.

Conclusions
Peer education strategy can be used to improve BC and BSE knowledge in adolescents. This strategy is low cost and could be very useful in low resource settings.


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108. Improving hand hygiene measures in low-resourced intensive care units: experience at the Kigali University Teaching Hospital in Rwanda

International Journal of Infection Control


Authors: Jean Paul Mvukiyehe, Eugene Tuyishime, Anne Ndindwanimana, Jennifer Rickard, Olivier Manzi, Gregory R. Madden Marcel E. Durieux, Paulin R. Banguti
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Health policy, Other

Background: Proper hand hygiene (HH) practices have been shown to reduce healthcare-acquired infections. Several potential challenges in low-income countries might limit the feasibility of effective HH, including preexisting knowledge gaps and staffing.

Aim: We sought to evaluate the feasibility of the implementation of effective HH practice at a teaching hospital in Rwanda.

Methods: We conducted a prospective quality improvement project in the intensive care unit (ICU) at the Kigali University Teaching Hospital. We collected data before and after an intervention focused on HH adherence as defined by the World Health Organization ‘5 Moments for Hand Hygiene’ and assuring availability of HH supplies. Pre-intervention data were collected throughout July 2019, and HH measures were implemented in August 2019. Post-implementation data were collected following a 3-month wash-in.

Results: In total, 902 HH observations were performed to assess pre-intervention adherence and 903 observations post-intervention adherence. Overall, HH adherence increased from 25% (222 of 902 moments) before intervention to 75% (677 of 903 moments) after intervention (P < 0.001). Improvement was seen among all health professionals (nurses: 19–74%, residents: 23–74%, consultants: 29–76%).

Conclusions: Effective HH measures are feasible in an ICU in a low-income country. Ensuring availability of supplies and training appears key to effective HH practices.


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109. Duration of intervals in the care seeking pathway for lung cancer in Bangladesh: A journey from symptoms triggering consultation to receipt of treatment

plos one


Authors: Adnan Ansar ,Virginia Lewis,Christine Faye McDonald,Chaojie Liu,Muhammad Aziz Rahman
Region / country: Southern Asia – Bangladesh
Speciality: Cardiothoracic surgery, Surgical oncology

Timeliness in seeking care is critical for lung cancer patients’ survival and better prognosis. The care seeking trajectory of patients with lung cancer in Bangladesh has not been explored, despite the differences in health systems and structures compared to high income countries. This study investigated the symptoms triggering healthcare seeking, preferred healthcare providers (including informal healthcare providers such as pharmacy retailers, village doctors, and “traditional healers”), and the duration of intervals in the lung cancer care pathway of patients in Bangladesh. A cross-sectional study was conducted in three tertiary care hospitals in Bangladesh among diagnosed lung cancer patients through face-to-face interview and medical record review. Time intervals from onset of symptom and care seeking events were calculated and compared between those who sought initial care from different providers using Wilcoxon rank sum tests. Among 418 study participants, the majority (90%) of whom were males, with a mean age of 57 ±9.86 years, cough and chest pain were the most common (23%) combination of symptoms triggering healthcare seeking. About two-thirds of the total respondents (60%) went to informal healthcare providers as their first point of contact. Living in rural areas, lower levels of education and lower income were associated with seeking care from such providers. The median duration between onset of symptom to confirmation of diagnosis was 121 days, between confirmation of diagnosis and initiation of treatment was 22 days, and between onset of symptom and initiation of treatment was 151 days. Pre-diagnosis durations were longer for those who had sought initial care from an informal provider (p<0.05). Time to first contact with a health provider was shorter in this study compared to other developed and developing countries but utilizing informal healthcare providers caused delays in diagnosis and initiation of treatment. Encouraging people to seek care from a formal healthcare provider may reduce the overall duration of the care seeking pathway.


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110. Engaging surgeons among clinician-scientists

South African Medical Journal


Authors: Ncedile Mankahla, T E Madiba, A G Fieggen
Region / country: Southern Africa – South Africa
Speciality: Health policy

Since completion of the Human Genome Project at the turn of the century, there have been significant advances in genomic technologies together with genomics research. At the same time, the gap between biomedical discovery and clinical application has narrowed through translational medicine, so establishing the era of personalised medicine. In bridging these two disciplines, the clinician-scientist has become an integral part of modern practice. Surgeons and surgical diseases have been less represented than physicians and medical conditions among clinician-scientists and research. Here, we explore the possible reasons for this and propose strategies for moving forward. Discovery-driven personalised medicine is both the present and the future of clinical patient care worldwide, and South Africa is uniquely placed to build capacity for biomedical discovery in Africa. Diverse engagement across clinical disciplines, including surgery, is necessary in order to integrate modern medicine into a developing-world contextualised perspective.


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111. Functional assessment of long bone fracture healing in Samburu County Referral Hospital (Kenya): the squat and smile challenge

OTA international


Authors: Sciuto Daniele, Marzorati Mauro, Shearer David W., Lanfranconi Francesca
Region / country: Eastern Africa – Kenya
Speciality: Trauma and orthopaedic surgery

Background:
The burden of musculoskeletal trauma is increasing in low- and middle-income countries. Due to the low clinical follow-up rates in these regions, the Squat-and-Smile test (S&S) has previously been proposed as a proxy to assess bone healing (BH) capacity after surgery involving bone fractures. This study deals with various aspects of using S&S and bone radiography examination to obtain information about an individual’s ability to recover after a trauma. In summary, we performed the S&S test to assess the possibility of recovering biomechanical function in lower limbs in a remote area of Kenya (Samburu County).

Methods:
Eighty-nine patients (17.9% F; 31.7 ± 18.9 yrs) who underwent intramedullary nail treatment for femur or tibia fractures were enrolled in this study. Both S&S [evaluated by a goal attainment scale (GAS)] and x-ray (evaluated by REBORNE, Bone Healing Score) were performed at 6 and 24 weeks, postoperatively. An acceptable margin for satisfactory S&S GAS scores was determined by assessing its validity, reliability, and sensitivity.

Results:
S&S GAS scores increased over time: 80.2% of patients performed a satisfactory S&S at the 24-weeks follow-up with a complete BH. A high correlation between S&S GAS and REBORNE at the 6- and 24- weeks’ timepoint was found. Facial expression correlated partially with BH. The S&S proved to be accurate at correctly depicting the BH process (75% area fell under the Receiver Operator Curve).

Conclusion:
The S&S provides a possible substitution for bone x-ray during BH assessment. The potential to remotely follow up the BH is certainly appealing in low- and middle-income countries, but also in high-income countries; as was recently observed with the Covid-19 pandemic when access to a hospital is not conceivable.


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112. Effective interventions in road traffic accidents among the young and novice drivers of low and middle-income countries: A scoping review

Clinical Epidemiology and Global Health


Authors: Gyan Gifty, Sabah Mohd Zubair, Amudha Poobalan, Kumar Sumitd
Region / country: Global
Speciality: Health policy, Trauma surgery

Problem considered
Road traffic accident (RTA) is the ninth leading cause of global mortality and are also contributes mortality rates among young adults aged 15–29 years. This paper aims to conduct a comprehensive review to provide evidence of effective interventions of RTA prevention among young adults.

Methods
Three databases, MEDLINE, Embase, and PsychINFO, were searched. Eligible articles were practical behavioural and technological interventions directly affecting young drivers. The quality assessment used critical appraisal tools from the Joanna Briggs Institute (JBI). A narrative approach was used to analyze data of the 1107 articles identified, 17 articles met the inclusion criteria. Six studies used a driving simulator; five studies were educational training interventions; one used an incentive and in-car GPS, and one video-based training. One intervention used a vehicle warning system. A motorcycle simulator intervention and two-hybrid interventions, a pc-training and field training, and a driving simulator and vehicle training were also identified.

Result
The Green Light for Life, a training program, was emphasized as it was a simple intervention, using parent influences to improve injury crash rates by 12.7% p < 0.001. Furthermore, RAPT, a driving simulator, improved gaze in the range of 52.1–70% p < 0.001, and HRT, a motorcycle simulator, showed 0.92, p < 0.001 proportion of hazard avoidance.

Conclusion
These interventions can provide important leads to be adapted and replicated in various settings globally, to improve RTA outcomes among young adults. Future research can adopt a qualitative approach to determine the willingness of use for these interventions and adherence to current interventions.


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113. Myths and Misconceptions of Traumatic Brain Injuries Among High School Learners and University Students in South Africa

Open UCT


Authors: Moodley Miranda
Region / country: Southern Africa – South Africa
Speciality: Neurosurgery, Trauma surgery

Traumatic Brain Injury (TBI) is a major cause of disability and death around the world with an annual worldwide prevalence rate ranging from 369 per 100 000 people (James et al., 2019). TBI is specifically more concerning in adolescents and young adults as rates of injuries acquired during this period are similar to adult rates, but with more far-reaching effects, especially in low and middle-income countries (Dewan et al., 2016). TBI has significant long-term effects (e.g., cognitive, behavioural, social) on adolescents and young adults, which are compounded in low and middle income countries (LMICs) like South Africa. However, myths and misconceptions regarding TBI and associated outcomes often cloud the understanding thereof and contribute to poor help-seeking behaviours post-TBI. Poor help-seeking behaviours post-TBI can impact TBI recovery and result in even worse impairments if appropriate help is not sought. This study aimed to describe and compare myths and misconceptions about head injuries or traumatic brain injuries (HI/TBI), including concussions, for high school learners (with/without HI/TBI) and university students (with/without HI/TBI). In terms of misconceptions, students (n=393) scored significantly higher on HI/TBI and concussion knowledge, compared to learners (n=80). Regression analyses showed that adolescence (learners) vs young adulthood (students) was a significant predictor of myths and misconceptions regarding TBI/HI; F (44, 369) = 3.32, p < .001; but not for concussion knowledge and attitudes; F (44, 369) = 1.10, p =.31 and F (44, 369) = .725, p =.904. Understanding what high school learners know and how this differs from university students' knowledge about TBI will help inform interventions tailored to adolescents and young adults – which is needed as they are a vulnerable population group.


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114. Protocol for a prospective cohort study of open tibia fractures in Malawi with a nested implementation of open fracture guidelines

Wellcome Open Research


Authors: Alexander Thomas Schade , Nohakhelha Nyamulani, Leonard Ngoe Banza, Andrew John Metcalfe, Andrew Leather , Jason J. Madan, David G. Lallloo, Williams James Harrison, Peter MacPherson
Region / country: Eastern Africa, Southern Africa – Malawi
Speciality: Trauma and orthopaedic surgery

Background: Road traffic injury (RTI) is the largest cause of death amongst 15–39-year-old people worldwide, and the burden of injuries such as open tibia fractures are rapidly increasing in Malawi. This study aims to investigate disability and economic outcomes of people with open tibia fractures in Malawi and improve these with locally delivered implementation of open fracture guidelines.
Methods: This is a prospective cohort study describing function, quality of life and economic burden of open tibia fractures in Malawi. In total, 160 participants will be recruited across six centres and will be followed-up with face-to-face interviews at six weeks, three months, six months and one year following injury. The primary outcome will be function at one year measured by the short musculoskeletal functional assessment (SMFA) score. Secondary outcomes will include quality of life measured by EuroQol EQ-5D-3L, catastrophic loss of income and implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability) at one year. A nested pilot pre-post implementation study of an interventional bundle for all open fractures will be developed based on other implementation studies from low- and middle-income countries (LMICs). Regression analysis will be used to model and investigate associations between SMFA score and fracture severity, infection and the pre- and post-training course period.
Outcome: This prospective cohort study will report patient reported outcomes from open tibia fractures in low-resource settings. Subsequent detailed evaluation of both the clinical and implementation components of the study will promote sustainability of improved open fractures management in the study sites and further scale-up of open fracture management guidelines.
Ethics: Ethics approval has been obtained from the Liverpool School of Tropical Medicine and College of Medicine Research and Ethics committee.


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115. Mixed Methods Evaluation of Simulation-Based Training for Postpartum Hemorrhage Management in Guatemala

BMC Pregnancy and Childbirth


Authors: Pooja S. Parameshwar, Katherine Bianco, Elizabeth B. Sherwin, Pamela K. Meza, Alisha Tolani, Paige Bates, Lillian Sie, Andrea Sofía López Enríquez, Diana E. Sanchez, Edgar R. Herrarte, Kay Daniels
Region / country: Central America – Guatemala
Speciality: Obstetrics and Gynaecology, Surgical Education

Background
To assess if simulation-based training (SBT) of B-lynch suture and uterine balloon tamponade (UBT) for the management of postpartum hemorrhage (PPH) impacted provider attitudes, practice patterns, and patient management in Guatemala, using a mixed-methods approach.

Methods
We conducted an in-country SBT course on the management of PPH in a governmental teaching hospital in Guatemala City, Guatemala. Participants were OB/GYN providers (n = 39) who had or had not received SBT before. Surveys and qualitative interviews evaluated provider knowledge and experiences with B-lynch and UBT to treat PPH. In addition, a retrospective chart review was performed to evaluate management of PPH over a 2-year period before and after the introduction of SBT.

Results
Multiple-choice surveys indicated that providers who received SBT were more comfortable performing and teaching B-lynch compared to those who did not (p = 0.003 and 0.005). Qualitative interviews revealed increased provider comfort with B-lynch compared to UBT and identified multiple barriers to uterine balloon tamponade implementation. Chart review demonstrated an increased use of UBT after the introduction of simulation-based training, though not statistically significant (p = 0.06) in contrast to no change in B-lynch use.

Conclusions
Simulation-based training had a stronger impact on provider comfort with B-lynch compared to uterine balloon tamponade. Qualitative interviews provided insight into the challenges that hinder uptake of uterine balloon tamponade, namely resource limitations and decision-making hierarchies. Capturing data through a mixed-methods approach allowed for more comprehensive program evaluation in low and middle income countries (LMICs).


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116. Context Specific Realities and Experiences of Nurses and Midwives in Basic Emergency Obstetric and Newborn Care Services in Two District Hospitals in Rwanda

BMC Nursing


Authors: Aurore Nishimwe, Daphney Nozizwe Conco, Marc Nyssen, Latifat Ibisomi
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Emergency surgery, Obstetrics and Gynaecology

Background
In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into the experiences of these healthcare workers in managing obstetric care emergencies are critical for improving quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. This is a qualitative part of a broader research about implementation of an mLearning and mHealth decision support tool (Safe Delivery Application), in basic emergency obstetric and newborn care services in Rwanda.

Methods
In this exploratory qualitative aspect of the research, the first author facilitated four focus group discussions with 26 nurses and midwives from two district hospitals in Rwanda. Each focus group discussion was made up of two parts. The first part focused on the participants’ reflections on the research results, while the second part explored their experiences of delivering obstetric care services in their respective district hospitals. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis.

Results
Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants’ narratives of lived experiences of providing BEmONC services are presented under two broad themes: (1) self-reflections on their current practices and (2) contextual factors influencing the delivery of BEmONC services.

Conclusion
The insights of nurses and midwives regarding the management of birth related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on their management of PPH and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health particularly in low and middle income countries.


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117. The role of cardiac rehabilitation in improving cardiovascular outcomes

Nature Reviews Cardiology


Authors: Rod S. Taylor, Hasnain M. Dalal & Sinéad T. J. McDonagh
Region / country: Global
Speciality: Cardiothoracic surgery

Cardiac rehabilitation is a complex intervention that seeks to improve the functional capacity, wellbeing and health-related quality of life of patients with heart disease. A substantive evidence base supports cardiac rehabilitation as a clinically effective and cost-effective intervention for patients with acute coronary syndrome or heart failure with reduced ejection fraction and after coronary revascularization. In this Review, we discuss the major contemporary challenges that face cardiac rehabilitation. Despite the strong recommendation in current clinical guidelines for the referral of these patient groups, global access to cardiac rehabilitation remains poor. The COVID-19 pandemic has contributed to a further reduction in access to cardiac rehabilitation. An increasing body of evidence supports home-based and technology-based models of cardiac rehabilitation as alternatives or adjuncts to traditional centre-based programmes, especially in low-income and middle-income countries, in which cardiac rehabilitation services are scarce, and scalable and affordable models are much needed. Future approaches to the delivery of cardiac rehabilitation need to align with the growing multimorbidity of an ageing population and cater to the needs of the increasing numbers of patients with cardiac disease who present with two or more chronic diseases. Future research priorities include strengthening the evidence base for cardiac rehabilitation in other indications, including heart failure with preserved ejection fraction, atrial fibrillation and congenital heart disease and after valve surgery or heart transplantation, and evaluation of the implementation of sustainable and affordable models of delivery that can improve access to cardiac rehabilitation in all income settings.


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118. Mobile Surgical Scouts Increase Surgical Access for Patients with Cleft Lip and Palate in Nepal

Facial Plastic Surgery & Aesthetic Medicine


Authors: David A. Shaye, Kiran Kishor Nakarmi, Pramila Shakya, Leeza Pradhan, Kabita Bhattarai, Badri Rayamajhi, Hemanta Dhoj Joshi, Courtney M. Yuen, Kailash Khaki Shrestha, and Shankar Man Rai
Region / country: Southern Asia – Nepal
Speciality: Health policy, Maxillofacial and oral surgery, Paediatric surgery, Plastic surgery

Background: In Nepal’s remote regions, challenging topography prevents patients with cleft lip and palate (CLP) from seeking care.

Objective: To measure the effect of a mobile surgical scout program on CLP surgical care in remote regions of Nepal.

Methods: Forty-four lay people were trained as mobile surgical scouts and over 5 months traversed remote districts of Nepal on foot to detect and refer CLP patients for surgical care. Surgical patients from remote districts were compared with matched time periods in the year before intervention. Diagnostic accuracy of the surgical scouts was assessed.

Findings: Mobile surgical scouts accurately diagnosed (90%) and referred (82%) patients for cleft surgery. Before the intervention, CLP surgeries from remote districts represented 3.5% of cleft surgeries performed. With mobile surgical scouting, patients from remote districts comprised 8.2% of all cleft surgeries (p = 0.007). When transportation and accompaniment was provided in addition to mobile surgical scouts, patients from remote districts represented 13.5% (p ≤ 0.001) of all cleft surgeries.

Conclusion: Task-shifting the surgical screening process to trained scouts resulted in accurate diagnoses, referrals, and increased access to cleft surgery in remote districts of Nepal


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119. Unmet Surgical Need in Malawi

Bergen Open Research Archive


Authors: Varela, Carlos Gomes
Region / country: Eastern Africa, Southern Africa – Malawi
Speciality: Health policy

Introduction
Globally, and especially in sub-Saharan Africa, including Malawi, surgical conditions receive a low level of priority in national health systems. The burden of surgical diseases is not well documented and the reasons for which people still live with treatable conditions and disabilities or sometimes present late for care have also not been studied. There is also little information on surgical deaths from untreated conditions in both adults and children, including trauma, as well as potential barriers to obtaining surgical care.
Objectives
The aim of this thesis was therefore to describe the untreated surgical conditions, in both adults and children, the barriers to surgical health care, as well as to document information about deaths from surgical conditions in Malawi.
Methods
This thesis is based on four papers. All four involved data collected using the SOSAS tool, which is a questionnaire-based data collection tool for documenting household information in the communities. The tool had three sections, the first section capturing demographic data for the households; including number of occupants, ages, gender, location and type of household, and tribe. The next two sections were similar but involved interviewing two different people and asking about information relating to surgical conditions present for both adults and paediatric age groups, including injuries, associated disability from acquired or congenital disorders, transportation to health facility and location of death from different surgical conditions. The two household members interviewed, included the head of household and another random member within the household. Data collection was centrally organized by a project group, and performed by third year medical students from the University of Malawi, College of Medicine.
Data was collected as a national survey from the 28 districts in Malawi. The National Statistics Board helped us to identify the villages used in the study.
Results
We found that a third of the Malawian population were living with a surgical condition and were in need of a surgical consultation or treatment. These conditions were either congenital or the result of a traumatic or other non-traumatic condition. We also found that almost one fifth of the children with a surgical condition that could have been treated by surgery, instead remained with a disability that affected their daily lives.
In addition, we found that transportation poses a barrier to timely access to surgical health care. Transportation barriers included the lack of efficient public transportation, cost implications, and long travel distances to get to a health facility capable of offering care by either consultation or surgical procedures.
Other findings were that acute abdominal distention, body masses and trauma, contribute to surgical conditions that are highly associated with mortality in Malawian communities. We also noted that there are various reasons that lead to delays in obtaining formal health care, including initial consultations with traditional herbalists before going to the hospital.
Conclusion
Almost 6 million Malawian people, including an estimated 2 million children, are living with a condition that could be treated by either a surgical procedure or consultation. There are an estimated 1 million disabled children currently living with such surgically treatable conditions. The treatment of these conditions is hampered by transportation barriers. The transportation barriers have led to delays in obtaining timely surgical health care service, something that often leads to mortality. The common causes of these deaths are from injuries, but also other surgical emergencies. Most of these deaths occur outside a health facility environment.


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120. Effects of free maternal policies on quality and cost of care and outcomes: an integrative review

Primary Health Care Research & Development


Authors: Boniface Oyugi , Sally Kendall , Stephen Peckham
Region / country: Global
Speciality: Health policy, Obstetrics and Gynaecology

Aim:
We conducted an integrative review of the global-free maternity (FM) policies and evaluated the quality of care (QoC) and cost and cost implications to provide lessons for universal health coverage (UHC).

Methodology:
Using integrative review methods proposed by Whittemore and Knafl (2005), we searched through EBSCO Host, ArticleFirst, Cochrane Central Registry of Controlled Trials, Emerald Insight, JSTOR, PubMed, Springer Link, Electronic collections online, and Google Scholar databases guided by the preferred reporting item for systematic review and meta-analysis protocol (PRISMA) guideline. Only empirical studies that described FM policies with components of quality and cost were included. There were 43 papers included, and the data were analysed thematically.

Results:
Forty-three studies that met the criteria were all from developing countries and had implemented different approaches of FM policy. Review findings demonstrated that some of the quality issues hindering the policies were poor management of complications, worsened referral systems, overburdening of staff because of increased utilisation, lack of transport, and low supply of stock. There were some quality improvements on monitoring vital signs by nurses and some procedures met the recommended standards. Equally, mothers still bear the burden of some costs such as the purchase of drugs, transport, informal payments despite policies being ‘free’.

Conclusions:
FM policies can reduce the financial burden on the households if well implemented and sustainably funded. Besides, they may also contribute to a decline in inequity between the rich and poor though not independently. In order to achieve the SDG goal of UHC by 2030, there is a need to promote awareness of the policy to the poor and disadvantaged women in rural areas to help narrow the inequality gap on utilisation and provide a sustainable form of transport through collaboration with partners to help reduce impoverishment of households. Also, there is a need to address elements such as cultural barriers and the role of traditional birth attendants which hinder women from seeking skilled care even when they are freely available


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121. Cervical Spine Trauma in East Africa: Presentation, Treatment, and Mortality

International Journal of Spine Surgery


Authors: Scott L. Zuckerman, Arsalan Haghdel, Noah L. Lessing, Joseph Carnevale, Beverly Cheserem, Albert Lazaro, Andreas Leidinger, Nicephorus Rutabasibwa, Hamisi K. Shabani, Halinder Mangat and Roger Härtl
Region / country: Eastern Africa – Tanzania
Speciality: Neurosurgery, Trauma and orthopaedic surgery, Trauma surgery

Background Cervical spine trauma (CST) leads to devastating neurologic injuries. In a cohort of CST patients from a major East Africa referral center, we sought to (a) describe presentation and operative treatment patterns, (b) report predictors of neurologic improvement, and (c) assess predictors of mortality.

Methods A retrospective, cohort study of CST patients presenting to a tertiary hospital in Dar Es Salaam, Tanzania, was performed. Demographic, injury, and operative data were collected. Neurologic exam on admission/discharge and in-hospital mortality were recorded. Univariate/multivariate logistic regression assessed predictors of operative treatment, neurologic improvement, and mortality.

Results Of 101 patients with CST, 25 (24.8%) were treated operatively on a median postadmission day 16.0 (7.0–25.0). Twenty-six patients (25.7%) died, with 3 (12.0%) in the operative cohort and 23 (30.3%) in the nonoperative cohort. The most common fracture pattern was bilateral facet dislocation (26.7%). Posterior cervical laminectomy and fusion and anterior cervical corpectomy were the 2 most common procedures. Undergoing surgery was associated with an injury at the C4–C7 region versus occiput–C3 region (odds ratio [OR] 6.36, 95% confidence interval [CI] 1.71–32.28, P = .011) and an incomplete injury (OR 3.64; 95% CI 1.19–12.25; P = .029). Twelve patients (15.8%) improved neurologically, out of the 76 total patients with a recorded discharge exam. Having a complete injury was associated with increased odds of mortality (OR 11.75, 95% CI 3.29–54.72, P < .001), and longer time from injury to admission was associated with decreased odds of mortality (OR 0.66, 95% CI 0.48–0.85, P = .006).

Conclusions Those most likely to undergo surgery had C4–C7 injuries and incomplete spinal cord injuries. The odds of mortality increased with complete spinal cord injuries and shorter time from injury to admission, probably due to more severely injured patients dying early within 24–48 hours of injury. Thus, patients living long enough to present to the hospital may represent a self-selecting population of more stable patients. These results underscore the severity and uniqueness of CST in a less-resourced setting.


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122. The practices of aseptic technique of perioperative nurses in operation room to prevent surgical site infection : integrative literature review

theseus


Authors: Phan Thi My Dung, Nguyen Ngoc Minh Thu
Region / country: Global
Speciality: General surgery, Health policy

Surgical site infections are the most common preventable health care-associated infections. However, the complications of SSIs are associated with additional inpatient stay costs, morbidity, and mortality. Perioperative nurses must be well-educated and well-trained to perform aseptic technique for preventing SSIs as well as facilitating safe surgical procedures for patients. Aseptic technique practices involve the performance of hand hygiene, donning gloves, applying surgical attire, preoperative aseptic skin preparation, aseptic instrument preparation, and aseptic environment maintenance.

The thesis aims to explore which elements are related to the perioperative nurses’ practices in aseptic technique in operation room, regarding the prevention of SSIs and how these practices affect to the outcomes of SSIs.

The purpose of this thesis is to promote understanding and awareness of aseptic technique in operation room, which contributes to SSI prevention. Particularly, the study is beneficial for senior nursing students and graduated nurses as a holistic picture of aseptic technique for further specific research related to this topic.

A combination of qualitative and quantitative methods was executed in this literature review. The data search and collection processes are mainly from electronic databases as EBSCO, SAGE, and PubMed in association with the consideration of inclusion and exclusion criteria. The year publication was from 2010 to 2020 in order to meet the requirement of timely and update knowledge provision. Inductive content analysis was conducted to analyse collected data and generate appropriate categories relevant to research questions.

Regard of SSI prevention, double set of sterile gloves is recommended in clinical practice to decrease the possibility of inner gloving perforation and bacterial transmission inside out. Surgical hand rubbing with alcohol-based disinfection solution is more preferred than traditional scrubbing. Despite insufficient evidence, surgical attire, including gown, surgical headgear, and SMs is routinely recommended in clinical practice compliance. If necessary, hair removal with clippers is preferable than razors. Shoe covers, a back-and-forth technique in skin preparation, adhesive surgical drapes were supported by a very low level of evidence. Meanwhile, staff movements, door openings, temperature, and airflow have been suggested to affect the integrity of the sterile field by a moderate amount of evidence. A minor point was also pointed out that 30-47% of entries and exits from the OR are unnecessary.


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123. Harvard Medical School Department of Global Health and Social Medicine COVID-19 seminar series: COVID and surgical, anesthetic and obstetric care

BMC Proceedings


Authors: Elizabeth Miranda, John G. Meara, Alaska Pendleton, Alexander W. Peters, Vatshalan Santhirapala, Nabeel Ashraf, Nivaldo Alonso, Sadoscar Hakizimana, Abebe Bekele, Kee B. Park & Paul Farmer
Region / country: Global
Speciality: Anaesthesia, General surgery, Health policy, Obstetrics and Gynaecology

On May 21, 2020, the Harvard Program in Global Surgery and Social Change (PGSSC) hosted a webinar as part of the Harvard Medical School Department of Global Health and Social Medicine’s COVID-19 webinar series. The goal of PGSSC’s virtual webinar was to share the experiences of surgical, anesthesia, and obstetric (SAO) providers on the frontlines of the COVID pandemic, from both high-income countries (HICs), such as the United States and the United Kingdom, as well as low- and middle-income countries (LMICs). Providers shared not only their experiences delivering SAO care during this global pandemic, but also solutions and innovations they and their colleagues developed to address these new challenges. Additionally, the seminar explored the relationship between surgery and health system strengthening and pandemic preparedness, and outlined the way forward, including a roadmap for prioritization and investment in surgical system strengthening. Throughout the discussion, other themes emerged as well, such as the definition of elective surgery and its implications during a persistent global pandemic, the safe and ethical reintroduction of surgical services, and the social inequities exposed by the stress placed on health systems by COVID-19. These proceedings document the perspectives shared by participants through their invited lectures as well as through the panel discussion at the end of the seminar.


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124. A longitudinal surgical systems strengthening research program for medical students: the exploration of a model for global health education

Global Health Research and Policy


Authors: Gregory L. Peck, Joseph S. Hanna, Erin M. Scott, Dhaval Mehta, Zina Model, Deesha Sarma, Elizabeth E. Ginalis, Zachary Berlant, Fernando Ferrera, Javier Escobar, Carlos A. Ordoñez, Carlos Morales & Vicente H. Gracias
Region / country: Northern America, South America – Colombia, United States of America
Speciality: Health policy, Surgical Education

Background
In response to the staggering global burden of conditions requiring emergency and essential surgery, the development of international surgical system strengthening (SSS) is fundamental to achieving universal, timely, quality, and affordable surgical care. Opportunity exists in identifying optimal collaborative processes that both promote global surgery research and SSS, and include medical students. This study explores an education model to engage students in academic global surgery and SSS via institutional support for longitudinal research.

Objectives
We set out to design a program to align global health education and longitudinal health systems research by creating an education model to engage medical students in academic global surgery and SSS.

Program design and implementation
In 2015, medical schools in the United States and Colombia initiated a collaborative partnership for academic global surgery research and SSS. This included development of two longitudinal academic tracks in global health medical education and academic global surgery, which we differentiated by level of institutional resourcing. Herein is a retrospective evaluation of the first two years of this program by using commonly recognized academic output metrics.

Main achievements
In the first two years of the program, there were 76 total applicants to the two longitudinal tracks. Six of the 16 (37.5%) accepted students selected global surgery faculty as mentors (Acute Care Surgery faculty participating in SSS with Colombia). These global surgery students subsequently spent 24 total working weeks abroad over the two-year period participating in culminating research experiences in SSS. As a quantitative measure of the program’s success, the students collectively produced a total of twenty scholarly pieces in the form of accepted posters, abstracts, podium presentations, and manuscripts in partnership with Colombian research mentors.

Policy implications
The establishment of scholarly global health education and research tracks has afforded our medical students an active role in international SSS through participation in academic global surgery research. We propose that these complementary programs can serve as a model for disseminated education and training of the future global systems-aware surgeon workforce with bidirectional growth in south and north regions with traditionally under-resourced SSS training programs.


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125. Evaluation of Surgical Glove Integrity: Does an African Country Receive Inferior Quality?

Ethiopian Medical Journal


Authors: Abebe Bekele, Mesikir Abate , Nardos Mekonnen, Barnabas Alayande , Dieudonne Hakizimana , Mulat Taye, Daniel Zemenfes
Region / country: Eastern Africa – Ethiopia
Speciality: Health policy

In a 2017 study, the incidence of glove perforation in Addis Ababa was found higher than most other publications. This poses a significant threat to both patients and the surgical workforce. We hypothesized that poor surgical glove quality may have contributed to the high incidence. Hence, we tested the integrity of six brands of sterile gloves. The assumption was the perforation rate in these gloves would be higher than the standard acceptable quality level (AQL).

From the 1,200 single gloves evaluated, 59 (4.9%) gloves had perforations. Brand 1 (13.5%) and Brand 5 (10%) had the highest rate of perforations, followed by Brand 3 (3.0%) Brand 6 (2.0%), Brand 2 (1.0%) and Brand 4, which had 0 perforations. Compared to the standard AQL 1.5 for surgical gloves at the time of the study, Brand 1 and Brand 5 had a significantly higher perforation rate (13.5%, CI=8.8%-18.2%, p=0.000) and (10.0%, CI=5.8%-14.2%, p=0.000), respectively.

Our study results showed unacceptably high rates of perforation for 2 glove brands. The implications of this are staggering for surgical staff. In Ethiopia, choice of surgical glove brand may be a determinant of surgical safety.

In view of our findings of a large proportion of glove perforations prior to use, we recommend, at minimum, that surgeons visually inspect gloves before and after donning. Relevant government institutions, contractors, importers, hospital administrators, and surgical teams must take collective responsibility for ensuring appropriate quality of gloves. Quality enforcement must be strengthened, and local production must be considered.


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126. An analysis of paediatric snakebites in north-eastern South Africa

South African Journal of Surgery


Authors: Johan Buitendag,S Variawa, D Wood, G Oosthuizen
Region / country: Southern Africa – South Africa
Speciality: Paediatric surgery

Background: Snakebites are an underappreciated health concern in middle- and lower-income countries. The lack of national data vastly impacts funding for this health crisis, as well as strategies for treatment and prevention. Children are particularly vulnerable to snakebite and data in this group is limited.
Methods: This study included paediatric patients, aged 13 years old or younger, admitted to Ngwelezana Tertiary Hospital, Department of Surgery with a snakebite or snakebite related complication, from 1 September 2008 to 31 December 2013. Data captured included demographics, time of presentation, syndromic symptoms, blood results and patient management.
Results: A total of 274 patients were included in this study. The median age at presentation was 8 years, with approximately 70% of the patients aged between 6 and 13 years, with a male predominance (56%). The median time of presentation after sustaining a snakebite was 7 hours (interquartile range 4–13 hours). The majority of patients (71%) presented with cytotoxic manifestations. A total of 53 patients received antivenom of whom 25% suffered adverse reactions. Fifty-six patients underwent one or more procedures on their affected limbs. Three patients required admission to the intensive care unit; all were part of the cytotoxic group and received antivenom. There were no recorded mortalities.
Conclusion: The majority of snakebites are cytotoxic in nature. One-fifth of the paediatric population require antivenom and one-fifth require a surgical procedure post envenomation. Adverse effects post antivenom use are common but manageable. Prevention programmes are needed to help reduce this burden of disease and a nationwide snakebite registry is long overdue


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127. Misconceptions About Traumatic Brain Injuries in Five Sub-Saharan African Countries

cureus


Authors: Oloruntoba Ogunfolaji, Chinedu Egu, Lorraine Sebopelo, Dawin Sichimba, Yvan Zolo, Crecencia Mashauri, Emmanuel Phiri, Neontle Sakaiwa, Andrew Alalade, Ulrick Sidney Kanmounye
Region / country: Eastern Africa, Southern Africa, Western Africa – Botswana, Cameroon, Nigeria, Tanzania, Uganda
Speciality: Neurosurgery, Trauma surgery

Background
Traumatic Brain Injury (TBI) remains a significant problem in certain regions of the world but receives little attention despite its enormous burden. This discrepancy could consequently lead to various misconceptions among the general public. This study evaluated misconceptions about TBI in five African countries.

Methods
Data for this cross-sectional study were collected using the Common Misconception about Traumatic Brain Injury (CM-TBI) questionnaire, which was electronically disseminated from January 16 to February 6, 2021. Associations between the percentage of correct answers and independent variables (i.e., sociodemographic characteristics and experience with TBI) were evaluated with the ANOVA test. Additionally, answers to the question items were compared against independent variables using the Chi-Square test. A P-value <0.05 was considered statistically significant.

Results
A total of 817 adults, 50.2% female (n=410), aged 24.3 ± 4.3 years, and majoritarily urban dwellers (94.6%, n=773) responded to the survey. They had received tertiary education (79.2%, n=647) and were from Nigeria (77.7%, n=635). Respondents had few misconceptions (mean correct answers=71.7%, 95% CI=71.0-72.4%) and the amnesia domain had the highest level of misconception (39.3%, 95% CI=37.7-40.8%). Surveyees whose friends had TBI were more knowledgeable about TBI (mean score difference=4.1%, 95% CI=1.2-6.9, P=0.01). Additionally, surveyees whose family members had experienced TBI had a better understanding of brain damage (mean score difference=5.7%, 95% CI=2.1-9.2%, P=0.002) and recovery (mean score difference=4.3%, 95% CI=0.40-8.2%, P=0.03).

Conclusion
This study identified some misconceptions about TBI among young adult Africans. This at-risk population should benefit from targeted education strategies to prevent TBI and reduce TBI patients' stigmatization in Africa.


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128. An Ethnographic Study of Nursing on a Surgery Ship Providing Humanitarian Care

UTS Digital Thesis Collection


Authors: Dawson Sonja Ann
Region / country: Global
Speciality: Emergency surgery, Health policy

Less than half the world’s population has access to essential health services (United Nations, 2020), the majority of whom live in low to middle-income countries (LMICs; Meara et al., 2015). The inability to access health services denies people a life of dignity. To bridge this current gap in the provision of health care, nongovernmental organisations are responding by deploying specialist, short term healthcare teams (Ng-Kamstra et al., 2016). Nurses, as the largest group of health professionals, provide care within those teams. Substantial literature is linked to nurses deployed in a disaster response situation, However, there is limited research into nurses’ roles within teams meeting a humanitarian response outside that urgent disaster context, and what their contribution brings. The purpose of this ethnographic study was to explore nursing involvement within humanitarian healthcare provision to generate insight into the area of humanitarian nursing in an acute, short term, nondisaster context and to extend the research literature surrounding this topic. The study was framed within the context of a faith-based nongovernmental organisation delivering specialist surgery on a civilian hospital ship. The aim was to advance the mission and purpose of humanitarian (nondisaster) nursing, providing a detailed description of the culture of nursing care in that setting. An interpretivist standpoint, influenced by a social constructivist theoretical position, was taken. Data were collected over 6 months, using participant observation, a reflection of artefacts, and the collective voice of volunteer nurses. Thematic analysis was conducted considering Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Findings elucidated nursing within the context of a community of nursing practice (CoNP), revealing four major themes: (1) “What drew us here?” (expressions of motivation), (2) “Who we are and how we do what we do” (expressions of engagement), (3) challenges (embracing change), and (4) development (expressions of transformation). This study contributes new knowledge by describing the culture of nursing and how nurses enact their care in a previously undescribed humanitarian context. Based on the analysis of findings, a professional practice model (PPM) named HHEALED was proposed. An in-depth application of the model was made to the specific organisational context framing the study. Recommendations arising from this study address nurses’ social and professional roles within humanitarian care that could further validate and strengthen policies and programs for the delivery of humanitarian health care for a mobile platform providing specialist surgical care.


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129. Understanding patient health-seeking behaviour to optimise the uptake of cataract surgery in rural Kenya, Zambia and Uganda: findings from a multisite qualitative study

International Health


Authors: Stevens Bechange, Emma Jolley, Patrick Tobi, Eunice Mailu, Juliet Sentongo, Titamenji Chulu, Maurice Abony, Moses Chege, Glenda Mulenga, Johnson Ngorok, Tesfaye Adera, Elena Schmidt
Region / country: Eastern Africa, Southern Africa – Kenya, Uganda, Zambia
Speciality: Health policy, Ophthalmology

Background
Cataract is a major cause of visual impairment globally, affecting 15.2 million people who are blind, and another 78.8 million who have moderate or severe visual impairment. This study was designed to explore factors that influence the uptake of surgery offered to patients with operable cataract in a free-of-charge, community-based eye health programme.

Methods
Focus group discussions and in-depth interviews were conducted with patients and healthcare providers in rural Zambia, Kenya and Uganda during 2018–2019. We identified participants using purposive sampling. Thematic analysis was conducted using a combination of an inductive and deductive team-based approach.

Results
Participants consisted of 131 healthcare providers and 294 patients. Two-thirds of patients had been operated on for cataract. Two major themes emerged: (1) surgery enablers, including a desire to regain control of their lives, the positive testimonies of others, family support, as well as free surgery, medication and food; and (2) barriers to surgery, including cultural and social factors, as well as the inadequacies of the healthcare delivery system.

Conclusions
Cultural, social and health system realities impact decisions made by patients about cataract surgery uptake. This study highlights the importance of demand segmentation and improving the quality of services, based on patients’ expectations and needs, as strategies for increasing cataract surgery uptake.


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130. We Asked the Experts: The Promises and Challenges of Surgical Telehealth in Low Resourced Settings

World Journal of Surgery


Authors: Phoebe Miller, Eyitayo Owolabi , Kathryn Chu
Region / country: Global
Speciality: Digital health

Access to safe and timely surgical care saves lives, but its multiple barriers in low- and middle-income countries (LMICs) contribute to high postoperative mortality [1]. In these settings, surgical health systems are fragile due to a shortage of supplies such as drugs, anesthesia equipment and oxygen, the maldistribution of surgical specialists, poor referral systems, and an inability to routinely track processes and outcomes indicators for quality improvement. The ongoing Covid-19 pandemic has heightened barriers to surgical care in LMICs with resultant increases in unmet surgical needs. On the other hand, the pandemic has revealed the great potentials of telehealth.

Telehealth, which is the provision of healthcare-related services over a distance using electronic and telecommunication technologies, has created solutions to leapfrog certain barriers to surgical care in LMICs. Long distance travel to reach facilities and extended waiting times to see specialists can be circumvented by phone and online consultations. These virtual visits are not only cost saving but can prevent critical delays in patient care. Remote consultations can take on various forms. Firstly, initial visits and preoperative instructions can be done through telehealth platforms from the comfort of patient homes. In certain low acuity and elective cases, video visits may make it possible to determine the need for an operation or the need for in-person visitation to assist surgical planning. Additionally, mobile apps, direct phone calls, and instant messaging are suitable for preoperative education and assisting patients in navigating barriers to surgical access in addition to using video chat platforms. Likewise, mHealth apps and real-time video features allow for postoperative follow-up including routine wound inspection and utilize community health workers, nurses, or general medical doctors located closer to the patient than the hospital that provided the surgical care. The addition of artificial intelligence technology to mHealth could aid these cadres to identify wound infections. In Rwanda, machine learning is being harnessed to detect postoperative wound infections in rural women after Cesarean sections [2]. Finally, outreach by surgeons to rural areas can be strengthened by remote preoperative consultations to identify appropriate operative candidates, provide virtual spaces for planning with local teams, and conduct postoperative follow-up. Therefore, telehealth maximizes the impact of visiting specialists and improves the quality of patient care.

Poor communication and referral networks between health facilities are major barriers to timely and quality access to surgical care in LMICs. Telehealth allows doctors and nurses in rural and primary care facilities to communicate quickly with surgeons at regional and tertiary hospitals. The mHealth app, Vula Mobile, is used ubiquitously by South African rural doctors and nurses to refer persons with surgical conditions to specialists at higher level hospitals. A 2019 study showed that one-third of acute orthopedic conditions were managed on this platform through expert advice without the need for transfer [3]. The median response time on the app was less than 30 minutes. In addition, metadata from mHealth referral apps can be used to track volumes, referral times, and patient flow, which might be used for quality improvement efforts. This type of telehealth platform shows promise and might be scaled-up in other LMICs to better link networks of non-specialist health care providers and surgeons.

If higher bandwidth is available, real-time video platforms, which allow for in-depth consultations and case discussions, can be used to overcome specialist shortages in LMICs. Virtual multi-disciplinary conferences are being used in South–South and North–South collaborations. For example, the Global Cancer Institute has a network of over 500 doctors from Africa, Asia, and Latin America who present cancer cases for discussion with US oncology experts [4].

The limited case mix at some LMIC training hospitals and the shortage of surgical subspecialists can impede the acquisition of certain operative skills. Telesurgery, or intra-operative tele-mentoring, is where a senior surgeon located remotely can give immediate and continuous feedback to the operating surgeon. Early attempts at South–South telesurgery collaborations have shown good patient outcomes [5].

Another telehealth innovation for skills acquisition is simulation, or the use of models to imitate the steps of an operation. Simulators can be high-fidelity units with computer animation or low-fidelity models made from inexpensive materials like cardboard boxes and graspers to learn three-dimensional techniques such as laparoscopic suturing and knot tying. Simulation has been shown to be particularly useful during the Covid-19 pandemic to augment training since elective operative volume has decreased in almost every country worldwide…


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131. Application of the research electronic data capture (REDCap) system in a low- and middle income country– experiences, lessons, and challenges

Health and Technology


Authors: O. Odukoya, D. Nenrot, H. Adelabu, N. Katam, E. Christian, J. Holl, A. Okonkwo, M. Kocherginsky, K.-Y. Kim, S. Akanmu, F. B. Abdulkareem, R. Anorlu, J. Musa, O. Lesi, C. Hawkins, O. Okeke, W. L. Adeyemo, S. Sagay, R. Murphy, L. Hou, F. T. Ogunsola & F. H. Wehbe
Region / country: Northern America, Western Africa – Nigeria, United States of America
Speciality: Digital health, Health policy, Other

The challenges of reliably collecting, storing, organizing, and analyzing research data are critical in low- and middle-income countries (LMICs), particularly in Sub-Saharan Africa where several healthcare and biomedical research organizations have limited data infrastructure. The Research Electronic Data Capture (REDCap) System has been widely used by many institutions and hospitals in the USA for data collection, entry, and management and could help solve this problem. This study reports on the experiences, challenges, and lessons learned from establishing and applying REDCap for a large US-Nigeria research partnership that includes two sites in Nigeria, (the College of Medicine of the University of Lagos (CMUL) and Jos University Teaching Hospital (JUTH)) and Northwestern University (NU) in Chicago, Illinois in the United States. The largest challenges to this implementation were significant technical obstacles: the lack of REDCap-trained personnel, transient electrical power supply, and slow/ intermittent internet connectivity. However, asynchronous communication and on-site hands-on collaboration between the Nigerian sites and NU led to the successful installation and configuration of REDCap to meet the needs of the Nigerian sites. An example of one lesson learned is the use of Virtual Private Network (VPN) as a solution to poor internet connectivity at one of the sites, and its adoption is underway at the other. Virtual Private Servers (VPS) or shared online hosting were also evaluated and offer alternative solutions. Installing and using REDCap in LMIC institutions for research data management is feasible; however, planning for trained personnel and addressing electrical and internet infrastructural requirements are essential to optimize its use. Building this fundamental research capacity within LMICs across Africa could substantially enhance the potential for more cross-institutional and cross-country collaboration in future research endeavors.


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132. Ghanaian views of short-term medical missions: The pros, the cons, and the possibilities for improvement

Globalization and Health


Authors: Efua Esaaba Mantey, Daniel Doh, Judith N. Lasker, Sirry Alang, Peter Donkor & Myron Aldrink
Region / country: Western Africa – Ghana
Speciality: Health policy, Other

Background
Various governments in Ghana have tried to improve healthcare in the country. Despite these efforts, meeting health care needs is a growing concern to government and their citizens. Short term medical missions from other countries are one of the responses to meet the challenges of healthcare delivery in Ghana. This research aimed to understand Ghanaian perceptions of short-term missions from the narratives of host country staff involved. The study from which this paper is developed used a qualitative design, which combined a case study approach and political economy analysis involving in-depth interviews with 28 participants.

Result
Findings show short term medical mission programs in Ghana were largely undertaken in rural communities to address shortfalls in healthcare provision to these areas. The programs were often delivered free and were highly appreciated by communities and host institutions. While the contributions of STMM to health service provision have been noted, there were challenges associated with how they operated. The study found concerns over language and how volunteers effectively interacted with communities. Other identified challenges were the extent to which volunteers undermined local expertise, using fraudulent qualifications by some volunteers, and poor skills and lack of experience leading to wrong diagnoses sometimes. The study found a lack of awareness of rules requiring the registration of practitioners with national professional regulatory bodies, suggesting non enforcement of volunteers’ need for local certification.

Conclusion
Short Term Medical Missions appear to contribute to addressing some of the critical gaps in healthcare delivery. However, there is an urgent need to address the challenges of ineffective utilisation and lack of oversight of these programs to maximise their benefits


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133. Late Diagnosis of Breast Cancer and Associated Factors Among Women Attending Hawassa University Comprehensive and Specialized Hospital Southern Ethiopia

BMC Women’s Health


Authors: Mesay Yoseph, Achamyelesh Gebresadik, Akalewold Alemayehu
Region / country: Eastern Africa – Ethiopia
Speciality: Surgical oncology

Background; Breast cancer is a significant public health issue in sub-Saharan Africa and the second commonest cancer overall. In Ethiopia, most women present at the late-stage presentation. This is because Ethiopian government gives less attention, and is not well-studied as well. Therefore, it is important to assess delays in diagnosis and treating breast cancer that has been associated with a more advanced stage of the disease and a decrease in patient survival rates.

Objective: To assess the magnitude and associated factors for late diagnosis of breast cancer among women attending Hawassa University Comprehensive Specialized Hospital in Southern Ethiopia.

Methodology: A facility-based cross-sectional study was conducted from December to January 2019. Data were collected from 261 consecutively selected clients based on the arrival of their hospital visit by using a pretested structured questionnaire and checklist. Physicians performed physical examinations and diagnoses. Data was checked for completeness and consistency, and entered into epi data, then exported to SPSS for analysis. Descriptive, Bivariate, and multivariable logistic regression analyses were performed using SPSS Version 25 Statistical Software.

Results: The magnitude of late diagnosis of breast cancer was 86.3%. The woman who had no initial advice for breast biopsy [AOR=5.1, 95% (CI=1.4-18.9)], not sharing the problem to others [AOR=4.7, 95% (CI=1.8-12.2)] and using traditional and faith healers as a first treatment choice [AOR=3.3, 95% (CI=1.2 – 8.8)] were associated with late diagnosis of breast cancer.

Conclusions: The majority of women having breast cancer were diagnosed at a late stage. It needs attention to provide better options of the modern health service, and providing accessible initial advice for breast biopsy, and creating awareness about the benefit of sharing problems with family to improve the health of mothers by early diagnosing and managing the breast cancer.


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134. A minimum data set for traumatic brain injuries in Iran

Chinese Journal of Traumatology


Authors: Maryam Edalatfar, Mohsen Sadeghi-Naini, Hamid Reza Khayat Kashani, Mitra Movahed, Mahdi Sharif-Alhoseini
Region / country: Middle East – Iran
Speciality: Neurosurgery, Trauma surgery

Purpose
Traumatic brain injury (TBI) is one of the major public health concerns worldwide. Developing a TBI registry could facilitate characterizing TBI, monitoring the quality of care, and quantifying the burden of TBI by collecting comparable and standardized epidemiological and clinical data. However, a national standard tool for data collection of the TBI registry has not been developed in Iran yet. This study aimed to develop a national minimum data set (MDS) for a hospital-based registry of patients suffering from TBI in Iran.

Methods
The MDS was designed in two phases, including a literature review and a Delphi study with content validation by an expert panel. After the literature review, a comprehensive list of administrative and clinical items was obtained. Through a two-round e-Delphi approach conducted by invited experts with clinical and research experience in the field of TBI, the final data elements were selected.

Results
An MDS of TBI was assigned to two parts: administrative part with five categories including 52 data elements, and clinical part with nine categories including 130 data elements.

Conclusion
For the first time in Iran, we developed an MDS specified for TBI consisting of 182 data elements. The MDS would facilitate implementing a TBI’s national level registry and providing essential, comparable, and standardized information.


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135. Acute kidney injury among medical and surgical in-patients in the Cape Coast Teaching Hospital, Cape Coast, Ghana: a prospective cross-sectional study

African Health Sciences


Authors: Richard KD Ephraim, Yaw A Awuku, Ignatious Tetteh-Ameh, Charles Baffe, Godsway Aglagoh, Victor A Ogunajo, Kizito Owusu-Ansah, Prince Adoba, Samuel Kumordzi, Joshua Quarshie
Region / country: Western Africa – Ghana
Speciality: Critical care

Background: Acute kidney injury (AKI) is a syndrome associated with high morbidity, mortality and high hospital costs. Despite its adverse clinical and economic effects, only a few studies have reported reliable estimates on the incidence of AKI in sub-Sahara Africa. We assessed the incidence and associated factors of AKI among medical and surgical patients admitted to a tertiary hospital in Ghana.

Methods: A prospective cross-sectional study was conducted among one hundred and forty-five (145) consecutive patients admitted to the medical and the surgical wards at the Cape Coast Teaching Hospital (CCTH), Cape Coast, Ghana from April 2017 to April 2018. Socio-demographic and clinical information were collected using structured questionnaires. AKI was diagnosed and staged with the KDIGO guideline, using admission serum creatinine as baseline kidney function.

Results: The mean age of the study participants was 46.6±17.7 years, whilst the male:female ratio was 68:77. The overall incidence of AKI among the participants was 15.9% (95% CI: 10.33 – 22.84%). Stage 1 AKI occurred in 56.5% of the participants, whilst stages 2 and 3 AKI respectively occurred among 4.1% and 2.8% of respondents. About 20% of the participants in the medical ward developed AKI (n= 15) whilst 12% of those in surgical ward developed AKI (n= 8). Among the participants admitted to the medical ward, 60.0%, 26.7% and 13.3% had stages 1, 2 and 3 AKI respectively. Whilst 50.0%, 25.0% and 25.0% respectively developed stages 1, 2 and 3 AKI in the surgical ward. Medical patients with AKI had hyper-tension (40%), followed by liver disease (33.3%); 37.5% of surgical inpatients had gastrointestinal (GI) disorders.

Conclusion: The incidence of AKI is high among medical and surgical patients in-patients in the CCTH, Ghana, with hypertension and liver disease as major comorbidities.


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136. We Asked the Experts: The Role of Rural Hospitals in Achieving Equitable Surgical Access in Low-Resourced Settings

World Journal of Surgery


Authors: Kathryn Chu, Rebecca Maine & Riaan Duvenage
Region / country: Global
Speciality: General surgery, Health policy

Strengthening and defining the role of rural hospitals within a surgical ecosystem is essential to improving quality and timely surgical access for rural people in low and middle-income countries (LMICs). Regional hospitals are the cornerstone of LMIC rural surgical care but have insufficient human resources and infrastructure that limit the surgical care they can provide. District hospitals are most accessible for many rural patients but also have limited surgical capacity. In order to surgical access for rural people, both regional and district hospital surgical services must be strengthened. A strong relationship between regional and district hospitals through a hub and spoke model is needed. Regional hospital surgeons can support training and supervision for and referrals from district hospitals. Telemedicine can play a key role to leapfrog physical barriers and surgical specialist shortages. The changing demographics of surgical disease will continue to worsen the strain on tertiary hospitals where most subspecialists in LMICs work. The fewer rural patients who need to travel to urban referral and tertiary facilities for problems that can be managed at lower-level facilities, the better access to timely surgical care for all.


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137. Effect of a multifaceted intervention to improve clinical quality of care through stepwise certification (SafeCare) in health-care facilities in Tanzania: a cluster-randomised controlled trial

The Lancet Global Health


Authors: Jessica J C King, Timothy Powell-Jackson, Christina Makungu, Nicole Spieker , Peter Risha , Abdallah Mkopi , Prof Catherine Goodman
Region / country: Eastern Africa – Tanzania
Speciality: Health policy

Background
Quality of care is consistently shown to be inadequate in health-care settings in many low-income and middle-income countries, including in private facilities, which are rapidly growing in number but often do not have effective quality stewardship mechanisms. The SafeCare programme aims to address this gap in quality of care, using a standards-based approach adapted to low-resource settings, involving assessments, mentoring, training, and access to loans, to improve clinical quality and facility business performance. We assessed the effect of the SafeCare programme on quality of patient care in faith-based and private for-profit facilities in Tanzania.

Methods
In this cluster-randomised controlled trial, health facilities were eligible if they were dispensaries, health centres, or hospitals in the faith-based or private for-profit sectors in Tanzania. We randomly assigned facilities (1:1) using computer-generated stratified randomisation to receive the full SafeCare package (intervention) or an assessment only (control). Implementing staff and participants were masked to outcome measurement and the primary outcomes were measured by fieldworkers who had no knowledge of the study group allocation. The primary outcomes were health worker compliance with infection prevention and control (IPC) practices as measured by observation of provider–patient interactions, and correct case management of undercover standardised patients at endline (after a minimum of 18 months). Analyses were by modified intention to treat. The trial is registered with ISRCTN, ISRCTN93644888.

Findings
Between March 7 and Nov 30, 2016, we enrolled and randomly assigned 237 health facilities to the intervention (n=118) or control (n=119). Nine facilities (seven intervention facilities and two control facilities) closed during the trial and were not included in the analysis. We observed 29 608 IPC indications in 5425 provider–patient interactions between Feb 7 and April 5, 2018. Health facilities received visits from 909 standardised patients between May 3 and June 12, 2018. Intervention facilities had a 4·4 percentage point (95% CI 0·9–7·7; p=0.015) higher mean SafeCare standards assessment score at endline than control facilities. However, there was no evidence of a difference in clinical quality between intervention and control groups at endline. Compliance with IPC practices was observed in 8181 (56·9%) of 14 366 indications in intervention facilities and 8336 (54·7%) of 15 242 indications in control facilities (absolute difference 2·2 percentage points, 95% CI −0·2 to −4·7; p=0·071). Correct management occurred in 120 (27·0%) of 444 standardised patients in the intervention group and in 136 (29·2%) of 465 in the control group (absolute difference −2·8 percentage points, 95% CI −8·6 to −3·1; p=0·36).

Interpretation
SafeCare did not improve clinical quality as assessed by compliance with IPC practices and correct case management. The absence of effect on clinical quality could reflect a combination of insufficient intervention intensity, insufficient links between structural quality and care processes, scarcity of resources for quality improvement, and inadequate financial and regulatory incentives for improvement.


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138. Assessing the Performance of Artificial Intelligence Systems for the Screening of Diabetic Retinopathy: A Systematic Review and Meta-Analysis

preprints


Authors: Ryan Sadjadi
Region / country: Global
Speciality: Ophthalmology

Diabetic retinopathy is the most common microvascular complication of diabetes mellitus and one of the leading causes of blindness globally. Due to the progressive nature of the disease, earlier detection and timely treatment can lead to substantial reductions in the incidence of irreversible vision-loss. Artificial intelligence (AI) screening systems have offered clinically acceptable and quicker results in detecting diabetic retinopathy from retinal fundus and optical coherence tomography (OCT) images. Thus, this systematic review and meta-analysis of relevant investigations was performed to document the performance of AI screening systems that were applied to fundus and OCT images of patients from diverse geographic locations including North America, Europe, Africa, Asia, and Australia. A systematic literature search on Medline, Global Health, and PubMed was performed and studies published between October 2015 and January 2020 were included. The search strategy was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, and AI-based investigations were mandatory for studies inclusion. The abstracts, titles, and full-texts of potentially eligible studies were screened against inclusion and exclusion criteria. Twenty-one studies were included in this systematic review; 18 met inclusion criteria for the meta-analysis. The pooled sensitivity of the evaluated AI screening systems in detecting diabetic retinopathy was 0.93 (95% CI: 0.92-0.94) and the specificity was 0.88 (95% CI: 0.86-0.89). The included studies detailed training and external validation datasets, criteria for diabetic retinopathy case ascertainment, imaging modalities, DR-grading scales, and compared AI results to those of human graders (e.g., ophthalmologists, retinal specialists, trained nurses, and other healthcare providers) as a reference standard. The findings of this study showed that the majority AI screening systems demonstrated clinically acceptable levels of sensitivity and specificity for detecting referable diabetic retinopathy from retinal fundus and OCT photographs. Further improvement depends on the continual development of novel algorithms with large and gradable sets of images for training and validation. If cost-effectiveness ratios can be optimized, AI can become a financially sustainable and clinically effective intervention that can be incorporated into the healthcare systems of low-to-middle income countries (LMICs) and geographically remote locations. Combining screening technologies with treatment interventions such as anti-VEGF therapy, acellular capillary laser treatment, and vitreoretinal surgery can lead to substantial reductions in the incidence of irreversible vision-loss due to proliferative diabetic retinopathy.


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139. Practical considerations for expediting breast cancer treatment in Brazil

The Lancet Regional Health – Americas


Authors: Gustavo Bretas, Nelson Luiz Renna, José Bines
Region / country: South America – Brazil
Speciality: General surgery, Surgical oncology

Patients in Brazil continue to present with late-stage breast cancer. Notwithstanding these figures, policies and programs to overcome this long-lasting scenario have had limited results. We enlist the main barriers for advancing breast cancer diagnosis in Brazil, based on the available evidence, and we propose feasible strategies that may serve as a platform to address this major public health challenge.


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140. Epidemiology of fractures and their treatment in Malawi: Results of a multicentre prospective registry study to guide orthopaedic care planning

plos one


Authors: Alexander Thomas Schade ,Foster Mbowuwa,Paul Chidothi,Peter MacPherson,Simon Matthew Graham,Claude Martin Jr.,William James Harrison,Linda Chokotho
Region / country: Southern Africa – Malawi
Speciality: Health policy, Trauma and orthopaedic surgery, Trauma surgery

Importance
Injuries cause 30% more deaths than HIV, TB and malaria combined, and a prospective fracture care registry was established to investigate the fracture burden and treatment in Malawi to inform evidence-based improvements.

Objective
To use the analysis of prospectively-collected fracture data to develop evidence-based strategies to improve fracture care in Malawi and other similar settings.

Design
Multicentre prospective registry study.

Setting
Two large referral centres and two district hospitals in Malawi.

Participants
All patients with a fracture (confirmed by radiographs)—including patients with multiple fractures—were eligible to be included in the registry.

Exposure
All fractures that presented to two urban central and two rural district hospitals in Malawi over a 3.5-year period (September 2016 to March 2020).

Main outcome(s) and measure(s)
Demographics, characteristics of injuries, and treatment outcomes were collected on all eligible participants.

Results
Between September 2016 and March 2020, 23,734 patients were enrolled with a median age of 15 years (interquartile range: 10–35 years); 68.7% were male. The most common injuries were radius/ulna fractures (n = 8,682, 36.8%), tibia/fibula fractures (n = 4,036, 17.0%), humerus fractures (n = 3,527, 14.9%) and femoral fractures (n = 2,355, 9.9%). The majority of fractures (n = 21,729, 91.6%) were treated by orthopaedic clinical officers; 88% (20,885/2,849) of fractures were treated non-operatively, and 62.7% were treated and sent home on the same day. Open fractures (OR:53.19, CI:39.68–72.09), distal femoral fractures (OR:2.59, CI:1.78–3.78), patella (OR:10.31, CI:7.04–15.07), supracondylar humeral fractures (OR:3.10, CI:2.38–4.05), ankle fractures (OR:2.97, CI:2.26–3.92) and tibial plateau fractures (OR:2.08, CI:1.47–2.95) were more likely to be treated operatively compared to distal radius fractures.

Conclusions and relevance
The current model of fracture care in Malawi is such that trained orthopaedic surgeons manage fractures operatively in urban referral centres whereas orthopaedic clinical officers mainly manage fractures non-operatively in both district and referral centres. We recommend that orthopaedic surgeons should supervise orthopaedic clinical officers to manage non operative injuries in central and district hospitals. There is need for further studies to assess the clinical and patient reported outcomes of these fracture cases, managed both operatively and non-operatively.


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141. Task-sharing to support paediatric and child health service delivery in low- and middle-income countries: current practice and a scoping review of emerging opportunities

Human Resources for Health


Authors: Yingxi Zhao, Christiane Hagel, Raymond Tweheyo, Nathanael Sirili, David Gathara & Mike English
Region / country: Eastern Africa, Southern Africa – Kenya, Malawi, South Africa, Tanzania, Uganda
Speciality: Paediatric surgery

Background
Demographic and epidemiological changes have prompted thinking on the need to broaden the child health agenda to include care for complex and chronic conditions in the 0–19 years (paediatric) age range. Providing such services will be undermined by general and skilled paediatric workforce shortages especially in low- and middle-income countries (LMICs). In this paper, we aim to understand existing, sanctioned forms of task-sharing to support the delivery of care for more complex and chronic paediatric and child health conditions in LMICs and emerging opportunities for task-sharing. We specifically focus on conditions other than acute infectious diseases and malnutrition that are historically shifted.

Methods
We (1) reviewed the Global Burden of Diseases study to understand which conditions may need to be prioritized; (2) investigated training opportunities and national policies related to task-sharing (current practice) in five purposefully selected African countries (Kenya, Uganda, Tanzania, Malawi and South Africa); and (3) summarized reported experience of task-sharing and paediatric and child health service delivery through a scoping review of research literature in LMICs published between 1990 and 2019 using MEDLINE, Embase, Global Health, PsycINFO, CINAHL and the Cochrane Library.

Results
We found that while some training opportunities nominally support emerging roles for non-physician clinicians and nurses, formal scopes of practices often remain rather restricted and neither training nor policy seems well aligned with probable needs from high-burden complex and chronic conditions. From 83 studies in 24 LMICs, and aside from the historically shifted conditions, we found some evidence examining task-sharing for a small set of specific conditions (circumcision, some complex surgery, rheumatic heart diseases, epilepsy, mental health).

Conclusion
As child health strategies are further redesigned to address the previously unmet needs careful strategic thinking on the development of an appropriate paediatric workforce is needed. To achieve coverage at scale countries may need to transform their paediatric workforce including possible new roles for non-physician cadres to support safe, accessible and high-quality care.


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142. Surgical Site Infections and Antimicrobial Resistance After Cesarean Section Delivery in Rural Rwanda

annals of global health


Authors: Lotta Velin , Grace Umutesi, Robert Riviello, Moses Muwanguzi, Lisa M. Bebell, Marthe Yankurije, Kara Faktor, Theoneste Nkurunziza, Gilbert Rukundo, Jean de Dieu Gatete, Ivan Emil, Bethany L. Hedt-Gauthier, Fredrick Kateera
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Obstetrics and Gynaecology

Background: As the volume of surgical cases in low- and middle-income countries (LMICs) increases, surgical-site infections (SSIs) are becoming more prevalent with anecdotal evidence of antimicrobial resistance (AMR), despite a paucity of data on resistance patterns.

Objectives: As a primary objective, this prospective study aimed to describe the epidemiology of SSIs and the associated AMR among women who delivered by cesarean at a rural Rwandan hospital. As secondary objectives, this study also assessed patient demographics, pre- and post-operative antibiotic use, and SSI treatment.

Methods: Women who underwent cesarean deliveries at Kirehe District Hospital between September 23rd, 2019, and March 16th, 2020, were enrolled prospectively. On postoperative day (POD) 11 (+/− 3 days), their wounds were examined. When an SSI was diagnosed, a wound swab was collected and sent to the Rwandan National Reference Laboratory for culturing and antibiotic susceptibility testing.

Findings: Nine hundred thirty women were enrolled, of whom 795 (85.5%) returned for the POD 11 clinic visit. 45 (5.7%) of the 795 were diagnosed with SSI and swabs were collected from 44 of these 45 women. From these 44 swabs, 57 potential pathogens were isolated. The most prevalent bacteria were coagulase-negative staphylococci (n = 12/57, 20.3% of all isolates), and Acinetobacter baumannii complex (n = 9/57, 15.2%). 68.4% (n = 39) of isolates were gram negative; 86.7% if excluding coagulase-negative staphylococci. No gram-negative pathogens isolated were susceptible to ampicillin, and the vast majority demonstrated intermediate susceptibility or resistance to ceftriaxone (92.1%) and cefepime (84.6%).

Conclusions: Bacterial isolates from SSI swab cultures in rural Rwanda predominantly consisted of gram-negative pathogens and were largely resistant to commonly used antibiotics. This raises concerns about the effectiveness of antibiotics currently used for surgical prophylaxis and treatment and may guide the appropriate selection of treatment of SSIs in rural Rwanda and comparable settings.


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143. Strengthening Antimicrobial Resistance Diagnostic Capacity in Rural Rwanda: A Feasibility Assessment

annals of global health


Authors: Grace Umutesi , Lotta Velin, Moses Muwanguzi, Kara Faktor, Carol Mugabo, Gilbert Rukundo, Aniceth Rucogoza, Marthe Yankurije, Christian Mazimpaka, Jean de Dieu Gatete, Cyprien Shyirambere, Bethany Hedt-Gauthier, Robert Riviello, Tharcisse Mpunga, Emil Ivan Mwikarago, Fredrick Kateera
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Other

Introduction: Antimicrobial resistance (AMR) is a global public health threat. Worse still, there is a paucity of data from low- and middle-income countries to inform rational antibiotic use.

Objective: Assess the feasibility of setting up microbiology capacity for AMR testing and estimate the cost of setting up microbiology testing capacity at rural district hospitals in Rwanda.

Methods: Laboratory needs assessments were conducted, and based on identified equipment gaps, appropriate requisitions were processed. Laboratory technicians were trained on microbiology testing processes and open wound samples were collected and cultured at the district hospital (DH) laboratories before being transported to the National Reference Laboratory (NRL) for bacterial identification and antibiotic susceptibility testing. Quality control (QC) assessments were performed at the DHs and NRL. We then estimated the cost of three scenarios for implementing a decentralized microbiology diagnostic testing system.

Results:There was an eight-month delay from the completion of the laboratory needs assessments to the initiation of sample collection due to the regional unavailability of appropriate supplies and equipment. When comparing study samples processed by study laboratory technicians and QC samples processed by other laboratory staff, there was 85.0% test result concordance for samples testing at the DHs and 90.0% concordance at the NRL. The cost for essential equipment and supplies for the three DHs was $245,871. The estimated costs for processing 600 samples ranged from $29,500 to $92,590.

Conclusion: There are major gaps in equipment and supply availability needed to conduct basic microbiology assays at rural DHs. Despite these challenges, we demonstrated that it is feasible to establish microbiological testing capacity in Rwandan DHs. Building microbiological testing capacity is essential for improving clinical care, informing rational antibiotics use, and ultimately, contributing to the establishment of robust national antimicrobial stewardship programs in rural Rwanda and comparable settings


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144. Medical Brain Drain and its Effect on the Nigerian Healthcare Sector

Walden Dissertations and Doctoral Studies


Authors: Oluwakemi Osigbesan
Region / country: Western Africa – Nigeria
Speciality: Health policy

Nigeria suffers from a huge brain drain issue across different sectors, particularly in the healthcare sector. The WHO assessed that there is a current shortage of 2.8 million physicians in the world A heuristic phenomenological method was used in this study to explore the lived experiences of 12 Nigerian healthcare practitioners that migrated to the United States. The push-pull theory served as the theoretical framework that grounded this study. The central research questions for this study focused primarily on the reasons healthcare practitioners are leaving Nigeria and what the impact of those decisions have on the Nigerian healthcare sector. Qualitative data were collected and analyzed identified three emerging themes: (a) challenges of living in Nigeria; (b) lack of government support; and (c) reality of knowledge gap. The participants were selected by using a purposive and snowball sampling method, and a semi-structure interview was used to collect data from the participants. The study used Moustakas’s heuristic phenomenological approach, which allowed the use of thematic analysis to record and identify passages of the text that fell into categories. The finding from the research puts the brain drain phenomenon on the Nigerian government and its lack of support in rebuilding the healthcare system. Recommendations were made based on the emergent themes on how the government can work with Nigerians in the diaspora to help strengthen the Nigerian healthcare sector and to create worthwhile policies/laws/regulations that will help build the country. Implication for positive social change include the creation of jobs for young Nigerians and creating proper policies and wage scale so that they can be on par with their counterpart


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145. Impact of SARS-CoV-2 on Ocular Surface Pathology and Treatment Practices: a Review

Current Ophthalmology Reports


Authors: Sila Bal, James Chodosh , Nandini Venkateswaran
Region / country: Global
Speciality: Ophthalmology

Purpose of Review
The ocular surface is a potential site of ocular involvement by SARS-CoV-2 infection. We performed a review of the literature to understand the pathogenesis of SARS-CoV-2 disease manifestations on the ocular surface as well as to elucidate emerging treatment patterns and practice changes during the COVID-19 pandemic.

Recent Findings
The ocular manifestations of SARS-CoV-2 are likely limited to a mild and transient conjunctivitis. Other manifestations have not been validated in larger cohorts. Ocular surface tissue should be considered potentially infectious due to the presence of host receptors on surface tissues. The availability of donor tissue in lower-middle income countries has been greatly impacted by the pandemic and would benefit from further investigation into transmissibility through donor tissue.

Summary
Transmission of SARS-CoV-2 through the ocular surface has yet to be confirmed. The most common ocular manifestation is a mild conjunctivitis. Ocular surface surgeons face specific challenges in the use of donor tissues and aerosolizing procedures and have adapted practice patterns accordingly.


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146. Magnitude of undernutrition and associated factors among children with cardiac disease at University of Gondar hospital, Ethiopia

BMC Nutrition


Authors: Mulat Asrade, Abdulkadir Shehibo , Zemene Tigabu
Region / country: Eastern Africa – Ethiopia
Speciality: Cardiothoracic surgery

Background
Undernutrition and cardiac disease are interconnected in a vicious cycle. Little is known about the effect of undernutrition on cardiac disease among children in low- and middle-income countries (LMICs). This study aimed to assess magnitude of undernutrition and associated factors among children with cardiac disease at University of Gondar hospital, northwest Ethiopia.

Method
This hospital-based cross-sectional study included children with cardiac disease presenting to the pediatric outpatient clinic at University of Gondar Hospital, Ethiopia. A self-administered questionnaire was administered to participating families, and medical records were reviewed. All participants who fulfill the inclusion criteria were included. Anthropometric measurements were made and the presence of malnutrition was diagnosed according to the WHO criteria. Associated factors of undernutrition analyzed by using binary logistic regression model. Variables with p-value ≤0.2 in bivariate analysis were fitted to the final multivariable analysis and those variables with p-value ≤0.05 were considered as having statistically significant association to the outcome variable. AOR and 95% confidence interval was calculated to assess the strength of association between the variables.

Result
A total of 269 patients participated in the study. 177 (65.7%) were undernourished, of whom 96 (54.5%) were underweight, 70 (39.7%) were stunted, and 95 (53.9%) were wasted. Pulmonary hypertension (adjusted odds ratio [AOR] = 3.82, 95%CI 1.80–8.10), NYHA/modified Ross class III and IV heart failure (AOR = 4.64, 1.69–12.72) and cardiac chamber enlargement (AOR = 2.91, 1.45–5.66) were associated with undernutrition.

Conclusion
Undernutrition is common among children with cardiac disease in northern Ethiopia. Children with pulmonary hypertension, high-grade heart failure, and cardiac chamber enlargement may warrant close follow-up for malnutrition.


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147. Empowering The Rural Surgeons, The Way Forward For Meeting The Surgical Needs Of Rural Areas

Journal of Global Surgery (ONE)


Authors: Gnanaraj Jesudian
Region / country: Southern Asia – India
Speciality: Urology surgery

Globally, 60% of the surgical procedures are carried out for 15% of the world population in developed countries. The Lancet commission on Global surgery estimates that a population of 100000 would ideally require 5000 surgical procedures every year. Although the national average is about 800 in most of the rural areas in India, in the North-eastern states it varies from 30 to 300. We look at the various models and options available for empowering the surgeons in the rural areas. Short Term Medical Missions have been used for a long time including those with structured programs. Pioneering long term medical missions are few and difficult to sustain. Empowering surgeons working in rural areas with modern surgical techniques is a sustainable solution with high impact. Empowering the rural surgeons with training in Gas Insufflation Less Laparoscopic Surgeries and Endoscopic Urology surgeries helped the surgical coverage in the target population of the 8 rural hospitals studied go up from 1287 per 100000 per year to 2880 the next year and 3739 the following year. It is a financially sustainable model that could be scaled up by funding travel of the trainers and equipment for the trainees.


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148. Identifying occupational hazards among healthcare workers in Australia and Bhutan

Curtin’s institutional repository


Authors: Rai Rajni
Region / country: Australia and New Zealand, Central Asia – Australia, Bhutan
Speciality: Health policy

This research project examined the epidemiology of occupational exposures to hazardous chemicals and agents among healthcare workers in Australia and Bhutan. Data from three population-based cross-sectional studies conducted in 2011, 2014 and 2016 in Australia were analysed and a cross-sectional survey was conducted in 2019 in three hospitals in Bhutan. The results indicate that a substantial proportion of healthcare workers in both countries were occupationally exposed to hazardous chemicals with exposure to asthmagens being the most common.


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149. The Status of Medical Devices and their Utilization in 9 Tertiary Hospitals and 5 Research institutions in Uganda

Global Clinical Engineering Journal


Authors: Robert Tamale Ssekitoleko, Beryl Ngabirano Arinda, Solomon Oshabahebwa, Lucy Kevin Namuli, Julius Mugaga, Catherine Namayega, Emmanuel Einyat Opolot, Jackline Baluka, Charles Ibingira, Ian Guyton Munabi, Moses Lutakome Joloba
Region / country: Eastern Africa – Uganda
Speciality: Health policy, Other

Introduction
Advancements in technology have led to great strides in research and innovation that has resulted in an improvement of healthcare provision around the world. However, it has been shown that majority of the technology is underutilized in Sub-Saharan Africa. The ever-increasing sophistication and cost of medical equipment means that access and proper use is limited in Low- and Middle-Income countries. There is however a general paucity of well documented evidence for utilization of medical equipment in LMICs. The aim of this study is therefore to evaluate the current availability and utilization of medical equipment in tertiary hospitals and research facilitates in Uganda. This will provide baseline information to clinical/biomedical engineers, innovators, managers as well as policy makers.

Methodology
The study evaluated the equipment currently used in 9 purposively selected public tertiary hospitals and 5 research laboratories representing different regions of Uganda. Data was collected by personnel specialized in the field of Biomedical Engineering utilizing a mixed method approach that involved inventory taking and surveys directed to the health workers in the designated health facilities.

Results
The hospitals contributed 1995 (85%) pieces of medical equipment while the research laboratories contributed 343 (15%) pieces amounting to 2338 pieces of equipment involved in the study. On average, 34% of the medical equipment in the health facilities were faulty and 85.6% lacked manuals.

Discussion and Conclusion
Although innovative solutions and donated equipment address the immediate and long-term goals of resource constrained settings, our study demonstrated that there are a number of issues around existing medical devices and these need immediate attention.


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150. Evaluating the effect of interventions for strengthening non-physician anesthetists’ education in Ethiopia: a pre- and post-evaluation study

BMC Medical Education


Authors: Yohannes Molla Asemu, Tegbar Yigzaw, Firew Ayalew Desta, Fedde Scheele , Thomas van den Akker
Region / country: Eastern Africa – Ethiopia
Speciality: Anaesthesia, Surgical Education

Background
Access to safe surgery has been recognized as an indispensable component of universal health coverage. A competent anesthesia workforce is a prerequisite for safe surgical care. In Ethiopia, non-physician anesthetists are the main anesthesia service providers. The Government of Ethiopia implemented a program intervention to improve the quality of non-physician anesthetists’ education, which included faculty development, curricula strengthening, student support, educational resources, improved infrastructure and upgraded regulations. This study aimed to assess changes following the implementation of this program.

Methods
A pre-and post-evaluation design was employed to evaluate improvement in the quality of non-physician anesthetists’ education. A 10-station objective structured clinical examination (OSCE) was administered to graduating class anesthetists of 2016 (n = 104) to assess changes in competence from a baseline study performed in 2013 (n = 122). Moreover, a self-administered questionnaire was used to collect data on students’ perceptions of the learning environment.

Results
The overall competence score of 2016 graduates was significantly higher than the 2013 class (65.7% vs. 61.5%, mean score difference = 4.2, 95% CI = 1.24–7.22, p < 0.05). Although we found increases in competence scores for 6 out of 10 stations, the improvement was statistically significant for three tasks only (pre-operative assessment, postoperative complication, and anesthesia machine check). Moreover, the competence score in neonatal resuscitation declined significantly from baseline (from 74.4 to 68.9%, mean score difference = − 5.5, 95% CI = -10.5 to − 0.5, p  0.05 in favor of females), and female students scored better in some stations. Student perceptions of the learning environment improved significantly for almost all items, with the largest percentage point increase in the availability of instructors from 38.5 to 70.2% (OR = 3.76, 95% CI = 2.15–6.55, p < 0.05).

Conclusion
The results suggest that the quality of non-physician anesthetists’ education has improved. Stagnation in competence scores of some stations and student perceptions of the simulated learning environment require specific attention.


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151. Shock index as a prognosticator for emergent surgical intervention and mortality in trauma patients in Johannesburg: A retrospective cohort study

Annals of Medicine and Surgery


Authors: Richard Crawford, Deirdre Kruger, Maeyane Moengab
Region / country: Southern Africa – South Africa
Speciality: Anaesthesia, Critical care, Emergency surgery, Trauma surgery

Introduction
Trauma is the leading cause of morbidity and mortality worldwide with exsanguination being the primary preventable cause through early surgical intervention. We assessed two popular trauma scoring systems, injury severity scores (ISS) and shock index (SI) to determine the optimal cut off values that may predict the need for emergent surgical intervention (ESI) and in-hospital mortality.

Methods
A retrospective analysis of patient records from a tertiary hospital’s trauma unit for the year 2019 was done. Descriptive statistics, univariate and multivariate logistic regression analyses were performed. Receiver operator characteristic (ROC) curve analysis was conducted and area under the curve (AUC) reported for predicting the need for ESI in all study participants, as well as in patients with penetrating injuries alone, based on continuous variables of ISS, SI or a combination of ISS and SI. The Youdin Index was applied to determine the optimal ISS and SI cut off values.

Results
A total of 1964 patients’ records were included, 89.0% were male and the median age (IQR) was 30 (26–37) years. Penetrating injuries accounted for 65.9% of all injuries. ISS and SI were higher in the ESI group with median (IQR) 11 (10–17) and 0.74 (0.60–0.95), respectively. The overall mortality rate was 4.5%. The optimal cut-off values for ESI and mortality by ISS (AUC) were 9 (0.74) and 12 (0.86) (p = 0.0001), with optimal values for SI (AUC) being 0.72 (0.60), and 0.91 (0.68) (p = 0.0001), respectively.


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152. Data on histological characteristics, survival patterns and determinants of mortality among colorectal, esophageal and prostate cancer patients in Ethiopia

Data in Brief


Authors: Hamid Yimam Hassen, Mohammed AhmedTekac , Jemal Beksisa, Jilcha Diribi Feyisad
Region / country: Eastern Africa – Ethiopia
Speciality: General surgery, Surgical oncology, Urology surgery

This article describes data collected retrospectively on a cohort of esophageal, colorectal and prostate cancer patients registered in the patient log book of Tikur Anbessa Specialized Hospital, Ethiopia, from January 1, 2012 to December 31, 2017. The key variables studied include histological characteristics of each type of cancer, clinical and TNM stages, baseline laboratory results (Carcinoembryonic antigen (CEA) for colorectal cancer, Prostate-Specific Antigen (PSA) for prostate cancer, hemoglobin level, etc.), clinical characteristics including sign and symptoms, family history of cancer, diagnostic and treatment modalities a patient received for each type of cancer. The event status (death) was also collected using death certificates (whenever available) and supplemented by telephone interviews with the patient or attendant. Furthermore, lifestyle characteristics of patients including tobacco use, alcohol consumption, khat (‘Catha edulis’) chewing, etc. and socioeconomic characteristics including age, sex, region of residence, marital status, and educational level were also collected. The aim that led to conduct the study that generated these data was to describe clinical presentation, histological characteristics, survival pattern, and to identify determinants of mortality among cancer patients in Ethiopia. Thus, independent survival analyzes were performed using Kaplan-Meier estimates and life table analysis. Furthermore, Cox’s proportional hazards regression was developed to investigate the survival pattern and determinants of cancer specific mortality among colorectal, esophageal and prostate cancer patients.


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153. Strategies for Improving Quality and Safety in Global Health: Lessons From Nontechnical Skills for Surgery Implementation in Rwanda

Global Health: Science and Practice


Authors: Daniel Josef Lindegger, Egide Abahuje, Kenneth Ruzindana, Elizabeth Mwachiro, Gilbert Rutayisire Karonkano, Wendy Williams, George Ntakiyiruta, Robert Riviello, Steven Yule and Simon Paterson-Brown
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Anaesthesia, General surgery, Health policy

In 2015 the Lancet Commission on Global Surgery published its report “Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development,”1 helping to galvanize a global movement to increase access to safe, timely, and affordable surgical and anesthesia care with an emphasis on equity. A goal of the movement is to enable the benefits of these efforts to be reaped most by impoverished and marginalized populations. The authors laid out 5 key messages, including the great number of operations required annually (approximately 143 million), especially among the poorest third of the world’s population, which receives only 6% of the operations. The commission called on nations to track and report on 6 metrics related to surgical care. Two of these metrics—surgeon, anesthetist, and obstetric (SAO) density (the number of specialist surgical, anesthetic, and obstetric providers per 100,000 population) and surgical volume (number of operations performed in operating rooms annually per 100,000 population)—are measurements …


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154. Association between alcohol consumption, marijuana use and road traffic injuries among commercial motorcycle riders: A population-based, case-control study in Dares Salaam, Tanzania

Accident Analysis & Prevention


Authors: George Kiwango, Filbert Francis, Candida Moshiroa , Jette Möller, Marie Hasselberg
Region / country: Eastern Africa – Tanzania
Speciality: Health policy, Trauma surgery

Background
Alcohol consumption and psychoactive drug use are well-recognised risk factors for road traffic injuries (RTIs). Both types of use may impair and affect drivers’ performance. Yet, there is limited literature on their contribution to RTIs among commercial motorcycle riders, particularly in low- and middle-income settings. This study aimed to determine the association between alcohol consumption, marijuana use and RTIs among commercial motorcycle riders in the city of Dar es Salaam, Tanzania.

Methods
We conducted a case-control study between July 2018 and March 2019. Cases (n = 164) were commercial motorcycle riders who had sustained an RTIs and attended at a hospital. Controls (n = 400) were commercial motorcycle riders who had not experienced an RTIs that led to hospital attendance during the past six months. Alcohol consumption was assessed using the Alcohol Use Disorder Identification (AUDIT) score, which classified participants as a non-drinker, normal drinker(1–7 scores) and risky drinker (scores ≥ 8). Marijuana use was assessed through self-reported use in the past year. We estimated odds ratios (ORs) using logistic regression adjusted for sociodemographic, driver-, and work-related factors.

Results
Risky drinking was associated with close to six times the odds of RTIs compared to non-drinkers (OR = 5.98, 95% CI: 3.25 – 11.0). The association remained significant even after adjusting for sociodemographic, driving and work-related factors (OR = 2.41, 95% CI: 1.01 – 5.76). The crude odds ratios of RTIs were significantly higher among users of marijuana than non-users (OR = 2.33, 95% CI: 1.38 – 3.95). However, the association did not remain statistically significant after adjusting for confounders (OR = 1.11, 95% CI = 0.49–2.48).

Conclusion
Our findings confirm increased odds of RTIs among commercial motorcycle riders with risky drinking behaviour even after taking sociodemographic, driving and work-related factors into account. Unlike alcohol consumption the relationship between marijuana use and RTIs among commercial motorcycle riders was unclear. Since motorcycle riders are more susceptible to the effect of alcohol due to higher demands of balance and coordination and because commercial motorcyclist riders, in particular, they spend a considerable amount of time on the road, our results underscore the importance of addressing hazardous alcohol consumption and marijuana use in future prevention strategies to enhance road safety.


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155. Going Global: Interest in Global Health Among US Otolaryngology Residents

annals of global health


Authors: Julia Toman , Melynda Barnes Oussayef, J. Zachary Porterfield
Region / country: Northern America – United States of America
Speciality: ENT surgery

Background: To meet the rising interest in surgical global health, some surgical residency programs offer global health experiences. The level of interest in these programs, however, and their role in residency recruitment and career planning has not been systematically evaluated.

Objective: (1) Define interest in global health among Otolaryngology residents in the USA. (2) Assess engagement of Otolaryngology residencies in global health training. (3) Determine barriers to global health training in residency.

Methods: A survey questionnaire was developed and sent to all Otolaryngology Residency Program Directors for distribution to all current Otolaryngology residents in the US.

Results: A total of 91 complete surveys were collected. A majority of respondents felt that global health was either “very important” or “extremely important” (67%). Two-thirds of respondents had prior global health experience (68%). While 56% of respondents would definitely participate in a global health elective and 78% would likely or definitely participate, only 37% of residency programs offered a global health experience. The availability of a global health elective significantly correlated with residency match choice in respondents with previous global health experience. The three most common barriers to participation were insufficient time, insufficient funding, and lack of program.

Conclusion: Participation in bilateral and equitable international electives is a unique experience of personal and professional growth. There is an interest in these opportunities during residency training among Otolaryngology residents that is not reflected in availability within training programs. This suggests the need for development of humanitarian outreach exposure through global health experiences during surgical residency training.


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156. Ethical Dilemmas in Surgical Mission Trips During the COVID-19 Pandemic

Otolaryngology–Head and Neck Surgery


Authors: Brianne B. Roby, Zahrah Taufique, Andrew Redmann, Asitha D. L. Jayawardena, Sivakumar Chinnadurai
Region / country: Caribbean, Northern America – Haiti, United States of America
Speciality: ENT surgery

This case is hypothetical and does not involve real patients or actual entities.

A long-running otolaryngology surgical teaching mission to Haiti was postponed in 2020 due to a combination of Haitian travel restrictions and American-based university travel bans during the coronavirus disease 2019 (COVID-19) pandemic. Several months have passed since the postponement of this recurring trip, and the local Haitian ear, nose, and throat (ENT) team has reached out to the international surgical teaching team to express their desire for surgical mission trips to return. The backlog of patients that the local team feels could not be treated without assistance continues to grow.

The COVID-19 vaccine is now available in the United States, and most US-based health care practitioners have been vaccinated, including all medical volunteers involved in this trip. University-based travel bans have also been lifted. Few Haitian health care providers have been vaccinated. Local Haitian travel restrictions are no longer being enforced, and it is legally possible to travel to the island. The international team has obtained enough personal protective equipment (PPE) to run a self-sufficient trip, but local PPE resources remain scarce.

Should the international surgical team restart mission work at this time? If so, what criteria need to be met for humanitarian organizations to provide safe and ethical care in the COVID-19 era when global inequality remains regarding vaccine distribution?


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157. Preliminary model assessing the cost-effectiveness of preoperative chlorhexidine mouthwash at reducing postoperative pneumonia among abdominal surgery patients in South Africa

Plos One


Authors: Mwayi Kachapila ,Adesoji O. Ademuyiwa,Bruce M. Biccard,Dhruva N. Ghosh,James Glasbey,Mark Monahan,Rachel Moore,Dion G. Morton,Raymond Oppong,Rupert Pearse,Tracy E. Roberts,NIHR Global Health Research Unit on Global Surgery ,ASOS Investigators ,STARSurg Collaborative
Region / country: Southern Africa – South Africa
Speciality: Critical care, General surgery

Background
Pneumonia is a common and severe complication of abdominal surgery, it is associated with increased length of hospital stay, healthcare costs, and mortality. Further, pulmonary complication rates have risen during the SARS-CoV-2 pandemic. This study explored the potential cost-effectiveness of administering preoperative chlorhexidine mouthwash versus no-mouthwash at reducing postoperative pneumonia among abdominal surgery patients.

Methods
A decision analytic model taking the South African healthcare provider perspective was constructed to compare costs and benefits of mouthwash versus no-mouthwash-surgery at 30 days after abdominal surgery. We assumed two scenarios: (i) the absence of COVID-19; (ii) the presence of COVID-19. Input parameters were collected from published literature including prospective cohort studies and expert opinion. Effectiveness was measured as proportion of pneumonia patients. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainties. The results of the probabilistic sensitivity analysis were presented using cost-effectiveness planes and cost-effectiveness acceptability curves.

Results
In the absence of COVID-19, mouthwash had lower average costs compared to no-mouthwash-surgery, $3,675 (R 63,770) versus $3,958 (R 68,683), and lower proportion of pneumonia patients, 0.029 versus 0.042 (dominance of mouthwash intervention). In the presence of COVID-19, the increase in pneumonia rate due to COVID-19, made mouthwash more dominant as it was more beneficial to reduce pneumonia patients through administering mouthwash. The cost-effectiveness acceptability curves shown that mouthwash surgery is likely to be cost-effective between $0 (R0) and $15,000 (R 260,220) willingness to pay thresholds.

Conclusions
Both the absence and presence of SARS-CoV-2, mouthwash is likely to be cost saving intervention for reducing pneumonia after abdominal surgery. However, the available evidence for the effectiveness of mouthwash was extrapolated from cardiac surgery; there is now an urgent need for a robust clinical trial on the intervention on non-cardiac surgery.


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158. Practical considerations for prostate hypofractionation in the developing world

nature reviews urology


Authors: Michael Yan, Andre G. Gouveia, Fabio L. Cury, Nikitha Moideen, Vanessa F. Bratti, Horacio Patrocinio, Alejandro Berlin, Lucas C. Mendez & Fabio Y. Moraes
Region / country: Global
Speciality: Surgical oncology, Urology surgery

External beam radiotherapy is an effective curative treatment option for localized prostate cancer, the most common cancer in men worldwide. However, conventionally fractionated courses of curative external beam radiotherapy are usually 8–9 weeks long, resulting in a substantial burden to patients and the health-care system. This problem is exacerbated in low-income and middle-income countries where health-care resources might be scarce and patient funds limited. Trials have shown a clinical equipoise between hypofractionated schedules of radiotherapy and conventionally fractionated treatments, with the advantage of drastically shortening treatment durations with the use of hypofractionation. The hypofractionated schedules are supported by modern consensus guidelines for implementation in clinical practice. Furthermore, several economic evaluations have shown improved cost effectiveness of hypofractionated therapy compared with conventional schedules. However, these techniques demand complex infrastructure and advanced personnel training. Thus, a number of practical considerations must be borne in mind when implementing hypofractionation in low-income and middle-income countries, but the potential gain in the treatment of this patient population is substantial.


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159. Evaluation and usability study of low-cost laparoscopic box trainer “Lap-Pack”: a 2-stage multicenter cohort study

International Journal of Surgery: Global Health


Authors: Chauhan Manish, Sawhney Riya , Da Silva Carolina F. , Aruparayil Noel , Gnanaraj Jesudian , Maiti, Sukumar , Mishra Anurag , Quyn Aaron ,Bolton William , Burke Joshua , Jayne David ,Valdastri Pietro
Region / country: Southern Asia – India
Speciality: General surgery, Surgical Education

Introduction:
Laparoscopic training is restricted in low resource settings due to limited access to specialist training equipment and financial constraints. This study aimed to evaluate simulation skills and usability of an original low-cost laparoscopic trainer, the “Lap-Pack,” developed at the University of Leeds, UK.

Methods:
Stage I evaluation was conducted in Kolkata (India) between March, 12 and 14, 2019. Laparoscopic simulation training was based on the 5 domains of fundamentals of laparoscopic surgery (FLS), which assessed skill acquisition across 7 rural surgeons from North-East India. The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) criteria was used to statistically analyze trainee performance between pretraining and posttraining sessions. Also, Lap-Pack was qualitatively compared with a commercial box trainer, Inovus Pyxus HD (IPHD). Stage II involved a multi-center usability study in 2 centers of India and the United Kingdom (2019). Seventy-eight participants performed 2 FLS tasks using Lap-Pack and provided scores on a 25-point questionnaire, including a preestablished Face-Validity Criteria and 4 evaluation categories—Usability, Camera, View, and, Material.

Results:
In stage I, the total posttraining MISTELS score for Lap-Pack was higher, that is 773.37 (SD: 183.67) than pretraining score, that is 351.2 (SD: 471.5). The posttraining scores showed laparoscopic skill acquisition with statistically significant (P<0.05) difference for precision cutting, intracorporeal and extracorporeal knot. In stage II, Lap-Pack scored highly in Face-Validity with a combined mean score of 4.81 [95% confidence interval (CI): 4.52–5.09, P<0.05] out of a possible 6. It scored highest (scale: 1=low to 7=high) in Usability 6.14 (95% CI: 6.05–6.22, P<0.05) and Camera 6.14 (95% CI: 6.01–6.27, P<0.05). The “Lightweight” (6.46, 95% CI: 6.32–6.60, P<0.05) and “Portability” (6.35, 95% CI: 6.18–6.51, P<0.05) features of Lap-Pack were appreciated.

Conclusion:
The Lap-Pack is a suitable low fidelity simulator for laparoscopic training in a low-resource setting.


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160. Provider Barriers and Facilitators of Breast Cancer Guideline-Concordant Therapy Delivery in Botswana: A Consolidated Framework for Implementation Research Analysis

Global Health and Cancer


Authors: Tlotlo B. Ralefala , Lebogang Mokokwe , Swetha Jammalamadugu , Dumelang Legobere, Warona S. Motlhwa, Anthony A. Oyekunle , FMCPath, Surbhi Grover , Frances K. Barg , Lawrence N. Shulman , Yehoda M. Martei
Region / country: Southern Africa – Botswana
Speciality: Surgical oncology

Introduction
Systemic treatment for breast cancer in Sub-Saharan Africa (SSA) is cost-effective. However, there is limited real-world data on the translation of breast cancer treatment guidelines into clinical practice in SSA. The study aimed to identify provider factors associated with adherence to breast cancer guideline-concordant care at Princess Marina Hospital (PMH) in Botswana.

Methods
The Consolidated Framework for Implementation Research was used to conduct one-on-one semi-structured interviews with breast cancer providers at PMH. Purposive sampling was used, and sample size determined by thematic saturation. Transcribed interviews were double-coded and analyzed in NVivo using an integrated analysis approach.

Results
Forty-one providers across eight departments were interviewed. There were variations in breast cancer guidelines used. Facilitators included a strong tension for change and a government-funded comprehensive cancer care plan. Common provider and health system barriers were lack of available resources, staff shortages and poor skills retention; lack of relative priority compared to HIV/AIDS, suboptimal interdepartmental communication and lack of a clearly defined national cancer control policy. Community-level barriers included accessibility and associated transportation costs. Participants recommended the formal implementation of future guidelines that involved key stakeholders in all phases of planning and implementation, strategic government buy-in, expansion of multidisciplinary tumor boards, leveraging non-governmental and academic partnerships, and setting-up monitoring, evaluation and feedback processes.

Discussion
The study identified complex, multi-level factors affecting breast cancer treatment delivery in Botswana. These results and recommendations will inform strategies to overcome specific barriers in order to promote standardized breast cancer care delivery and improve survival outcomes.

Implications for Practice
To address the increasing cancer burden in low- and middle-income countries, resource-stratified guidelines have been developed by multiple international organizations to promote high quality guideline-concordant care. However, these guidelines still require adaptation in order to be successfully translated into clinical practice in the countries where they intend to be used. This study highlights a systematic approach of evaluating important contextual factors associated with the successful adaptation and implementation of resource-stratified guidelines in sub-Saharan Africa. In Botswana, there is a critical need for local stakeholder input to inform country-level and facility-level resources, cancer care accessibility and community-level barriers and facilitators.


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161. Barriers to Trauma Care in South and Central America: a systematic review

European Journal of Orthopaedic Surgery & Traumatology


Authors: Florence Kinder, Sarah Mehmood, Harry Hodgson, Peter Giannoudis , Anthony Howard
Region / country: Central America, South America
Speciality: Trauma surgery

Introduction
Trauma is widespread in Central and South America and is a significant cause of morbidity and mortality. Providing high quality emergency trauma care is of great importance. Understanding the barriers to care is challenging; this systematic review aims to establish current the current challenges and barriers in providing high-quality trauma care within the 21 countries in the region.

Methods
OVID Medline, Embase, EBM reviews and Global Health databases were systematically searched in October 2020. Records were screened by two independent researchers. Data were extracted according to a predetermined proforma. Studies of any type, published in the preceding decade were included, excluding grey literature and non-English records. Trauma was defined as blunt or penetrating injury from an external force. Studies were individually critically appraised and assessed for bias using the RTI item bank.

Results
57 records met the inclusion criteria. 20 countries were covered at least once. Nine key barriers were identified: training (37/57), resources and equipment (33/57), protocols (29/57), staffing (17/57), transport and logistics (16/57), finance (15/57), socio-cultural (13/57), capacity (9/57), public education (4/57).

Conclusion
Nine key barriers negatively impact on the provision of high-quality trauma care and highlight potential areas for improving care in Central & South America. Many countries in the region, along with rural areas, are under-represented by the current literature and future research is urgently required to assess barriers to trauma management in these countries.


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162. Counselling and pregnancy outcomes in women with congenital heart disease- current status and gap analysis from Madras Medical College Pregnancy And Cardiac disease (M-PAC) registry

International Journal of Cardiology Congenital Heart Disease


Authors: Justin Paul Gnanaraja, Anne Princy , Anju Surendran , on behalf of the M-PAC investigators
Region / country: Southern Asia – India
Speciality: Cardiothoracic surgery, Obstetrics and Gynaecology

Introduction
Congenital heart disease (CHD) is becoming an increasingly important cause of heart disease in pregnancy in low- and middle – income countries (LMICs). Preconception and contraception counselling based on risk stratification has the potential to reduce maternal complications. Data is lacking from LMICs on the availability and effectiveness of preconception counselling (PCC) in women with CHD (WWCHD).

Methods
Madras Medical College Pregnancy and Cardiac disease (M-PAC) Registry is a single center prospective observational registry conducted at a tertiary referral institution in South India from July 2016 to December 2019. Baseline features and feto-maternal outcomes were compared in WWCHD with and without PCC. Predictors of post-delivery contraception were identified.

Results
Of the 107 eligible pregnancies with data on counselling, only 49.5% had received PCC. Pregnancies involving women with corrected CHDs (62.3% vs 33.3%; P ​= ​0.006) and cyanotic CHD (20.8% vs 11.1%; P ​= ​0.042) were more likely to get PCC. High risk mWHO categories were non-significantly less likely to get PCC (32% vs 39%). Primary outcome of death or heart failure was non-significantly low in the PCC group (3.8% vs 7.4% P ​= ​0.4). Patients with high risk m WHO categories were less likely to get Tier I contraceptives post-delivery (46% vs 79.7% P ​= ​0.004).

Conclusion
Preconception and post conception counselling, which have the potential to improve outcome in WWCHD, are being underused in LMICs. Health care systems should ensure multidisciplinary pregnancy and heart team approach to offer timely lesion specific pre-conceptional counselling, shared decision making and appropriate peri-pregnancy care for WWCHD.


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163. Burden of disease among the world’s poorest billion people: An expert-informed secondary analysis of Global Burden of Disease estimates

plos one


Authors: Matthew M. Coates,Majid Ezzati,Gisela Robles Aguilar,Gene F. Kwan,Daniel Vigo,Ana O. Mocumbi,Anne E. Becker,Julie Makani,Adnan A. Hyder,Yogesh Jain,D. Cristina Stefan,Neil Gupta,Andrew Marx,Gene Bukhman
Region / country: Global
Speciality: Health policy

Background
The health of populations living in extreme poverty has been a long-standing focus of global development efforts, and continues to be a priority during the Sustainable Development Goal era. However, there has not been a systematic attempt to quantify the magnitude and causes of the burden in this specific population for almost two decades. We estimated disease rates by cause for the world’s poorest billion and compared these rates to those in high-income populations.

Methods
We defined the population in extreme poverty using a multidimensional poverty index. We used national-level disease burden estimates from the 2017 Global Burden of Disease Study and adjusted these to account for within-country variation in rates. To adjust for within-country variation, we looked to the relationship between rates of extreme poverty and disease rates across countries. In our main modeling approach, we used these relationships when there was consistency with expert opinion from a survey we conducted of disease experts regarding the associations between household poverty and the incidence and fatality of conditions. Otherwise, no within-country variation was assumed. We compared results across multiple approaches for estimating the burden in the poorest billion, including aggregating national-level burden from the countries with the highest poverty rates. We examined the composition of the estimated disease burden among the poorest billion and made comparisons with estimates for high-income countries.

Results
The composition of disease burden among the poorest billion, as measured by disability-adjusted life years (DALYs), was 65% communicable, maternal, neonatal, and nutritional (CMNN) diseases, 29% non-communicable diseases (NCDs), and 6% injuries. Age-standardized DALY rates from NCDs were 44% higher in the poorest billion (23,583 DALYs per 100,000) compared to high-income regions (16,344 DALYs per 100,000). Age-standardized DALY rates were 2,147% higher for CMNN conditions (32,334 DALYs per 100,000) and 86% higher for injuries (4,182 DALYs per 100,000) in the poorest billion, compared to high-income regions.

Conclusion
The disease burden among the poorest people globally compared to that in high income countries is highly influenced by demographics as well as large disparities in burden from many conditions. The comparisons show that the largest disparities remain in communicable, maternal, neonatal, and nutritional diseases, though NCDs and injuries are an important part of the “unfinished agenda” of poor health among those living in extreme poverty.


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164. Estimating the Specialist Surgical Workforce Density in South Africa

annals of global health


Authors: Ritika Tiwari , Usuf Chikte, Kathryn M. Chu
Region / country: Southern Africa – South Africa
Speciality: Anaesthesia, General surgery, Health policy, Obstetrics and Gynaecology

Background: South Africa is an upper middle-income country with inequitable access to healthcare. There is a maldistribution of doctors between the private and public sectors, the latter which serves 86% of the population but has less than half of the human resources.

Objective: The objective of this study was to estimate the specialist surgical workforce density in South Africa.

Methods: This was a retrospective record-based review of the specialist surgical workforce in South Africa as defined by registration with the Health Professionals Council of South Africa for three cadres: 1) surgeons, and 2) anaesthesiologists, and 3) obstetrician/gynaecologists (OBGYN).

Findings: The specialist surgical workforce in South Africa doubled from 2004 (N = 2956) to 2019 (N = 6144). As of December 2019, there were 3096 surgeons (50.4%), 1268 (20.6%) OBGYN, and 1780 (29.0%) anaesthesiologists. The specialist surgical workforce density in 2019 was 10.5 per 100,000 population which ranged from 1.8 in Limpopo and 22.8 per 100,000 in Western Cape province. The proportion of females and those classified other than white increased between 2004–2019.

Conclusion: South Africa falls short of the minimum specialist workforce density of 20 per 100,000 to provide adequate essential and emergency surgical care. In order to address the current and future burden of disease treatable by surgical care, South Africa needs a robust surgical healthcare system with adequate human resources, to translate healthcare services into improved health outcomes.


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165. Role of General Practitioners in transforming surgical care in rural Nepal – A descriptive study from eastern Nepal.

Journal of General Practice and Emergency Medicine of Nepal


Authors: Binod Dangal, Jessica Yuen Kwan Ng, Bikash Gauchan, Man Bahadur Khadka, Mandeep Pathak
Region / country: Southern Asia – Nepal
Speciality: General surgery, Obstetrics and Gynaecology, Trauma and orthopaedic surgery

Introduction: Nepal is a low-to-middle-income country (LMIC) with a predominantly rural population. Almost 10-20% of patients presenting to hospital require surgical care. The availability of skilled human resources in managing surgical care in rural areas of Nepal has to expand to meet this need. The objective of this study is to describe and demonstrate how General Practitioners (GPs) can be upskilled to provide surgical care in rural district hospitals in Nepal.

Method: It is a retrospective review of all surgical procedures performed by GPs from 1st February 2016 to 31st January 2021 at Charikot hospital. Data was collected from a prospectively maintained Electronic Health Record (EHR) system (Bahmini). Details of data collected included name of the procedure and its respective specialty. GP Task shifting and targeted surgical training programs for common orthopedic procedures and pediatric herniotomy were described in detail.

Result: A wide range of surgical procedures were performed by GPs over 5 years. This included interventions for obstetric emergencies, trauma and orthopedics, gynecological issues, general surgery of adult and childhood. A total of 2037 surgeries were performed by GPs including: Cesarean section 25%, 19.7% were orthopedics surgeries followed by 13.5% of mesh repair for abdominal hernia, 9.3% eversion of sac for Hydrocele, 8.7% appendectomy, 5.2% hysterectomy, 3% of pediatric herniotomy and others.

Conclusion: GPs can be further trained to perform important common surgical procedures to improve access to surgical care for rural communities.


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166. Vision impairment and traffic safety outcomes in low-income and middle-income countries: a systematic review and meta-analysis

the lancet global health


Authors: Prabhath Piyasena, Victoria Odette Olvera-Herrera, Ving Fai Chan, Prof Mike Clarke, David M Wright , Graeme MacKenzie , Prof Gianni Virgili , Prof Nathan Congdon
Region / country: Global
Speciality: Health policy, Ophthalmology, Trauma surgery

Background
Road traffic injuries are a major public health concern and their prevention requires concerted efforts. We aimed to systematically analyse the current evidence to establish whether any aspects of vision, and particularly interventions to improve vision function, are associated with traffic safety outcomes in low-income and middle-income countries (LMICs).

Methods
We did a systematic review and meta-analysis to assess the association between poor vision and traffic safety outcomes. We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials in the Cochrane Library from database inception to April 2, 2020. We included any interventional or observational studies assessing whether vision is associated with traffic safety outcomes, studies describing prevalence of poor vision among drivers, and adherence to licensure regulations. We excluded studies done in high-income countries. We did a meta-analysis to explore the associations between vision function and traffic safety outcomes and a narrative synthesis to describe the prevalence of vision disorders and adherence to licensure requirements. We used random-effects models with residual maximum likelihood method. The systematic review protocol was registered on PROSPERO, CRD-42020180505.

Findings
We identified 49 (1·8%) eligible articles of 2653 assessed and included 29 (59·2%) in the various data syntheses. 15 394 participants (mean sample size n=530 [SD 824]; mean age of 39·3 years [SD 9·65]; 1167 [7·6%] of 15 279 female) were included. The prevalence of vision impairment among road users ranged from 1·2% to 26·4% (26 studies), colour vision defects from 0·5% to 17·1% (15 studies), and visual field defects from 2·0% to 37·3% (ten studies). A substantial proportion (range 10·6–85·4%) received licences without undergoing mandatory vision testing. The meta-analysis revealed a 46% greater risk of having a road traffic crash among those with central acuity visual impairment (risk ratio [RR] 1·46 [95% CI 1·20–1·78]; p=0·0002, 13 studies) and a greater risk among those with defects in colour vision (RR 1·36 [1·01–1·82]; p=0·041, seven studies) or the visual field (RR 1·36 [1·25–1·48]; p<0·0001, seven studies). The I2 value for overall statistical heterogeneity was 63·4%.

Interpretation
This systematic review shows a positive association between vision impairment and traffic crashes in LMICs. Our findings provide support for mandatory vision function assessment before issuing a driving licence.


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167. Incidence patterns, care continuum and impact of treatment on survival among women with breast cancer in Ghana and the United States

University of Minnesota Digital Conservancy


Authors: Mburu Eddah
Region / country: Northern America, Western Africa – Ghana, United States of America
Speciality: General surgery, Surgical oncology

Breast cancer is the most commonly diagnosed cancer among women worldwide. Of the five breast cancer subtypes, triple negative breast cancer (TNBC) is the most aggressive subtype. Black women in the US and Ghana are more likely to be diagnosed with TNBC, at young ages and advanced stages. Combining information from Ghana and the US, this project identified the breast cancer care continuum in Ghana, examined the breast cancer incidence patterns in Ghana and the US and assessed the optimal surgical treatment for TNBC. In the first manuscript, we examined how women in Ghana navigate the healthcare system and factors that influence their decisions and ability to seek and access breast cancer care. We interviewed thirty-one women diagnosed with breast cancer in Kumasi, Ghana. Based on the findings from the interviews, we presented a framework showing specific steps in the pathways and how women transition from one step to another. In the second manuscript, we assessed factors explaining the younger age at breast cancer diagnosis among Ghanaian women compared to women in the US. To achieve these aims we analyzed breast cancer data from the Kumasi Cancer Registry, the only population-based cancer registry in Ghana, and compared it to the US Surveillance, Epidemiology and End Results (SEER) data. Population age structure, screening and cohort effects explain the younger age at breast cancer diagnosis among women in Ghana In the third manuscript, we examined whether the poor prognosis of TNBC warrants a more aggressive surgical approach and whether there is value in expanded use of radiation therapy among women with TNBC who receive mastectomy. We found that breast conserving surgery followed by radiotherapy is an effective treatment for women with early-stage TNBC. Findings from this dissertation are timely due to the rapidly rising burden of breast cancer in sub-Saharan Africa and persistent disparities in the US.


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168. The potential use of digital health technologies in the African context: a systematic review of evidence from Ethiopia

npj Digital Medicine


Authors: Tsegahun Manyazewal, Yimtubezinash Woldeamanuel, Henry M. Blumberg, Abebaw Fekadu & Vincent C. Marconi
Region / country: Eastern Africa – Ethiopia
Speciality: Digital health, Health policy

The World Health Organization (WHO) recently put forth a Global Strategy on Digital Health 2020–2025 with several countries having already achieved key milestones. We aimed to understand whether and how digital health technologies (DHTs) are absorbed in Africa, tracking Ethiopia as a key node. We conducted a systematic review, searching PubMed-MEDLINE, Embase, ScienceDirect, African Journals Online, Cochrane Central Registry of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform databases from inception to 02 February 2021 for studies of any design that investigated the potential of DHTs in clinical or public health practices in Ethiopia. This review was registered with PROSPERO (CRD42021240645) and it was designed to inform our ongoing DHT-enabled randomized controlled trial (RCT) (ClinicalTrials.gov ID: NCT04216420). We found 27,493 potentially relevant citations, among which 52 studies met the inclusion criteria, comprising a total of 596,128 patients, healthy individuals, and healthcare professionals. The studies involved six DHTs: mHealth (29 studies, 574,649 participants); electronic health records (13 studies, 4534 participants); telemedicine (4 studies, 465 participants); cloud-based application (2 studies, 2382 participants); information communication technology (3 studies, 681 participants), and artificial intelligence (1 study, 13,417 participants). The studies targeted six health conditions: maternal and child health (15), infectious diseases (14), non-communicable diseases (3), dermatitis (1), surgery (4), and general health conditions (15). The outcomes of interest were feasibility, usability, willingness or readiness, effectiveness, quality improvement, and knowledge or attitude toward DHTs. Five studies involved RCTs. The analysis showed that although DHTs are a relatively recent phenomenon in Ethiopia, their potential harnessing clinical and public health practices are highly visible. Their adoption and implementation in full capacity require more training, access to better devices such as smartphones, and infrastructure. DHTs hold much promise tackling major clinical and public health backlogs and strengthening the healthcare ecosystem in Ethiopia. More RCTs are needed on emerging DHTs including artificial intelligence, big data, cloud, cybersecurity, telemedicine, and wearable devices to provide robust evidence of their potential use in such settings and to materialize the WHO’s Global Strategy on Digital Health.


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169. Qualitative exploration of health system response to COVID-19 pandemic applying the WHO health systems framework: Case study of a Nigerian state

Scientific African


Authors: Oluwaseun Oladapo Akinyemi, Oluwafemi Akinyele Popoola, Adeol Fowotadec ,Olukemi Adekanmbid , Eniol O.Cadmus, AdebusolaAdebayo
Region / country: Western Africa – Nigeria
Speciality: Health policy

Pandemics can result in significantly high rates of morbidity and mortality with higher impact in Lower- and Middle-Income Countries like Nigeria. Health systems have an important role in a multi-sector response to pandemics, as there are already concerns that COVID-19 will significantly divert limited health care resources. This study appraised the readiness and resilience of the Nigerian health system to the COVID-19 pandemic, using Oyo State, southwest Nigeria, as a case study. This study was a cross-sectional qualitative study involving key informant and in-depth interviews. Purposive sampling was used in recruiting participants who were members of the Task Force on COVID-19 in the state and Emergency Operations Centre (EOC) members (physicians, nurses, laboratory scientists, “contact tracers”, logistic managers) and other partners. The state’s health system response to COVID 19 was assessed using the WHO health systems framework. Audio recordings of the interviews done in English were transcribed and thematic analysis of these transcripts was carried out using NVIVO software. Results show that the state government responded promptly by putting in place measures to address the COVID-19 pandemic. However, the response was not adequate owing to the fact that the health system has already been weakened by various challenges like poor funding of the health system, shortage of human resources and inadequate infrastructure. These contributed to the health system’s sub-optimal response to the pandemic. In order to arm the health system for adequate and appropriate response during major health disasters like pandemics, fundamental pillars of the health system-finance, human resources, information and technology, medical equipment and leadership – need to be addressed in order to have a resilient health system.


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170. Procedural fairness for radiotherapy priority setting in a low resource context

Bioethics


Authors: Rebecca J. DeBoer, Cam Nguyen, Espérance Mutoniwase, Anita Ho, Grace Umutesi, Jean Bosco Bigirimana, Scott A. Triedman, Cyprien Shyirambere
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Other, Surgical oncology

Radiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve their populations. This mismatch between demand and supply creates the need for priority setting. There is no widely accepted system to guide patient prioritization for radiotherapy in a low resource context. In the absence of consensus on allocation principles, fair procedures for priority setting should be established. Research is needed to understand what elements of procedural fairness are important to decision makers in diverse settings, assess the feasibility of implementing fair procedures for priority setting in low resource contexts, and improve these processes. This study presents the views of decision makers engaged in everyday radiotherapy priority setting at a cancer center in Rwanda. Semi-structured interviews with 22 oncology physicians, nurses, program leaders, and advisors were conducted. Participants evaluated actual radiotherapy priority setting procedures at the program (meso) and patient (micro) levels, reporting facilitators, barriers, and recommendations. We discuss our findings in relation to the leading Accountability for Reasonableness (AFR) framework. Participants emphasized procedural elements that facilitate adherence to normative principles, such as objective criteria that maximize lives saved. They ascribed fairness to AFR’s substantive requirement of relevance more than transparency, appeals, and enforcement. They identified several challenges unresolved by AFR, such as conflicting relevant rationales and unintended consequences of publicity and appeals. Implementing fair procedure itself is resource intensive, a paradox that calls for innovative, context-appropriate solutions. Finally, socioeconomic and structural barriers to care that undermine procedural fairness must be addressed.


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171. The revival of telemedicine in the age of COVID-19: Benefits and impediments for Pakistan

Annal of Medecine & Surgery


Authors: Maheera Farooqi, Irfan Ullah, Muhammad Irfan, Anab Rehan Taseer, Talal Almas, Mohammad Mehedi Hasan, Fatima Muhammad Asad Khan, Abdulaziz Alshamlan, Abdulaziz Abdulhadi, Vikneswaran Raj Nagarajand
Region / country: Southern Asia – Pakistan
Speciality: Digital health, Other

Dear Editor

Defined as “the use of information and telecommunication technologies (ICT) in medicine, telemedicine intends to provide appropriate healthcare at a distance, hence eliminating the need for direct contact between a patient and physician [1]. It can be classified according to the type of interaction (pre-recorded or real-time) and type of format in which information is conveyed (videos, pictures, audio, etc.) [2]. Particularly in the setting of a natural or man-made disaster, telemedicine is known to function as a key component in the emergency response, enabling people to access routine care and health support despite widespread disruptions in health services [3].

The relevance of telemedicine to our health systems is more evident than ever today as we continue to battle the COVID- 19 pandemic that has modified our lifestyle and approach to medical care. In the face of lockdowns and social distancing protocols, telemedicine technologies are being employed for online consultations, monitoring and evaluating symptoms, tracking and circumventing COVID-19 hotspots, and addressing individual concerns through chat bots [4].

Although the age of COVID-19 has significantly propelled the adoption of telemedicine services globally, its market was booming even prior to the onset of the COVID-19 pandemic, with a market size estimated around US$50 billion as of 2019, projected to increase over 9-fold in the coming decade [5]. A growing body of literature supports the role of telemedicine in providing timely, affordable, and premium quality healthcare services surpassing geographical barriers, which is especially advantageous for resource limited countries. However, while it is being integrated in the health infrastructure in USA, Europe and South East Asia with increasing momentum, its future in the developing world remains obscure [6].

Although the rate is considerably slower than developed countries, developing countries are gradually adapting to the changing times with efforts to make high-quality healthcare accessible to the masses from the comfort of their residence via digital interventions. Sub-Saharan Africa, for example, has reported a significant increase in mobile health technology [7]. The implementation of telemedicine amid a concomitant burden of communicable and non-communicable diseases in low and middle income countries (LMICs) can have consequential impacts in addressing the basic health needs of the population. By reducing travel costs and time, telemedicine enables rural and marginalized communities to access the same quality of medical resources and care as urban dwellers, and promotes health equity [6].


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172. Outcomes of Renal Trauma in Indian Urban Tertiary Healthcare Centres: A Multicentre Cohort Study

World Journal of Surgery


Authors: Bhakti Sarang, Nakul Raykar, Anita Gadgil, Gunjan Mishra, Martin Gerdin Wärnberg, Amulya Rattan, Monty Khajanchi, Kapil Dev Soni, Monali Mohan, Naveen Sharma, Vineet Kumar, Deepa KV & Nobhojit Roy On behalf of the Towards Improved Trauma Care Outcomes TITCO-India
Region / country: Southern Asia – India
Speciality: General surgery, Trauma surgery, Urology surgery

Background
Renal trauma is present in 0.5–5% of patients admitted for trauma. Advancements in radiologic imaging and minimal-invasive techniques have led to decreased need for surgical intervention. We used a large trauma cohort to characterise renal trauma patients, their management and outcomes.

Methods
We analysed “Towards Improved Trauma Care Outcomes in India” cohort from four urban tertiary public hospitals in India between 1st September 2013 and 31st December 2015. The data of patients with renal trauma were extracted using International Classification of Diseases 10 codes and analysed for demographic and clinical details.

Results
A total of 16,047 trauma patients were included in this cohort. Abdominal trauma comprised 1119 (7%) cases, of which 144 (13%) had renal trauma. Renal trauma was present in 1% of all the patients admitted for trauma. The mean age was 28 years (SD-14.7). A total of 119 (83%) patients were male. Majority (93%) were due to blunt injuries. Road traffic injuries were the most common mechanism (53%) followed by falls (29%). Most renal injuries (89%) were associated with other organ injuries. Seven of the 144 (5%) patients required nephrectomy. Three patients had grade V trauma; all underwent nephrectomy. The 30-day in-hospital mortality, in patients with renal trauma, was 17% (24/144).

Conclusion
Most renal trauma patients were managed nonoperatively. 89% of patients with renal trauma had concomitant injuries. The renal trauma profile from this large cohort may be generalisable to urban contexts in India and other low- and middle-income countries.


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173. Trauma Registry Data as a Policy-Making Tool: A Systematic Review on the Research Dimensions

Bulletin of Emergency And Trauma


Authors: Mohammadreza Mobinizadeh , Farzan Berenjian , Efat Mohammadi , Farhad Habibi , Alireza Olyaeemanesh , Kazem Zendedel, Mahdi Sharif-Alhoseini
Region / country: Global
Speciality: Health policy, Trauma surgery

Objective: To review the research dimensions of trauma registry data on health policy making.
Methods: PubMed and EMBASE were searched until July 2020. Keywords were used on the search process included Trauma, Injury, Registry and Research, which were searched by using appropriate search strategies. The included articles had to: 1. be extracted from data related to trauma registries; 2- be written in English; 3- define a time period and a patient population; 4- preferably have more details and policy recommendations; and 5- preferably have a discussion on how to improve diagnosis and treatment. The results obtained from the included studies were qualitatively analyzed using thematic synthesis and comparative tables.
Results: In the primary round of search, 19559 studies were retrieved. According to PRISMA statement and also performing quality appraisal process, 30 studies were included in the final phase of analysis. In the final papers’ synthesis, 14 main research domains were extracted and classified in terms of the policy implication and research priority. The domains with the highest frequency were “The relationship between trauma registry data and hospital care protocols for trauma patients” and “The causes of Disability Adjusted Life Years (DALYs) due to trauma”.
Conclusion: Using trauma registry data as a tool for policy-making could be helpful in several ways, namely increasing the quality of patient care, preventing injuries and decreasing their number, figuring out the details of socioeconomic status effects, and improving the quality of researches in practical ways. Also, follow-up of patients after trauma surgery as one of the positive effects of the trauma registry can be the focus of attention of policy-making bodies.


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174. Nursing students’ experiences with simulation-based education as a pedagogic method in low-resource settings: A mixed-method study

Journal of Clinical Nursing


Authors: Bodil Bø , Bartholomayo Paulo Madangi , Hanitra Ralaitafika , Hege Langli Ersdal , Ingrid Tjoflåt
Region / country: Eastern Africa, Southern Africa – Madagascar, Tanzania
Speciality: Surgical Education

Aims and Objectives
This study introduced simulation-based education in nurse education programs in Tanzania and Madagascar and explored nursing students’ experiences with this pedagogic method as a mode of learning.

Background
Simulation-based education has barely been introduced to education programs in resource-constrained settings. The study was conducted in two nurse education programs: one in rural Tanzania and the other in the mid-land of Madagascar. Both institutions offer diploma programs in nursing. Simulation-based education has not been included in the teaching methods used in these nursing programs.

Design
A descriptive and convergent mixed method design was employed.

Methods
Ninety-nine nursing students were included in the study. Simulation sessions followed by data collection took place once in 2017 and twice in 2018. Data were collected by means of several questionnaires and six focus groups. The data were analyzed using descriptive statistics and qualitative content analysis. The Standards for Reporting Qualitative Research (SRQR) was used to report the results.

Results
The quantitative data revealed that the students rated all the questions related to the simulation design elements, educational practices, and students’ satisfaction and self-confidence in learning with scores of above four on a 5-point Likert scale. The qualitative data from the first theme, building competence and confidence, further emphasized and outlined the quantitative results. Additionally, the qualitative data revealed a second theme, improving through encouragement and corrections. The students clearly expressed that they wanted to be aware of their weaknesses to be able to improve; however, the provision of feedback should be carried out in an encouraging way.

Conclusion
The findings indicated that the nursing students were satisfied with simulation as a pedagogic method, as it improved their competence and prepared them for professional practice. Further research is necessary to explore whether the students are able to transfer their knowledge into clinical practice.


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175. Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study

The Lancet Regional Health – Americas


Authors: Paul Truchea, Letícia Nunes Campos, Enzzo Barrozo Marrazzo, Ayla Gerk Rangel, Ramon Bernardino, Alexis N Bowder, Alexandra M Buda, Isabella Faria, Laura Pompermaier, Henry E. Ricef, David Watters, Fernanda Lage Lima Dantas, David P. Mooneyi, Fabio Botelhoj, Rodrigo Vaz Ferreira, Nivaldo Alonso
Region / country: South America – Brazil
Speciality: Critical care, Emergency surgery, General surgery, Health policy

Background
The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care.

Methods
Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil’s Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state.

Findings
Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog.

Interpretation
Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.


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176. Training programme in gasless laparoscopy for rural surgeons of India (TARGET study) – Observational feasibility study

International Journal of Surgery Open


Authors: N. Aruparayil , J. Gnanaraj , S. Maiti , M. Chauhan , A. Quyn , A. Mishra , L. Bains , G. Mathew , C. Harris , B. Cundill , A. Fellows , K. Gordon , B. Dawkins , B. Shinkins , J. Brown , D. Jayne
Region / country: Southern Asia – India
Speciality: General surgery, Surgical Education

Background
Benefits of laparoscopic surgery are well recognised but uptake in rural settings of low- and middle-income countries is limited due to implementation barriers. Gasless laparoscopy has been proposed as an alternative but requires a trained rural surgical workforce to upscale. This study evaluates a feasibility of implementing a structured laparoscopic training programme for rural surgeons of North-East India.

Methods
A 3-day training programme was held at Kolkata Medical College in March 2019. Laparoscopic knowledge and Fundamentals of Laparoscopic Skills (FLS) were assessed pre and post simulation training using multiple choice questions and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), respectively. Competency with an abdominal lift device was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and live operating performance via the Global Operative Assessment of Laparoscopic Skills (GOALS) scores during live surgery. Costs of the training programme and qualitative feedback were evaluated.

Results
Seven rural surgeons participated. There was an improvement in knowledge acquisition (mean difference in MCQ score 5.57 (SD = 4.47)). The overall normalised mean MISTELS score for the FLS tasks improved from 386.02 (SD 110.52) pre-to 524.40 (SD 94.98) post-training (p = 0.09). Mean OSATS score was 22.4 out of 35 (SD 3.31) indicating competency with the abdominal lift device whilst a mean GOALS score of 16.42 out of 25 (SD 2.07) indicates proficiency in performing diagnostic laparoscopy using the gasless technique during live operating. Costs of the course were estimated at 354 USD for trainees and 461 USD for trainers.

Conclusion
Structured training programme in gasless laparoscopy improves overall knowledge and skills acquisition in laparoscopic surgery for rural surgeons of North-East India. It is feasible to deliver a training programme in gasless laparoscopy for rural surgeons. Larger studies are needed to assess the benefits for wider adoption in a similar context.


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177. Global Surgery Education and Training Programmes—a Scoping Review and Taxonomy

Indian Journal of Surgery


Authors: Eric O’Flynn, Arbab Danial , Jakub Gajewski
Region / country: Global
Speciality: Health policy, Surgical Education

Global surgery is an emerging field of study and practice, aiming to respond to the worldwide unmet need for surgical care. As a relatively new concept, it is not clear that there is a common understanding of what constitutes “global surgery education and training”. This study examines the forms that global surgery education and training programmes and interventions take in practice, and proposes a classification scheme for such activities. A scoping review of published journal articles and internet websites was performed according to the PRISMA Extension for Scoping Review guidelines. PubMed MEDLINE, EMBASE and Google were searched for sources that described global surgery education and training programme. Only sources that explicitly referenced a named education programme, were surgical in nature, were international in nature, were self-described as “global surgery” and presented new information were included. Three hundred twenty-seven records were identified and 67 were ultimately included in the review. “Global surgery education and training” interventions described in the literature most commonly involved both a High-Income Country (HIC) institution and a Low- and Middle-Income Country (LMIC) institution. The literature suggests that significant current effort is directed towards academic global surgery programmes in HIC institutions and HIC surgical trainee placements in LMICs. Four categories and ten subcategories of global surgery education and training were identified. This paper provides a framework from which to study global surgery education and training. A clearer understanding of the forms that such interventions take may allow for more strategic decision making by actors in this field


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178. Interventions for health workforce retention in rural and remote areas: a systematic review

Human Resources for Health


Authors: Deborah Russell, Supriya Mathew, Michelle Fitts, Zania Liddle, Lorna Murakami-Gold, Narelle Campbell, Mark Ramjan, Yuejen Zhao, Sonia Hines, John S. Humphreys, John Wakerman
Region / country: Global
Speciality: Health policy

Background
Attracting and retaining sufficient health workers to provide adequate services for residents of rural and remote areas has global significance. High income countries (HICs) face challenges in staffing rural areas, which are often perceived by health workers as less attractive workplaces. The objective of this review was to examine the quantifiable associations between interventions to retain health workers in rural and remote areas of HICs, and workforce retention.

Methods
The review considers studies of rural or remote health workers in HICs where participants have experienced interventions, support measures or incentive programs intended to increase retention. Experimental, quasi-experimental and observational study designs including cohort, case–control, cross-sectional and case series studies published since 2010 were eligible for inclusion. The Joanna Briggs Institute methodology for reviews of risk and aetiology was used. Databases searched included MEDLINE (OVID), CINAHL (EBSCO), Embase, Web of Science and Informit.

Results
Of 2649 identified articles, 34 were included, with a total of 58,188 participants. All study designs were observational, limiting certainty of findings. Evidence relating to the retention of non-medical health professionals was scant. There is growing evidence that preferential selection of students who grew up in a rural area is associated with increased rural retention. Undertaking substantial lengths of rural training during basic university training or during post-graduate training were each associated with higher rural retention, as was supporting existing rural health professionals to extend their skills or upgrade their qualifications. Regulatory interventions requiring return-of-service (ROS) in a rural area in exchange for visa waivers, access to professional licenses or provider numbers were associated with comparatively low rural retention, especially once the ROS period was complete. Rural retention was higher if ROS was in exchange for loan repayments.

Conclusion
Educational interventions such as preferential selection of rural students and distributed training in rural areas are associated with increased rural retention of health professionals. Strongly coercive interventions are associated with comparatively lower rural retention than interventions that involve less coercion. Policy makers seeking rural retention in the medium and longer term would be prudent to strengthen rural training pathways and limit the use of strongly coercive interventions.


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179. ERAS Society Recommendations for Improving Perioperative Care in Low- and Middle-Income Countries Through Implementation of Existing Tools and Programs: An Urgent Need for the Surgical Safety Checklist and Enhanced Recovery After Surgery

World Journal of Surgery


Authors: Ravi Oodit, Bruce Biccard, Gregg Nelson, Olle Ljungqvist , Mary E. Brindle
Region / country: Global
Speciality: Anaesthesia, Critical care, Health policy

The Lancet Commission and Global Surgery Foundation in 2015 highlighted the need for access to safe and affordable surgical and anesthetic care in low- and middle-income countries (LMICs) [1]. Patients that do have access to care in LMICs, however, have a higher risk of complications and mortality than in high-income countries (HICs). Ninety-six percent of all perioperative deaths worldwide occur in LMICs, and the economic impact of this is a staggering 2.6% of the combined gross domestic product of LMICs [1]. Although it is a common belief that the greatest contributors to adverse outcomes in LMICs are poor access to care and late presentation, deficits in the quality of accessible care are a substantial concern.

Following the Lancet Commission and the World Health Assembly Resolution 68.15, all member countries committed to developing a National, Surgical, Obstetric and Anaesthesia Plan (NSOAP) to assist in improving access to safe surgery and anesthesia [1]. The missing link in the NSOAP strategy is support for the implementation of standardized, evidence-based perioperative care guidelines and tools to measure guideline compliance and outcomes. This is crucial not only because of the need to improve perioperative care but as access to safe surgery and anesthesia improves, there is likely to be increased patient volume and pressure on the healthcare system to provide quality surgical care. A new set of tools need not be developed to improve perioperative care in LMICs. These tools already exist with evidence for their effectiveness. The Surgical Safety Checklist (SSC) and Enhanced Recovery After Surgery (ERAS) Program are two examples [2, 3]. Barriers to acceptance, adoption, and implementation of existing tools present the greatest hurdles that must be overcome to improve perioperative outcomes in LMICs.

The SSC is a communication tool used by the surgical team to confirm that appropriate actions are taken in the perioperative period to maintain patient safety. At the same time, the three pause points within the checklist include conversation prompts to ensure there is a shared understanding between the surgical team members. The SSC was designed to optimize its effectiveness in LMICs with a focus on influencing globally relevant outcomes using recommendations that are applicable and supported by the resources in LMICs. As a result, the use of the SSC has been shown to significantly reduce perioperative morbidity and mortality in LMICs as well as in HIC settings, and its impact may be larger when implemented well in LMICs [2].

Despite evidence of effectiveness, the acceptance and adoption of the SSC remain poor in LMICs with ranges between 20 and 40% when compared with facilities in HIC where rates of adoption range between 80 and 95% [4]. The reasons for this failed penetrance relate to a lack of resources and infrastructure for initial and ongoing implementation and audits and surgical hierarchies that may not support aspects of the SSC, such as encouraging all members of the team to vocalize concerns if they exist. The barriers to successful implementation are further exacerbated by checklist fatigue and similar factors that also lead to decreased meaningful use in HICs. The need for improved implementation of the SSC in LMICs has been recognized by global health organizations. With this increased focus on quality and safety initiatives and implementation, it is time to consider other strategies for improvement.

ERAS is another tool that has the potential to benefit LMICs with strategies that have demonstrated benefits across a variety of settings and clinical outcomes [3]. The ERAS program is based on implementation of evidence-based clinical practice guidelines performed by a multidisciplinary perioperative team, using tools to monitor and evaluate compliance to the guidelines and patient outcomes concurrently. Randomized trials of ERAS-based care vs traditional care conducted in HICs have shown a significant reduction in length of stay (20–40%) and complications (20–30%). Cost studies of ERAS have demonstrated a return-on-investment ratio up to 7.3 (i.e., a savings of $7.3 for every $1 invested), showing that ERAS is value-based surgery [3].

There are few established ERAS programs in LMICs, however, data from these centers demonstrate similar benefits to HICs [5]. Whether these benefits can be achieved at scale remains unknown, and the crux of the issue relates to how ERAS is applied in tertiary-university centers in LMICs compared to the district and regional levels. ERAS guidelines in their current format are specialty-specific, predominantly for elective procedures, and thus likely to be easily implemented in tertiary-university LMIC hospitals, which have similar subspecialty units. The implementation in these units will have the added benefit of facilitating the teaching and training of all perioperative team members.

The greatest unmet surgical and anesthetic need is, however, at the district and regional level in LMICs [1]. Unlike tertiary hospitals, surgery in these centers is often performed on an emergency basis by surgeons with no sub-specialty training. To address this gap, the ERAS® Society, in partnership with the World Bank and perioperative leaders in LMICs, has undertaken the development of a generic perioperative ERAS® Society guideline for elective and emergency surgery. This approach will integrate the SSC and be applied to patients undergoing a variety of operations including general and obstetrical surgery. These practices will focus on key ERAS measures such as patient education/engagement, avoidance of opioids and prolonged fasting, early mobilization, and early feeding. In addition to these guidelines, the ERAS® Society and World Bank are developing a tailored implementation program and monitoring tool to assess guideline compliance and patient outcomes specifically targeted to LMICs.

ERAS and the SSC share a similar quality that makes them well-suited for adoption in poorly resourced settings—that is their adaptability. Both tools are designed to be tailored to suit the context in which they will be adopted. Combining the NSOAP strategy with existing tools such as SSC and ERAS have the potential to provide a platform to improve the quality of surgical care in LMICs with improved patient outcomes and service efficiency, at scale, rapidly and make a significant contribution to addressing the unmet surgical and anesthetic need in LMICs.


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180. Letter: Global Neurosurgery Scope and Practice

Neurosurgery Open


Authors: Ulrick Sidney Kanmounye, Ignatius N Esene
Region / country: Global
Speciality: Health policy, Neurosurgery

To the Editor:

Russell Andrews, the global neurosurgery section editor at the World Neurosurgery journal, argues that it is difficult to define global neurosurgery because of the breadth of articles labeling themselves as global neurosurgery.1 There are numerous definitions of global neurosurgery, but we will discuss 2 commonly used definitions. First, the World Federation of Neurosurgical Societies’ Global Neurosurgery Committee (WFNS GNC) defines global neurosurgery as, “The clinical and public health practice of neurosurgery with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it.”2 Next, we can define global neurosurgery based on the definition of global surgery by Bath et al,3 that is, “the enterprise of providing improved and equitable [neuro]surgical care to the world’s population, with its core tenets as the issues of need, access, and quality.”3 The 2 definitions have more in common than they differ from one another, and the differences alone cannot explain the confusion around what is and is not global neurosurgery.

Multiple factors are responsible for the confusion around the definition and scope of global neurosurgery. A chasm separates the academic global neurosurgery community from neurosurgeons and neurosurgical organizations working toward increasing accessibility in low-resource settings.1,4 Academic neurosurgery is responsible for the 2 definitions mentioned above (de facto definitions), whereas many within the neurosurgical community are familiar with a de jure definition. Historically, global neurosurgery has been viewed as high-income country (HIC) neurosurgeons and neurosurgical organizations delivering care or investing in low- and middle-income countries (LMICs).1 This narrative is responsible for the misconception that global neurosurgery is humanitarian or international neurosurgery. While all humanitarian and international neurosurgery falls in the realm of global neurosurgery, all global neurosurgery is not international or humanitarian. This de jure definition puts LMICs on the receiving end of partnerships and fails to acknowledge that global neurosurgery initiatives equally benefit HIC institutions and neurosurgeons. For example, neurosurgery has benefited greatly from reverse innovation, including the development of endoscopic third ventriculostomy with choroid plexus cauterization in Uganda.5

Moreover, the de jure definition assumes that lack of access to safe, timely, and affordable neurosurgical care is only true in LMICs. We know from recent studies that this is not true—for example, Rahman et al6 reported significant disparities in the geographic distribution of US neurosurgeons. Also, in a review of out-of-pocket expenditures for cranial surgery at a US center, Yoon et al7 reported an increase in the proportion of patients facing financial risk.

To clarify the misconception, we must return to the WFNS GNC’s definition. This definition does not differentiate between HICs and LMICs, and it does not focus on times of humanitarian crisis. As a result, we can say that global neurosurgery is not defined by the country’s income category but rather by the existence of barriers to seeking, reaching, and receiving safe, timely, and affordable neurosurgical care. To reach this goal, global neurosurgery borrows from health systems research to devise holistic solutions that will increase access to care.2–4

Early global neurosurgeons learned that staff education and purchase of equipment and consumables without buy-in from local leadership or investments in information management were unsustainable and inefficient.3,4 As a result, global neurosurgeons have adopted a systems-engineering mindset to identify problems and map out solutions.4 They analyze interactions between the health system’s components (workforce, service delivery, infrastructure, information management, funding, and governance). They design interventions in collaboration with stakeholders because they understand that health systems are complex and have many essential parts.8 No part can independently provide the output of the whole, and the health system’s performance is not always improved if its parts are improved independently.8 Similarly, a sports team will not be improved simply because the best players at each position have been recruited. Team managers must factor in the relationships between players, players’ strengths and weaknesses, and team culture during recruitment.


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181. Severe impact of COVID-19 pandemic on non-COVID patient care and health delivery: An observational study from a large multispecialty hospital of India

Indian Journal of Medical Sciences


Authors: Raju Vaishya​, Anupam Sibal, P. Shiva Kumar
Region / country: Southern Asia – India
Speciality: Critical care, Emergency surgery, Health policy

OBJECTIVES:
The COVID-19 pandemic has severely impacted health-care delivery globally, especially for non-COVID diseases. These cases received suboptimal attention and care during the pandemic. In this observational cohort study, we have studied the impact of the COVID-19 pandemic on various aspects of medical and surgical practices.

MATERIAL AND METHODS:
This observational, cross-sectional cohort study was performed on the data of a 710 bedded, multispecialty, and tertiary care corporate hospital of the national capital of India. The data of the pandemic period (April 1, 2020–March 31, 2021) were divided into three main groups and were then compared with the patient data of the preceding non-pandemic year (April 1, 2019–March 31, 2020) of more than six hundred thousand cases.

RESULTS:
From the data of 677,237 cases in these 2 years, we found a significant effect of COVID-19 pandemic on most spheres of clinical practice (P < 0.05), including outpatient attendance and surgical work. The specialties providing critical and emergency care were less affected. Although the total hospital admissions reduced by 34.07%, these were not statistically significant (P = 0.506), as the number of COVID-19 admissions took place during this time and compensated for the drop.

CONCLUSION:
The COVID-19 pandemic has significantly impacted health-care delivery to non-COVID cases across all the major medical and surgical specialties. Still, major urgent surgical and interventional work for cases was undertaken with due precautions, without waiting for the ongoing pandemic to end, as the delay in their treatment could have been catastrophic.


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182. Community engagement and involvement in Ghana: conversations with community stakeholders to inform surgical research

Research Involvement and Engagement


Authors: Karolin Kroese, Bernard Appiah Ofori, Darling Ramatu Abdulai, Mark Monahan, Angela Prah & Stephen Tabiri
Region / country: Western Africa – Ghana
Speciality: General surgery, Health policy

Background: Involving patients and communities with health research in low- and middle-income countries (LMICs) contributes to increasing the likelihood that research is relevant in local context and caters to the needs of the population, including vulnerable and marginalised groups. When done right, it can also support empowerment of wider communities in taking ownership of their own health, lead to increased access and uptake of health services and generally improve the wellbeing of individuals. However, the evidence base of how to undertake successful community engagement and involvement (CEI) activities in LMICs is sparse. This paper aims to add to the available literature and describes how the Global Health Research Unit on Global Surgery’s (GSU) team in Ghana worked collaboratively with the Unit’s team in the UK and a UK-based Public Advisory Group to involve community stakeholders in rural Ghana with surgical research. The aim was to explore ways of reaching out to patients and community leaders in rural Ghana to have conversations that inform the relevance, acceptability, and feasibility of a clinical trial, called TIGER.
Methods: As this kind of larger scale involvement of community stakeholders with research was a novel way of working for the team in Ghana, a reflective approach was taken to outline step-by-step how the GSU team planned and undertook these involvement activities with 31 hernia patients, two Chiefs (community leaders), a community finance officer and a local politician in various locations in Ghana. The barriers that were experienced and the benefits of involving community stakeholders are highlighted with the aim to add to the evidence base of CEI in LMICs.
Results: GSU members from the UK and Ghana planned and organised successful involvement activities that focused on establishing the best way to talk to patients and other community stakeholders about their experiences of living with hernias and undergoing hernia repairs, and their perceptions of the impact of hernias on the wider community. The Ghanaian team suggested 1:1 conversations in easily accessible locations for rural patient contributors, creating a welcoming environment and addressing contributors in their local dialects. A UK-based Public Advisory Group helped in the initial stages of planning these conversations by highlighting potential barriers when approaching rural communities and advising on how to phrase questions around personal experiences. Conversations mainly focused on understanding the needs of hernia patients in rural Ghana to then incorporate these in the design of the TIGER trial to ensure its relevance, acceptability and feasibility. When talking to patient contributors, the GSU teams found that they were more likely to open up when they knew members of the team and the opportunity to speak to local leaders only arose because of the Ghanaian team members being well-respected amongst communities. The experiences of the patient and community contributors led to changes in the study protocol, such as including women in the patient cohort for the trial, and allowed the GSU teams to confirm the relevance and acceptability of this trial. These conversations also taught the team a lot about perceptions of health in rural communities, allowed the Ghanaian team to establish relationships with community leaders that can be utilised when future studies need input from the public, and has changed the minds of the Ghanaian research team about the importance of involving patients with research.
Conclusion: This paper contributes to the evidence base on successful CEI activities in LMICs by providing an example of how CEI can be planned and organised, and the benefits this provides. The conversations the teams had with patient contributors in Ghana are an example of successful patient consultations. Even though there are certain limitations to the extent of these involvement activities, a solid foundation has been built for researchers and community stakeholders to establish relationships for ongoing involvement.


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183. Health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa: a systematic review

BMC Public Health


Authors: Gloria Gbenonsi, Mouna Boucham, Zakaria Belrhiti, Chakib Nejjari, Inge Huybrechts & Mohamed Khalis
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: General surgery, Health policy, Plastic surgery, Surgical oncology

Background
Breast cancer patients in sub-Saharan Africa experience long time intervals between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing treatment time intervals has not been widely investigated. This review aimed to identify existing information on health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.

Methods
PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program Quality-Assessment Tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.

Results
From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence diagnostic and treatment intervals in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.

Conclusion
The present review shows that diagnostic and treatment intervals among women with breast cancer in sub-Saharan Africa are influenced by many related health system factors. Policy makers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region.


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184. Future Health Spending Forecast in Leading Emerging BRICS Markets in 2030 – Health Policy Implications

Health Research Policy and Systems


Authors: Mihajlo Jakovljevic, Demetrios Lamnissos, Ronny Westerman, Vijay Kumar Chattu, Arcadio Cerda
Region / country: Global
Speciality: Health policy, Other

Introduction: BRICS leading Emerging Markets are increasingly shaping the landscape of global health sector demand and supply for medical goods and services. BRICS’ share of global health spending and future projections will play a prominent role during upcoming 2020s. The purpose of current research was to examine decades long, underlying historical trends in BRICS’ nations health spending and explore these data as the grounds for reliable forecasting of their health expenditures up to 2030.

Methods: BRICS’ health spending data spanning 1995 – 2017 were extracted from IHME’s Financing Global Health 2019 database. Total health expenditure, government, prepaid private and out-of-pocket spending per capita and GDP share of total health spending, were forecasted 2018 – 2030. The ARIMA (Autoregressive Integrated Moving Average) models were used to obtain future projection based on time series analysis.

Results: Per capita health spending in 2030 is projected to be: Brazil: $1767 (95% PI: 1615, 1977) ; Russia: $1933 (95% PI: 1549, 2317); India: $468 (95% PI: 400.4, 535) ; China: $1707 (95% PI: 1079, 2334); South Africa $1379 (95% PI: 755, 2004). Health spending %GDP shares in 2030 are projected to be: Brazil: 8.4% (95% PI: 7.5, 9.4) ; Russia: 5.2% (95% PI: 4.5, 5.9) ; India: 3.5% (95% PI: 2.9%,4.1%) ; China: 5.9% (95% PI: 4.9, 7.0) ; South Africa: 10.4% (95% PI: 5.5, 15.3).

Conclusions: All BRICS expose long term trend to increase their per capita spending in PPP (purchase power parity) terms. India and Russia are highly likely to maintain stable total health spending GDP% share until 2030. China, as the major driver of global economic growth will be capable of significantly expanding its investment into the health sector across an array of indicators. Brazil is the only large nation whose GDP% share of health expenditure is about to contract substantially during the third decade of the 21st century. The steepest curve of increase in per capita spending until 2030 seems to be attributable to India while Russia should achieve the highest values in absolute terms. Health policy implications of long term trends in health spending indicate the need for Health Technology Assessment dissemination among BRICS ministries of health and national health insurance funds. Matters of cost-effective allocation of limited resources shall remain the core challenge in 2030 as well.


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185. The Future of Immersive Technology in Global Surgery Education

Indian Journal of Surgery


Authors: Matthew Pears , Stathis Konstantinidis
Region / country: Global
Speciality: Health policy, Other, Surgical Education

The second wave of immersive reality technology is required that enhances and exploits current applications, empirical evidence and worldwide interest. If this is successful, low- and middle-income countries will have improved access, less costs and reduced practical limitations. Affordability, availability, accessibility and appropriateness are determinates, and help from several innovative areas can achieve these targets. Artificial intelligence will allow autonomous support of trainees to accelerate their skills when interacting on mobile applications, as deep learning algorithms will generate models that identify data and patterns within them and provide feedback much like a human educator. Future immersive content needs to be high quality, tailored to the learners’ needs and created with minimal time and expenses. The co-creation process involves the integration of learners into the entire development process and a single learning goal can be identified that will have high reusability to surgical students. Sustainability of the material is ensured in the design stage leading to increased cost-effectiveness benefits. One framework has a proven high impact on the co-design of healthcare resources and is discussed. The connectivity of future immersive technology resources has been a major obstacle between regions in their uptake. A handful of collaboration platforms have been created that can deliver immersive content and experiences; the spearhead in this area will be from augmented reality and telesurgery. Opportunity for powerful, large-scale data culture via blockchain collaboration will be an emerging theme that will also drive towards affordability, availability, accessibility and appropriateness in the future global landscape of immersive technology in surgical education.


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186. A Qualitative Analysis of Burn Injury Patient and Caregiver Experiences in Kwazulu-Natal, South Africa: Enduring the Transition to a Post-Burn Life

European Burn Journal


Authors: Camerin A. Rencken ,Abigail D. Harrison ,Adam R. Aluisio ,Nikki Allorto
Region / country: Southern Africa – South Africa
Speciality: Health policy, Plastic surgery, Trauma surgery

Over 95% of fire-related burns occur in low- and middle-income countries (LMICs), an important and frequently overlooked global health disparity, yet research is limited from LMICs on how survivors and their caregivers recover and successfully return to their pre-burn lives. This study examines the lived experiences of burn patients and caregivers, the most challenging aspects of their recoveries, and factors that have assisted in recovery. This qualitative study was conducted in KwaZulu-Natal, South Africa at a 900-bed district hospital. Participants (n = 35) included burn patients (n = 13) and caregivers (n = 22) after discharge. In-depth interviews addressed the recovery process after a burn injury. Data were coded using NVivo 12. Analysis revealed three major thematic categories. Coded data were triangulated to analyze caregiver and patient perspectives jointly. The participants’ lived experiences fell into three main categories: (1) psychological impacts of the burn, (2) enduring the transition into daily life, and (3) reflections on difficulties survivors face in returning for aftercare. The most notable discussions regarded stigma, difficulty accepting self-image, loss of relationships, returning to work, and barriers in receiving long-term aftercare at the hospital outpatient clinic. Patients and caregivers face significant adversities integrating into society. This study highlights areas in which burn survivors may benefit from assistance to inform future interventions and international health policy.


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187. Patterns of care of breast cancer patients in Morocco – A study of variations in patient profile, tumour characteristics and standard of care over a decade

The Breast


Authors: Hind Mrabti, Catherine Sauvaget, Abdellatif Benider ,Karima Bendahhou, Farida Selmouni, Richard Muwonge, Leila Alaoui, Eric Lucas, Youssef Chami, Patricia Villain, Loubna Abousselham , Andre L. Carvalho,Maria Bennani, Hassan Errihani, Rengaswamy Sankaranarayanan, Rachid Bekkali , Partha Basu
Region / country: Northern Africa – Morocco
Speciality: Health policy, Surgical oncology

Guided by a national cancer plan (2010–19), Morocco made significant investments in improving breast cancer detection and treatment. A breast cancer pattern-of-care study was conducted to document the socio-demographic profiles of patients and tumour characteristics, measure delays in care, and assess the status of dissemination and impact of state-of-the-art management. The retrospective study conducted among 2120 breast cancer patients registered during 2008–17 at the two premier-most oncology centres (Centre Mohammed VI or CM-VI and Institut National d’Oncologie or INO) also measured temporal trends of the different variables.

Median age (49 years) and other socio-demographic characteristics of the patients remained constant over time. A significant improvement in coverage of the state-financed health insurance scheme for indigent populations was observed over time. Median interval between onset of symptoms and first medical consultation was 6 months with a significant reduction over time. Information on staging and molecular profile were available for more than 90% and 80% of the patients respectively. Approximately 55% of the patients presented at stage I/II and proportion of triple-negative cancers was 16%; neither showing any appreciable temporal variation. Treatment information was available for more than 90% of the patients; 69% received surgery with chemotherapy and/or radiation. Treatment was tailored to stage and molecular profiles, though breast conservation therapy was offered to less than one-fifth. When compared using the EUSOMA quality indicators for breast cancer management, INO performed better than CM-VI. This was reflected in nearly 25% difference in 5-year disease-free survival for early-stage cancers between the centres.


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188. Augmented, Mixed, and Virtual Reality-Based Head-Mounted Devices for Medical Education: Systematic Review

JMIR Serious Games


Authors: Sandra Barteit , Lucia Lanfermann , Till Bärnighausen , Florian Neuhann , Claudia Beiersmann
Region / country: Global
Speciality: Health policy, Surgical Education

Background:
Augmented reality (AR), mixed reality (MR), and virtual reality (VR), realized as head-mounted devices (HMDs), may open up new ways of teaching medical content for low-resource settings. The advantages are that HMDs enable repeated practice without adverse effects on the patient in various medical disciplines; may introduce new ways to learn complex medical content; and may alleviate financial, ethical, and supervisory constraints on the use of traditional medical learning materials, like cadavers and other skills lab equipment.

Objective:
We examine the effectiveness of AR, MR, and VR HMDs for medical education, whereby we aim to incorporate a global health perspective comprising low- and middle-income countries (LMICs).

Methods:
We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and Cochrane guidelines. Seven medical databases (PubMed, Cochrane Library, Web of Science, Science Direct, PsycINFO, Education Resources Information Centre, and Google Scholar) were searched for peer-reviewed publications from January 1, 2014, to May 31, 2019. An extensive search was carried out to examine relevant literature guided by three concepts of extended reality (XR), which comprises the concepts of AR, MR, and VR, and the concepts of medicine and education. It included health professionals who took part in an HMD intervention that was compared to another teaching or learning method and evaluated with regard to its effectiveness. Quality and risk of bias were assessed with the Medical Education Research Study Quality Instrument, the Newcastle-Ottawa Scale-Education, and A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions. We extracted relevant data and aggregated the data according to the main outcomes of this review (knowledge, skills, and XR HMD).

Results:
A total of 27 studies comprising 956 study participants were included. The participants included all types of health care professionals, especially medical students (n=573, 59.9%) and residents (n=289, 30.2%). AR and VR implemented with HMDs were most often used for training in the fields of surgery (n=13, 48%) and anatomy (n=4, 15%). A range of study designs were used, and quantitative methods were clearly dominant (n=21, 78%). Training with AR- and VR-based HMDs was perceived as salient, motivating, and engaging. In the majority of studies (n=17, 63%), HMD-based interventions were found to be effective. A small number of included studies (n=4, 15%) indicated that HMDs were effective for certain aspects of medical skills and knowledge learning and training, while other studies suggested that HMDs were only viable as an additional teaching tool (n=4, 15%). Only 2 (7%) studies found no effectiveness in the use of HMDs.

Conclusions:
The majority of included studies suggested that XR-based HMDs have beneficial effects for medical education, whereby only a minority of studies were from LMICs. Nevertheless, as most studies showed at least noninferior results when compared to conventional teaching and training, the results of this review suggest applicability and potential effectiveness in LMICs. Overall, users demonstrated greater enthusiasm and enjoyment in learning with XR-based HMDs. It has to be noted that many HMD-based interventions were small-scale and conducted as short-term pilots. To generate relevant evidence in the future, it is key to rigorously evaluate XR-based HMDs with AR and VR implementations, particularly in LMICs, to better understand the strengths and shortcomings of HMDs for medical education.


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189. The need for adaptable global guidance in health systems strengthening for musculoskeletal health: a qualitative study of international key informants

Global Health Research and Policy


Authors: Andrew M. Briggs, Joanne E. Jordan, Deborah Kopansky-Giles, Saurab Sharma, Lyn March, Carmen Huckel Schneider, Swatee Mishrra, James J. Young , Helen Slater
Region / country: Global
Speciality: Health policy, Trauma and orthopaedic surgery

Background
Musculoskeletal (MSK) conditions, MSK pain and MSK injury/trauma are the largest contributors to the global burden of disability, yet global guidance to arrest the rising disability burden is lacking. We aimed to explore contemporary context, challenges and opportunities at a global level and relevant to health systems strengthening for MSK health, as identified by international key informants (KIs) to inform a global MSK health strategic response.

Methods
An in-depth qualitative study was undertaken with international KIs, purposively sampled across high-income and low and middle-income countries (LMICs). KIs identified as representatives of peak global and international organisations (clinical/professional, advocacy, national government and the World Health Organization), thought leaders, and people with lived experience in advocacy roles. Verbatim transcripts of individual semi-structured interviews were analysed inductively using a grounded theory method. Data were organised into categories describing 1) contemporary context; 2) goals; 3) guiding principles; 4) accelerators for action; and 5) strategic priority areas (pillars), to build a data-driven logic model. Here, we report on categories 1–4 of the logic model.

Results
Thirty-one KIs from 20 countries (40% LMICs) affiliated with 25 organisations participated. Six themes described contemporary context (category 1): 1) MSK health is afforded relatively lower priority status compared with other health conditions and is poorly legitimised; 2) improving MSK health is more than just healthcare; 3) global guidance for country-level system strengthening is needed; 4) impact of COVID-19 on MSK health; 5) multiple inequities associated with MSK health; and 6) complexity in health service delivery for MSK health. Five guiding principles (category 3) focussed on adaptability; inclusiveness through co-design; prevention and reducing disability; a lifecourse approach; and equity and value-based care. Goals (category 2) and seven accelerators for action (category 4) were also derived.

Conclusion
KIs strongly supported the creation of an adaptable global strategy to catalyse and steward country-level health systems strengthening responses for MSK health. The data-driven logic model provides a blueprint for global agencies and countries to initiate appropriate whole-of-health system reforms to improve population-level prevention and management of MSK health. Contextual considerations about MSK health and accelerators for action should be considered in reform activities.


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190. Global head and neck surgery research during the COVID pandemic: A bibliometric analysis

Annals of Medicine and Surgery


Authors: Olga Mbougo Djoutsop , Jolyvette Voufo Mbougo , Ulrick Sidney Kanmounye
Region / country: Global
Speciality: ENT surgery, General surgery

Background
Before the COVID-19 pandemic, access to otolaryngology and head-and-neck surgery was limited in low- and middle-income countries (LMICs). The pandemic has increased the burden on LMIC health systems by causing unanticipated expenses, delayed care, and changes in research activity. We aimed to assess the landscape of global ENT research during the pandemic.

Materials and methods
The authors developed a search strategy composed of the following keywords: “otolaryngology,” “head and neck surgery,” and “low- and middle-income countries.” Then, they searched eleven citation databases via the Web of Science from January 01, 2020, to May 03, 2021. They imported the result as metadata into VosViewer and ran bibliometric analyses to identify the most influential institutions, countries, and themes.

Results
During the study period, 3077 articles were published. Two hundred eighty-nine articles (9%) mentioned COVID-19 explicitly. The second most common theme was pediatric ENT (223 articles, 7%). The United States had the most publications [1616 articles, 12,033 citations, and 2986 total link strength (TLS)], followed by China (336 articles, 10,981 citations, and 571 TLS). South Africa, the first African country, was fourth (302 articles, 699 citations, and 908 TLS), while Brazil, the first South American country, was seventh (158 articles, 582 citations, and 376 TLS). The most prolific institution was the National Institute of Allergy and Infectious Diseases (186 articles, 1110 citations, and 674 TLS).

Conclusion
COVID-19 was the most common research theme during the pandemic, surpassing pediatric ENT.


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191. Magnitude, Factors Associated with Cesarean Delivery and Its Appropriateness

IntechOpen


Authors: Awoke Giletew Wondie
Region / country: Eastern Africa – Ethiopia
Speciality: Obstetrics and Gynaecology

Inappropriate use of CS can have profoundly negative consequences for women and the broader community. A recent meeting of the International Confederation of Midwifes, the International Federation of Gynecologists and Obstetrics and the Gates Foundation to discuss the impact of rising CS rates on maternal and infant mortality in LMICs highlights the international importance of the issue. Knowledge of CS determinants is a first step in the effort to define strategies to reduce unnecessary CSs. Previous studies showed that the main reasons for performing CS are clinical factors. However, non-clinical factors such as demographic, health system factors, organizational variables were overlooked determinants that best predicted which women have a higher risk of CS.


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192. Age at Primary Cleft Lip Repair

Plastic and reconstructive surgery. Global open


Authors: Vanderburg, R, Alonso, N, Desai, P, Donkor, P, Mossey, P, Stieber, E & V Mehendale
Region / country: Global
Speciality: Maxillofacial and oral surgery, Paediatric surgery, Plastic surgery

Background: The bellwether procedures described by the Lancet Commission on Global Surgery represent the ability to deliver adult surgical services after there is a clear and easily made diagnosis. There is a need for pediatric surgery bellwether indicators. A pediatric bellwether indicator would ideally be a routinely performed procedure, for a relatively common condition that, in itself, is rarely lethal at birth, but that should ideally be treated with surgery by a standard age. Additionally, the condition should be easy to diagnose, to minimize the confounding effects of delays or failures in diagnosis. In this study, we propose the age at primary cleft lip
(CL) repair as a bellwether indicator for pediatric surgery.
Method: We reviewed the surgical records of 71,346 primary cleft surgery patients and ultimately studied age at CL repair in 40,179 patients from 73 countries, treated by Smile Train partners for 2019. Data from Smile Train’s database were correlated with World Bank and WHO indicators.
Results: Countries with a higher average age at CL repair (delayed access to surgery) had higher maternal, infant, and child mortality rates as well as a greater risk of catastrophic health expenditure for surgery. There was also a negative correlation between delayed CL repair and specialist surgical workforce numbers, life expectancy, percentage of deliveries by C-section, total health expenditure per capita, and Lancet Commission on Global Surgery procedure rates.
Conclusion: These findings suggest that age at CL repair has potential to serve as a bellwether indicator for pediatric surgical capacity in Lower- and Middleincome Countrie


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193. Public Awareness Knowledge of Availability And Willingness to Use Neurosurgical Care Services in Africa: A CrossSectional ESurvey Protocol

international Journal of Surgery Protocols


Authors: Chibuikem Ikwuegbuenyi, Gideon Adegboyega , Arsene Daniel Nyalundja, Michael A Bamimore, Daniel Safari Nteranya, Lorraine Arabang Sebopelo, Ulrick Sidney Kanmounye
Region / country: Central Africa, Eastern Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Health policy, Neurosurgery

Background: Barriers to care cause delays in seeking, reaching, and getting care. These delays affect low-and middle-income countries (LMICs), where 9 out of 10 LMIC inhabitants have no access to basic surgical care. Knowledge of healthcare utilization behavior within underserved communities is useful when developing and implementing health policies. Little is known about the neurosurgical health-seeking behavior of African adults. This study evaluates public awareness, knowledge of availability, and readiness for neurosurgical care services amongst African adults.

Methodology: The cross-sectional study will be run using a self-administered e-survey hosted on Google Forms (Google, CA, USA) disseminated from 10th May 2021 to 10th June 2021. The Questionnaire would be in two languages, English and French. The survey will contain closed-ended, open-ended, and Likert Scale questions. The structured questionnaire will have four sections with 42 questions; Sociodemographic characteristics, Definition of neurosurgery care, Knowledge of neurosurgical diseases, practice and availability, and Common beliefs about neurosurgical care. All consenting adult Africans will be eligible. A minimum sample size of 424 will be used. Data will be analyzed using SPSS version 26 (IBM, WA, USA). Odds ratios and their 95% confidence intervals, Chi-Square test, and ANOVA will be used to test for associations between independent and dependent variables. A P-value <0.05 will be considered statistically significant. Also, a multinomial regression model will be used.

Dissemination: The study findings will be published in an academic peer-reviewed journal, and the abstract will be presented at an international conference.

Highlights

The burden of neurosurgical diseases is enormous in low- and middle-income countries, especially in Africa.
Unfortunately, most neurosurgical needs in Africa are unmet because of delays in seeking, reaching, and getting care.
Most efforts aimed at reducing barriers to care have focused on improving the neurosurgical workforce density and infrastructure. Little or no efforts have been directed towards understanding or reducing the barriers to seeking care.
We aimed to understand public awareness, willingness to use, and knowledge of the availability of neurosurgical care in Africa.
The study findings can inform effective strategies that promote the utilization of neurosurgical services and patient education in Africa.


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194. Fixation of intertrochanteric femur fractures using the SIGN intramedullary nail augmented by a lateral plate in a resource-limited setting without intraoperative fluoroscopy: assessment of functional outcomes at one-year follow-up at Juba Teaching Hospital

OTA International


Authors: Areu Mapuor M.M., von Kaeppler Ericka P. , Madison Brian Billya , Aguto Akau A. , Alphones Jamesa , Zirkle Lewis G. , Morshed Saamb , Shearer David W
Region / country: Eastern Africa – South Sudan
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Objectives:
The incidence of hip fracture is high and increasing globally due to an aging population. Morbidity and mortality from these injuries are high at baseline and worse without prompt surgical treatment to facilitate early mobilization. Due to resource constraints, surgeons in low-income countries often must adapt available materials to meet these surgical needs. The objective of this study is to assess functional outcomes after surgical fixation of intertrochanteric femur fractures with the Surgical Implant Generation Network (SIGN) intramedullary nail augmented by a lateral SIGN plate.

Design:
Prospective case series

Setting:
Juba Teaching Hospital, Tertiary Referral Hospital for South Sudan

Participants:
Adult patients with intertrochanteric hip fractures

Intervention:
SIGN nail augmented by a lateral plate

Main Outcome Measurements:
Primary outcome was hip function as measured by a modified Harris Hip Score (mHHS) at 1-year after surgery. Secondary endpoints were the occurrence of reoperation or infection at 1-year after surgery.

Results:
Thirty patients were included, 16 (53%) men and 14 (47%) women, with a mean age of 62 years. Fractures were classified as AO/OTA Type 31A1 in 12 (40%) patients, 31A2 in 15 (50%) patients, and 31A3 in 3 (10%) patients. Mean mHHS at 1-year was 75.10 ± 21.2 with 76% categorized as excellent or good scores. There was 1 (3%) infection and 2 (7%) reoperations.

Conclusions:
The SIGN nail augmented by a lateral plate achieved good or excellent hip function in the majority of patients with intertrochanteric hip fractures. This may be a suitable alternative to conventional implants for hip fracture patients in low-resource settings to allow mobilization.


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195. Availability of facility resources and services and infection-related maternal outcomes in the WHO Global Maternal Sepsis Study: a cross-sectional study

the lancet Global health


Authors: Vanessa Brizuela, Cristina Cuesta, Gino Bartolelli, Abdulfetah Abdulkadir Abdosh, Sabina Abou Malham, Bouchra Assarag, Rigoberto Castro Banegas, Virginia Díaz, Faysal El-Kak, Mohamed El Sheikh, Aquilino M Pérez, João Paulo Souza, Mercedes Bonet, Edgardo Abalos, on behalf of the WHO GLOSS Research Group*
Region / country: Global
Speciality: Health policy, Obstetrics and Gynaecology

Background
Infections are among the leading causes of maternal mortality and morbidity. The Global Maternal Sepsis and Neonatal Initiative, launched in 2016 by WHO and partners, sought to reduce the burden of maternal infections and sepsis and was the basis upon which the Global Maternal Sepsis Study (GLOSS) was implemented in 2017. In this Article, we aimed to describe the availability of facility resources and services and to analyse their association with maternal outcomes.
Methods
GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries and included 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections. All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4 were eligible for inclusion. In this study, we included all GLOSS participating facilities that collected facility-level data (446 of 713 facilities). We used data obtained from individual forms completed for each enrolled woman and their newborn babies by trained researchers who checked the medical records and from facility forms completed by hospital administrators for each participating facility. We described facilities according to country income level, compliance with providing core clinical interventions and services according to women’s needs and reported availability, and severity of infection-related maternal outcomes. We used a logistic multilevel mixed model for assessing the association between facility characteristics and infection-related maternal outcomes.
Findings
We included 446 facilities from 46 countries that enrolled 2560 women. We found a high availability of most services and resources needed for obstetric care and infection prevention. We found increased odds for severe maternal outcomes among women enrolled during the post-partum or post-abortion period from facilities located in low-income countries (adjusted odds ratio 1·84 [95% CI 1·05–3·22]) and among women enrolled during pregnancy or childbirth from non-urban facilities (adjusted odds ratio 2·44 [1·02–5·85]). Despite compliance being high overall, it was low with regards to measuring respiratory rate (85 [24%] of 355 facilities) and measuring pulse oximetry (184 [57%] of 325 facilities).
Interpretation
While health-care facilities caring for pregnant and recently pregnant women with suspected or confirmed infections have access to a wide range of resources and interventions, worse maternal outcomes are seen among recently pregnant women located in low-income countries than among those in higher-income countries; this trend is similar for pregnant women. Compliance with cost-effective clinical practices and timely care of women with particular individual characteristics can potentially improve infection-related maternal outcomes.
Funding
UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and US Agency for International Development.


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196. Research to improve surgical oncological care on the surgical department, Maputo Central Hospital

Run Universidade Nova


Authors: MORAIS, Atílio Luís Monteiro de
Region / country: Southern Africa – Mozambique
Speciality: Health policy, Surgical oncology

Purpose: Regarding adequate care for oncological patients, requiring surgical interventions at the Surgical Department of Maputo Central Hospital (MCH), the largest hospital in Mozambique, the aim of those studies, was first to assess the surgical resources, surgical oncology team skills, identify and characterize prevalent cancers treated and general knowledge in oncology and surgical oncology, expecting the development of a comprehensive curriculum in surgical oncology fellowship fit for the Hospital and all Mozambique country. Methods: The study 1, done in 2017, was based on surgeons questionnaire (The Cancer Units Assessment Checklist for low- or middle-income African countries (annex I), visiting the unities (oncology service, ICU, operations room, etc.) collecting information according to the Portuguese-speaking African Countries Assessment of Surgical Oncology Capacity Survey (PSAC-Surgery – annex II). The study 2, done in 2018, by retrospective analysis of individual cancer patient registries of MCH, the prevalent cancers has been identified and characterized (annex IV). And the general knowledge in oncology and surgical oncology, this issue was evaluated by simple test administered anonymously and without prior notice to all surgeons and residents at the Surgical Department (annex V). The domains was about basis of Oncology, Radiotherapy, Pathology, Chemotherapy, Pain management, Surgical oncology and Clinical pathway. The study 3, done in 2019, a three-round modified-Delphi approach was implemented to obtain consensus on surgical oncology training curriculum. The participants were purposefully selected 23 experts in surgical oncology working in Mozambique. In round one, participants answered a questionnaire regarding the content of the curriculum and the timing and venue of training. Draft of the curriculum was produced. In round 2, answers from the first round and the curriculum draft were presented to a purposeful selected sample of nationally recognized experts in oncology and surgical oncology, including members of the Mozambican College of Surgeons and leadership of the Ministry of Health. A final round was carried out to discuss the final version of the training program in surgical oncology with extensive participation of majority of african experts in surgical oncology (Aortic, Maputo). Results: Breast, esophagus and colorectal cancers were the most commonly treated neoplasms in MCH (at Surgical department). A range of technical and resource needs as well as the gaps in knowledge and skills were identified. All surgeons recognized the need to create a training program in oncology at the undergraduate level, specific training for residents and continuing oncological education for general surgeons, to improve the practice of surgical oncology. Basic principles of oncology and basic principles of surgical oncology should be included in the curriculum of surgical residency in Mozambique, a 24-months fellowship in surgical oncology should take place after residency in the surgical field and should occur at Maputo Central Hospital and at comprehensive cancer centers. The final proposal for the program was divided into the following structure: a – theoretical components; b – duration; c – location; d – methodology; e – technical skills in oncology; and f – competency and paid particular attention to the oncological diseases prevalent in Mozambique.


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197. Prevalence and Mortality of Triple-Negative Breast Cancer in West Africa: Biologic and Sociocultural Factors

JCO Global Oncology


Authors: Gift C. Nwagu , Shristi Bhattarai , Monica Swahn, Saad Ahmed , Ritu Aneja
Region / country: Western Africa
Speciality: General surgery, Surgical oncology

Key Objective
Triple-negative breast cancer (TNBC) is a malignant breast cancer, lacking targeted therapy, which would benefit from further research to understand its nature and the observed variation in its malignancy between women of differing ancestries. This large-scale systematic literature review examines the current and emerging biologic and nonbiologic factors, which have been shown to influence TNBC disease outcomes among indigenous West African (WA) females while discussing some prospective steps that could be adopted by health care systems for the reduction of this burden.

Knowledge Generated
WA women are the most burdened populations in relation to TNBC. Biologic and economic factors have been shown to significantly influence the TNBC disease outcomes. Women’s education initiatives, specialist training, and accessible health care are needed in WA countries.

Relevance
The determination of WA-specific biologic, cultural, and socioeconomic TNBC factors could align efforts in developing treatment options and physician recommendations to cancer-burdened women.


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198. Quality of Life in Patients Undergoing Cardiac Surgery: Role of Coping Strategies

Cureus


Authors: Khizra Iqbal, Yusra Irshad, Syed Rafay Ali Gilani Sr., Shafqat Hussain, Mubashar Ahmad, Usman A. Khan, Varda S. Choudhry, Aemen S. Khakwani
Region / country: Southern Asia – Pakistan
Speciality: Cardiothoracic surgery

Adaptive coping strategies are used to reduce stress in patients undergoing cardiac surgery. These strategies have a major role in physical health, psychological health, quality of life and also affect an individual’s response to the disease. The current study was conducted to comprehend the impact of coping strategies on the quality of life of patients suffering from cardiac disease. A purposive convenient sampling method was used to collect data from different hospitals in South Punjab. We applied Carver’s Brief Coping Orientation to Problem Experienced (Brief COPE) inventory and the WHO quality of life scale. A cross-sectional research design was proposed for the study. The findings of the study showed that coping strategies and quality of life are associated with each other, and the use of emotion-focused and problem-focused coping strategies have a significant impact on patients experiencing cardiac surgery. Demographic details of patients also revealed the differences in both variables. Implications and future recommendations have also been discussed.


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199. How to improve access to medical imaging in low- and middle-income countries ?

the lancet


Authors: Guy Frija , Ivana Blažić ,Donald P. Frush , Monika Hierath , Michael Kawooya ,Lluis Donoso-Bach ,Boris Brkljačić
Region / country: Global
Speciality: Health policy, Other

Imaging has become key in the care pathway of communicable and non-communicable diseases. Yet, there are major shortages of imaging equipment and workforce in low- and middle-income countries (LMICs). The International Society of Radiology outlines a plan to upscale the role of imaging in the global health agenda and proposes a holistic approach for LMICs. A generic model for organising imaging services in LMICs via regional Centres of Reference is presented. The need to better exploit IT and the potential of artificial intelligence for imaging, also in the LMIC setting, is highlighted.

To implement the proposed plan, involvement of professional and international organisations is considered crucial. The establishment of an International Commission on Medical Imaging under the umbrella of international organisations is suggested and collaboration with other diagnostic disciplines is encouraged to raise awareness of the importance to upscale diagnostics at large and to foster its integration into the care pathway globally.


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200. Level of knowledge and practice of female healthcare providers about early detection methods of breast cancer at Debre Tabor Comprehensive Specialised Hospital: a cross-sectional study

ecancer


Authors: Aragaw Tesfaw, Hanna Berihun, Eshetie Molla, Gashaw Mihret, Dejen Getaneh Feleke, Ermias Sisay Chanie, Biruk Demissie, Tewodros Yosef, Abel Shita, Fitalew Tadele, Efrem Fenta
Region / country: Eastern Africa – Ethiopia
Speciality: General surgery, Surgical oncology

Background: Despite the higher mortality rate of breast cancer in low and middle-income countries, the practice of early detection methods is low and the majority of the patients presenting at an advanced stage of the disease need palliative care with low survival rates. Although healthcare providers are the key for practicing early detection methods of breast cancer for themselves and their clients, little is known about their knowledge and practice of early detection methods of breast cancer in Northcentral Ethiopia.

Methods: An institution-based cross-sectional study was conducted among female healthcare providers at Debre Tabor Comprehensive Specialised Hospital. Data were collected using a structured self-administered questionnaire. The data were analysed using SPSS version 23. Descriptive statistics were used to describe the socio-demographic information of participants. Binary and multivariable logistic regression with adjusted odds ratio (AOR) and 95% confidence interval (CI) was used to identify factors associated with the outcome variable. Statistical significance was declared at p 2 years (AOR = 3.2; 95% CI: 1.72, 5.29), history of any breast problem (AOR = 1.4; 95% CI: 1.02, 2.37), family history of breast cancer (AOR = 4.0; 95% CI: 2.58, 15.84), having good knowledge (AOR = 2.9; 95% CI: 1.3, 6.52) and history of comorbidities (AOR = 1.09; 95% CI: 1.09, 3.59) were the factors associated with the practice of breast self-examination.

Conclusion: Our study found that the knowledge and practice of breast cancer early detection methods was low in the study setting. Only less than half of female healthcare providers practiced regular breast self-examination, which suggests the need to provide training for healthcare providers to fill the gap and to promote early detection of breast cancer cases.


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201. Epidemiology and Anatomic Distribution of Colorectal Cancer in South Africa

Open University of Cape Town


Authors: Amer Akrem
Region / country: Southern Africa – South Africa
Speciality: General surgery, Surgical oncology

Background: Colorectal cancer (CRC) is the 5th most common cancer in subSaharan Africa (SSA) and the 3rd most common cancer in Southern Africa. CRC characteristics in SSA, including anatomic distribution, are not well described. Objective: To describe patient characteristics and anatomic location of colorectal adenocarcinoma (CRC-AC) in South Africa. Design: This was a retrospective study of CRC using the South African National Cancer Registry from 2006-2011. Main Outcome Measures: Patient age, gender, racial/ethnic group, province, histology type, and tumour location. Results: 6146 patients were included in the analysis. Among patients with adenocarcinomas, the median age of presentation was 60 (interquartile range, 49-70) years. 1372 (25%) of patients were < 50 years and 2870 (52%) were male. There were 5498 (89%) cases of adenocarcinoma (AC). 1277 (26%) CRC-AC were right colonic lesions, 1214 (25%) were left colonic lesions, and 2404 (49%) lesions were located in the rectum. Patients ≥ 50 years at presentation (OR=1.29. p< 0.001) and from Limpopo province (OR=1.46, p=0.029) were more likely to have left colonic and rectal adenocarcinoma on multivariate analysis. Patients who were black (OR=1.67, p< 0.001), had right colonic lesions (OR=1.25, p=0.007), and were from Mpumalanga (OR=1.67, p=0.007), Limpopo (OR=1.60, p=0.002), or Northwest (OR=1.76, p=0.001), were significantly associated with early onset adenocarcinoma. Conclusion: CRC-AC in South Africa presents at an earlier age than in HICs, such as the US. Early-onset CRC is higher in black South Africans who live in Mpumalanga, Limpopo, and Northwest in comparison with other provinces. The majority of colorectal cancer were leftsided and rectal; thus screening flexible sigmoidoscopy should be considered. Further studies on the age-specific incidence and the genetics and epigenetics of CRC-AC in South Africa are needed.


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202. The Effectiveness of Cancer Pain Management in a Tertiary Hospital Outpatient Pain Clinic in Thailand: A Prospective Observational Study

Pain Research and Management


Authors: Suratsawadee Wangnamthip , Skaorat Panchoowong , Carolina Donado , Kimberly Lobo , Pimporn Phankhongsap ,Pinyo Sriveerachai ,Pramote Euasobhon , Pranee Rushatamukayanunt , Sahatsa Mandee ,Nantthasorn Zinboonyahgoon ,Charles B. Berde
Region / country: South-eastern Asia – Thailand
Speciality: Surgical oncology

Context. In a previous retrospective study, cancer pain management was effective in 47.5% of a cohort assessed after 3 months in a pain clinic at Siriraj Hospital. New guidelines were established, including a multidisciplinary approach, availability of pain interventions, and palliative care referral. Objectives. The objective was to examine the effectiveness of the updated approach. Methods. With IRB approval, outpatients with cancer were enrolled from January to December 2018. Assessments were recorded at baseline and three consecutive visits (BL, FU1, FU2, and FU3), including Numerical Rating Scale (NRS), the Brief Pain Inventory (BPI), the Edmonton Symptom Assessment System (ESAS), side effects, and analgesic use. The primary outcome was a favorable response, defined as an NRS decrease more than 30% or NRS <4. Secondary outcomes included trends over time in BPI, ESAS, side effects, and analgesic use. Pain response predictors at FU3 were analyzed using logistic regression. Results. Among 150 patients, 72 (48%) completed follow-ups. Of these, 61% achieved a favorable response at FU3. Pain interference diminished at all visits relative to baseline (). Median morphine equivalent daily dosage (MEDD) at BL was 20 mg/day, with a statistically significant, but clinically modest increase to 26.4 mg/day at FU3. Radiation therapy during pain care was a predictor of pain responders. Conclusion. The current Siriraj multidisciplinary approach provided effective relief of pain and stabilization of other cancer-related symptoms. Radiation therapy during pain care can be used to predict pain outcomes. Ongoing improvement domains were identified and considered in the context of cultural, economic, and geographic factors.


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203. Mobile Ecological Momentary Assessment and Intervention and Health Behavior Change Among Adults in Rakai, Uganda: Pilot Randomized Controlled Trial

JMIR Formative Research


Authors: Laura K Beres , Ismail Mbabali ,Aggrey Anok , Charles Katabalwa , Jeremiah Mulamba ,Alvin G Thomas ,Eva Bugos , Gertrude Nakigozi , Mary K Grabowski , Larry W Chang
Region / country: Eastern Africa – Uganda
Speciality: Health policy, Other

Background:
An extraordinary increase in mobile phone ownership has revolutionized the opportunities to use mobile health approaches in lower- and middle-income countries (LMICs). Ecological momentary assessment and intervention (EMAI) uses mobile technology to gather data and deliver timely, personalized behavior change interventions in an individual’s natural setting. To our knowledge, there have been no previous trials of EMAI in sub-Saharan Africa.

Objective:
To advance the evidence base for mobile health (mHealth) interventions in LMICs, we conduct a pilot randomized trial to assess the feasibility of EMAI and establish estimates of the potential effect of EMAI on a range of health-related behaviors in Rakai, Uganda.

Methods:
This prospective, parallel-group, randomized pilot trial compared health behaviors between adult participants submitting ecological momentary assessment (EMA) data and receiving behaviorally responsive interventional health messaging (EMAI) with those submitting EMA data alone. Using a fully automated mobile phone app, participants submitted daily reports on 5 different health behaviors (fruit consumption, vegetable consumption, alcohol intake, cigarette smoking, and condomless sex with a non–long-term partner) during a 30-day period before randomization (P1). Participants were then block randomized to the control arm, continuing EMA reporting through exit, or the intervention arm, EMA reporting and behavioral health messaging receipt. Participants exited after 90 days of follow-up, divided into study periods 2 (P2: randomization + 29 days) and 3 (P3: 30 days postrandomization to exit). We used descriptive statistics to assess the feasibility of EMAI through the completeness of data and differences in reported behaviors between periods and study arms.

Results:
The study included 48 participants (24 per arm; 23/48, 48% women; median age 31 years). EMA data collection was feasible, with 85.5% (3777/4418) of the combined days reporting behavioral data. There was a decrease in the mean proportion of days when alcohol was consumed in both arms over time (control: P1, 9.6% of days to P2, 4.3% of days; intervention: P1, 7.2% of days to P3, 2.4% of days). Decreases in sex with a non–long-term partner without a condom were also reported in both arms (P1 to P3 control: 1.9% of days to 1% of days; intervention: 6.6% of days to 1.3% of days). An increase in vegetable consumption was found in the intervention (vegetable: 65.6% of days to 76.6% of days) but not in the control arm. Between arms, there was a significant difference in the change in reported vegetable consumption between P1 and P3 (control: 8% decrease in the mean proportion of days vegetables consumed; intervention: 11.1% increase; P=.01).

Conclusions:
Preliminary estimates suggest that EMAI may be a promising strategy for promoting behavior change across a range of behaviors. Larger trials examining the effectiveness of EMAI in LMICs are warranted.

Trial Registration:
ClinicalTrials.gov NCT04375423; https://www.clinicaltrials.gov/ct2/show/NCT04375423


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204. Economic Consequences of Caesarean Section Delivery: Evidence From a Household Survey in Tanzania

Research Square


Authors: Peter Binyaruka, Amani Thomas Mori
Region / country: Eastern Africa – Tanzania
Speciality: Health policy, Obstetrics and Gynaecology

Background: Caesarean section (C-section) delivery is an important indicator of access to life-saving essential obstetric care. Yet, there is limited understanding of the costs of utilising C-section delivery care in sub-Saharan Africa. Thus, we estimated the direct and indirect patient cost of accessing C-section in Tanzania

Methods: Cross-sectional survey data of 2012 was used, which covered 3000 households from 11 districts in three regions. We interviewed women who had given births in the last 12 months before the survey to capture their experience of care. We used a regression model to estimate the effect of C-section on costs, while inequality on C-section coverage and delivery costs were assessed with a concentration index.

Results: C-section increased the likelihood of paying for health care by 16% compared to normal delivery. The additional cost of C-section compared to normal delivery was 20 USD, but reduced to about 11 USD when restricted to public facilities. Women with C-section delivery spent an extra 2 days at the health facility compared to normal delivery, but this was reduced slightly to 1.9 days in public facilities. The distribution of C-section coverage was significantly in favour of wealthier than poorest women (CI=0.2052, p<0.01), and this pro-rich pattern was consistent in rural districts but with unclear pattern in urban districts.

Conclusions: C-section is a life-saving intervention but is associated with significant economic burden especially among the poor families. More health resources are needed for provision of free maternal care, reduce inequality in access and improve birth outcomes in Tanzania.


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205. Feasibility and diagnostic accuracy of Telephone Administration of an adapted wound heaLing QuestiONnaire for assessment for surgical site infection following abdominal surgery in low and middle-income countries (TALON): protocol for a study within a trial (SWAT)

Trials


Authors: NIHR Global Health Research Unit on Global Surgery
Region / country: Global
Speciality: General surgery, Health policy

Background
Surgical site infection is the most common complication of abdominal surgery, with a global impact on patients and health systems. There are no tools to identify wound infection that are validated for use in the global setting. The overall aim of the study described in this protocol is to evaluate the feasibility and validity of a remote, digital pathway for wound assessment after hospital discharge for patients in low- and middle-income countries (LMICs).

Methods
A multi-centre, international, mixed-methods study within a trial, conducted in two stages (TALON-1 and TALON-2). TALON-1 will adapt and translate a universal reporter outcome measurement tool (Bluebelle Wound Healing Questionnaire, WHQ) for use in global surgical research (SWAT store registration: 126) that can be delivered over the telephone. TALON-2 will evaluate a remote wound assessment pathway (including trial retention) and validate the diagnostic accuracy of this adapted WHQ through a prospective cohort study embedded within two global surgery trials. Embedded community engagement and involvement activities will be used to optimise delivery and ensure culturally attuned conduct. TALON-1 and TALON-2 are designed and will be reported in accordance with best practice guidelines for adaptation and validation of outcome measures, and diagnostic test accuracy studies.

Discussion
Methods to identify surgical site infection after surgery for patients after hospital discharge have the potential to improve patient safety, trial retention, and research efficiency. TALON represents a large, pragmatic, international study co-designed and delivered with LMIC researchers and patients to address an important research gap in global surgery trial methodology.


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206. Direct Cost of Illness for Spinal Cord Injury: A Systematic Review

Global Spine Journal


Authors: Hamid Malekzadeh, Mahdi Golpayegani, Zahra Ghodsi, Mohsen Sadeghi-Naini, Mohammadhossein Asgardoon, Vali Baigi, Alexander R. Vaccaro, Vafa Rahimi-Movaghar
Region / country: Global
Speciality: Neurosurgery, Trauma and orthopaedic surgery, Trauma surgery

Study Design:
Systematic review.

Objective:
Providing a comprehensive review of spinal cord injury cost of illness studies to assist health-service planning.

Methods:
We conducted a systematic review of the literature published from Jan. 1990 to Nov. 2020 via Pubmed, EMBASE, and NHS Economic Evaluation Database. Our primary outcomes were overall direct health care costs of SCI during acute care, inpatient rehabilitation, within the first year post-injury, and in the ensuing years.

Results:
Through a 2-phase screening process by independent reviewers, 30 articles out of 6177 identified citations were included. Cost of care varied widely with the mean cost of acute care ranging from $290 to $612,590; inpatient rehabilitation from $19,360 to $443,040; the first year after injury from $32,240 to $1,156,400; and the ensuing years from $4,490 to $251,450. Variations in reported costs were primarily due to neurological level of injury, study location, methodological heterogeneities, cost definitions, study populations, and timeframes. A cervical level of the injury, ASIA grade A and B, concomitant injuries, and in-hospital complications were associated with the greatest incremental effect in cost burden.

Conclusion:
The economic burden of SCI is generally high and cost figures are broadly higher for developed countries. As studies were only available in few countries, the generalizability of the cost estimates to a regional or global level is only limited to countries with similar economic status and health systems. Further investigations with standardized methodologies are required to fill the knowledge gaps in the healthcare economics of SCI.


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207. Cancer Screening Programs in Low- and Middle-Income Countries: Strategies for Success

Annals of Surgical Oncology


Authors: Brittany G. Sullivan , Alliya Qazi MD & Maheswari Senthil
Region / country: Global
Speciality: Surgical oncology

Cancer is a leading global health problem and, as of 2020, accounts for 10 million deaths per year.1 The World Health Organization (WHO) estimates that between 30 and 50% of cancer deaths can be prevented by avoiding risk factors, early detection via screening, and proper treatment. The majority of cases occur in low- and middle-income countries (LMIC).2 Despite awareness of the magnitude of this problem by the global health community and the large-scale efforts to implement screening programs, very few programs are successful and, more importantly, sustainable. Although there are several barriers to implementation of a cancer screening program, the critical barriers are lack of awareness and acceptance of the screening programs by the people residing in the specific geographic regions. In the article by Pak et al. entitled Cancer Awareness and Stigma in Rural Assam India: Baseline Survey of the Detect Early and Save Her/Him (DESH) Program, the authors highlight the cultural and psychosocial barriers to cancer screening.3

The DESH program is a well-organized screening program with multiple components that consists of an initial baseline survey followed by implementation of mobile cancer screening and subsequent follow-up of patients regarding final diagnosis and treatment. The DESH program in Assam, India, focuses on breast, oral, and cervical cancers due to the high incidence of these cancers in this region and the availability of validated screening tests. The baseline survey was validated in a smaller cohort (n = 20) of local participants before widespread implementation to nearly 1000 participants. The survey consisted of multiple sections that focused on areas such as awareness of the carcinogenic effects of certain lifestyle choices, i.e., consumption of betel nuts and smoking, spiritual/religious beliefs, stigma around cancer diagnoses, and knowledge about screening programs and local health care facilities. Through this approach, they found that the majority (92.9%) of participants were not aware of cancer screening availability and had never undergone prior screening. Additionally, over 90% of the survey participants reported consumption of betel nuts, but less than half (46.9%) were aware of the carcinogenic effects of betel nuts. Finally, 42–57% of participants reported negative stigma towards cancer diagnosis. Specifically, more than 30% of participants believed that either cancer is a punishment from God or is caused by bad karma and evil spirits. Furthermore, 20% of participants described fear of cancer screening. These results highlight the complex interplay between knowledge gaps, misconceptions, and cancer stigma that could affect the acceptance, and thereby the success, of a screening program.

Taneja et al. identified similar sociocultural barriers regarding cervical cancer screening in India. Specifically, barriers identified included lack of awareness about screening, poor knowledge about initial symptoms, social stigma, cost, and familial obligations. Hence, it is not surprising that only 5% of eligible women have undergone screening for cervical cancer in India, compared with up to 84% in developed countries.4 This is disconcerting since cervical cancer has the potential for prevention and/or cure due to the length of the premalignant and preinvasive period, emphasizing the importance of a population-based screening program. The benefits of an effective screening program for this disease were demonstrated by Sankaranarayanan et al. in a study of over 130,000 healthy women, in which participants were randomly assigned to undergo cervical cancer screening with either human papillomavirus (HPV) testing, cytologic testing, or visual inspection with acetic acid (VIA). Single-round HPV testing was associated with a significantly reduced number of advanced cases [hazard ratio (HR) 0.47, 95% confidence interval (CI) 0.32–0.69] and mortality5 (HR 0.53, 95% CI 0.33–0.83) compared with the control group. The results of this study highlight that implementation of a successful screening program with the right screening test is associated with decreased mortality, even in low-resource settings. However, the main challenge is to screen enough people for the screening program to be effective. The National Cancer Prevention and Control Program launched in 2010 in Morocco, with augmented and expanded infrastructure and considered an exemplar for screening programs in LMIC, had major challenges with uptake of screening and poor participation in early identification of precancerous lesions.


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208. Validation of the Interagency Integrated Triage Tool in a resource-limited, urban emergency department in Papua New Guinea: a pilot study

The Lancet Regional Health – Western Pacific


Authors: Rob Mitchell, Ovia Bue, Gary Nou, Jude Taumomoa, Ware Vagoli , Steven Jack , Colin Banks , Gerard O’Reilly, Sarah Bornstein, Tracie Ham, Teri Reynolds, Sarah Körver, Peter Cameron
Region / country: Melanesia – Papua New Guinea
Speciality: Emergency surgery

Background
The Interagency Integrated Triage Tool (IITT) is a three-tier triage system designed for resource-limited emergency care (EC) settings. This study sought to assess the validity and reliability of a pilot version of the tool in an urban emergency department (ED) in Papua New Guinea.

Methods
A pragmatic observational study was conducted at Gerehu General Hospital in Port Moresby, commencing eight weeks after IITT implementation. All ED patients presenting within the subsequent two-month period were included. Triage assessments were performed by a variety of ED clinicians, including community health workers, nurses and doctors. The primary outcome was sensitivity for the detection of time-critical illness, defined by ten pre-specified diagnoses. The association between triage category and ED outcomes was examined using Cramer’s V correlation coefficient. Reliability was assessed by inter-rater agreement between a local and an experienced, external triage officer.

Findings
Among 4512 presentations during the study period, 58 (1.3%) were classified as category one (emergency), 967 (21.6%) as category two (priority) and 3478 (77.1%) as category three (non-urgent). The tool’s sensitivity for detecting the pre-specified set of time-sensitive conditions was 70.8% (95%CI 58.2-81.4%), with negative predictive values of 97.3% (95%CI 96.7 – 97.8%) for admission/transfer and 99.9% (95%CI 99.7 – 100.0%) for death. The admission/transfer rate was 44.8% (26/58) among emergency patients, 22.9% (223/976) among priority patients and 2.7% (94/3478) among non-urgent patients (Cramer’s V=0.351, p=0.00). Four of 58 (6.9%) emergency patients, 19/976 (2.0%) priority patients and 3/3478 (0.1%) non-urgent patients died in the ED (Cramer’s V=0.14, p=0.00). The under-triage rate was 2.7% (94/3477) and the over-triage rate 48.2% (28/58), both within pre-specified limits of acceptability. On average, it took staff 3 minutes 34 seconds (SD 1:06) to determine and document a triage category. Among 70 observed assessments, weighted κ was 0.84 (excellent agreement).

Interpretation
The pilot version of the IITT demonstrated acceptable performance characteristics, and validation in other EC settings is warranted.

Funding
This project was funded through a Friendship Grant from the Australian Government Department of Foreign Affairs and Trade and an International Development Fund Grant from the Australasian College for Emergency Medicine Foundation.


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209. Identifying the epidemiology of traumatic injury in Benghazi, Libya through the implementation of an electronic trauma registry

eScholarship McGill


Authors: Elgheriani Ali
Region / country: Northern Africa – Libya
Speciality: Health policy, Trauma and orthopaedic surgery, Trauma surgery

Traumatic injury is the leading cause of morbidity and mortality globally, and there is little data in the literature for low middle-income countries (LMIC), although it is slowly growing. Libya has been suffering from low resources that are further strained by an ongoing civil war. Benghazi Medical Centre (BMC) is the only operating trauma public hospital in the country’s eastern region and trauma is on the rise. Currently, there is no system in place to identify the trends of traumatic injuries nor any formal surveillance. The objective of this thesis is to describe the epidemiology of traumatic injuries and identify gaps in the trauma system.Methods: This is a prospective study conducted at BMC’s emergency room through the implementation of an electronic trauma registry, iTrauma application. Data collection occurred during January of 2017 over a 10-day trial period. Upon the traumatic patient’s arrival to the emergency department twenty-five data points were collected and entered into iTrauma. Data points included patient demographics, mechanism of injury and clinical outcomes. Results: A total of 231 patients were evaluated and included into the TR. Males were at higher risk for traumatic injury making up 68% of injured patients. The average age was 31 years old, however, the majority of were in the 0-10 and 31-40 age groups. Falls were the most common cause of injury at 31%, followed closely by motor vehicle collisions at 30%. None of the patients injured in a car collision wore a seatbelt, and half of motorbike collision patients dawned helmets. The most common type of injury was bone fractures at 13% and the most common anatomical region was extremity injuries. The vast majority of trauma patients arrived by private vehicle (57%), whereas 20% arrived by ambulance. In terms of clinical outcome, 36% of patients were either treated and discharged in the ER or discharged by the 2 weeks follow up. However, there was a mortality rate of at least 11%. Conclusion: Traumatic injuries lead to a high mortality rate and carry a large burden to the individual clinically and economically. The implementation of a simple TR was shown to be feasible and has a tremendous value in identifying the epidemiology of traumatic injury, most notably falls and motor vehicle collisions. Advocating for programs that address preventative measures can have remarkable benefits in reducing morbidity and mortality. Furthermore, continued support for TR can evolve with the institution and provide ongoing improvement to quality of care


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210. Healthcare-associated infections and antimicrobial use in surgical wards of a large urban central hospital in Blantyre, Malawi: a point prevalence survey

Infection Prevention in Practice


Authors: Gabriel Kambale Bunduki, Nicholas Feasey, Marc Y.R. Henrion, Patrick Noah, Janelisa Musaya
Region / country: Southern Africa – Malawi
Speciality: General surgery, Health policy, Other

Background
There are limited data on healthcare-associated infections (HAI) from African countries like Malawi.

Aim
We undertook a point prevalence survey of HAI and antimicrobial use in the surgery department of Queen Elizabeth Central Hospital (QECH) in Malawi and ascertained the associated risk factors for HAI.

Methods
A cross-sectional point prevalence survey (PPS) was carried out in the surgery department of QECH. The European Centre for Disease Prevention and Control PPS protocol version 5.3 was adapted to our setting and used as a data collection tool.

Findings
105 patients were included in the analysis; median age was 34 (IQR: 24–47) years and 55.2% patients were male. Point prevalence of HAI was 11.4% (n=12/105) (95% CI: 6.0%–19.1%), including four surgical site infections, four urinary tract infections, three bloodstream infections and one bone/joint infection. We identified the following risk factors for HAI; length-of-stay between 8 and 14 days (OR=14.4, 95% CI: 1.65–124.7, p=0.0143), presence of indwelling urinary catheter (OR=8.3, 95% CI: 2.24–30.70, p=0.003) and history of surgery in the past 30 days (OR=5.11, 95% CI: 1.46–17.83, p=0.011). 29/105 patients (27.6%) were prescribed antimicrobials, most commonly the 3rd-generation cephalosporin, ceftriaxone (n=15).

Conclusion
The prevalence rates of HAI and antimicrobial use in surgery wards at QECH are relatively high. Hospital infection prevention and control measures need to be strengthened to reduce the burden of HAI at QECH.


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211. Reimagining Universal Health Coverage: Safe and Affordable Surgery

Journal of International Development Cooperation


Authors: Minsol Kim, Kee Bum Park, Sangchul Yoon
Region / country: Southern Africa, Southern Asia – Pakistan, Zambia
Speciality: Health policy

UN sustainable development goals (SDGs) and universal health coverage (UHC) are significant health goals the world needs to achieve. Despite concerted efforts to attain UHC, the world is still lagging. Compared to the sizable number of resources put into the treatment of well-known communicable diseases, such as HIV/AIDs, tuberculosis, and malaria, surgery is relatively underutilized despite its potential. Scaling up surgical interventions, however, is crucial since it can save many people’s lives and help avert the economic losses incurred due to diseases. Moreover, increased surgical capacity in low-to-middle-income countries (LMICs) could prove useful in overcoming pandemics, such as COVID-19. To upgrade the surgical capacity of the LMICs, it is essential to incorporate National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs) into their national health policies. In this paper, the illustrative cases of two countries that adopted NSOAPs with a different model. Zambia and Pakistan, are examined. We conclude by giving recommendations to countries that are yet to adopt NSOAPs


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212. Surgical Management and Outcomes of Wilms Tumor in Rwanda: A Retrospective Study of Patients Operated on at the University Teaching Hospital of Kigali-Rwanda

Rwanda Medical Journal


Authors: Mpirimbanyi, C., Ndibanje, A. J., Curci, M. , Kanyamuhunga, A.
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: General surgery, Paediatric surgery

BACKGROUND: Wilms tumor is the most common renal tumor in children and accounts for 6-8% of all childhood malignancies and has a variable survival rate worldwide. The aim of this study was to describe the surgical management and outcomes of care for Wilms tumor patients operated at the University Teaching Hospital of Kigali (CHUK).
METHODS: This is a retrospective chart review conducted at CHUK in Rwanda. It includes all children who had a confirmed Wilms tumor diagnosis operated from July 2012 to June 2016. Patient’s demographics, staging, surgical management, and outcomes were analyzed.
RESULTS: A total of 58 patients diagnosed with Wilms tumor were identified. 52.6% were female. The median age was four years, interquartile range (IQR): 1-10 years. The majority of the children were stage II (39.7%) and the minority being stage V (5.2%). Treatment offered was in accordance with the Societe Internationale d’ Oncologie Pediatrique (SIOP) protocol; 91.2% of patients received four weeks of preoperative chemotherapy and a median of 15 weeks postoperative chemotherapy (IQR: 8,26). The resection rate was 100% for those with unilateral tumors. The spillage rate was 15.8%. At the time of the study, the mortality rate was 19.3%, recurrence was 7%, and 12.3% were lost to follow-up.
CONCLUSION: The introduction of a single national protocol for treating Wilms tumor in Rwanda with a dedicated management team, including the surgical and pediatric oncology services, has led to early outcomes approaching the ones in high-income countries, but efforts also need to include earlier detection of this tumor.


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213. Breast Cancer in the Gaza Strip: The impact of the medical permit regime on public health

repository library Georgetown.Edu


Authors: Isabel Roemer
Region / country: Middle East – Palestinian Territories
Speciality: General surgery, Health policy, Surgical oncology

For the last 14 years, the Gaza Strip has been subject to an illegal blockade imposed by the Israeli and Egyptian governments. This severe restriction on movement prevents Gazans from accessing critical resources and makes access to health care, even for the most severely ill patients, contingent on a convoluted permit system run by the Israeli military. Consequences of the permit system include major delays in treatment and adverse health outcomes. My thesis explores the impact of the permit system on health outcomes for breast cancer patients in Gaza and offers recommendations for improving public health via community-based and political initiatives


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214. Readiness to Provide Antenatal Corticosteroids for Threatened Preterm Birth in Public Health Facilities in Northern India

Global Health: Science and Practice


Authors: Ankita Kankaria, Mona Duggal, Anshul Chauhan, Debarati Sarkar, Suresh Dalpath, Akash Kumar, Gursharan Singh Dhanjal, Vijay Kumar, Vanita Suri, Rajesh Kumar, Praveen Kumar and James A. Litch
Region / country: Southern Asia – India
Speciality: Health policy, Obstetrics and Gynaecology

Introduction:
In 2014, the Government of India (GOI) released operational guidelines on the use of antenatal corticosteroids (ACS) in preterm labor. However, without ensuring the quality of childbirth and newborn care at facilities, the use of ACS in low- and middle-income countries is potentially harmful. This study assessed the readiness to provide ACS at primary and secondary care public health facilities in northern India.

Methods:
A cross-sectional study was conducted in 37 public health facilities in 2 districts of Haryana, India. Facility processes and program implementation for ACS delivery were assessed using pretested study tools developed from the World Health Organization (WHO) quality of care standards and WHO guidelines for threatened preterm birth.

Results:
Key gaps in public health facilities’ process of care to provide ACS for threatened preterm birth were identified, particularly concerning evidence-based practices, competent workforce, and actionable health information system. Emphasis on accurate gestational age estimation, quality of childbirth care, and quality of preterm care were inadequate. Shortage of trained staff was widespread, and a disconnect was found between knowledge and attitudes regarding ACS use. ACS administration was provided only at district or subdistrict hospitals, and these facilities did not uniformly record ACS-specific indicators. All levels lacked a comprehensive protocol and job aids for identifying and managing threatened preterm birth.

Conclusions:
ACS operational guidelines were not widely disseminated or uniformly implemented. Facilities require strengthened supervision and standardization of threatened preterm birth care. Facilities need greater readiness to meet required conditions for ACS use. Increasing uptake of a single intervention without supporting it with adequate quality of maternal and newborn care will jeopardize improvement in preterm birth outcomes. We recommend updating and expanding the existing GOI ACS operational guidelines to include specific actions for the safe and effective use of ACS in line with recent scientific evidence.


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215. Disruptions of neurological services, its causes and mitigation strategies during COVID-19: a global review

Journal of Neurology


Authors: David García-Azorín, Katrin M. Seeher, Charles R. Newton, Njideka U. Okubadejo, Andrea Pilotto, Deanna Saylor, Andrea Sylvia Winkler, Chahnez Charfi Triki , Matilde Leonardi
Region / country: Global
Speciality: Health policy, Neurosurgery

Background
The COVID-19 pandemic leads to disruptions of health services worldwide. To evaluate the particular impact on neurological services a rapid review was conducted.

Methods
Studies reporting the provision of neurological services during the pandemic and/or adopted mitigation strategies were included in this review. PubMed and World Health Organization’s (WHO) COVID-19 database were searched. Data extraction followed categories used by WHO COVID-19 pulse surveys and operational guidelines on maintaining essential health services during COVID-19.

Findings
The search yielded 1101 articles, of which 369 fulfilled eligibility criteria, describing data from 210,419 participants, being adults (81%), children (11.4%) or both (7.3%). Included articles reported data from 105 countries and territories covering all WHO regions and World Bank income levels (low income: 1.9%, lower middle: 24.7%, upper middle: 29.5% and high income; 44.8%). Cross-sectoral services for neurological disorders were most frequently disrupted (62.9%), followed by emergency/acute care (47.1%). The degree of disruption was at least moderate for 75% of studies. Travel restrictions due to lockdowns (81.7%) and regulatory closure of services (65.4%) were the most commonly reported causes of disruption. Authors most frequently described telemedicine (82.1%) and novel dispensing approaches for medicines (51.8%) as mitigation strategies. Evidence for the effectiveness of these measures is largely missing.

Interpretation
The COVID-19 pandemic affects all aspects of neurological care. Given the worldwide prevalence of neurological disorders and the potential long-term neurological consequences of COVID-19, service disruptions are devastating. Different strategies such as telemedicine might mitigate the negative effects of the pandemic, but their efficacy and acceptability remain to be seen.


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216. Survival of south african women with breast cancer receiving anti-retroviral therapy for HIV

The Breast


Authors: Boitumelo Phakathi, Sarah Nietz , Herbert Cubasch, Caroline Dickens, Therese Dix-Peek, Maureen Joffe, Alfred I. Neugut, Judith Jacobson, Raquel Duarte, Paul Ruff
Region / country: Southern Africa – South Africa
Speciality: General surgery, Other, Surgical oncology

Purpose
Breast cancer outcomes in sub-Saharan Africa is reported to be poor, with an estimated five-year survival of 50% when compared to almost 90% in high-income countries. Although several studies have looked at the effect of HIV in breast cancer survival, the effect of ARTs has not been well elucidated.

Methods
All females newly diagnosed with invasive breast cancer from May 2015–September 2017 at Charlotte Maxeke Johannesburg Academic and Chris Hani Baragwanath Academic Hospital were enrolled. We analysed overall survival and disease-free survival, comparing HIV positive and negative patients. Kaplan-Meier survival curves were generated with p-values calculated using a log-rank test of equality while hazard ratios and their 95% confidence intervals (CIs) were estimated using Cox regression models.

Results
Of 1019 patients enrolled, 22% were HIV positive. The overall survival (95% CI) was 53.5% (50.1–56.7%) with a disease-free survival of 55.8% (52.1–59.3) after 4 years of follow up. HIV infection was associated with worse overall survival (HR (95% CI): 1.50 (1.22–1.85), p < 0.001) and disease-free survival (OR (95% CI):2.63 (1.71–4.03), p < 0.001), especially among those not on ART at the time of breast cancer diagnosis. Advanced stage of the disease and hormone-receptor negative breast cancer subtypes were also associated with poor survival.

Conclusion
HIV infection was associated with worse overall and disease-free survival. HIV patients on ARTs had favourable overall and disease-free survival and with ARTs now being made accessible to all the outcome of women with HIV and breast cancer is expected to improve.


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217. Adopting localised health financing models for universal health coverage in Low and middle-income countries: lessons from the National Health lnsurance Scheme in Ghana

Heliyon


Authors: Maximillian Kolbe Domapielle
Region / country: Western Africa – Ghana
Speciality: Health policy

The health-related Sustainable Development Goals (SDGs) and the Coronavirus Pandemic (COVID-19) have recently increased awareness of the need for countries to increase fiscal space for health. Prior to these, many Low and Middle-Income Countries (LMICs) had embraced the concept of Universal Health Coverage (UHC) and have either commenced or are in the process of implementing various models of health insurance in order to provide financial access to health care to their populations. While evidence of a relationship between experimentation with UHC and increased access to and utilisation of health care in LMICs is common, there is inadequate research evidence on the specific health financing model that is most appropriate for pursuing the objectives of UHC in these settings. Drawing on a synthesis of empirical and theoretical discourses on the feasibility of UHC in LMICs, this paper argues that the journey towards UHC is not a ‘one size fits all’ process, but a long-term policy engagement that requires adaptation to the specific socio-cultural and political economy contexts of implementing countries. The study draws on the WHO’s framework for tracking progress towards UHC using the implementation of a mildly progressive pluralistic health financing model in Ghana and advocates a comprehensive discourse on the potential for LMICs to build resilient and responsive health systems to facilitate a gradual transition towards UHC.


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218. Taking Paediatrics Abroad: Working with low- and middle-income countries in a global pandemic

Journal of Paediatrics and Child Health Journal of Paediatrics and Child Health


Authors: Anneka Parker, Eap Tek Chheng, Titus Nasi, Thyna Orelly, George Aho, Sally Whitaker, James Weaver, Sue Phin, Ruth Baker, Susan Woolfenden, Kathryn Currow
Region / country: Global
Speciality: Health policy, Paediatric surgery

Children and young people around the world face challenges to their health and wellbeing. In particular, in low- and middle-income countries they experience a higher burden of disease, exacerbated by global inequity limiting access to quality health care. According to the inverse care law, the availability of quality health care varies inversely to the need of the population, and hardworking health-care professionals in under-resourced countries may face impediments to continued education or subspecialty training. In line with the Sustainable Development Goals, collaborations have been developed between high-income and low- and-middle-income countries to address global disparities in health. These collaborations face challenges of high financial costs, difficulties creating long-term sustainable change, and with the emergence of the COVID-19 pandemic, border closures preventing fly-in volunteers. In this paper, we describe the development of an innovative, paediatric-specific model of care for training and support between high- and low-income countries – Taking Paediatrics Abroad Ltd. Taking Paediatrics Abroad supports the development of mutually beneficial relationships between Australian paediatric health-care professionals and paediatric health-care professionals in developing countries and remote, underserved Australian Aboriginal communities. Since May 2020, there have been over 100 sessions covering a vast array of paediatric specialties. This article explores Taking Paediatrics Abroad’s model of care, its implementation and challenges, and opportunities for the future


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219. Access to care solutions in healthcare for obstetric care in Africa: A systematic review

plos one


Authors: Anjni Joiner ,Austin Lee ,Phindile Chowa ,Ramu Kharel ,Lekshmi Kumar ,Nayara Malheiros Caruzzo ,Thais Ramirez ,Lindy Reynolds ,Francis Sakita ,Lee Van Vleet ,Megan von Isenburg ,Anna Quay Yaffee ,Catherine Staton ,Joao Ricardo Nickenig Vissoci
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Health policy, Obstetrics and Gynaecology

Background
Emergency Medical Services (EMS) systems exist to reduce death and disability from life-threatening medical emergencies. Less than 9% of the African population is serviced by an emergency medical services transportation system, and nearly two-thirds of African countries do not have any known EMS system in place. One of the leading reasons for EMS utilization in Africa is for obstetric emergencies. The purpose of this systematic review is to provide a qualitative description and summation of previously described interventions to improve access to care for patients with maternal obstetric emergencies in Africa with the intent of identifying interventions that can innovatively be translated to a broader emergency context.

Methods
The protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371. We searched the following electronic databases for all abstracts up to 10/19/2020 in accordance to PRISMA guidelines: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. Articles were included if they were focused on a specific mode of transportation or an access-to-care solution for hospital or outpatient clinic care in Africa for maternal or traumatic emergency conditions. Exclusion criteria included in-hospital solutions intended to address a lack of access. Reference and citation analyses were performed, and a data quality assessment was conducted. Data analysis was performed using a qualitative metasynthesis approach.

Findings
A total of 6,457 references were imported for screening and 1,757 duplicates were removed. Of the 4,700 studies that were screened against title and abstract, 4,485 studies were excluded. Finally, 215 studies were assessed for full-text eligibility and 152 studies were excluded. A final count of 63 studies were included in the systematic review. In the 63 studies that were included, there was representation from 20 countries in Africa. The three most common interventions included specific transportation solutions (n = 39), community engagement (n = 28) and education or training initiatives (n = 27). Over half of the studies included more than one category of intervention.

Interpretation
Emergency care systems across Africa are understudied and interventions to improve access to care for obstetric emergencies provides important insight into existing solutions for other types of emergency conditions. Physical access to means of transportation, efforts to increase layperson knowledge and recognition of emergent conditions, and community engagement hold the most promise for future efforts at improving emergency access to care.


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220. Gender-role behaviour and gender identity in girls with classical congenital adrenal hyperplasia

BMC Pediatrics


Authors: Sumudu Nimali Seneviratne, Umesh Jayarajah, Shamaali Gunawardana, Malik Samarasinghe & Shamya de Silva
Region / country: Southern Asia – Sri Lanka
Speciality: Obstetrics and Gynaecology, Paediatric surgery

Introduction
Girls with classical congenital adrenal hyperplasia (CAH) are exposed to excess fetal adrenal androgens in-utero, and often born with masculinised genitalia. They are conventionally reared as females, but show more “boyish” gender-role behaviour (GRB) and gender-identity (GI) issues in childhood and adolescence. Male-rearing is also reported mainly due to delayed treatment and/or socio-cultural factors. We compared GRB/GI in girls with CAH with healthy age matched children, and explored for associations with socio-demographic and diagnosis/treatment related factors.

Methods
GRB and GI were assessed using the Gender Identity Questionnaire for children (GIQC) in 27 girls with classical CAH at a specialised clinic, and compared with 50 age-matched healthy controls, with exploratory-analysis based on socio-demographic and diagnosis/treatment-related factors.

Results
Girls with CAH had lower total GIQC scores compared to healthy children (3.29 vs. 4.04, p = < 0.001) with lower GRB score (3.39 vs. 4.23, p < 0.001), and tendency for lower GI score (3.19 vs. 3.5, p = 0.08). Exploratory analysis showed no differences based on diagnosis/treatment factors including age, degree of virilisation at diagnosis and surgical procedures. and only subtle changes based on ethnicity and maternal education.

Discussion/conclusion
Girls with CAH managed at a specialised centre showed more masculinised GRB and tendency for ambiguous GI, which did not vary upon diagnosis/treatment related factors, suggesting that prenatal androgen exposure was the likely contributor. Clinicians should be vigilant about the increased risk of gender-related problems in girls with CAH, irrespective of sociocultural background and despite early treatment.


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221. Assessing service availability and readiness to manage cervical cancer in Bangladesh

BMC Cancer


Authors: Shagoofa Rakhshanda, Koustuv Dalal, Hasina Akhter Chowdhury, Cinderella Akbar Mayaboti, Progga Paromita, A. K. M. Fazlur Rahman, A. H. M. Eanayet Hussain & Saidur Rahman Mashreky
Region / country: South-eastern Asia – Bangladesh
Speciality: Obstetrics and Gynaecology, Surgical oncology

Background
The second most common cancer among females in Bangladesh is cervical cancer. The national strategy for cervical cancer needs monitoring to ensure that patients have access to care. In order to provide accurate information to policymakers in Bangladesh and other low and middle income countries, it is vital to assess current service availability and readiness to manage cervical cancer at health facilities in Bangladesh.

Methods
An interviewer-administered questionnaire adapted from the World Health Organization Service Availability and Readiness Assessment Standard Tool was used to collect cross-sectional data from health administrators of 323 health facilities in Bangladesh. Services provided were categorized into domains and service readiness was determined by mean readiness index (RI) scores. Data analysis was conducted using STATA version 13.

Results
There were seven tertiary and specialized hospitals, 118 secondary level health facilities, 124 primary level health facilities, and 74 NGO/private hospitals included in the study. Twenty-six per cent of the health facilities provided services to cancer patients. Among the 34 tracer items used to assess cancer management capacity of health facilities, four cervical cancer-specific tracer items were used to determine service readiness for cervical cancer. On average, tertiary and specialized hospitals surpassed the readiness index cutoff of 70% with adequate staff and training (100%), equipment (100%), and diagnostic facilities (85.7%), indicating that they were ready to manage cervical cancer. The mean RI scores for the rest of the health facilities were below the cutoff value, meaning that they were not prepared to provide adequate cervical cancer services.

Conclusion
The health facilities in Bangladesh (except for some tertiary hospitals) lack readiness in cervical cancer management in terms of guidelines on diagnosis and treatment, training of staff, and shortage of equipment. Given that cervical cancer accounts for more than one-fourth of all female cancers in Bangladesh, management of cervical cancer needs to be available at all levels of health facilities, with primary level facilities focusing on early diagnosis. It is recommended that appropriate standard operating procedures on cervical cancer be developed for each level of health facilities to contribute towards attaining sustainable developmental goals.


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222. Building an ecosystem of safe surgery and anesthesia through cleft care

Journal Cleft Lip Palate and Craniofacial Anomalies


Authors: Susannah Schaefer, Erin Stieber
Region / country: Global
Speciality: Anaesthesia, Health policy, Maxillofacial and oral surgery, Plastic surgery

Cleft lip and/or palate (CLP) is among the world’s most common congenital anomalies, affecting an estimated 1 in 700 live births. CLP can lead to a wide range of health problems, including feeding difficulties that contribute to malnutrition, oral health challenges, delays in speech and language development, and long-term emotional and physical health issues. Receiving timely high-quality cleft surgical and anesthesia care, in addition to a range of interdisciplinary health services, is critical to the health and development of children impacted by CLP.

Too often, however, whether a baby receives this essential treatment is dependent upon the city, country, or region in which they are born. The global burden of surgical disease is a significant and long-neglected area within global health that disproportionately affects low-and middle-income countries (LMICs) compared to high-income countries (HICs). The estimated 1.7 billion children who live without access to surgical care around the globe, including many with CLP, live with a greater risk of life-long disability and a higher risk of mortality.

Barriers to surgical care in LMICs include a lack of trained health-care providers, inadequate infrastructure, high out-of-pocket costs, and lack of political prioritization. Historically, short-term missions have sought to address the burden of surgical conditions such as CLP, but this short-term, siloed approach fails to address – and in many cases has only perpetuated – the systemic causes of global surgical inequity, which cuts across sectors, disciplines, and borders. As momentum for the prioritization of surgical care grows, it is also clear that outdated models must be replaced by approaches that strengthen the entire ecosystem of safe surgery and anesthesia care


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223. Impact of the COVID-19 pandemic on paediatric patients with cancer in low-income, middle-income and high-income countries: protocol for a multicentre, international, observational cohort study

BMJ Open


Authors: Noel Peter, Soham Bandyopadhyay, Kokila Lakhoo and Global Health Research Group on Children’s Non-Communicable Diseases Collaborative
Region / country: Global
Speciality: Health policy, Paediatric surgery, Surgical oncology

Introduction
Childhood cancers are a leading cause of non-communicable disease deaths for children around the world. The COVID-19 pandemic may have impacted on global children’s cancer services, which can have consequences for childhood cancer outcomes. The Global Health Research Group on Children’s Non-Communicable Diseases is currently undertaking the first international cohort study to determine the variation in paediatric cancer management during the COVID-19 pandemic, and the short-term to medium-term impacts on childhood cancer outcomes.

Methods and analysis
This is a multicentre, international cohort study that will use routinely collected hospital data in a deidentified and anonymised form. Patients will be recruited consecutively into the study, with a 12-month follow-up period. Patients will be included if they are below the age of 18 years and undergoing anticancer treatment for the following cancers: acute lymphoblastic leukaemia, Burkitt lymphoma, Hodgkin lymphoma, Wilms tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas and neuroblastomas. Patients must be newly presented or must be undergoing active anticancer treatment from 12 March 2020 to 12 December 2020. The primary objective of the study was to determine all-cause mortality rates of 30 days, 90 days and 12 months. This study will examine the factors that influenced these outcomes. χ2 analysis will be used to compare mortality between low-income and middle-income countries and high-income countries. Multilevel, multivariable logistic regression analysis will be undertaken to identify patient-level and hospital-level factors affecting outcomes with adjustment for confounding factors.

Ethics and dissemination
At the host centre, this study was deemed to be exempt from ethical committee approval due to the use of anonymised registry data. At other centres, participating collaborators have gained local approvals in accordance with their institutional ethical regulations. Collaborators will be encouraged to present the results locally, nationally and internationally. The results will be submitted for publication in a peer-reviewed journal.


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224. An assessment of human resource distribution for public eye health services in KwaZulu-Natal, South Africa

African Vision and Eye Health


Authors: Zamadonda N. Xulu-Kasaba, Khathutshelo P. Mashige, Kovin S. Naidoo
Region / country: Southern Africa – South Africa
Speciality: Health policy, Ophthalmology

Background: The development of human resources for eye health (HReH), aimed at achieving a 25% reduction in visual impairment by the year 2020, was one of the VISION 2020 objectives.

Aim: To assess HReH in the public sector of KwaZulu-Natal (KZN), and its effect on the accessibility of eye care in the province.

Setting: All public eye facilities in KZN.

Methods: A quantitative cross-sectional study using a close-ended questionnaire to assess distribution and outputs of HReH. At the end of the questionnaire, respondents gave general comments on their ability to provide services.

Results: Human resource rates were 0.89 for ophthalmologists, 2.44 for cataract surgeons, 4.8 for optometrists and 4.7 for ophthalmic nurses per 1 million population. Most health facilities had some HReH working in them, albeit none had dispensing opticians. Regression analysis showed that 67.1% of variation in cataract surgery was because of the number of surgeons available. Cataract surgical rates were low with a waiting period of up to 18 months. In addition to the refractive error regression analysis of 33.7%, spectacle supply was low, with a backlog of up to 9 months in some facilities.

Conclusion: Overall, HReH targets as per VISION 2020 and the National Prevention of Blindness have not been met in this region. Dispensing opticians are not employed in any of the province’s health districts. An increase in the eye health workforce is necessary to improve the eye health outcomes for people dependent on public eye facilities.


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225. The regulation of healthcare professions and support workers in international context

Human Resources for Health


Authors: Mike Saks
Region / country: Global
Speciality: Health policy

Background
The objective of this paper is to outline and compare the regulation of paid healthcare professions and associated support workers in international context, bringing out the lessons to be learned as appropriate. Modern neo-liberal societies have sought to enhance healthcare through greater professional regulation, albeit in different ways and at variable pace. This general trend is illustrated with reference to medicine in the UK. However, although such reforms have helpfully cascaded to other health professions, government policy in high-income countries has not yet adequately regulated the interrelated group of non-professionalised health support workers who form the largest and least recognised part of the workforce. Nonetheless, in low- and middle-income (LMIC) countries—aside from the greater need for regulation of health professions—there is even more of an imperative to regulate the disparate, largely invisible support workforce.

Methods
With reference to existing studies of the medical and wider health professions in the UK and selected other higher income societies, the importance of health professional regulation to the public is underlined in the Global North. The larger gap in the regulation of support workers in modern neo-liberal countries is also emphasised on a similar basis, with an increasingly ageing population and advances in healthcare. It is argued from the very limited patchwork of secondary literature, though, that policy-makers may want to focus even more on enhancing regulation of both the professional and non-professional workforce in LMIC societies centred mainly in the Global South, drawing on lessons from the Global North.

Results/conclusions
Efforts to reform health professional regulatory approaches in more economically developed countries, while needing refinement, are likely to have had a positive effect. However, even in these societies there are still substantial shortfalls in the regulation of health support workers. There are even larger gaps in LMICs where there are fewer health professional staff and a greater dependence on support workers. With higher rates of morbidity and mortality, there is much more scope here for reforming health regulation in the public interest to extend standards and mitigate risk, following the pattern for healthcare professions in the Global North.


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226. Barriers and enablers to country adoption of National Surgical, Obstetric, and Anesthesia Plans

Journal of Public Health and Emergency


Authors: Ché L. Reddy, Elizabeth Miranda, Rifat Atun
Region / country: Global
Speciality: Health policy

This paper examines the adoption and diffusion of National Surgical Obstetric and Anaesthesia Plans (NSOAPs), a policy instrument, to improve surgical healthcare services in low- and middle-income countries (LMICs). It draws on recent trends in health system reform and empiricism to understand NSOAP effectiveness for large-scale improvement in surgical system objectives (surgical outcomes, patient satisfaction and financial risk protection). While the study reveals that NSOAP adoption has occurred in several countries, its translation into effective, responsive and equitable coverage of surgical healthcare services (diffusion) with enduring impact has yet to occur on a large-scale. NSOAP adoption and diffusion has been constrained by two principal considerations: (I) suboptimal funding allocation to develop NSOAPs and implement within a health system context; (II) inadequate translation of the NSOAP into implementable activities that lead to improved health system performance. We argue that a systems perspective—dynamically optimizing the NSOAP in relation to specific health system, adoption system, and contextual factors—may enhance the scale-up of NSOAPs and lead to sustainably funded programs that enhance the effectiveness, efficiency, responsiveness and equity of surgical healthcare service over the long-term. We explore three specific areas—technology, financing, governance—which could be harnessed to enhance the adoption and diffusion of NSOAPs.


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227. Global Radiotherapy: Current Status and Future Directions—White Paper

JCO Global Oncology


Authors: May Abdel-Wahab, Soehartati S. Gondhowiardjo , Arthur Accioly Rosa , Yolande Lievens , Noura El-Haj, Jose Alfredo Polo Rubio,Gregorius Ben Prajogi , Herdis Helgadottir , Eduardo Zubizarreta ,Ahmed Meghzifene, Varisha Ashraf, Stephen Hahn, Tim Williams, Mary Gospodarowicz
Region / country: Global
Speciality: Health policy, Other, Surgical oncology

Recognizing the increase in cancer incidence globally and the need for effective cancer control interventions, several organizations, professional bodies, and international institutions have proposed strategies to improve treatment options and reduce mortality along with minimizing overall incidence. Despite these efforts, an estimated 9.6 million deaths in 2018 was attributed to this noncommunicable disease, making it the second leading cause of death worldwide. Left unchecked, this will further increase in scale, with an estimated 29.5 million new cases and 16.3 million deaths occurring worldwide in 2040. Although it is known and generally accepted that cancer services must include radiotherapy, such access is still very limited in many parts of the world, especially in low- and middle-income countries. After thorough review of the current status of radiotherapy including programs worldwide, as well as achievements and challenges at the global level, the International Atomic Energy Agency convened an international group of experts representing various radiation oncology societies to take a closer look into the current status of radiotherapy and provide a road map for future directions in this field. It was concluded that the plethora of global and regional initiatives would benefit further from the existence of a central framework, including an easily accessible repository through which better coordination can be done. Supporting this framework, a practical inventory of competencies needs to be made available on a global level emphasizing the knowledge, skills, and behavior required for a safe, sustainable, and professional practice for various settings. This white paper presents the current status of global radiotherapy and future directions for the community. It forms the basis for an action plan to be developed with professional societies worldwide.


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228. Understanding context: A qualitative analysis of the roles of family caregivers of people living with cancer in Vietnam and the implications for service development in low-income settings

Psycho-Oncology


Authors: Hien Thi Ho, Chris Jenkins, Hoa Le Phuong Nghiem, Minh Van Hoang, Olinda Santin
Region / country: South-eastern Asia – Vietnam
Speciality: Surgical oncology

Objectives
Research on the needs of family caregivers of people living with cancer remains disproportionately focused in high income contexts. This research gap adds to the critical challenge on global equitable delivery of cancer care. This study describes the roles of family caregivers of people living with cancer in Vietnam and possible implications for intervention development.

Methods
Semi-structured interviews and focus groups with family caregivers (n = 20) and health care providers (n = 22) were conducted in two national oncology hospitals. Findings were verified via workshops with carers (n = 11) and health care professionals (n = 28) in five oncology hospitals representing different regions of Vietnam. Data was analyzed collaboratively by an international team of researchers according to thematic analysis.

Results
Family caregivers in Vietnam provide an integral role in the delivery of inpatient cancer care. In the hospital environment families are responsible for multiple roles including feeding, hydration, changing, washing, moving, wound care and security of personal belongings. Central to this role is primary decision making in terms of treatment and end-of-life care; relaying information, providing nutritional, emotional and financial support. Families are forced to manage severe complications and health care needs with minimal health literacy and limited health care professional input.

Conclusions
Understanding context and the unique roles of family caregivers of people living with cancer is critical in the development of supportive services. As psycho-oncology develops in low and middle income contexts, it is essential that family caregiver roles are of significant importance.


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229. Macrovascular Complications in Patients with Diabetes Mellitus: Incidence and Impact on Survival in Kazakhstan

Research Square


Authors: Antonio Sarría-Santamera, Binur Orazumbekova, Tilektes Maulenkul, Alessandro Salustri, Natalya Glushkova, Daniyar Makashev, Abuzhappar Gaipov DOI:
Region / country: Central Asia – Kazakhstan
Speciality: General surgery, Vascular surgery

Background and aim: Diabetic patients are at an increased risk for the development of macrovascular complications such as acute myocardial infarction (AMI), stroke and lower-limb amputations (LLA). This study aimed to explore a. the incidence of hospital admission for macrovascular complications (AMI, stroke, and LLA); b. to assess the impact of hospital admission on survival in a large population with diabetes mellitus living in Kazakhstan.

Materials and methods: Retrospective observational study using a nationwide anonymized electronic database of 98.469 hospitalized diabetic patients from Kazakhstan between November 2013 and December 2019. The incidence of hospital admissions for AMI, stroke and LLA were obtained to calculate their all-time cumulative incidence, and survival rate at follow-up.

Results: The all-time cumulative incidence of hospital admissions was 1.30% for AMI, 1.94% for stroke and 2.94% for LLA. The incidence of macrovascular complications was statistically significantly higher in males compared to females (p-value<0.05). 29.03% of diabetic patients with AMI, 25.16% with stroke and 29.80% with LLA died during the follow-up period. Individuals with AMI had 3.58 (95% CI 3.20; 4.01) times, with stroke 3.86 (95% CI 3.52; 4.24) times and with LLA 3.63 (95% CI 3.38; 3.88) times higher hazard of 6-year death compared to diabetic patients free of these complications. The stratified survival analysis by sex indicated the lower survival in women than in men, and the lower survival in older age groups.

Conclusion: The results from this study shows that cumulative incidence of AMI and stroke among diabetic patients admitted in the hospitals in Kazakhstan between 2013-2019 years was similar to the estimates from other countries, but the incidence of LLA was significantly higher in Kazakhstan. Patients with diabetes mellitus (DM) in Kazakhstan are at high risk of excess mortality if they suffer from macro-vascular complications. More research is required to explore the reasons for the high incidence of those complications, in order to propose systematic solutions for lowering the incidence and improve survival.


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230. Dataset evaluating the treatment timeliness of cervical cancer in Zambia

Data in Brief


Authors: Jane Mwamba Mumba, Lackson Kasonka , Okola Basil Owiti , John Andrew , Mwansa Ketty Lubeya, Lufunda Lukama , Charlotte Kasempa, Susan C. Msadabwe , Chester Kalinda
Region / country: Southern Africa – Zambia
Speciality: Health policy, Obstetrics and Gynaecology, Surgical oncology

Cervical cancer is the fourth most common cancer diagnosed among women globally. Effective screening routines and early detection are vital in reducing its disease burden and mortality. Several factors can influence the timely detection and treatment of cervical cancer, especially in low middle-income countries where the burden of this disease is highest. The data presented in this paper relates to the research article “Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia”. The raw and analysed data include the studied patients’ social demographic factors, clinical data concerning the stage and histological subtype of cancer, dates at which the various activities within the cancer treatment pathway occurred and delays to definitive treatment of cervical cancer at Zambia’s only cancer treatment facility. Detailing delays to the treatment of cervical cancer allows recognition of specific points in the cancer treatment pathway requiring intervention to effectively improve cancer care and reduce the morbidity and mortality associated with the disease.


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231. Qualities of Effective Vital Anaesthesia Simulation Training Facilitators Delivering Simulation-Based Education in Resource-Limited Settings

Anesthesia & Analgesia


Authors: Adam I Mossenson , Jonathan G Bailey , Sara Whynot , Patricia Livingston
Region / country: Global
Speciality: Anaesthesia, Surgical Education

BACKGROUND:
Lack of access to safe and affordable anesthesia and surgical care is a major contributor to avoidable death and disability across the globe. Effective education initiatives are a viable mechanism to address critical skill and process gaps in perioperative teams. Vital Anaesthesia Simulation Training (VAST) aims to overcome barriers limiting widespread application of simulation-based education (SBE) in resource-limited environments, providing immersive, low-cost, multidisciplinary SBE and simulation facilitator training. There is a dearth of knowledge regarding the factors supporting effective simulation facilitation in resource-limited environments. Frameworks evaluating simulation facilitation in high-income countries (HICs) are unlikely to fully assess the range of skills required by simulation facilitators working in resource-limited environments. This study explores the qualities of effective VAST facilitators; knowledge gained will inform the design of a framework for assessing simulation facilitators working in resource-limited contexts and promote more effective simulation faculty development.

METHODS:
This qualitative study used in-depth interviews to explore VAST facilitators’ perspectives on attributes and practices of effective simulation in resource-limited settings. Twenty VAST facilitators were purposively sampled and consented to be interviewed. They represented 6 low- and middle-income countries (LMICs) and 3 HICs. Interviews were conducted using a semistructured interview guide. Data analysis involved open coding to inductively identify themes using labels taken from the words of study participants and those from the relevant literature.

RESULTS:
Emergent themes centered on 4 categories: Persona, Principles, Performance and Progression. Effective VAST facilitators embody a set of traits, style, and personal attributes (Persona) and adhere to certain Principles to optimize the simulation environment, maximize learning, and enable effective VAST Course delivery. Performance describes specific practices that well-trained facilitators demonstrate while delivering VAST courses. Finally, to advance toward competency, facilitators must seek opportunities for skill Progression.

Interwoven across categories was the finding that effective VAST facilitators must be cognizant of how context, culture, and language may impact delivery of SBE. The complexity of VAST Course delivery requires that facilitators have a sensitive approach and be flexible, adaptable, and open-minded. To progress toward competency, facilitators must be open to self-reflection, be mentored, and have opportunities for practice.

CONCLUSIONS:
The results from this study will help to develop a simulation facilitator evaluation tool that incorporates cultural sensitivity, flexibility, and a participant-focused educational model, with broad relevance across varied resource-limited environments.


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232. Addressing quality in surgical services in sub-Saharan Africa: hospital context and data standardisation matter

BMJ Journal


Authors: Tihitena Negussie Mammo, Thomas G Weiser
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Health policy

In low-and-middle-income countries (LMICs), there remain critical gaps in the quality of surgical care. Comparatively high rates of surgical adverse events occur and are likely highly preventable. There has been substantial focus on improving access to health services, including surgical care in LMICs, yet quality oversight and improvement practices remain limited in these settings.4 Over the past decade, surgical volume has doubled in the most resource-poor settings; between 2004 and 2012, the annual number of operations jumped from 234 million to 313 million, with the biggest growth occurring in countries with the lowest amount of healthcare spending.5 6 This signals a profound shift: whereas prior efforts were focused on infections and maternal health, non-communicable diseases such as cancers and trauma are an increasing priority for LMIC health systems. With the rapid growth in surgical delivery, the quality and safety of care are critically important. Poor outcomes and high morbidity breed mistrust, scepticism and fear among local populations, and thus hinder the mission of health systems to provide timely and essential services, especially risky ones like surgery.


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233. Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals

Surgery


Authors: David F. Grabski, Margaret Ajiko, Peter Kayima , Nensi Ruzgar , David Nyeko , Tamara N. Fitzgerald , Monica Langer , Maija Cheung , Bruno Cigliano , Sergio D’Agostino , Robert Baird , Damian Duffy , Janat Tumukunde , Mary Nabukenya , Martin Ogwang , Phyllis Kisa , John Sekabira , Nasser Kakembo , Doruk Ozgediz
Region / country: Eastern Africa – Uganda
Speciality: Anaesthesia, Paediatric surgery

Background
Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children’s surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity.

Methods
Two years of a prospective clinical database of children’s surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered.

Results
From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society.

Conclusion
This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.


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234. Improving the experience of facility-based delivery for vulnerable women through obstetric care navigation: a qualitative evaluation

BMC Pregnancy and Childbirth


Authors: Kirsten Austad, Michel Juarez, Hannah Shryer, Patricia L. Hibberd, Mari-Lynn Drainoni, Peter Rohloff & Anita Chary
Region / country: Central America – Guatemala
Speciality: Health policy, Obstetrics and Gynaecology

Background
Global disparities in maternal mortality could be reduced by universal facility delivery. Yet, deficiencies in the quality of care prevent some mothers from seeking facility-based obstetric care. Obstetric care navigators (OCNs) are a new form of lay health workers that combine elements of continuous labor support and care navigation to promote obstetric referrals. Here we report qualitative results from the pilot OCN project implemented in Indigenous villages in the Guatemalan central highlands.

Methods
We conducted semi-structured interviews with 17 mothers who received OCN accompaniment and 13 staff—namely physicians, nurses, and social workers—of the main public hospital in the pilot’s catchment area (Chimaltenango). Interviews queried OCN’s impact on patient and hospital staff experience and understanding of intended OCN roles. Audiorecorded interviews were transcribed, coded, and underwent content analysis.

Results
Maternal fear of surgical intervention, disrespectful and abusive treatment, and linguistic barriers were principal deterrents of care seeking. Physicians and nurses reported cultural barriers, opposition from family, and inadequate hospital resources as challenges to providing care to Indigenous mothers. Patient and hospital staff identified four valuable services offered by OCNs: emotional support, patient advocacy, facilitation of patient-provider communication, and care coordination. While patients and most physicians felt that OCNs had an overwhelmingly positive impact, nurses felt their effort would be better directed toward traditional nursing tasks.

Conclusions
Many barriers to maternity care exist for Indigenous mothers in Guatemala. OCNs can improve mothers’ experiences in public hospitals and reduce limitations faced by providers. However, broader buy-in from hospital staff—especially nurses—appears critical to program success. Future research should focus on measuring the impact of obstetric care navigation on key clinical outcomes (cesarean delivery) and mothers’ future care seeking behavior.


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235. C/Can City Engagement Process: An Implementation Framework for Strengthening Cancer Care in Cities in Low- and Middle-Income Countries

JCO Global Oncology


Authors: Silvina Frech , BPharm, Rebecca Morton Doherty , Maria Cristina Lesmes Duque ,Oscar Ramirez , Alicia Pomata , Angelica Samudio , Osei A. Antwi , Yin Yin Htun , Rai Mra , Pe Thet Htoon , Ernest Baawuah Osei-Bonsu , Rafaela Komorowski Dal Molin , Nana Mebonia , Isabel Mestres , Aung Naing Soe , Sophie Bussmann-Kemdjo , Maria Fernanda Navarro , Susan Henshall , Rolando Camacho ,
Region / country: Global
Speciality: Health policy, Surgical oncology

The effective implementation of locally adapted cancer care solutions in low- and middle-income countries continues to be a challenge in the face of fragmented and inadequately resourced health systems. Consequently, the translation of global cancer care targets to local action for patients has been severely constrained. City Cancer Challenge (C/Can) is leveraging the unique value of cities as enablers in a health systems response to cancer that prioritizes the needs of end users (patients, their caregivers and families, and health care providers). C/Can’s City Engagement Process is an implementation framework whereby local stakeholders lead a staged city-wide process over a 2- to 3-year period to assess, plan, and execute locally adapted cancer care solutions. Herein, the development and implementation of the City Engagement Process Framework (CEPF) is presented, specifying the activities, outputs, processes, and indicators across the process life cycle. Lessons learned on the application of the framework in the first so-called Key Learning cities are shared, focusing on the early outputs from Cali, Colombia, the first city to join C/Can in 2017. Creating lasting change requires the creation of a high-trust environment to engage the right stakeholders as well as adapting to local context, leveraging local expertise, and fostering a sustainability mindset from the outset. In the short term, these early learnings inform the refinement of the approach in new cities. Over time, the implementation of this framework is expected to validate the proof-of-concept and contribute to a global evidence base for effective complex interventions to improve cancer care in low- and middle-income countries.


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236. Case studies for implementing MCDA for tender and purchasing decisions in hospitals in Indonesia and Thailand

Journal of Pharmaceutical Policy and Practice volume


Authors: Anke-Peggy Holtorf, Erna Kristin, Anunchai Assamawakin, Nilawan Upakdee, Rina Indrianti & Napassorn Apinchonbancha
Region / country: South-eastern Asia – Indonesia, Thailand
Speciality: Health policy

Background
A multi-criteria decision analysis (MCDA) approach has been suggested for helping purchasers in low- and middle-income countries in an evidence-based assessment of multi-source pharmaceuticals to mitigate potential adverse consequences of price-based decisions on patient access to effective medicines. Six workshops for developing MCDA-instruments for purchasing were conducted in Indonesia, Kazakhstan, Thailand, and Kuwait in 2017–2020. In Indonesia and Thailand, two pilot-initiatives aimed to implement the instruments for hospital drug purchasing decisions.

Objective
By analysing and comparing the experiences and progress from the MCDA-workshops and the two case-examples for hospital implementation in Indonesia and Thailand, we aim to gain insights, which will support future implementation.

Methods
The selection of criteria and their average weight were compared quantitatively across the MCDA-instruments developed in all four countries and settings. Implementation experiences from two case-examples were studied, which included (1) testing the instrument across a variety of drugs in seven hospitals in Thailand and (2) implementation in one specialty hospital in Indonesia. Semi-structured interviews were conducted via web-conferences with four diverse stakeholders in the pilot implementation projects in Thailand and Indonesia. The open responses were evaluated through qualitative content analysis and synthesis using grounded theory coding.

Results
Drivers for implementation were making ‘better’ decisions, achieving transparency and a rational selection process, reducing drug shortages, and assuring consistent quality. Challenges were seen on the technical level (definition or of criteria, scoring methods, access to data) or change-related challenges (resistance, perception of increased workload, lack of competencies or capabilities, lack of resources). The comparison of the MCDA instruments revealed high similarity, but also clear need for local adaptations in each specific case.

Conclusion
A set a of measures targeting challenges related to utility, methodology, data requirements, capacity building and training as well as the broader societal impact can help to overcome challenges in the implementation. Careful planning of implementation and organizational change is recommended for ensuring commitment and fit to local context and culture. Designing a collaborative change program for each application of MCDA-based purchasing will enable healthcare stakeholders to maximally benefit in terms of quality and effectiveness of care and access for patients.


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237. Global survey on disruption and mitigation of neurological services during COVID-19: the perspective of global international neurological patients and scientific associations

Journal of Neurology


Authors: Chahnez Charfi Triki, Matilde Leonardi, Salma Zouari Mallouli, Martina Cacciatore, Kimberly Coard Karlshoej, Francesca Giulia Magnani, Charles R. Newton, Andrea Pilotto, Deanna Saylor, Erica Westenberg, Donna Walsh, Andrea Sylvia Winkler, Kiran T. Thakur, Njideka U. Okubadejo & David Garcia-Azorin
Region / country: Global
Speciality: Health policy, Neurosurgery

Background
The COVID-19 pandemic outbreak has dramatically disrupted healthcare systems. Two rapid WHO pulse surveys studied disruptions in mental health services, but did not particularly focus on neurology. Here, a global survey was conducted and addresses the impact of the pandemic on neurology services.

Methods
A cross-sectional study was carried out in which 34 international neurological associations were asked to distribute the survey to national associations. The responses represented the national situation, in November–December 2020, with regard to the main disrupted neurological services, reasons and the mitigation strategies implemented as well as the disruption on training of residents and on neurological research. A comparison with the situation in February–April 2020, first pandemic wave, was also requested.

Findings
54 completed surveys came from 43 countries covering all the 6 WHO regions. Overall, neurological services disruption was reported as mild by 26%, moderate by 30%, complete by 13% of associations. The most affected services were cross-sectoral neurological services (57%) and neurorehabilitation (56%). The second wave of the pandemic, however, was associated with the improvement of service provision for diagnostics services (44%) and for neurorehabilitation (41%). Governmental directives were the major cause of services’ disruption (56%). Mitigation strategies were mostly established through telemedicine (48%). Almost half of respondents reported a significant impact on neurological research (48%) and educational activities (60%). Most associations (67%) were not involved in decision making for neurological patients’ issues by their national government.

Interpretation
The COVID-19 pandemic affects neurological services and raises the universal need for the development of neurological health care at the policy, systems and services levels. A global national plan on mitigation strategies for disruption of neurological services during pandemic situations should be established and neurological scientific and patients associations should get involved in decision making.


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238. Facilitators, barriers and potential solutions to the integration of depression and non-communicable diseases (NCDs) care in Malawi: a qualitative study with service providers

International Journal of Mental Health Systems volume


Authors: Chifundo Colleta Zimba, Christopher F. Akiba, Maureen Matewere, Annie Thom, Michael Udedi, Jones Kaponda Masiye, Kazione Kulisewa, Vivian Fei-ling Go, Mina C. Hosseinipour, Bradley Neil Gaynes & Brian Wells Pence
Region / country: Eastern Africa, Southern Africa – Malawi
Speciality: Health policy, Other

Background
Integration of depression services into infectious disease care is feasible, acceptable, and effective in sub-Saharan African settings. However, while the region shifts focus to include chronic diseases, additional information is required to integrate depression services into chronic disease settings. We assessed service providers’ views on the concept of integrating depression care into non-communicable diseases’ (NCD) clinics in Malawi. The aim of this analysis was to better understand barriers, facilitators, and solutions to integrating depression into NCD services.

Methods
Between June and August 2018, we conducted nineteen in-depth interviews with providers. Providers were recruited from 10 public hospitals located within the central region of Malawi (i.e., 2 per clinic, with the exception of one clinic where only one provider was interviewed because of scheduling challenges). Using a semi structured interview guide, we asked participants questions related to their understanding of depression and its management at their clinic. We used thematic analysis allowing for both inductive and deductive approach. Themes that emerged related to facilitators, barriers and suggested solutions to integrate depression assessment and care into NCD clinics. We used CFIR constructs to categorize the facilitators and barriers.

Results
Almost all providers knew what depression is and its associated signs and symptoms. Almost all facilities had an NCD-dedicated room and reported that integrating depression into NCD care was feasible. Facilitators of service integration included readiness to integrate services by the NCD providers, availability of antidepressants at the clinic. Barriers to service integration included limited knowledge and lack of training regarding depression care, inadequacy of both human and material resources, high workload experienced by the providers and lack of physical space for some depression services especially counseling. Suggested solutions were training of NCD staff on depression assessment and care, engaging hospital leaders to create an NCD and depression care integration policy, integrating depression information into existing documents, increasing staff, and reorganizing clinic flow.

Conclusion
Findings of this study suggest a need for innovative implementation science solutions such as reorganizing clinic flow to increase the quality and duration of the patient-provider interaction, as well as ongoing trainings and supervisions to increase clinical knowledge.


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239. Management of chronic non-communicable diseases in Ghana: a qualitative study using the chronic care model

BMC Public Health


Authors: Hubert Amu, Eugene Kofuor Maafo Darteh, Elvis Enowbeyang Tarkang & Akwasi Kumi-Kyereme
Region / country: Western Africa – Ghana
Speciality: Health policy, Other

Background
While the burden and mortality from chronic non-communicable diseases (CNCDs) have reached epidemic proportions in sub-Saharan Africa (SSA), decision-makers and individuals still consider CNCDs to be infrequent and, therefore, do not pay the needed attention to their management. We, therefore, explored the practices and challenges associated with the management of CNCDs by patients and health professionals.

Methods
This was a qualitative study among 82 CNCD patients and 30 health professionals. Face-to-face in-depth interviews were used in collecting data from the participants. Data collected were analysed using thematic analysis.

Results
Experiences of health professionals regarding CNCD management practices involved general assessments such as education of patients, and specific practices based on type and stage of CNCDs presented. Patients’ experiences mainly centred on self-management practices which comprised self-restrictions, exercise, and the use of anthropometric equipment to monitor health status at home. Inadequate logistics, work-related stress due to heavy workload, poor utility supply, and financial incapability of patients to afford the cost of managing their conditions were challenges that militated against the effective management of CNCDs.

Conclusions
A myriad of challenges inhibits the effective management of CNCDs. To accelerate progress towards meeting the Sustainable Development Goal 3 on reducing premature mortality from CNCDs, the Ghana Health Service and management of the respective hospitals should ensure improved utility supply, adequate staff motivation, and regular in-service training. A chronic care management policy should also be implemented in addition to the review of the country’s National Health Insurance Scheme (NHIS) by the Ministry of Health and the National Health Insurance Authority to cover the management of all CNCDs.


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240. Augmented Package of Palliative Care for Women With Cervical Cancer: Responding to Refractory Suffering

JCO Global Oncology


Authors: Eric L. Krakauer , Khadidjatou Kane, Xiaoxiao Kwete ,Gauhar Afshan, Lisa Bazzett-Matabele , Danta Dona Ruthnie Bien-Aimé , Lawrence F. Borges , Sarah Byrne-Martelli , Stephen Connor , Raimundo Correa, C. R. Beena Devi, Mamadou Diop, Shekinah N. Elmore , Nahla Gafer , Annekathryn Goodman, Surbhi Grover , Annette Hasenburg , Kelly Irwin , Mihir Kamdar, Suresh Kumar , Quynh Xuan Nguyen Truong , Tom Randall ,Maryam Rassouli , Cristiana Sessa, Dingle Spence ,Ted Trimble , Cherian Varghese, Elena Fidarova
Region / country: Global
Speciality: Surgical Education, Surgical oncology

The essential package of palliative care for cervical cancer (EPPCCC), described elsewhere, is designed to be safe and effective for preventing and relieving most suffering associated with cervical cancer and universally accessible. However, it appears that women with cervical cancer, more frequently than patients with other cancers, experience various types of suffering that are refractory to basic palliative care such as what can be provided with the EPPCCC. In particular, relief of refractory pain, vomiting because of bowel obstruction, bleeding, and psychosocial suffering may require additional expertise, medicines, or equipment. Therefore, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an augmented package of palliative care for cervical cancer with which even suffering refractory to the EPPCCC often can be relieved. The package consists of medicines, radiotherapy, surgical procedures, and psycho-oncologic therapies that require advanced or specialized training. Each item in this package should be made accessible whenever the necessary resources and expertise are available.


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241. Essential Package of Palliative Care for Women With Cervical Cancer: Responding to the Suffering of a Highly Vulnerable Population

JCO Global Oncology


Authors: Eric L. Krakauer , Khadidjatou Kane, Xiaoxiao Kwete , Gauhar Afshan, Lisa Bazzett-Matabele , Danta Dona Ruthnie Bien-Aimé , Lawrence F. Borges , Sarah Byrne-Martelli , Stephen Connor , Raimundo Correa, C. R. Beena Devi, Mamadou Diop, Shekinah N. Elmore , Nahla Gafer , Annekathryn Goodman, Surbhi Grover , Annette Hasenburg , Kelly Irwin , Mihir Kamdar, Suresh Kumar , Quynh Xuan Nguyen Truong , Tom Randall , Maryam Rassouli , Cristiana Sessa, Dingle Spence ,Ted Trimble , Cherian Varghese, Elena Fidarova
Region / country: Global
Speciality: Obstetrics and Gynaecology, Surgical oncology

Women with cervical cancer, especially those with advanced disease, appear to experience suffering that is more prevalent, complex, and severe than that caused by other cancers and serious illnesses, and approximately 85% live in low- and middle-income countries where palliative care is rarely accessible. To respond to the highly prevalent and extreme suffering in this vulnerable population, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an essential package of palliative care for cervical cancer (EPPCCC). The EPPCCC consists of a set of interventions, medicines, simple equipment, social supports, and human resources, and is designed to be safe and effective for preventing and relieving all types of suffering associated with cervical cancer. It includes only inexpensive and readily available medicines and equipment, and its use requires only basic training. Thus, the EPPCCC can and should be made accessible everywhere, including for the rural poor. We provide guidance for integrating the EPPCCC into gynecologic and oncologic care at all levels of health care systems, and into primary care, in countries of all income levels.


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242. Evaluation of postoperative refractive error correction after cataract surgery

Plos One


Authors: Ellen Konadu Antwi-Adjei ,Emmanuel Owusu,Emmanuel Kobia-Acquah,Emmanuella Esi Dadzie,Emmanuel Anarfi,Seth Wanye
Region / country: Western Africa – Ghana
Speciality: Ophthalmology

Suboptimal cataract surgery outcomes remain a challenge in most developing countries. In Ghana, about 2 million people have been reported to be blind due to cataract with about 20% new cases being recorded yearly. The aim of this study was to evaluate postoperative correction of refractive errors after cataract surgery in a selected eye hospital in Ashanti Region, Ghana. This was a retrospective study where medical records of patients (aged 40–100) who reported to an eye hospital in Ghana from 2013–2018 were reviewed. Included in the study were patients aged ≥40 years and patients with complete records. Data on patient demographics, type of surgery, intra-ocular lens (PCIOL) power, availability of biometry, postoperative refraction outcomes, pre- and postoperative visual acuity were analyzed. Data of two hundred and thirteen eyes of 190 patients who met the inclusion criteria were analyzed. Descriptive analysis and Chi-square test were carried out to determine the mean, median, standard deviation and relevant associations. The mean ± SD age was 67.21±12.2 years (51.2% were females). Small Incision Cataract Surgery (99.5%) with 100% IOL implants was the main cataract surgery procedure in this study. Pre-operative biometry was performed for 38.9% of all patients on their first eye surgery and 41.5% for second eye surgeries. About 71% eyes in this study were blind (presenting VA<3/60) before surgery; 40.4% had post-operative VA <3/60. Pre-existing ocular comorbidities discovered post- surgery, attributed to suboptimal visual outcomes. More than half (55.3%) of patients did not undergo postoperative refraction due to loss to follow-up. Year of surgery (p = .017), follow up visits< 2months (p < .0001) and discovered comorbidity post-surgery (p = .035) were the factors significantly associated with postoperative refraction. Myopia and compound myopic astigmatism were the dominant refractive error outcomes. The timing of post-operative refraction had a significant effect on postoperative refraction done. These findings indicate a clinically meaningful significance between completion of postoperative care and postoperative refraction done. Consequently, with settings in most developing countries, where less biometry is done, it is appropriate that post-operative refractive services are encouraged and done earlier to enhance the patients’ expectations while increasing cataract surgery patronage.


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243. Synthesizing postpartum care pathways, facilitators, and barriers for women after cesarean section: a qualitative analysis from rural Rwanda

Journal of Global Health Reports


Authors: Brittany L Powell, Theoneste Nkurunziza, Fredrick Kateera , Leila Dusabe, Marthe Kubwimana, Rachel Koch, Bethany L Hedt-Gauthier, Robert Riviello
Region / country: Eastern Africa – Rwanda
Speciality: Obstetrics and Gynaecology

Background
In low- and middle-income countries (LMICs), c-section is the most commonly performed operation, and surgical site infection (SSI) is the most common post-operative complication following all surgical procedures performed. Whilst multiple interventions have been rolled out to address high SSI rates, strategies for optimal care of patients at risk of developing SSIs need to include an understanding of the general care seeking behaviors, facilitators, and barriers among high-risk groups, including mothers delivering via c-section. This study explores the healthcare experiences of women who delivered by c-section section, from giving birth through recovery, and their associated decision-making, perceptions of care, and social and financial supports.

Methods
We conducted protocol-guided interviews in rural Kirehe District, Rwanda with twenty-five mothers who delivered by c-section at Kirehe District Hospital between February-April 2018, exploring their experience with delivery, hospitalization, recovery, and complications. Coded interviews were analyzed using the Grounded Theory approach to identify emergent themes. Thematic saturation was achieved.

Results
Overall, women largely followed the tiered referral system, as it was designed. A majority faced financial barriers to returning to care, and a majority were not able to describe the reason for their c-section, the complications experienced, or the treatment prescribed. We constructed a process map to summarize key steps where interventions should be designed to promote facilitators, to reduce barriers, and to identify and target the women being diverted from this designated path.

Conclusions
Understanding the existing healthcare pathway and the associated facilitators and barriers among postpartum women is critical to designing appropriate interventions that properly serve their needs. Our findings strongly suggest that moving or complimenting post-operative wound assessments from the health center into home-based care, and ensuring unified messaging around c-section indications, care, and complications at the community-level are two of the areas that may improve utilization of existing healthcare infrastructure for women who deliver by c-section in rural districts in Rwanda.


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244. Neurotrauma Registry Implementation in Colombia: A Qualitative Assessment

Journal of Neurosciences in Rural Practice


Authors: Erica D. Johnson, Sangki Oak, Dylan P. Griswold  , Sandra Olaya, Juan C. Puyana, Andres M. Rubiano 
Region / country: South America – Colombia
Speciality: Neurosurgery, Trauma surgery

Objectives Latin America is among several regions of the world that lacks robust data on injuries due to neurotrauma. This research project sought to investigate a multi-institution brain injury registry in Colombia, South America, by conducting a qualitative study to identify factors affecting the creation and implementation of a multi-institution TBI registry in Colombia before the establishment of the current registry.

Methods Key informant interviews and participant observation identified barriers and facilitators to the creation of a TBI registry at three health care institutions in this upper-middle-income country in South America.

Results The study identified barriers to implementation involving incomplete clinical data, limited resources, lack of information and technology (IT) support, time constraints, and difficulties with ethical approval. These barriers mirrored similar results from other studies of registry implementation in low- and middle-income countries (LMICs). Ease of use and integration of data collection into the clinical workflow, local support for the registry, personal motivation, and the potential future uses of the registry to improve care and guide research were identified as facilitators to implementation. Stakeholders identified local champions and support from the administration at each institution as essential to the success of the project.

Conclusion Barriers for implementation of a neurotrauma registry in Colombia include incomplete clinical data, limited resources and lack of IT support. Some factors for improving the implementation process include local support, personal motivation and potential uses of the registry data to improve care locally. Information from this study may help to guide future efforts to establish neurotrauma registries in Latin America and in LMICs.


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245. Feasibility of establishing an infant hearing screening program and measuring hearing loss among infants at a regional referral hospital in south western Uganda

Plos one


Authors: Amina Seguya ,Francis Bajunirwe,Elijah Kakande,Doreen Nakku
Region / country: Eastern Africa – Uganda
Speciality: ENT surgery, Paediatric surgery

Introduction
Despite the high burden of hearing loss (HL) globaly, most countries in resource limited settings lack infant hearing screening programs(IHS) for early HL detection. We examined the feasibility of establishing an IHS program in this setting, and in this pilot program measured the prevalence of infant hearing loss (IHL) and described the characteristics of the infants with HL.

Methods
We assessed feasibility of establishing an IHS program at a regional referral hospital in south-western Uganda. We recruited infants aged 1 day to 3 months and performed a three-staged screening. At stage 1, we used Transient Evoked Oto-acoustic Emissions (TEOAEs), at stage 2 we repeated TEOAEs for infants who failed TEOAEs at stage 1 and at stage 3, we conducted Automated brainstem responses(ABRs) for those who failed stage 2. IHL was present if they failed an ABR at 35dBHL.

Results
We screened 401 infants, mean age was 7.2 days (SD = 7.1). 74.6% (299 of 401) passed stage 1, the rest (25.4% or 102 of 401) were referred for stage 2. Of those referred (n = 102), only 34.3% (35 of 102) returned for stage 2 screening. About 14.3% (5/35) failed the repeat TEOAEs in at least one ear. At stage 3, 80% (4 of 5) failed the ABR screening in at least one ear, while 25% (n = 1) failed the test bilaterally. Among the 334 infants that completed the staged screening, the prevalence of IHL was 4/334 or 12 per 1000. Risk factors to IHL were Newborn Special Care Unit (NSCU) admission, gentamycin or oxygen therapy and prematurity.

Conclusions
IHS program establishment in a resource limited setting is feasible. Preliminary data indicate a high prevalence of IHL. Targeted screening of infants at high risk may be a more realistic and sustainable initial step towards establishing IHS program s in a developing country like Uganda.


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246. A critical threshold for global pediatric surgical workforce density

Pediatric Surgery International


Authors: Megan E. Bouchard, Yao Tian, Jeanine Justiniano, Samuel Linton, Christopher DeBoer, Fizan Abdullah & Monica Langer
Region / country: Global
Speciality: Paediatric surgery

Purpose
1.7 billion children lack access to surgical care, particularly in low- and middle-income countries (LMIC). The pediatric surgical workforce density (PSWD), an indicator of surgical access, correlates with survival of complex pediatric surgical problems. To determine if PSWD also correlates with population-level health outcomes for children, we compared PSWD with pediatric-specific mortality rates and determined the PSWD associated with improved survival.

Methods
Using medical licensing registries, pediatric surgeons practicing in 26 countries between 2015 and 2019 were identified. Countries’ PSWD was calculated as the ratio of pediatric surgeons per 100,000 children. The correlation between neonatal, infant and under 5 mortality rates and PSWD was assessed using Spearman’s correlations and piecewise linear regression models.

Results
Four LIC, eight L-MIC, ten UMIC and four HIC countries, containing 420 million children, were analyzed. The median PSWD by income group was 0.03 (LIC), 0.12 (L-MIC), 1.34 (UMIC) and 2.13 (HIC). PSWD strongly correlated with neonatal (0.78, p < 0.001), infant (0.82, p < 0.001) and under 5 (0.83, p  0.37. Currently, PSWD in LMICs is inadequate to meet UN Sustainable Development Goal 3.2 for child mortality.


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247. Cerebral aneurysms in Africa: A scoping review

Interdisciplinary Neurosurgery


Authors: Francklin Tetinou, Ulrick Sidney Kanmounye, Samantha Sadler, Adaeze Juanita Oriaku, Aliyu Baba Ndajiwo, Nourou Dine A.Bankole
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, South America, Western Africa
Speciality: Neurosurgery

Introduction
The epidemiology, management, and prognosis of cerebral aneurysms in Africa remain poorly understood. Most data to date has been from modeling studies. The authors aimed to describe the landscape of cerebral aneurysms in Africa based on published literature.

Methods
Articles on cerebral aneurysms in Africa from inception to June 9, 2020, were pulled from multiple databases (Medline, World Health Organization (WHO) Global Health Library/Global Index Medicus African Journals Online, and Google Scholar). The search results were merged, uploaded into Rayyan. After deduplication, titles and abstracts were screened independently by four reviewers (FDT, USK, IN, NDAB) based on the pre-defined inclusion and exclusion criteria. A full-text review was conducted, followed by data extraction of study, patient, neuroimaging, therapeutic, and prognostic characteristics.

Results
Thirty-three articles were included in the full-text retrieval. These studies were published across 13 (24.0%) countries, notably in Morocco (30.3%, n = 10) and South Africa (15.2%, n = 5), and 14 (42.4%) of them were published on or after 2015. Together, the studies totaled 2289 patients; there was a female predominance in 18 (54.5%) study cohorts, and the most frequently cited aneurysms were located in the internal carotid (12.1%, n = 352) and anterior cerebral arteries (9.5%, n = 275). Open surgery (27.3%, n = 792) was the most widely used option in these studies ahead of coiling (3.2%, n = 94). The reported mortality rate following surgical intervention was 7.9%.

Conclusion
There are few peer-reviewed reports of aneurysm practice and variability in access to cerebral aneurysm care in Africa.


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248. Letter: Operationalizing Global Neurosurgery Research in Neurosurgical Journals

Neurosurgery


Authors: Andre E Boyke, Nathan A Shlobin,Vaishnavi Sharma, Donald K E Detchou, Myron Rolle
Region / country: Global
Speciality: Neurosurgery

Traumatic brain injury (TBI) affects roughly 69 million individuals per year, many of who reside in low- and middle-income countries (LMICs).1 While there exist several limitations to treating TBI in LMICs, many can be properly addressed if given the attention and focus required to usher in change. Case in point, the governing body of neurotrauma literature is produced in high-income countries (HICs), which pose additional constraints in settings with limited medical equipment, health infrastructure, and available staff, as seen in several LMICs.1-3 In addition, approximately 23 300 additional neurosurgeons are required to address more than 5 million essential neurosurgical cases that are unmet annually, all of which occur in LMICs.4 We believe operationalizing global neurosurgery research in neurosurgical journals can serve to bridge this gap and provide a space for leaders across the world to share pearls of knowledge toward reducing the global burden of neurological diseases and disorders, including TBI.

Fortunately, there is a growing movement to ensure the provision of timely, safe, and affordable neurosurgical care to all individuals who require it. In 2015, the Lancet commission on surgery published an article that brought attention to the need for neurosurgical enhancement on a global scale.5 This group offered targets focusing on increasing access to surgery and expanding knowledge of barriers to equitable care in LMICs by the year 2030. Still, inequities in access to neurosurgical care remain rampant, stressing a need for targeted efforts as potential remedy.

Global Neurosurgery has gained significant momentum as evident by the upward trend of peer-reviewed abstracts and articles submitted and published in neurosurgical journals. A PubMed search of the phrase “global neurosurgery” displays an ascending trend with 3 published articles in 2015, 42 articles in 2018, and 82 in the year 2020.6 This positive trend speaks to the impact of efforts made by communities such as The Lancet, the World Federation of Neurosurgical Societies (WFNS), Global Neurosurgery Committee (GNC), American Association of Neurological Surgeons (AANS), and many other organizations aimed at strengthening neurosurgery globally. Global neurosurgery conferences provide additional unique opportunities to connect partners in LMICs and HICs to develop education, advocacy, and policy. Importantly, the rise in the digital world amid the COVID-19 pandemic has enabled participants—particularly from LMICs—to overcome barriers such as visa acquisition, funding for travel and lodging, and time away from school and/or work.7,8


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249. Tracking the Workforce 2020-2030: Making the Case for a Cancer Workforce Registry

JCO Global Oncology


Authors: Archita Srivastava ,Matthew Jalink, Fabio Ynoe de Moraes , Christopher M. Booth , Scott R. Berry, Fidel Rubagumya , Felipe Roitberg , Manju Sengar , Nazik Hammad
Region / country: Global
Speciality: Surgical oncology

Existing literature has described the projected increase in cancer incidence and the associated deficiencies in the cancer workforce. However, there is currently a lack of research into the necessary policy and planning steps that can be taken to mitigate this issue. Herein, we review current literature in this space and highlight the importance of implementing oncology workforce registries. We propose the establishment of cancer workforce registries using the WHO Minimum Data Set for Health Workforce Registry by adapting the data set to suit the multidisciplinary nature of the cancer workforce. The cancer workforce registry will track the trends of the workforce, so that evidence can drive decisions at the policy level. The oncology community needs to develop and optimize methods to collect information for these registries. National cancer societies are likely to continue to lead such efforts, but ministries of health, licensing bodies, and academic institutions should contribute and collaborate.


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250. Evaluation of a surgical treatment algorithm for neglected clubfoot in low-resource settings

International Orthopaedics


Authors: Manon Pigeolet, Saiful Imam, Gheorghe Cristian Ninulescu, Shafiul Kabir, Pierre R. Smeesters & Hasib Mahmud
Region / country: Southern Asia – Bangladesh
Speciality: Paediatric surgery, Trauma and orthopaedic surgery

Purpose
Idiopathic clubfoot affects approximately 1/1000 alive-born infants, of whom 80–91% are born in low- or middle-income countries (LMICs). This retrospective study aimed to evaluate the morphological, functional, and social outcomes in patients with neglected clubfoot in rural Bangladesh, after receiving surgical treatment.

Methods
Patients received a posteromedial release (PMR) with or without an additional soft tissue intervention (group 1), a PMR with an additional bony intervention (group 2), or a triple arthrodesis (group 3) according to our surgical algorithm. Patients were followed until two year post-intervention. Evaluation was done using a modified International Clubfoot Study Group Outcome evaluation score and the Laaveg-Ponseti score.

Results
Twenty-two patients with 32 neglected clubfeet (ages 2–24 years) received surgical treatment. Nineteen patients with 29 clubfeet attended follow-up. At two year follow-up an excellent, good, or fair Laaveg-Ponseti score was obtained in 81% (group 1), 80% (group 2), and 0% (group 3) of the patients (p value 0.0038). Age at intervention is inversely correlated with the Laaveg-Ponseti score at two year follow-up (p < 0.0001). All patients attended school or work and were able to wear normal shoes.

Conclusion
Our treatment algorithm is in line with other surgical algorithms used in LMICs. Our data reconfirms that excellent results can be obtained with a PMR regardless of age. Our algorithm follows a pragmatic approach that takes into account the reality on the ground in many LMICs. Good functional outcomes can be achieved with PMR for neglected clubfoot. Further research is needed to investigate the possible role of triple arthrodesis.


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251. Utilization of eye health services and diabetic retinopathy: a cross-sectional study among persons living with diabetes visiting a tertiary eye care facility in Ghana

BMC Health Services Research


Authors: Bridgid Akrofi, John Tetteh, Kwesi N. Amissah-Arthur, Eileen N.A. Buxton , Alfred Yawson
Region / country: Western Africa – Ghana
Speciality: Health policy, Ophthalmology

Background
There have been a major advance made in screening, early diagnosis, and prompt treatment of Diabetic Retinopathy among Person living with diabetes (PLWD). However, screening services remain a challenge in Low-Middle-Income-Countries where access to eye care professionals is inadequate. This study assesses the utilization of Eye Health Service prevalence (UEHS) among PLWD and associated factors and further quantifies its association with Non-Proliferative Diabetic Retinopathy (NPDR).

Methods
A cross-sectional study design with a random sample of 360 PLWD was conducted at Korle-Bu Teaching Hospital, a National Referral Centre in Ghana from May to July 2019. UEHS and DR were the study outcomes. We adopted Poisson and Probit regression analysis to assess factors associated with UEHS over the past year. We employed pairwise and phi correlation (fourfold correlational analysis) to assess the relationship between UEHS and DR (ordinal and binary respectively). Ordered Logistic and Poisson regression were applied to assess the association between the UEHS and DR. Stata 16.1 was used to perform the analyses and a p-value ≤ 0.05 was deemed significant.

Results
The prevalence of UEHS over the past year and DR was 21.7 %(95 %CI = 17.7–26.2) and 65.0 %(95 %CI = 59.9–69.8 respectively. The prevalence of severe NPDR with Clinically Significant Macular Edema (CSME) was 23.9 %(19.8–28.6). Type of diabetes, increasing age, educational level, mode of payment for healthcare services, marital status, years since diagnosis, and current blood glucose significantly influenced UEHS. There was a negative relationship between DR and UEHS (Pairwise and φ correlation were − 20 and − 15 respectively; p < 0.001). Non-UEHS among PLWD doubles the likelihood of experiencing severe NPDR with CSME compared with UEHS among PLWD [aOR(95 %CI) = 2.05(1.03–4.08)]. Meanwhile, the prevalence of DR among patients per non-UEHS was insignificantly higher [12 %; aPR(95 %CI) = 0.89–1.41)] compared with patients who utilized eye care health service.

Conclusions
Most of the PLWD did not utilize the eye health service even once in a year and that was highly influenced by type of diabetes and increasing age. Type 2 diabetes patients and middle age decreased the likelihood of UEHS. There was a negative relationship between DR and UEHS among PLWD and this doubled the likelihood of experiencing severe NPDR with CSME. Structured health education and screening interventions are key to improving UEHS.


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252. Undergraduate Surgical Education: a Global Perspective

Indian Journal of Surgery


Authors: Krithi Ravi, Ugonna Angel Anyamele, Moniba Korch, Nermin Badwi, Hassan Ali Daoud , Sayed Shah Nur Hussein Shah
Region / country: Eastern Africa, Northern Africa, Western Europe – Egypt, Kenya, Morocco, Somalia, United Kingdom
Speciality: Surgical Education

Undergraduate surgical education is failing to prepare medical students to care for patients with surgical conditions, and has been significantly compromised by the COVID-19 pandemic. We performed a literature review and undertook semi-structured reflections on the current state of undergraduate surgical education across five countries: Egypt, Morocco, Somaliland, Kenya, and the UK. The main barriers to surgical education at medical school identified were (1) the lack of standardised surgical curricula with mandatory learning objectives and (2) the inadequacy of human resources for surgical education. COVID-19 has exacerbated these challenges by depleting the pool of surgical educators and reducing access to learning opportunities in clinical environments. To address the global need for a larger surgical workforce, specific attention must be paid to improving undergraduate surgical education. Solutions proposed include the development of a standard surgical curriculum with learning outcomes appropriate for local needs, the incentivisation of surgical educators, the incorporation of targeted online and simulation teaching, and the use of technology.


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253. Predictors of Rehabilitation Service Utilisation among Children with Cerebral Palsy (CP) in Low- and Middle-Income Countries (LMIC): Findings from the Global LMIC CP Register

Brain Sciences


Authors: Mahmudul Hassan Al Imam ,Israt Jahan ,Mohammad Muhit ,Denny Hardianto ,Francis Laryea ,Amir Banjara Chhetri ,Hayley Smithers-Sheedy ,Sarah McIntyre,Nadia Badawi ,Gulam Khandaker
Region / country: South-eastern Asia, Southern Asia, Western Africa – Bangladesh, Ghana, Indonesia, Nepal
Speciality: Paediatric surgery, Trauma and orthopaedic surgery

Background: We assessed the rehabilitation status and predictors of rehabilitation service utilisation among children with cerebral palsy (CP) in selected low- and middle-income countries (LMICs). Methods: Data from the Global LMIC CP Register (GLM-CPR), a multi-country register of children with CP aged <18 years in selected countries, were used. Descriptive and inferential statistics (e.g., adjusted odds ratios) were reported. Results: Between January 2015 and December 2019, 3441 children were registered from Bangladesh (n = 2852), Indonesia (n = 130), Nepal (n = 182), and Ghana (n = 277). The proportion of children who never received rehabilitation was 49.8% (n = 1411) in Bangladesh, 45.8% (n = 82) in Nepal, 66.2% (n = 86) in Indonesia, and 26.7% (n = 74) in Ghana. The mean (Standard Deviation) age of commencing rehabilitation services was relatively delayed in Nepal (3.9 (3.1) year). Lack of awareness was the most frequently reported reason for not receiving rehabilitation in all four countries. Common predictors of not receiving rehabilitation were older age at assessment (i.e., age of children at the time of the data collection), low parental education and family income, mild functional limitation, and associated impairments (i.e., hearing and/or intellectual impairments). Additionally, gender of the children significantly influenced rehabilitation service utilisation in Bangladesh. Conclusions: Child’s age, functional limitation and associated impairments, and parental education and economic status influenced the rehabilitation utilisation among children with CP in LMICs. Policymakers and service providers could use these findings to increase access to rehabilitation and improve equity in rehabilitation service utilisation for better functional outcome of children with CP


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254. Effectiveness of an mHealth system on access to eye health services in Kenya: a cluster-randomised controlled trial

The Lancet Digital Health


Authors: Hillary Rono, Andrew Bastawrous, David Macleod, Ronald Mamboleo , Cosmas Bunywera , Emmanuel Wanjala , Stephen Gichuhi , Prof Matthew J Burton
Region / country: Eastern Africa – Kenya
Speciality: Ophthalmology

Background
There is limited access to eye health services in many low-income and middle-income populations. We aimed to assess the effectiveness in increasing service utilisation of the Peek Community Eye Health (Peek CEH) system, a smartphone-based referral system comprising decision support algorithms (Peek Community Screening app), SMS reminders, and real-time reporting.

Methods
In this cluster-randomised controlled trial of eye health in Kenya, community unit clusters were defined as one health centre and its catchment population. Clusters were randomly allocated (1:1) to receive Peek CEH and referral (intervention group) or standard care via periodic health centre-based outreach clinics and onward referral (control group). Individuals in the intervention group were assessed at home by screeners and those referred were asked to present for triage assessment in a central location. They received regular SMS reminders. In both groups, community sensitisation was done followed by a triage clinic at the cluster health centre 4 weeks after sensitisation. During triage, individuals in both groups were assessed and treated and, if necessary, referred to a specific hospital. Individuals in the intervention group received further SMS reminders. The primary outcome was the mean attendance rate (the number of people per 10 000 population) at triage of those with confirmed eye conditions, as assessed at 4 weeks after sensitisation in the intention-to-treat population. We estimated the intervention effect using a Student’s t-test on cluster-level rates. This trial is registered with Pan African Clinical Trial Registry, number 201807329096632.

Findings
Between Nov 26, 2018, and June 7, 2019, of the 85 community units in Trans Nzoia County, Kenya, 49 were excluded. We randomly allocated 18 community units each to the intervention group (68 348 individuals) and the control group (60 243 individuals). 9387 individuals from the intervention group and 3070 from the control group attended triage assessment. The mean attendance rate at triage by individuals with eye problems was 1429 (92% CI 1228–1629) in the intervention group and 522 (418–625) in the control group (rate difference 906 per 10 000 [95% CI 689–1124; p<0·0001]).

Interpretation
The Peek CEH system increased primary care attendance by people with eye problems compared with standard approaches, indicating the potential of this mobile health package to increase service uptake and guide appropriate task sharing.


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255. Global Landscape of Glioblastoma Multiforme Management in the Stupp Protocol Era: Systematic Review Protocol

International Journal of Surgery Protocols


Authors: Gideon Adegboyega, Ulrick Sidney Kanmounye , Tatjana Petrinic, Ahmad Ozair, Soham Bandyopadhyay, Ashvin Kuri, Yvan Zolo, Katya Marks, Serena Ramjee, Ronnie E. Baticulon, Babar Vaqas
Region / country: Global
Speciality: Neurosurgery, Surgical oncology

Background: Glioblastoma multiforme is the most common and aggressive primary adult brain neoplasm. The current standard of care is maximal safe surgical resection, radiotherapy with concomitant temozolomide, followed by adjuvant temozolomide according to the Stupp protocol. Although the protocol is well adopted in high-income countries (HICs), little is known about its adoption in low- and middle-income countries (LMICs). The aim of this study is to describe a protocol design for a systematic review of published studies outlining the differences in GBM management between HICs and LMICs.

Methods: A systematic review will be conducted. MedLine via Ovid, Embase and Global Index Medicus will be searched from inception to date in order to identify the relevant studies. Adult patients (>18 years) with histologically confirmed primary unifocal GBM will be included. Surgical and chemoradiation management of GBM tumours will be considered. Commentaries, original research, non-peer reviewed pieces, opinion pieces, editorials and case reports will be included.

Results: Primary outcomes will include rates of complications, disability-adjusted life years (DALYs), prognosis, progression-free survival (PFS), overall survival (OS) as well as rate of care abandonment and delay. Secondary outcomes will include the presence of neuro-oncology subspecialty training programs.

Discussion: This systematic review will be the first to compare the current landscape of GBM management in HICs and LMICs, highlighting pertinent themes that may be used to optimise treatment in both financial brackets.

Systematic Review Registration: The protocol has been registered on the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42020215843).


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256. Emergency Department Outcome of Patients with Traumatic Brain Injury – A Retrospective Study from Pakistan

PPakistan Journal Of Neurological surgery


Authors: Uzair Yaqoob, Farrukh Javeed, Lal Rehman, Mashika Pahwani, Sara Madni,Muhammad Muizz Uddin
Region / country: Southern Asia – Pakistan
Speciality: Neurosurgery, Trauma surgery

Introduction: Traumatic brain injury (TBI) is a leading cause of global morbidity and mortality in both adults and children. As with other severe injuries, the outcome of TBIs is also gravely related to the quality of emergency care. Effective emergency care significantly contributes to reduced morbidity and mortality. This study was ensued to evaluate the characteristics of TBIs in Pakistan and their outcomes in the emergency department (ED).

Methods: This retrospective review included records of all TBI patients seen in the Neurosurgical ED of Jinnah Postgraduate Medical Centre, Karachi, Pakistan from 1st September 2019 till 7th December 2019.

Results: During the study period, 5,546 patients with TBI were seen in the ED; an estimated 56.5 patients per day. There were 4,054 (73.1%) male and 1,492 (26.9%) female patients. Most of these (26%) were of age <10 years. The most common culprit of TBI was road traffic accidents (RTAs) (n=2,163; 39%) followed by accidental fall (n=1,785; 32.2%). Head injury was mostly mild (n=4,034; 72.8%) and only 265 (4.7%) had a severe injury. Only 10% (n=549) patients were admitted for further treatment, 16% were managed in the ED then discharged, and 67% were immediately discharged from the ED after the first examination and necessary management. The ED mortality rate of TBIs was 2.2% (n=123/5,546) in our study. All of these cases had severe head injuries.

Conclusion: Major culprits of TBI are RTAs and accidental falls. TBIs are mostly mild-to-moderate and the ED mortality rate is low.


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257. Lessons for Latin America from Mexico’s Experience With Patient Safety and Covid Response

IJQHC Communications


Authors: Odet Sarabia González
Region / country: Northern America – Mexico
Speciality: Health policy

Globally, more than 1 in 10 patients continue to be harmed due to safety lapses during their care.[1] Unsafe care results in over three million deaths each year. The health burden of harm is estimated at 64 million Disability-Adjusted Life Years (DALYs) per year similar to that of HIV/AIDS. Most of this burden is in low- and middle-income countries (LMICs). Recent estimates suggest that as many as 4 in 100 people die from unsafe care in the developing world [1]. The COVID-19 pandemic has clearly shown the risk of patient harm. The estimated proportion of hospital-acquired COVID-19 cases ranges from 12.5% to 44% [1]. As many as one third of these cases are reported to be among healthcare staff.
In Mexico, the Patient Safety journey started in 2002, with the National Crusade for Quality in Health Care,[2] the first Quality Policy in Latin America. The efforts to improve patient safety in Mexico can be divided into three distinct waves. A fourth wave has commenced with the pandemic. These lessons on patient safety are even more important now in the COVID era and can be applied in the region and elsewhere


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258. Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

The Lancet


Authors: Global PaedSurg Research Collaboration
Region / country: Global
Speciality: Paediatric surgery

Background
Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

Methods
We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

Findings
We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality.

Interpretation
Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.


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259. Infection Prevention and Control at Lira University Hospital, Uganda: More Needs to Be Done

Tropical Medicine and Infectious Disease


Authors: Marc Sam Opollo ,Tom Charles Otim ,Walter Kizito ,Pruthu Thekkur ,Ajay M.V. Kumar ,Freddy Eric Kitutu ,Rogers Kisame,Maria Zolfo
Region / country: Eastern Africa – Uganda
Speciality: Health policy

Globally, 5%–15% of hospitalized patients acquire infections (often caused by antimicrobial-resistant microbes) due to inadequate infection prevention and control (IPC) measures. We used the World Health Organization’s (WHO) ‘Infection Prevention and Control Assessment Framework’ (IPCAF) tool to assess the IPC compliance at Lira University hospital (LUH), a teaching hospital in Uganda. We also characterized challenges in completing the tool. This was a hospital-based, cross-sectional study conducted in November 2020. The IPC focal person at LUH completed the WHO IPCAF tool. Responses were validated, scored, and interpreted per WHO guidelines. The overall IPC compliance score at LUH was 225/800 (28.5%), implying a basic IPC compliance level. There was no IPC committee, no IPC team, and no budgets. Training was rarely or never conducted. There was no surveillance system and no monitoring/audit of IPC activities. Bed capacity, water, electricity, and disposal of hospital waste were adequate. Disposables and personal protective equipment were not available in appropriate quantities. Major challenges in completing the IPCAF tool were related to the detailed questions requiring repeated consultation with other hospital stakeholders and the long time it took to complete the tool. IPC compliance at LUH was not optimal. The gaps identified need to be addressed urgently.


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260. The evaluation of a surgical task-sharing program in South Sudan

UBC Theses and Dissertations


Authors: Mina Salehi
Region / country: Central Africa, Eastern Africa – South Sudan
Speciality: General surgery, Health policy, Surgical Education

Background: Five billion people lack timely, affordable, and safe surgical services. Sub-Saharan Africa (SSA) is the region with the scarcest access to surgical care. The surgical workforce is crucial in closing this gap. In SSA, South Sudan has one of the lowest surgical workforce density. Task-sharing being a cost-effective training method, in 2019, the University of British Columbia collaborated with Médecins Sans Frontières to create the Essential Surgical Skills program and launched it in South Sudan. This study aims to evaluate this pilot program. Methods: This is a mixed-method prospective cohort study. Quantitative data include pre- and post-training outputs (number and types of surgeries, complication, re-operation, and mortality) and surgical proficiency of the trainees (quiz, Entrustable Professional Activity (EPA), and logbook data), and online survey for trainers. Semi-structured interviews were performed with trainees at the program completion. Results: Since July 2019, trainees performed 385 operations. The most common procedures were skin graft (14.8%), abscess drainage (9.61%), wound debridement and transverse laparotomy (7.79% each). 172 EPAs have been completed, out of which 136 (79%) showed that the trainee could independently perform the procedure. During the training, the operating room and surgical ward mortality remained similar to the pre-training phase. Furthermore, the surgical morbidity decreased from 25% to less than 5%. The pass rate for all quizzes was 100%. Interviews and survey showed that trainees’ surgical knowledge, interprofessional teamwork, trainers’ global insight on surgical training in Low- and Middle-Income Countries (LMICs), and patient care has improved. Also, the program empowered trainees, developed career path, and local acceptance and retention. The modules were relevant to community needs. Conclusions: This study casts light on the feasibility of training surgeons through a virtual platform in under-resourced regions. The COVID-19 global pandemic highlighted the need to make LMICs independent from fly-in trainers and traditional apprenticeship. Knowledge translation of this training platform’s evaluation will hopefully inform Ministries of Health and their partners to develop their National Surgical, Obstetric and Anesthesia Plans (NSOAPs). Furthermore, thanks to its scalability, both across levels of training and geography, it paves the way for virtual surgical education everywhere in the world.


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261. Economic Impact of surgery on households and individuals in low income countries: A systematic review

International Journal of Surgery


Authors: Esther Platt, Matthew Doe, Na Eun Kim, Bright Chirengendure , Patrick Musonda, Simba Kaja, Caris Grimes
Region / country: Global
Speciality: Health policy, Other

Background
Surgical disease in Low Income Countries (LIC) is common, and overall provision of surgical care is poor. A key component of surgical health systems as part of universal health coverage (UHC) is financial risk protection (FRP) – the need to protect individuals from financial hardship due to accessing healthcare. We performed a systematic review to amalgamate current understanding of the economic impact of surgery on the individual and household. Our study was registered on Research registry (www.researchregistry.com).

Methods
We searched Pubmed and Medline for articles addressing economic aspects of surgical disease/care in low income countries. Data analysis was descriptive in light of a wide range of methodologies and reporting measures. Quality assessment and risk of bias analysis was performed using study design specific Joanna-Briggs Institute checklists. This study has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines.

Results
31 full text papers were identified for inclusion; 22 descriptive cross-sectional studies, 4 qualitative studies and 5 economic analysis studies of varying quality. Direct medical, direct non-medical and indirect costs were variably reported but were substantial, resulting in catastrophic expenditure. Costs had far reaching economic impacts on individuals and households, who used entire savings, took out loans, reduced essential expenditure and removed children from school to meet costs.

Conclusion
Seeking healthcare for surgical disease is economically devastating for individuals and households in LICs. Policies directed at strengthening surgical health systems must seek ways to reduce financial hardship on individuals and households from both direct and indirect costs and these should be monitored and measured using defined instruments from the patient perspective


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262. Predictors of iron consumption for at least 90 days during pregnancy: Findings from National Demographic Health Survey, Pakistan (2017–2018)

BMC Pregnancy and Childbirth


Authors: Sumera Aziz Ali, Savera Aziz Ali, Shama Razzaq, Nayab Khowaja, Sarah Gutkind, Fazal Ur Raheman & Nadir Suhail
Region / country: Southern Asia – Pakistan
Speciality: Obstetrics and Gynaecology

Background
Iron supplementation is considered an imperative strategy for anemia prevention and control during pregnancy in Pakistan. Although there is some evidence on the predictors of iron deficiency anemia among Pakistani women, there is a very limited understanding of factors associated with iron consumption among Pakistani pregnant women. Thus, this study aimed to investigate the predictors of iron consumption for at least ≥90 days during pregnancy in Pakistan.

Methods
We analyzed dataset from the nationally representative Pakistan Demographic Health Survey 2017–2018. The primary outcome of the current study was the consumption of iron supplementation for ≥90 days during the pregnancy of the last birth. Women who had last childbirth 5 years before the survey and who responded to the question of iron intake were included in the final analysis (n = 6370). We analyzed the data that accounted for complex sampling design by including clusters, strata, and sampling weights.

Results
Around 30% of the women reported consumed iron tablets for ≥90 days during their last pregnancy. In the multivariable logistic regression analysis, we found that factors such as women’s age (≥ 25 years) (adjusted prevalence ratio (aPR) = 1.52; 95% CI: 1.42–1.62)], wealth index (rich/richest) (aPR = 1.25; [95% CI: 1.18–1.33]), primary education (aPR = 1.33; [95% CI: 1.24–1.43), secondary education (aPR = 1.34; [95% CI: 1.26–1.43), higher education (aPR = 2.13; [95% CI: 1.97–2.30), women’s say in choosing husband (aPR = 1.68; [95% CI: 1.57–1.80]), ≥ five antenatal care visits (aPR =2.65; [95% CI (2.43–2.89]), history of the last Caesarian-section (aPR = 1.29; [95% CI: 1.23–1.36]) were significantly associated with iron consumption for ≥90 days.

Conclusion
These findings demonstrate complex predictors of iron consumption during pregnancy in Pakistan. There is a need to increase the number of ANC visits and the government should take necessary steps to improve access to iron supplements by targeting disadvantaged and vulnerable women who are younger, less educated, poor, and living in rural areas.


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263. Rheumatic heart disease: The role of global cardiac surgery.

Journal of Cardiac Surgery


Authors: Dominique Vervoort , Manuel J Antunes, A Thomas Pezzella
Region / country: Global
Speciality: Cardiothoracic surgery

Rheumatic heart disease (RHD) remains a neglected disease of poverty. While nearly eradicated in high-income countries due to timely detection and treatment of acute rheumatic fever, RHD remains highly prevalent in low- and middle-income countries (LMICs) and among indigenous and disenfranchised populations in high-income countries. As a result, over 30 million people in the world have RHD, of which approximately 300,000 die each year despite this being a preventable and treatable disease. In LMICs, such as in Latin America, sub-Saharan Africa, and Southeast Asia, access to cardiac surgical care for RHD remains limited, impacting countries’ population health and resulting economic growth. Humanitarian missions play a role in this context but can only make a difference in the long term if they succeed in training and establishing autonomous local surgical teams. This is particularly difficult because these populations are typically young and largely noncompliant to therapy, especially anticoagulation required by mechanical valve prostheses, while bioprostheses have unacceptably high degeneration rates, and valve repair requires considerable experience. Devoted and sustained leadership and local government and public health cooperation and support with the clinical medical and surgical sectors are absolutely essential. In this review, we describe historical developments in the global response to RHD with a focus on regional, international, and political commitments to address the global burden of RHD. We discuss the surgical and clinical considerations to properly manage surgical RHD patients and describe the logistical needs to strengthen cardiac centers caring for RHD patients worldwide.


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264. Does Advanced Trauma Life Support Training work? 10-Year Follow Up of Advanced Trauma Life Support India Program

Journal of the American College of Surgeons


Authors: Amulya Rattan, Amit Gupta , Subodh Kumar , Sushma Sagar , Suresh Sangi , Neerja Bannerjee , Radhesh Nambiar , Vinod Jain , Parli Ravi , Mahesh C. Misra ,
Region / country: Southern Asia – India
Speciality: Health policy, Trauma surgery

Background
Studies evaluating the efficacy of ATLS in Low & Middle-income countries (LMICs) are limited. We followed up ATLS providers certified by ATLS India program over a decade (2008-2018), aiming at measuring the benefits, if any, in knowledge, skills & attitude (KSA) from ATLS, and attrition over time.

Methods
Survey instrument was developed taking a cue from published literature on ATLS and improvised using the Delphi method. Randomly selected ATLS providers were sent the survey instrument via email, as a Google form along with a statement of purpose. Results are presented descriptively.

Results
1030 (41.2%) doctors responded. Improvement in knowledge (n=1013; 98.3%), psychomotor skills (n=986; 95.7%), organizational skills (n=998; 96.9%), overall trauma management (n=1013; 98.7%), self-confidence (n= 939; 91%) and ATLS promulgation at workplace in personal capacity (904; 87.8%) were reported. More than 60% opined benefits lasting beyond two years; more than 40% opined cognitive (492; 47.8%), psychomotor (433; 42%), and organizational benefits (499; 48.4%) lasting beyond three years. The Faculty-ATLS subgroup reported significantly more improvement in confidence, tendency to teach ATLS at the workplace, and retention of organizational skills than the providers’ subgroup. Lack of trained manpower (660; 64.1%) & attitude issues (n-495; 48.1%) were the major impediments at workplace. One third (n=373; 36.2%) recalled & enumerated life/ limb saving incidents applying ATLS principles.

Conclusion
Cognitive, psychomotor, organizational, and affective impact of ATLS is overwhelmingly positive in the Indian scenario. Till establishing formal trauma systems, ATLS remains the best hope for critically injured patients in LMICs.


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265. Global birth defects app: An innovative tool for describing and coding congenital anomalies at birth in low resource settings

ulster University


Authors: Helen Dolk, Aminkeng Zawuo Leke, Phil Whitfield, Rebecca Moore, Katy Karnell, Ingeborg Barišić, Linda Barlow‐Mosha, Lorenzo D. Botto, Ester Garne, Pilar Guatibonza, Shana Godfred‐Cato, Christine M. Halleux, Lewis B. Holmes, Cynthia A. Moore, Ieda Orioli, Neena Raina, Diana Valencia
Region / country: Global
Speciality: Health policy, Obstetrics and Gynaecology

Background: Surveillance programs in low‐ and middle‐income countries (LMICs) have difficulty in obtaining accurate information about congenital anomalies.

Methods: As part of the ZikaPLAN project, an International Committee developed an app for the description and coding of congenital anomalies that are externally visible at birth, for use in low resource settings. The “basic” version of the app was designed for a basic clinical setting and to overcome language and terminology barriers by providing diagrams and photos, sourced mainly from international Birth Defects Atlases. The “surveillance” version additionally allows recording of limited pseudonymized data relevant to diagnosis, which can be uploaded to a secure server, and downloaded by the surveillance program data center.

Results: The app contains 98 (88 major and 10 minor) externally visible anomalies and 12 syndromes (including congenital Zika syndrome), with definitions and International Classification of Disease v10 ‐based code. It also contains newborn examination videos and links to further resources. The user taps a region of the body, then selects among a range of images to choose the congenital anomaly that best resembles what they observe, with guidance regarding similar congenital anomalies. The “basic” version of the app has been reviewed by experts and made available on the Apple and Google Play stores. Since its launch in November 2019, it has been downloaded in 39 countries. The “surveillance” version is currently being field‐tested.

Conclusion: The global birth defects app is a mHealth tool that can help in developing congenital anomaly surveillance in low resource settings to support prevention and care.


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266. Medical and Nursing Students’ Perception and Experience of Virtual Classrooms during the COVID-19 Pandemic in Nepal

Interdisciplinary Journal of Virtual Learning in Medical Sciences


Authors: Pramila Poudel, Garima Tripathi , Ramesh Ghimire
Region / country: Southern Asia – Nepal
Speciality: Surgical Education

Background: On March 9, 2020, the government of Nepal declared suspension of all academic activities in line with a nationwide lockdown following the COVID-19 outbreak. To keep pace with the academic calendar, medical universities resumed their teaching and learning activities through virtual means on account of nonfeasibility of holding physical classes. The present study sought to identify the perception and experiences of undergraduate medical and nursing students regarding the virtual classrooms.
Methods: We adopted a sequential explanatory mixed method design whereby data were collected in two phases. Quantitative data were gathered from a survey (n=737) and qualitative data from focused group discussion (n=14). The participants were recruited using a non-probability Peer Esteem Snowballing technique. Quantitative data were analyzed using descriptive and inferential statistics, whereas qualitative data was examined using a narrative thematic analytic approach.
Results: Mean age of participants was 22±2.01 with (81%) female participation. The quantitative findings revealed that the “synchrony” domain had the highest mean score (4.10±0.47) and “course interaction” had the lowest mean score (2.93±0.81) amongst the four domains. The domains were significantly correlated to each other (P=0.01) and (P=0.05). Results from focus group discussion indicated that interactions were lower in the virtual classes and there was a great variation between the learners’ perception and their experiences of virtual classrooms. Students preferred blended classes to be implemented in future sessions.
Conclusion: In spite of various challenges, the students perceived the transition from traditional to virtual classrooms in a positive and enthusiastic way. An effective virtual learning experience requires a modified instructional approach on the part of educators and a consistent attitude from learners.


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267. Recommendations for streamlining precision medicine in breast cancer care in Latin America.

cancer reports


Authors: Alvarado-Cabrero I, Doimi F, Ortega V, de Oliveira Lima JT, Torres R, Torregrosa L
Region / country: Central America, South America
Speciality: General surgery, Surgical oncology

Background
The incidence of breast cancer (BC) in LMICs has increased by more than 20% within the last decade. In areas such as Latin America (LA), addressing BC at national levels evoke discussions surrounding fragmented care, limited resources, and regulatory barriers. Precision Medicine (PM), specifically companion diagnostics (CDx), links disease diagnosis and treatment for better patient outcomes. Thus, its application may aid in overcoming these barriers.
Recent findings
A panel of LA experts in fields related to BC and PM were provided with a series of relevant questions to address prior to a multi-day conference. Within this conference, each narrative was edited by the entire group, through numerous rounds of discussion until a consensus was achieved. The panel proposes specific, realistic recommendations for implementing CDx in BC in LA and other LMIC regions. In these recommendations, the authors strived to address all barriers to the widespread use and access mentioned previously within this manuscript.
Conclusion
This manuscript provides a review of the current state of CDx for BC in LA. Of most importance, the panel proposes practical and actionable recommendations for the implementation of CDx throughout the Region in order to identify the right patient at the right time for the right treatment.


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268. Anaesthesia facility evaluation: a Whatsapp survey of hospitals in Burundi

Southern African Journal of Anaesthesia and Analgesia


Authors: GC Sund, MS Lipnick, TJ Law, EA Wollner, GE Rwibuka
Region / country: Central Africa – Burundi
Speciality: Anaesthesia

Background: Data regarding the capacity to provide safe anaesthesia is lacking in many low-income countries. With the increasing popularity of WhatsApp for both personal and professional communication in Africa, we sought to test the feasibility of using this platform to administer a brief survey of anaesthesia equipment availability in Burundi. The aims of the study were to survey a subset of anaesthesia equipment availability in Burundi and to assess the suitability of using a WhatsApp chat group to administer such a survey.

Methods: The survey was distributed via WhatsApp by ATSARPS (Agora des Techniciens Supérieurs Anesthésistes Réanimateurs pour la Promotion de la Santé), an association of anaesthesia providers in Burundi. The questions focused on the presence of five pieces of anaesthesia equipment recommended by the World Health Organization – World Federation of Societies of Anesthesiologists (WHO–WFSA) International Standards for a Safe Practice of Anesthesia, namely a Lifebox pulse oximeter, anaesthesia machine, capnograph, ECG and defibrillator. Questions were sent as free text, and responses were received as a reply or as a personal message to the president of ATSARPS who sent the survey.

Results: Responses received represented data from 55 (85%) of the 65 hospitals that offer anaesthesia care across Burundi. Eightynine per cent of hospitals had a Lifebox pulse oximeter, 91% had an anaesthesia machine, 16% had capnography, 24% had an ECG and 14% had a defibrillator. Among hospitals which responded to our survey, only 60% reported perfoming general endotracheal anaesthesia on a monthly basis.

Conclusion: Data collection in low- and middle-income countries (LMICs) can be challenging; therefore, simple, low-cost methods of data collection need to be developed. We have demonstrated the feasibility of using a WhatsApp chat group among a national society of anaesthesia providers in Burundi to perform an initial abbreviated audit of anaesthesia facilities. We have also identified significant deficits in anaesthesia equipment in Burundi.


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269. Epidemiology of Surgical Amputations in Tamale Teaching Hospital, Ghana

Journal of Medical and Biomedical Sciences


Authors: Tolgou Yempabe, Waliu Jawula Salisu, Alexis D. B. Buunaaim, Hawawu Hussein, Charles N. Mock
Region / country: Western Africa – Ghana
Speciality: General surgery, Trauma and orthopaedic surgery, Vascular surgery

The current study aimed to explore the details of surgical amputations in Tamale, Ghana. This was a retrospective descriptive study. We analyzed case files of 112 patients who underwent surgical amputations
between 2011 and 2017. Demographics, site of amputation, indication for amputation, and outcomes were
retrieved from case files. Descriptive statistics were used to report the means and frequencies. Associations
between variables were assessed using Chi-Square, ANOVA, and Student’s t-test. The mean age of the participants was 43.6±23.1 years (range 2 to 86). Most (64.3%) were males. Lower limb amputations accounted for most (78.6%) cases. Diabetic vasculopathy was the most prevalent indication (44.6%), followed by trauma (36.6%). The mean hospital stay was 30.1±22.4 days (range 5 to 120). Surgical site infection (17.9%) was the main complication. In our study setting, there is thus far limited capability for proper management of diabetes mellitus, which needs to be improved. There is also an urgent need for multidisciplinary foot care teams that will help patients receive comprehensive care to reduce complications from diabetes and other vasculopathies


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270. Changes in body mass index, obesity, and overweight in Southern Africa development countries, 1990 to 2019: Findings from the Global Burden of Disease, Injuries, and Risk Factors Study

Obesity Science and Practice


Authors: Philimon N. Gona , Ruth W. Kimokoti , Clara M. Gona , Suha Ballout ,Sowmya R. Rao , Chabila C. Mapoma, Justin Lo , Ali H. Mokdad
Region / country: Southern Africa
Speciality: General surgery, Health policy

Background
High body mass index (BMI) is associated with stroke, ischemic heart disease (IHD), and type 2 diabetes mellitus (T2DM). An epidemiological analysis of the prevalence of high BMI, stroke, IHD, and T2DM was conducted for 16 Southern Africa Development Community (SADC) using Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study data.

Methods
GBD obtained data from vital registration, verbal autopsy, and ICD codes. Prevalence of high BMI (≥25 kg/m2), stroke, IHD, and T2DM attributed to high BMI were calculated. Cause of Death Ensemble Model and Spatiotemporal Gaussian regression was used to estimate mortality due to stroke, IHD, and T2DM attributable to high BMI.

Results
Obesity in adult females increased 1.54‐fold from 12.0% (uncertainty interval [UI]: 11.5–12.4) to 18.5% (17.9–19.0), whereas in adult males, obesity nearly doubled from 4.5 (4.3–4.8) to 8.8 (8.5–9.2). In children, obesity more than doubled in both sexes, and overweight increased by 27.4% in girls and by 37.4% in boys. Mean BMI increased by 0.7 from 22.4 (21.6–23.1) to 23.1 (22.3–24.0) in adult males, and by 1.0 from 23.8 (22.9–24.7) to 24.8 (23.8–25.8) in adult females. South Africa 44.7 (42.5–46.8), Swaziland 33.9 (31.7–36.0) and Lesotho 31.6 (29.8–33.5) had the highest prevalence of obesity in 2019. The corresponding prevalence in males for the three countries were 19.1 (17.5–20.7), 19.3 (17.7–20.8), and 9.2 (8.4–10.1), respectively. The DRC and Madagascar had the least prevalence of adult obesity, from 5.6 (4.8–6.4) and 7.0 (6.1–7.9), respectively in females in 2019, and in males from 4.9 (4.3–5.4) in the DRC to 3.9 (3.4–4.4) in Madagascar.

Conclusions
The prevalence of high BMI is high in SADC. Obesity more than doubled in adults and nearly doubled in children. The 2019 mean BMI for adult females in seven countries exceeded 25 kg/m2. SADC countries are unlikely to meet UN2030 SDG targets. Prevalence of high BMI should be studied locally to help reduce morbidity.


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271. The unmet need for treatment of children with musculoskeletal impairment in Malawi

Research Square


Authors: Leonard Banza Ngoie, Eva Dybvik, Geir Hallan , Jan-Erik Gjertsen , Nyengo Mkandawire , Carlos Varela, Sven Young
Region / country: Southern Africa – Malawi
Speciality: Paediatric surgery, Trauma and orthopaedic surgery

Background More than a billion people globally are living with disability and the prevalence is likely to increase rapidly in the coming years in low- and middle-income countries (LMICs). The vast majority of those living with disability are children residing in LMICs. There is very little reliable data on the epidemiology of musculoskeletal impairments (MSIs) in children and even less is available for Malawi

Methods Clusters were selected across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the national distribution of the population. Clusters were distributed around all 27-mainland districts of Malawi. Population of Malawi was 18.3 million from 2018 estimates, based on age categories we estimated that about 8.9 million were 16 years and younger. MSI diagnosis from our randomized sample was extrapolated to the population of Malawi, confidence limits was calculated using normal approximation.

Results Of 3,792 children aged 16 or less who were enumerated, 3,648 (96.2%) were examined and 236 were confirmed to have MSI, giving a prevalence of MSI of 6.5% (CI 5.7-7.3). Extrapolated to the Malawian population this means as many as 576,000 (95% CI 505,000-647,000) children could be living with MSI in Malawi. Overall, 46% of MSIs were due to congenital causes, 34% were neurological in origin, 8.4% were due to trauma, 7.8% were acquired non-traumatic non-infective causes, and 3.4% were due to infection. We estimated a total number of 112,000 (80,000-145,000) children in need of Prostheses and Orthoses (P&O), 42,000 (22,000-61,000) in need of mobility aids (including 37,000 wheel chairs), 73,000 (47,000-99,000) in need of medication, 59,000 (35,000-82,000) in need of physical therapy, and 20,000 (6,000-33,000) children in need of orthopaedic surgery. Low parents’ educational level was one factor associated with an increased risk of MSI

Conclusion This survey has uncovered a large burden of MSI among children aged 16 and under in Malawi. The burden of musculoskeletal impairment in Malawi is mostly unattended, revealing a need to scale up both P&O services, physical & occupational therapy, and surgical services in the country


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272. Impact of the COVID-19 Pandemic on Oncology Clinical Research in Latin America (LACOG 0420)

JCO Global Oncology


Authors: Aline B. Lara Gongora ,Gustavo Werutsky ,Denis L. Jardim , Angelica Nogueira-Rodrigues , Carlos H. Barrios , Clarissa Mathias,Fernando Maluf ,Rachel Riechelmann,Maurício Fraga, Henry Gomes , William N. William ,Camilla A. F. Yamada, Gilberto de Castro Jr , Daniela D. Rosa, Andreia C. de Melo , Raul Sala,Eva Bustamante, Denisse Bretel, Oscar Arrieta , Andrés F. Cardona , Diogo A. Bastos
Region / country: Central America, South America
Speciality: Other, Surgical oncology

PURPOSE
COVID-19 has affected cancer care worldwide. Clinical trials are an important alternative for the treatment of oncologic patients, especially in Latin America, where trials can be the only opportunity for some of them to access novel and, sometimes, standard treatments.

METHODS
This was a cross-sectional study, in which a 22-question survey regarding the impact of the COVID-19 pandemic on oncology clinical trials was sent to 350 representatives of research programs in selected Latin American institutions, members of the Latin American Cooperative Oncology Group.

RESULTS
There were 90 research centers participating in the survey, with 70 of them from Brazil. The majority were partly private or fully private (n = 77; 85.6%) and had confirmed COVID-19 cases at the institution (n = 57; 63.3%). Accruals were suspended at least for some studies in 80% (n = 72) of the responses, mostly because of sponsors’ decision. Clinical trials’ routine was affected by medical visits cancelation, reduction of patients’ attendance, reduction of other specialties’ availability, and/or alterations on follow-up processes. Formal COVID-19 mitigation policies were adopted in 96.7% of the centers, including remote monitoring and remote site initiation visits, telemedicine visits, reduction of research team workdays or home office, special consent procedures, shipment of oral drugs directly to patients’ home, and increase in outpatient diagnostic studies. Importantly, some of these changes were suggested to be part of future oncology clinical trials’ routine, particularly the ones regarding remote methods, such as telemedicine.

CONCLUSION
To our knowledge, this was the first survey to evaluate the impact of COVID-19 on Latin American oncology clinical trials. The results are consistent with surveys from other world regions. These findings may endorse improvements in clinical trials’ processes and management in the postpandemic period.


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273. The Role of Noncommunicable Diseases in the Pursuit of Global Health Security

Health Security


Authors: Deliana Kostova, Patricia Richter, Gretchen Van Vliet, Michael Mahar, and Ronald L. Moolenaar
Region / country: Global
Speciality: Health policy, Other

Noncommunicable diseases and their risk factors are important for all aspects of outbreak preparedness and response, affecting a range of factors including host susceptibility, pathogen virulence, and health system capacity. This conceptual analysis has 2 objectives. First, we use the Haddon matrix paradigm to formulate a framework for assessing the relevance of noncommunicable diseases to health security efforts throughout all phases of the disaster life cycle: before, during, and after an event. Second, we build upon this framework to identify 6 technical action areas in global health security programs that are opportune integration points for global health security and noncommunicable disease objectives: surveillance, workforce development, laboratory systems, immunization, risk communication, and sustainable financing. We discuss approaches to integration with the goal of maximizing the reach of global health security where infectious disease threats and chronic disease burdens overlap.


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274. Opportunities For Improvement in The Administration of Neoadjuvant Chemotherapy For T4 Breast Cancer: A Comparison of The United States and Nigeria

The Oncologist


Authors: Anya Romanoff ,Olalekan Olasehinde ,Debra A. Goldman ,Olusegun I. Alatise , Jeremy Constable ,Ngozi Monu , Gregory C. Knapp ,Oluwole Odujoko ,Emmanuella Onabanjo ,Adewale O. Adisa ,Adeolu O. Arowolo ,Adeleye D. Omisore ,Olusola C. Famurewa ,Benjamin O. Anderson ,Mary L. Gemignani , T. Peter Kingham
Region / country: Northern America, Western Africa – Nigeria, United States of America
Speciality: General surgery, Surgical oncology

BACKGROUND
Neoadjuvant chemotherapy (NAC) is an integral component of T4 breast cancer (BCa) treatment. We compared response to NAC for T4 BCa in the U.S. and Nigeria to direct future interventions.

MATERIALS AND METHODS
Cross‐sectional retrospective analysis included all non‐metastatic T4 BCa patients treated from 2010‐2016 at Memorial Sloan Kettering Cancer Center (New York, U.S.) and Obafemi Awolowo University Teaching Hospitals Complex (Ile Ife, Nigeria). Pathologic complete response (pCR) and survival were compared and factors contributing to disparities evaluated.

RESULTS
308 patients met inclusion criteria: 157 (51%) in the U.S. and 151 (49%) in Nigeria. All U.S. patients received NAC and surgery compared with 93 (62%) Nigerian patients. 56/93 (60%) Nigerian patients completed their prescribed course of NAC. In Nigeria, older age and higher socioeconomic status were associated with treatment receipt.

Fewer patients in Nigeria had immunohistochemistry performed (100% U.S. vs. 18% Nigeria). Of those with available receptor subtype, 18% (28/157) of U.S. patients were triple negative vs. 39% (9/23) of Nigerian patients. Overall pCR was seen in 27% (42/155) of U.S. patients and 5% (4/76) of Nigerian patients. Five‐year survival was significantly shorter in Nigeria vs. the U.S. (61% vs. 72%). However, among the subset of patients who received multimodality therapy, including NAC and surgery with curative intent, 5‐year survival (67% vs. 72%) and 5‐year recurrence‐free survival (48% vs. 61%) did not significantly differ between countries.

CONCLUSION
Addressing health system, socioeconomic, and psychosocial barriers is necessary for administration of complete NAC to improve BCa outcomes in Nigeria.


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275. Comparison of Challenges and Problems Encountered in the Practice of Exclusive Breast Feeding by Primiparous and Multiparous Women in Rural Areas of Sindh, Pakistan: A Cross-Sectional Study

cureus


Authors: Sana Zafar, Khizer Shamim, Syeda Mehwish, Mohsin Arshad, Rahil Barkat
Region / country: Southern Asia – Pakistan
Speciality: Health policy, Obstetrics and Gynaecology

Introduction: The UNICEF (United Nations International Children Education Fund) and WHO (World Health Organization) recommend exclusive breastfeeding (EBF) for the first six months of life. EBF is considered to be an important practice for enhancing infant health and wellbeing. Breastfeeding offers a wide range of psychological and physical health benefits in the long-term and short-term for young children, infants, and mothers. This study aims to compare exclusive breastfeeding practice among primiparous and multiparous mothers including reasons for discontinuing exclusive breastfeeding and problems faced during breastfeeding.

Methodology: This cross-sectional study was conducted in rural areas of Sindh, registered with the Maternal Newborn Health Registry (MNHR). The study used a systematic sampling technique for the enrollment of study participants. A survey questionnaire was used to collect data from mothers about the practices of EBF. A total of 397 mothers were interviewed and analyzed.

Results: Among Primiparous mothers, 14.1% of mothers initiated breastfeeding within one hour of birth, while 22.4% of multiparous mothers, initiated breastfeeding within one hour of birth. The difference between the two is statistically insignificant (p-value=0.234). A high percentage of multiparous mothers exclusively breastfed their infants for six months (63.5%) as compared to primiparous mothers (51.5%). The most common reason for introducing pre-lacteal feed before six months among primiparous mothers is the lack of adequate milk production to fulfill baby needs; this was the case for 35.4% of mothers. On the other hand, the baby remaining hungry post breastfeeding was the major reason among multiparous mothers (44.0%) for introducing pre-lacteal feed before six months.

Conclusion: This study helped in the identification of issues faced by primiparous and multiparous mothers during exclusive breastfeeding. Interventions for promoting EBF need to be tailored as per the need and challenges of the population.


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276. Invasive breast Cancer treatment in Tanzania: landscape assessment to prepare for implementation of standardized treatment guidelines

BMC Cancer


Authors: Rupali Sood, Nestory Masalu, Roisin M. Connolly, Christina A. Chao, Lucas Faustine, Cosmas Mbulwa, Benjamin O. Anderson , Anne F. Rositch
Region / country: Eastern Africa – Tanzania
Speciality: General surgery, Surgical oncology

Background
Incidence of breast cancer continues to rise in low- and middle-income countries, with data from the East African country of Tanzania predicting an 82% increase in breast cancer from 2017 to 2030. We aimed to characterize treatment pathways, receipt of therapies, and identify high-value interventions to increase concordance with international guidelines and avert unnecessary breast cancer deaths.

Methods
Primary data were extracted from medical charts of patients presenting to Bugando Medical Center, Tanzania, with breast concerns and suspected to have breast cancer. Clinicopathologic features were summarized with descriptive statistics. A Poisson model was utilized to estimate prevalence ratios for variables predicted to affect receipt of life-saving adjuvant therapies and completion of therapies. International and Tanzanian guidelines were compared to current care patterns in the domains of lymph node evaluation, metastases evaluation, histopathological diagnosis, and receptor testing to yield concordance scores and suggest future areas of focus.

Results
We identified 164 patients treated for suspected breast cancer from April 2015–January 2019. Women were predominantly post-menopausal (43%) and without documented insurance (70%). Those with a confirmed histopathology diagnosis (69%) were 3 times more likely to receive adjuvant therapy (PrR [95% CI]: 3.0 [1.7–5.4]) and those documented to have insurance were 1.8 times more likely to complete adjuvant therapy (1.8 [1.0–3.2]). Out of 164 patients, 4% (n = 7) received concordant care based on the four evaluated management domains. The first most common reason for non-concordance was lack of hormone receptor testing as 91% (n = 144) of cases did not undergo this testing. The next reason was lack of lymph node evaluation (44% without axillary staging) followed by absence of abdominopelvic imaging in those with symptoms (35%) and lack of histopathological confirmation (31%).

Conclusions
Patient-specific clinical data from Tanzania show limitations of current breast cancer management including axillary staging, receipt of formal diagnosis, lack of predictive biomarker testing, and low rates of adjuvant therapy completion. These findings highlight the need to adapt and adopt interventions to increase concordance with guidelines including improving capacity for pathology, developing complete staging pathways, and ensuring completion of prescribed adjuvant therapies.


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277. Surgical Clip Ligation of Anterior Communicating Artery Aneurysm in a Resource-Limited Setting

cureus


Authors: Christopher Markosian, Igor Kurilets Jr., Luke D. Tomycz
Region / country: Eastern Europe – Ukraine
Speciality: Vascular surgery

Anterior communicating artery (ACOM) aneurysm clipping with intraoperative measures to ensure total occlusion and avoid ischemic complications is standard in countries such as the United States. However, alternatives need to be considered in resource-limited settings. The clipping of an unruptured, superiorly projecting ACOM aneurysm in a resource-limited setting is presented and special nuances that optimize safety are described. Careful surgical technique, meticulous identification of relevant anatomy, post-ligation inspection of the aneurysm and adjacent vessels, and possibly needle puncture of the aneurysm dome are critical to achieve favorable results.


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278. Moral Distress and Resilience Associated with Cancer Care Priority Setting in a Resource Limited Context

The Oncologist


Authors: Rebecca J. DeBoer , Espérance Mutoniwase , Cam Nguyen , Anita Ho , Grace Umutesi , Eugene Nkusi , Fidele Sebahungu , Katherine Van Loon , Lawrence N. Shulman , Cyprien Shyirambere
Region / country: Global
Speciality: Health policy, Surgical oncology

Background
Moral distress and burnout are highly prevalent among oncology clinicians. Research is needed to better understand how resource constraints and systemic inequalities contribute to moral distress in order to develop effective mitigation strategies. Oncology providers in low- and middle-income countries (LMICs) are well positioned to provide insight into the moral experience of cancer care priority setting and expertise to guide solutions.

Methods
Semi-structured interviews were conducted with a purposive sample of 22 oncology physicians, nurses, program leaders, and clinical advisors at a cancer center in Rwanda. Interviews were recorded, transcribed verbatim, and analyzed using the framework method.

Results
Participants identified sources of moral distress at three levels of engagement with resource prioritization: witnessing program-level resource constraints drive cancer disparities, implementing priority setting decisions into care of individual patients, and communicating with patients directly about resource prioritization implications. They recommended individual and organizational level interventions to foster resilience, such as communication skills training and mental health support for clinicians, interdisciplinary team-building, fair procedures for priority setting, and collective advocacy for resource expansion and equity.

Conclusion
This study adds to the current literature an in-depth examination of the impact of resource constraints and inequities on clinicians in a low resource setting. Effective interventions are urgently needed to address moral distress, reduce clinician burnout, and promote well-being among a critical but strained oncology workforce. Collective advocacy is concomitantly needed to address the structural forces that constrain resources unevenly and perpetuate disparities in cancer care and outcomes.


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279. From the breast to the upper jaw: A rare case of metastatic breast cancer

South Sudan Medical Journal


Authors: Funmilola O. Wuraola , Bamidele A. Famurewa , Olalekan Olasehinde , Oluwole O. Odujoko , Olufunlola M. Adesina , Stephen B. Aregbesola
Region / country: Western Africa – Nigeria
Speciality: General surgery, Surgical oncology

Breast cancer is the commonest malignancy in women globally. Metastases of advanced breast carcinoma to bones, lungs and liver are well known but spread to maxillary bone presenting as maxillary sinus and palatal swelling is rare. We present a case of advanced breast carcinoma in a female Nigerian with clinical, radiological and histopathological features of lung and right maxillary bone metastases. To the best of our knowledge, this is the first reported case of metastatic breast cancer to the lungs and maxilla in Nigeria. The debilitating sequelae of advanced untreated breast carcinoma in a resource limited setting with suboptimal comprehensive cancer care are highlighted.


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280. Artificial intelligence: A rapid case for advancement in the personalization of Gynaecology/Obstetric and Mental Health care

Women’s Health


Authors: Gayathri Delanerolle, Xuzhi Yang, Suchith Shetty, Vanessa Raymont, Ashish Shetty, Peter Phiri, Dharani K Hapangama, Nicola Tempest, Kingshuk Majumder, Jian Qing Shi
Region / country: Global
Speciality: Obstetrics and Gynaecology, Other

To evaluate and holistically treat the mental health sequelae and potential psychiatric comorbidities associated with obstetric and gynaecological conditions, it is important to optimize patient care, ensure efficient use of limited resources and improve health-economic models. Artificial intelligence applications could assist in achieving the above. The World Health Organization and global healthcare systems have already recognized the use of artificial intelligence technologies to address ‘system gaps’ and automate some of the more cumbersome tasks to optimize clinical services and reduce health inequalities. Currently, both mental health and obstetric and gynaecological services independently use artificial intelligence applications. Thus, suitable solutions are shared between mental health and obstetric and gynaecological clinical practices, independent of one another. Although, to address complexities with some patients who may have often interchanging sequelae with mental health and obstetric and gynaecological illnesses, ‘holistically’ developed artificial intelligence applications could be useful. Therefore, we present a rapid review to understand the currently available artificial intelligence applications and research into multi-morbid conditions, including clinical trial-based validations. Most artificial intelligence applications are intrinsically data-driven tools, and their validation in healthcare can be challenging as they require large-scale clinical trials. Furthermore, most artificial intelligence applications use rate-limiting mock data sets, which restrict their applicability to a clinical population. Some researchers may fail to recognize the randomness in the data generating processes in clinical care from a statistical perspective with a potentially minimal representation of a population, limiting their applicability within a real-world setting. However, novel, innovative trial designs could pave the way to generate better data sets that are generalizable to the entire global population. A collaboration between artificial intelligence and statistical models could be developed and deployed with algorithmic and domain interpretability to achieve this. In addition, acquiring big data sets is vital to ensure these artificial intelligence applications provide the highest accuracy within a real-world setting, especially when used as part of a clinical diagnosis or treatment.


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281. Barriers and facilitators to online medical and nursing education during the COVID-19 pandemic: perspectives from international students from low- and middle-income countries and their teaching staff

Human Resources for Health


Authors: Wen Li, Robyn Gillies, Mingyu He, Changhao Wu, Shenjun Liu, Zheng Gong , Hong Sun
Region / country: Global
Speciality: Health policy, Surgical Education

Background
The COVID-19 pandemic posed a huge challenge to the education systems worldwide, forcing many countries to provisionally close educational institutions and deliver courses fully online. The aim of this study was to explore the quality of the online education in China for international medical and nursing students from low- and middle-income countries (LMICs) as well as the factors that influenced their satisfaction with online education during the COVID-19 pandemic.

Methods
Questionnaires were developed and administered to 316 international medical and nursing students and 120 teachers at a university in China. The Chi-square test was used to detect the influence of participants’ personal characteristics on their satisfaction with online education. The Kruskal–Wallis rank-sum test was employed to identify the negative and positive factors influencing the online education satisfaction. A binary logistic regression model was performed for multiple-factor analysis to determine the association of the different categories of influential factors—crisis-, learner-, instructor-, and course-related categories, with the online education satisfaction.

Results
Overall, 230 students (response rate 72.8%) and 95 teachers (response rate 79.2%) completed the survey. It was found that 36.5% of students and 61.1% of teachers were satisfied with the online education. Teachers’ professional title, students’ year of study, continent of origin and location of current residence significantly influenced the online education satisfaction. The most influential barrier for students was the severity of the COVID-19 situation and for teachers it was the sense of distance. The most influential facilitating factor for students was a well-accomplished course assignment and for teachers it was the successful administration of the online courses.

Conclusions
Several key factors have been identified that affected the attitudes of international health science students from LMICs and their teachers towards online education in China during the COVID-19 pandemic. To improve the online education outcome, medical schools are advised to promote the facilitating factors and cope with the barriers, by providing support for students and teaching faculties to deal with the anxiety caused by the pandemic, caring for the state of mind of in-China students away from home, maintaining the engagement of out-China students studying from afar and enhancing collaborations with overseas institutions to create practice opportunities at students’ local places.


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282. Burden of Cervical Cancer in the Eastern Mediterranean Region During the Years 2000 and 2017: Retrospective Data Analysis of the Global Burden of Disease Study

JMIR Public Health Surveillance


Authors: Fereshteh Safaeian, Shidrokh Ghaemimood , Ziad El-Khatib,Sahba Enayati , Roksana Mirkazemi , Bruce Reeder
Region / country: Middle East, Northern Africa, Southern Asia
Speciality: Obstetrics and Gynaecology, Surgical oncology

Background:
Cervical cancer is a growing health concern, especially in resource-limited settings.

Objective:
The objective of this study was to assess the burden of cervical cancer mortality and disability-adjusted life years (DALYs) in the Eastern Mediterranean Region (EMR) and globally between the years 2000 and 2017 by using a pooled data analysis approach.

Methods:
We used an ecological approach at the country level. This included extracting data from publicly available databases and linking them together in the following 3 steps: (1) extraction of data from the Global Burden of Disease (GBD) study in the years 2000 and 2017, (2) categorization of EMR countries according to the World Bank gross domestic product per capita, and (3) linking age-specific population data from the Population Statistics Division of the United Nations (20-29 years, 30-49 years, and >50 years) and GBD’s data with gross national income per capita and globally extracted data, including cervical cancer mortality and DALY numbers and rates per country. The cervical cancer mortality rate was provided by the GBD study using the following formula: number of cervical cancer deaths × 100,000/female population in the respective age group.

Results:
The absolute number of deaths due to cervical cancer increased from the year 2000 (n=6326) to the year 2017 (n=8537) in the EMR; however, the mortality rate due to this disease decreased from the year 2000 (2.7 per 100,000) to the year 2017 (2.5 per 100,000). According to age-specific data, the age group ≥50 years showed the highest mortality rate in both EMR countries and globally, and the age group of 20-29 years showed the lowest mortality rate both globally and in the EMR countries. Further, the rates of cervical cancer DALYs in the EMR were lower compared to the global rates (2.7 vs 6.8 in 2000 and 2.5 vs 6.8 in 2017 for mortality rate per 100,000; 95.8 vs 222.2 in 2000 and 86.3 vs 211.8 in 2017 for DALY rate per 100,000; respectively). However, the relative difference in the number of DALYs due to cervical cancer between the year 2000 and year 2017 in the EMR was higher than that reported globally (34.9 vs 24.0 for the number of deaths and 23.5 vs 18.1 for the number of DALYs, respectively).

Conclusions:
We found an increase in the burden of cervical cancer in the EMR as per the data on the absolute number of deaths and DALYs. Further, we found that the health care system has an increased number of cases to deal with, despite the decrease in the absolute number of deaths and DALYs. Cervical cancer is preventable if human papilloma vaccination is taken and early screening is performed. Therefore, we recommend identifying effective vaccination programs and interventions to reduce the burden of this disease.


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283. The role of Mitrofanoff appendicovesicostomy in the management of a pelvic fracture distraction defect in a 24- year-old man after multiple failed reconstruction attempts

East and Central African Journal of Surgery


Authors: Mumba Chalwe, Seke M.E. Kazuma
Region / country: Eastern Africa – Zambia
Speciality: General surgery, Trauma and orthopaedic surgery, Trauma surgery, Urology surgery

Failed Pelvic Fracture Distraction Defect repairs present a considerable challenge for management. Re-do urethroplasties for failed repairs are associated with higher recurrence and morbidity rates. The case presented describes a male patient with a pelvic fracture urethral distraction defect (PFUDD) who had undergone multiple failed repairs. The Mitrofanoff appendicovesicostomy was successfully carried out and the patient remains continent to date. The Mitrofanoff appendicovesicostomy is not commonly employed in the management of adult urethral stricture disease. We present our experience with managing a pelvic fracture urethral disruption defect (PFUDD) after multiple failed urethroplasties using a continent catheterisable urinary diversion technique


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284. Surgical management and outcomes of late-presenting acute limb ischaemia at 2 referral hospitals in Addis Ababa, Ethiopia: A 1-year prospective study

East and Central African Journal of Surgery


Authors: Nebyou Seyoum, Berhanu D. Mekonnen, Berhanu N. Alemu
Region / country: Eastern Africa – Ethiopia
Speciality: Emergency surgery, Vascular surgery

Objective: The study was performed to show the overall perspective of surgical management for acute limb ischemia specific to Ethiopian population.
Methods: A prospective planned cohort study was conducted to analyze the socio-demography, clinical presentation, causes of limb ischemia, and outcomes of surgical intervention, and variables associated with complications of acute limb ischemia.
Results:A total of 102 patients were operated upon. The male to female ratio was 2:1; the mean age of presentation was 54±17 years. Patients presented after an average of 9±4.8 days of symptom onset. The type of procedures performed were, thrombectomy 51(47.2%), primary amputation 24(22.2%), bypass or interposition vascular grafts 10(9.2%), embolectomy 10(9.2%), primary vascular repair 7(6.4%), and femoro-femoral graft 6(5.5%). Local and systemic complications occurred in 35.3% and 17.6% respectively. Amputation after re-vascularization surgery was seen in 32.4%. A 30-day total amputation & mortality rate was 52.9% and 9.8% respectively. Clinical variables found to have a statistical significant association (P<0.05) with complications were age ≥ 60 years, late presentation (≥ 9days), patients with hypertensive disease and previous myocardial infarction.
Conclusions: Optimizing co-morbidities, timely detection and treating immediately on arrival could potentially play a key role in improving surgical outcomes of acute limb ischemia.


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285. Respiratory morbidity and mortality of traumatic cervical spinal cord injury at a level I trauma center in India

Spinal Cord Series and Cases


Authors: Deep Sengupta, Ashish Bindra, Niraj Kumar, Keshav Goyal, Pankaj Kumar Singh, Arvind Chaturvedi, Rajesh Malhotra & Ashwani Kumar Mishra
Region / country: Southern Asia – India
Speciality: Emergency surgery, Neurosurgery, Trauma and orthopaedic surgery, Trauma surgery

Study design
Descriptive retrospective.

Objectives
To evaluate the burden of respiratory morbidity in terms of ventilator dependence (VD) days and length of stay in neurotrauma ICU (NICU) and hospital, and to determine mortality in patients with traumatic cervical spinal cord injury (CSCI) in a low middle-income country (LMIC).

Setting
Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India.

Methods
A total of 135 patients admitted with CSCI in the NICU between January 2017 to December 2018 were screened. Information regarding age, gender, American Spinal Injury Association (ASIA) impairment scale (AIS), level of injury, duration of VD, length of NICU, hospital stay, and outcome in terms of mortality or discharge from the hospital were obtained from the medical records.

Results
A total of 106 CSCI patients were analyzed. The mean (SD) age of patients was 40 (±16) years and male: female ratio was 5:1. The duration of VD, duration of NICU, and hospital stay was a median of 8 days (IQR 1127), 6 days (IQR 1118), and 15 days (IQR 3127) respectively. Mortality was 19% (20/106). The mortality was significantly associated with poorer AIS score, VD, and duration of ICU and hospital stay. All patients were discharged to home only after they became ventilator-free.

Conclusions
The ventilator burden, hospital stay, and mortality are high in patients with CSCI in LMICs. Poor AIS scores, prolonged VD, ICU and hospital stay are associated with mortality. There is a need for comprehensive CSCI rehabilitation programs in LMICs to improve outcome.


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286. Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia

Gynecologic Oncology Reports


Authors: Jane Mwamba Mumba, Lackson Kasonka, Okola Basil Owiti, Mwansa Ketty Lubeya , Lufunda Lukama, Susan C Msadabwe, Chester Kalinda
Region / country: Central Africa, Eastern Africa – Zambia
Speciality: Obstetrics and Gynaecology, Surgical oncology

Expedited diagnostic processes for all suspected cervical cancer cases remain essential in the effort to improve clinical outcomes of the disease. However, in some developing countries like Zambia, there is paucity of data that assesses factors influencing diagnostic and treatment turnaround time (TAT) and other metrics vital for quality cancer care. We conducted a retrospective hospital-based study at the Cancer Diseases Hospital (CDH) for cervical cancer cases presenting to the facility between January 2014 and December 2018. Descriptive statistics were used to summarize demographic characteristics while a generalized linear model of the negative binomial was used to assess determinants of overall TAT. Our study included 2121 patient case files. The median age was 49 years (IQR: ±17) and most patients (n=634, 31%) were aged between 41–50 years. The International Federation of Gynaecology and Obstetrics (FIGO) Cancer stage II (n =941, 48%) was the most prevalent while stage IV (n=103, 5.2%) was the least. The average diagnostic TAT in public laboratories was 1.48 (95%CI: 1.21–1.81) times longer than in private laboratories. Furthermore, referral delay was 55 days (IQR: 24–152) and the overall TAT (oTAT) was 110 days (IQR: 62–204). The age of the patient, HIV status, stage of cancer and histological subtype did not influence oTAT while marital status influenced oTAT. The observed longer oTAT may increase irreversible adverse health outcomes among cervical cancer patients. There is a need to improve cancer care in Zambia through improved health expenditure especially in public health facilities.


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287. Increasing Antimicrobial Resistance in Surgical Wards at Mulago National Referral Hospital, Uganda, from 2014 to 2018—Cause for Concern?

Tropical Medicine and Infectious Disease


Authors: Gerald Mboowa ,Dickson Aruhomukama ,Ivan Sserwadda ,Freddy Eric Kitutu ,Hayk Davtyan ,Philip Owiti ,Edward Mberu Kamau ,Wendemagegn Enbiale ,Anthony Reid ,Douglas Bulafu ,Jeffrey Kisukye ,Margaret Lubwama ,Henry Kajumbula
Region / country: Eastern Africa – Uganda
Speciality: General surgery, Health policy, Other

Antimicrobial Resistance (AMR) and Healthcare Associated Infections (HAIs) are major global public health challenges in our time. This study provides a broader and updated overview of AMR trends in surgical wards of Mulago National Referral Hospital (MNRH) between 2014 and 2018. Laboratory data on the antimicrobial susceptibility profiles of bacterial isolates from 428 patient samples were available. The most common samples were as follows: tracheal aspirates (36.5%), pus swabs (28.0%), and blood (20.6%). Klebsiella (21.7%), Acinetobacter (17.5%), and Staphylococcus species (12.4%) were the most common isolates. The resistance patterns for different antimicrobials were: penicillins (40–100%), cephalosporins (30–100%), β-lactamase inhibitor combinations (70–100%), carbapenems (10–100%), polymyxin E (0–7%), aminoglycosides (50–100%), sulphonamides (80–100%), fluoroquinolones (40–70%), macrolides (40–100%), lincosamides (10–45%), phenicols (40–70%), nitrofurans (0–25%), and glycopeptide (0–20%). This study demonstrated a sustained increase in resistance among the most commonly used antibiotics in Uganda over the five-year study period. It implies ongoing hospital-based monitoring and surveillance of AMR patterns are needed to inform antibiotic prescribing, and to contribute to national and global AMR profiles. It also suggests continued emphasis on infection prevention and control practices (IPC), including antibiotic stewardship. Ultimately, laboratory capacity for timely bacteriological culture and sensitivity testing will provide a rational choice of antibiotics for HAI.


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288. Oxygen delivery systems for adults in Sub-Saharan Africa: A scoping review

Journal of Global Health


Authors: Neelima Navuluri, Maria L Srour, Peter S Kussin, David M Murdoch, Neil R MacIntyre, Loretta G Que, Nathan M Thielman, Eric D McCollum
Region / country: Central Africa, Eastern Africa, Southern Africa, Western Africa
Speciality: Critical care, Health policy, Other

Background
Respiratory diseases are the leading cause of death and disability worldwide. Oxygen is an essential medicine used to treat hypoxemia from respiratory diseases. However, the availability and utilization of oxygen delivery systems for adults in sub-Saharan Africa is not well-described. We aim to identify and describe existing data around oxygen availability and provision for adults in sub-Saharan Africa, determine knowledge or research gaps, and make recommendations for future research and capacity building.

Methods
We systematically searched four databases for articles on April 22, 2020, for variations of keywords related to oxygen with a focus on countries in sub-Saharan Africa. Inclusion criteria were studies that included adults and addressed hypoxemia assessment or outcome, oxygen delivery mechanisms, oxygen availability, oxygen provision infrastructure, and oxygen therapy and outcomes.

Results
35 studies representing 22 countries met inclusion criteria. Availability of oxygen delivery systems ranged from 42%-94% between facilities, with wide variability in the consistency of availability. There was also wide reported prevalence of hypoxemia, with most studies focusing on specific populations. In facilities where oxygen is available, health care workers are ill-equipped to identify adult patients with hypoxemia, provide oxygen to those who need it, and titrate or discontinue oxygen appropriately. Oxygen concentrators were shown to be the most cost-effective delivery system in areas where power is readily available.

Conclusions
There is a substantial need for building capacity for oxygen delivery throughout sub-Saharan Africa. Addressing this critical issue will require innovation and a multi-faceted approach of developing infrastructure, better equipping facilities, and health care worker training


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289. Global community perception of ‘surgical care’ as a public health issue: a cross sectional survey

BMC Public Health


Authors: Nurhayati Lubis, Meena Nathan Cherian, Chinmayee Venkatraman , Fiemu E. Nwariaku
Region / country: Global
Speciality: Health policy

Background
In the last decade surgical care has been propelled into the public health domain with the establishment of a World Health Organisation (WHO) designated programme and key publications. The passing of the historic World Health Assembly Resolution (WHA) acknowledged surgical care as a vital component towards achieving Universal Health Coverage (UHC). We conducted the first worldwide survey to explore the perception of surgical care as a public health issue.

Method
The anonymous, cross sectional survey targeted worldwide participants across a range of professional backgrounds, including non-medical using virtual snowball sampling method (in English) using Google Forms (Google Inc., Mountain View, CA, USA) from 20th February 2019 to 25th June 2019. The survey questions were designed to gauge awareness on Sustainable Development Goals (SDGs), UHC, WHO programmes and key publications on surgical care as well as perception of surgical care as a priority topic in public health.

Results
The survey was completed by 1954 respondents from 118 countries. Respondents were least aware of surgical care as a teaching topic in public health courses (27%; n = 526) and as a WHO programme (20%; n = 384). 82% of respondents were aware of UHC (n = 1599) and of this 72% (n = 1152) agreed that surgical care fits within UHC. While 77% (n = 1495) of respondents were aware of SDGs, only 19% (n = 370) agreed that surgery was a priority to meet SDGs. 48% (n = 941) rated surgical care as a cost-effective component of Primary Health Care. 88% (n = 1712) respondents had not read the WHA Resolution on ‘Strengthening emergency and essential surgical care and anaesthesia as a component of UHC’.

Conclusion
There is still a widespread gap in awareness on the importance of surgical care as a public health issue amongst our respondents. Surgical care was not seen as a priority to reach the SDGs, less visible as a WHO programme and not perceived as an important topic for public health courses.


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290. Analysing a Global Health Education Framework for Public Health Education Programs in India

The University of Sydney


Authors: Sawleshwarkar, Shailendra Nagorao
Region / country: Southern Asia – India
Speciality: Health policy, Surgical Education

Academic global health is of increasing interest to educators and students in public health but competency domains as well as education pathways that deliver this training, are still being identified and refined. This thesis was undertaken using an education program development paradigm and aimed to analyse the factors shaping global health education in India by examining multistakeholder perspectives. The research framework consisted of four components: curriculum and content, students, faculty and key experts, and employers. Studies captured the perspectives of students through a survey and focus group discussions, faculty and other key experts through semi-structured interviews, and employers through job advertisement analysis. We identified eleven global health competency domains focussed on three aspects: foundational competencies, core public health skills and soft skills. Global health and public health were seen as interconnected, with global health having transnational context and public health having a more national focus. Global health was seen as a nascent concept in India and although integration of global health education into the public health curriculum was supported, there were concerns given that public health is still too new a discipline in India. Global health competencies were seen as a ‘step up’ from the public health competencies. Based on the results, a two-level approach to global health education is proposed for Indian public health institutions. The first approach, targeted at recent graduates, focuses on a ‘foundational global health education’ within public health programs such as an MPH. The second approach is an ‘Executive Global Health Certificate Program’, aimed at experienced public health professionals planning to enter the global health workforce. This thesis has outlined a framework for Indian and other LMIC institutions looking to expand the scope of public health education and intend to develop global health education programs.


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291. Management of prolonged first stage of labour in a low-resource setting: lessons learnt from rural Malawi

BMC Pregnancy and Childbirth


Authors: Wouter Bakker, Elisabeth van Dorp, Misheck Kazembe, Alfred Nkotola, Jos van Roosmalen & Thomas van den Akker
Region / country: Southern Africa – Malawi
Speciality: Health policy, Obstetrics and Gynaecology

Background
Caesarean sections without medical indication cause substantial maternal and perinatal ill-health, particularly in low-income countries where surgery is often less safe. In presence of adequate labour monitoring and by appropriate use of evidence-based interventions for prolonged first stage of labour, unnecessary caesarean sections can be avoided. We aim to describe the incidence of prolonged first stage of labour and the use of amniotomy and augmentation with oxytocin in a low-resource setting in Malawi.

Methods
Retrospective analysis of medical records and partographs of all women who gave birth in 2015 and 2016 in a rural mission hospital in Malawi. Primary outcomes were incidence of prolonged first stage of labour based on partograph tracings, caesarean section indications and utilization of amniotomy and oxytocin augmentation.

Results
Out of 3246 women who gave birth in the study period, 178 (5.2%) crossed the action line in the first stage of labour, of whom 21 (11.8%) received oxytocin to augment labour. In total, 645 women gave birth by caesarean section, of whom 241 (37.4%) with an indication ‘prolonged first stage of labour’. Only 113 (46.9%) of them crossed the action line and in 71/241 (29.5%) membranes were still intact at the start of caesarean section. Excluding the 60 women with prior caesarean sections, 14/181 (7.7%) received oxytocin prior to caesarean section for augmentation of labour.

Conclusion
The diagnosis prolonged first stage of labour was often made without being evident from labour tracings and two basic obstetric interventions to prevent caesarean section, amniotomy and labour augmentation with oxytocin, were underused.


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292. Health research capacity building of health workers in fragile and conflict-affected settings: a scoping review of challenges, strengths, and recommendations

Health Research Policy and Systems


Authors: Rania Mansour, Hady Naal, Tarek Kishawi, Nassim El Achi, Layal Hneiny , Shadi Saleh
Region / country: Global
Speciality: Health policy

Background
Fragile and conflict-affected settings (FCAS) have a strong need to improve the capacity of local health workers to conduct health research in order to improve health policy and health outcomes. Health research capacity building (HRCB) programmes are ideal to equip health workers with the needed skills and knowledge to design and lead health-related research initiatives. The study aimed to review the characteristics of HRCB studies in FCASs in order to identify their strengths and weaknesses, and to recommend future directions for the field.

Methods
We conducted a scoping review and searched four databases for peer-reviewed articles that reported an HRCB initiative targeting health workers in a FCAS and published after 2010. Commentaries and editorials, cross-sectional studies, presentations, and interventions that did not have a capacity building component were excluded. Data on bibliographies of the studies and HRCB interventions and their outcomes were extracted. A descriptive approach was used to report the data, and a thematic approach was used to analyse the qualitative data.

Results
Out of 8822 articles, a total of 20 were included based on the eligibility criteria. Most of the initiatives centred around topics of health research methodology (70%), targeted an individual-level capacity building angle (95%), and were delivered in university or hospital settings (75%). Ten themes were identified and grouped into three categories. Significant challenges revolved around the lack of local research culture, shortages in logistic capability, interpersonal difficulties, and limited assessment and evaluation of HRCB programmes. Strengths of HRCB interventions included being locally driven, incorporating interactive pedagogies, and promoting multidisciplinary and holistic training. Common recommendations covered by the studies included opportunities to improve the content, logistics, and overarching structural components of HRCB initiatives.

Conclusion
Our findings have important implications on health research policy and related capacity building efforts. Importantly, FCASs should prioritize (1) funding HRCB efforts, (2) strengthening equitable international, regional, and national partnerships, (3) delivering locally led HRCB programmes, (4) ensuring long-term evaluations and implementing programmes at multiple levels of the healthcare system, and (5) adopting engaging and interactive approaches.


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293. Communication Intervention Using Digital Technology to Facilitate Informed Choices at Childbirth in the Context of the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial

JMIR Research Protocols


Authors: Carmen Simone Grilo Diniz , Ana Carolina Arruda Franzon , Beatriz Fioretti-Foschi , Denise Yoshie Niy , Livia Sanches Pedrilio , Edson Amaro Jr , João Ricardo Sato
Region / country: South America – Brazil
Speciality: Health policy, Other

Background:
In Brazil and other low- and middle-income countries, excess interventions in childbirth are associated with an increase in preterm and early-term births, contributing to stagnant morbidity and mortality of mothers and neonates. The fact that women often report a negative experience with vaginal childbirth, with physical pain and feelings of unsafety, neglect, or abuse, may explain the high acceptability of elective cesarean sections. The recognition of information needs and of the right to informed choice during childbirth can help change this reality. The internet has been the main source of health information, but its quality is highly variable.

Objective:
This study aimed to develop and evaluate an information and communication strategy through a smartphone app with respect to childbirth, to facilitate informed choices for access to safer and evidence-based care in the context of the COVID-19 pandemic.

Methods:
A randomized controlled trial, with 2 arms (intervention and control) and a closed, blind, parallel design, will be conducted with a smartphone app designed for behavior and opinion research in Brazil, with women of reproductive age previously registered on the app. After completing an entry questionnaire to verify the eligibility criteria and obtaining ethical consent, approximately 20,000 participants will be randomly allocated to the intervention and control groups at a 1:1 ratio. Participants allocated to the intervention group will be invited to engage in a digital information and communication strategy, which is designed to expand evidence-based knowledge on the advantages and disadvantages of options for labor and childbirth and the safety of the care processes. The information is based on the guidelines of the Ministry of Health and the World Health Organization for a positive childbirth experience and has been updated to include the new challenges and disruptions in maternity care within the context of the COVID-19 pandemic. The control group will receive information regarding disposable and reusable diapers as a placebo intervention. The groups will be compared in their responses in generating the birth plan and the entry and exit questionnaires, regarding responses less or more aligned with the guidelines for a positive childbirth experience. A qualitative component to map information needs is included.

Results:
The digital trial started recruiting participants in late October 2020, and data collection has been projected to be complete by December 2020.

Conclusions:
This study will evaluate an innovative intervention that has the potential to promote better communication between women and providers, such that they can make better choices using an approach suitable for use during the COVID-19 pandemic


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294. Timeliness of diagnosis of breast and cervical cancers and associated factors in low-income and middle-income countries: a scoping review protocol

BMJ Open.


Authors: Chukwudi A Nnaji, Paul Kuodi, Fiona M Walter, Jennifer Moodley
Region / country: Global
Speciality: General surgery, Obstetrics and Gynaecology, Surgical oncology

Introduction
Breast and cervical cancer are leading causes of morbidity and mortality in women globally, with disproportionately high burdens in low-income and middle-income countries (LMICs). While the incidence of both cancers increases across LMICs, many cases continue to go undiagnosed or diagnosed late. The aim of this review is to comprehensively map the current evidence on the time to breast or cervical cancer diagnosis and its associated factors in LMICs.

Methods and analysis
This scoping review (ScR) will be informed by Arksey and O’Malley’s enhanced ScR methodology framework. It will be reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We will conduct a comprehensive search of the following electronic databases: MEDLINE (via PubMed), Cochrane Library, Scopus and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Two reviewers will independently screen all abstracts and full texts using predefined inclusion criteria. All publications describing the time to diagnosis and its associated factors in the contexts of breast or cervical cancer will be considered for inclusion. Evidence will be narratively synthesised and analysed using a predefined conceptual framework.

Ethics and dissemination
As this is a ScR of publicly available data, with no primary data collection, it will not require ethical approval. Findings will be disseminated widely through a peer-reviewed publication and forums such as conferences and community engagement sessions. This review will provide a user-friendly evidence summary for understanding the enormity of diagnostic delays and associated factors for breast and cervical cancers in LMICs, while helping to inform policy actions and implementation of interventions for addressing such delays.


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295. Short-term general, gynecologic, orthopedic, and pediatric surgical mission trips in Nicaragua: A cost-effectiveness analysis

Journal of Global Health


Authors: Keyanna P Taylor , Anna Ortiz , Jason Paltzer
Region / country: Central America – Nicaragua
Speciality: General surgery, Obstetrics and Gynaecology, Paediatric surgery, Trauma and orthopaedic surgery

Background Short-term surgical missions facilitated by non-governmental organizations (NGOs) may be a possible platform for cost-effective international global surgical efforts. The objective of this study is to determine if short-term surgical mission trips provided by the non-governmental organization (NGO) Esperança to Nicaragua from 2016 to 2020 are cost-effective.
Methods Using a provider perspective, the costs of implementing the surgical trips were collected via Esperança’s previous trip reports. The reports and patient data were analyzed to determine disability-adjusted life years averted from each surgical procedure provided in Nicaragua from 2016-2020. Average cost-effectiveness ratios for each surgical trip specialty were calculated to determine the average cost of averting one disability adjusted life year.
Results Esperança’s surgical missions’ program in Nicaragua from 2016 to 2020 was found to be cost-effective, with pediatric and gynecology surgical specialties being highly cost-effective and general and orthopedic surgical specialties being moderately cost-effective. These results were echoed in both scenarios of the sensitivity analysis, except for the orthopedic specialty which was found to not be cost-effective when testing an increased discount rate.
Conclusions The cost-effectiveness of short-term surgical missions provided by NGOs can be cost-effective, but limitations include inconsistent data from a societal perspective and lack of an appropriate counterfactual. Future studies should examine the capacity for NGOs to collect adequate data and conduct rigorous economic evaluations


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296. The role of health service delivery networks in achieving universal health coverage in Africa

South Eastern European Journal of Public Health


Authors: Knovicks Simfukwe , Yusuff Adebayo Adebisi ,Amos Abimbola Oladunni ,Salma Elmukashfi Eltahir Mohammed, Don Eliseo Lucero-Prisno III
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Health policy

Most countries in Africa are faced with health system problems that vary from one to the next. Countries with a low Human Development Index (HDI) seem to be more prone to challenges in health service delivery. To mark its 70th anniversary on World Health Day, the World Health Organization (WHO) selected the theme “Universal Health Coverage (UHC): Everyone, Everywhere” and the slogan “Health for All. ”UHC refers to ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship. UHC is a WHO’s priority objective. Most governments have made it their major goal.

This paper provides a perspective on the challenges of achieving UHC in Sub-Saharan Africa (SSA). It also endeavors to spotlight the successful models of Health Service Delivery Networks (HSDNs) that make significant strides in making progress towards achieving UHC. HSDNs propose models that facilitate the attainment of affordability and accessibility while maintaining quality in delivering health services. Additionally, it brings up to speed the challenges associated with setting up HSDNs in health systems in SSA. It then makes propositions of what measures and strategic approaches should be implemented to strengthen HSDNs in SSA. This paper further argues that UHC is not only technically feasible but it is also attainable if countries embrace HSDNs in SSA.


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297. Sequential improvement in paediatric medulloblastoma outcomes in a low-and-middle-income country setting over three decades

South African Journal of Oncology


Authors: Johann Riedemann, Anthony Figaji, Alan Davidson, Clare Stannard, Komala Pillay, Tracy Kilborn, Jeannette Parkes
Region / country: Global
Speciality: Neurosurgery, Paediatric surgery, Surgical oncology

Background: Medulloblastoma (MB) is the commonest malignant brain tumour of childhood. Accurate clinical data on paediatric MB in the low-and-middle-income countries (LMIC) setting are lacking. Sequential improvements in outcomes seen in high-income countries are yet to be reflected in LMICs.

Aim: The aim of this study was quantification of paediatric MB outcomes in the LMIC setting over three decades of advances in multidisciplinary intervention.

Setting: Cape Town, South Africa.

Methods: This was a retrospective study of 136 children with MB diagnosed between 1985 and 2015. The modified Chang criteria were used for risk stratification. The primary objective of this study was overall survival (OS), quantified by analysis of epidemiological, clinical and pathological data.

Results: OS improved significantly during the most recent decade (2005–2015) when compared with the preceding two decades (1985–1995 and 1995–2005). Despite reduced-dose craniospinal irradiation (CSI) for standard risk cases, OS was significantly greater than during the preceding two decades. High-risk disease was identified in 71.4% of cases and was associated with significantly inferior OS compared with standard-risk cases. Improved OS was positively correlated with the therapeutic era, three-dimensional (3D) conformal radiotherapy technique, older age at diagnosis, classic and desmoplastic histology, extent of resection and absence of leptomeningeal spread on imaging.

Conclusion: Advances in multidisciplinary management of MB in our combined service are associated with improved survival. Access to improved imaging modalities, advances in surgical techniques, increased number of patients receiving risk-adapted combination chemotherapy or radiotherapy, as well as CSI using a linear accelerator with 3D planning, are considered as contributing factors.


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298. Views from Multidisciplinary Oncology Clinicians on Strengthening Cancer Care Delivery Systems in Tanzania

The Oncologist


Authors: Sarah K. Nyagabona , Rohan Luhar , Jerry Ndumbalo , Nanzoke Mvungi , Mamsau Ngoma , Stephen Meena , Sadiq Siu , Mwamvita Said , Julius Mwaiselage , Edith Tarimo , Geoffrey Buckle , Msiba Selekwa , Beatrice Mushi , Elia J. Mmbaga , Katherine Van Loon , Rebecca J. DeBoer
Region / country: Eastern Africa – Tanzania
Speciality: Surgical oncology

Background
In response to the increasing burden of cancer in Tanzania, the Ministry of Health Community Development, Gender, Elderly and Children launched National Cancer Treatment Guidelines (TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care in the country. At Ocean Road Cancer Institute (ORCI), we developed a theory-informed implementation strategy to promote guideline-concordant care. As part of the situation analysis for implementation strategy development, we conducted focus group discussions to evaluate clinical systems and contextual factors that influence guideline-based practice prior to launching of TNCTG.

Methods
In June 2019, three focus group discussions were conducted with a total of 21 oncology clinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogue about facilitators and barriers to delivery of guideline concordant care. Discussions were audio recorded, transcribed, translated, and analyzed using thematic framework analysis.

Results
Participants identified factors both within the inner context of ORCI clinical systems and outside of ORCI. Themes within the clinical systems included: capacity and infrastructure, information technology, communication, efficiency and quality of services provided. Contextual factors external to ORCI included: inter-institutional coordination, oncology capacity in peripheral hospitals, public awareness and beliefs, and financial barriers. Participants provided pragmatic suggestions for strengthening cancer care delivery in Tanzania.

Conclusion
Our results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broader guideline implementation strategy, in effort to improve uptake of the TNCTGs at ORCI.


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299. Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research

Journal of Medical Internet Research


Authors: Andrea H Rossman ,Hadley W Reid ,Michelle M Pieters , Cecelia Mizelle , Megan von Isenburg , Nimmi Ramanujam , Megan J Huchko, Lavanya Vasudevan
Region / country: Global
Speciality: Obstetrics and Gynaecology, Other, Surgical oncology

Background:
Nearly 90% of deaths due to cervical cancer occur in low- and middle-income countries (LMICs). In recent years, many digital health strategies have been implemented in LMICs to ameliorate patient-, provider-, and health system–level challenges in cervical cancer control. However, there are limited efforts to systematically review the effectiveness and current landscape of digital health strategies for cervical cancer control in LMICs.

Objective:
We aim to conduct a systematic review of digital health strategies for cervical cancer control in LMICs to assess their effectiveness, describe the range of strategies used, and summarize challenges in their implementation.

Methods:
A systematic search was conducted to identify publications describing digital health strategies for cervical cancer control in LMICs from 5 academic databases and Google Scholar. The review excluded digital strategies associated with improving vaccination coverage against human papillomavirus. Titles and abstracts were screened, and full texts were reviewed for eligibility. A structured data extraction template was used to summarize the information from the included studies. The risk of bias and data reporting guidelines for mobile health were assessed for each study. A meta-analysis of effectiveness was planned along with a narrative review of digital health strategies, implementation challenges, and opportunities for future research.

Results:
In the 27 included studies, interventions for cervical cancer control focused on secondary prevention (ie, screening and treatment of precancerous lesions) and digital health strategies to facilitate patient education, digital cervicography, health worker training, and data quality. Most of the included studies were conducted in sub-Saharan Africa, with fewer studies in other LMIC settings in Asia or South America. A low risk of bias was found in 2 studies, and a moderate risk of bias was found in 4 studies, while the remaining 21 studies had a high risk of bias. A meta-analysis of effectiveness was not conducted because of insufficient studies with robust study designs and matched outcomes or interventions.

Conclusions:
Current evidence on the effectiveness of digital health strategies for cervical cancer control is limited and, in most cases, is associated with a high risk of bias. Further studies are recommended to expand the investigation of digital health strategies for cervical cancer using robust study designs, explore other LMIC settings with a high burden of cervical cancer (eg, South America), and test a greater diversity of digital strategies.


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300. Empanelment of health care facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India

Plos One


Authors: Jaison Joseph ,Hari Sankar D.,Devaki Nambiar
Region / country: Southern Asia – India
Speciality: Health policy

Introduction
India’s Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the world’s largest health assurance scheme providing health cover of 500,000 INR (about USD 6,800) per family per year. It provides financial support for secondary and tertiary care hospitalization expenses to about 500 million of India’s poorest households through various insurance models with care delivered by public and private empanelled providers. This study undertook to describe the provider empanelment of PM-JAY, a key element of its functioning and determinant of its impact.

Methods
We carried out secondary analysis of cross-sectional administrative program data publicly available in PM-JAY portal for 30 Indian states and 06 UTs. We analysed the state wise distribution, type and sector of empanelled hospitals and services offered through PM-JAY scheme across all the states and UTs.

Results
We found that out of the total facilities empanelled (N = 20,257) under the scheme in 2020, more than half (N = 11,367, 56%) were in the public sector, while 8,157 (40%) facilities were private for profit, and 733 (4%) were private not for profit entities. State wise distribution of hospitals showed that five states (Karnataka (N = 2,996, 14.9%), Gujarat (N = 2,672, 13.3%), Uttar Pradesh (N = 2,627, 13%), Tamil Nadu (N = 2315, 11.5%) and Rajasthan (N = 2,093 facilities, 10.4%) contributed to more than 60% of empanelled PMJAY facilities: We also observed that 40% of facilities were offering between two and five specialties while 14% of empanelled hospitals provided 21–24 specialties.

Conclusion
A majority of the hospital empanelled under the scheme are in states with previous experience of implementing publicly funded health insurance schemes, with the exception of Uttar Pradesh. Reasons underlying these patterns of empanelment as well as the impact of empanelment on service access, utilisation, population health and financial risk protection warrant further study. While the inclusion and regulation of the private sector is a goal that may be served by empanelment, the role of public sector remains critical, particularly in underserved areas of India.


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301. Economic Evaluations of Breast Cancer Care in Low- and Middle-Income Countries: A Scoping Review

The Oncologist


Authors: Parsa Erfani, Kayleigh Bhangdia, Catherine Stauber, Jean Claude Mugunga, Lydia E. Pace, Temidayo Fadelu
Region / country: Global
Speciality: General surgery, Surgical oncology

Background
Understanding the cost of delivering breast cancer (BC) care in low- and middle-income countries (LMICs) is critical to guide effective care delivery strategies. This scoping review summarizes the scope of literature on the costs of BC care in LMICs and characterizes the methodological approaches of these economic evaluations.

Materials and Methods
A systematic literature search was performed in five databases and gray literature up to March 2020. Studies were screened to identify original articles that included a cost outcome for BC diagnosis or treatment in an LMIC. Two independent reviewers assessed articles for eligibility. Data related to study characteristics and methodology were extracted. Study quality was assessed using the Drummond et al. checklist.

Results
Ninety-one articles across 38 countries were included. The majority (73%) of studies were published between 2013 and 2020. Low-income countries (2%) and countries in Sub-Saharan Africa (9%) were grossly underrepresented. The majority of studies (60%) used a health care system perspective. Time horizon was not reported in 30 studies (33%). Of the 33 studies that estimated the cost of multiple steps in the BC care pathway, the majority (73%) were of high quality, but studies varied in their inclusion of nonmedical direct and indirect costs.

Conclusion
There has been substantial growth in the number of BC economic evaluations in LMICs in the past decade, but there remain limited data from low-income countries, especially those in Sub-Saharan Africa. BC economic evaluations should be prioritized in these countries. Use of existing frameworks for economic evaluations may help achieve comparable, transparent costing analyses.


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302. Emergency Department Characteristics and Capabilities in Quito, Ecuador

annals of global health


Authors: AUGUSTO MALDONADO, ANDRÉS M. PATIÑO ,ALEXIS S. KEARNEY ,DIANA TIPÁN, VALERIE CHAVEZ-FLORES, MICHAELA BANKS ,KRISLYN M. BOGGS ,CARLOS A. CAMARGO
Region / country: South America – Ecuador
Speciality: Emergency surgery

Background: Emergency care is an essential part of a health system. Ecuador has recognized emergency medicine as a specialty and has two emergency medicine
residency training programs. However, little has been published about emergency department characteristics and capabilities in Ecuador.
Objective: We described the characteristics and capabilities of emergency departments (EDs) in Quito, Ecuador, in 2017, using the National Emergency Department Inventory
(NEDI) survey.
Methods: The 23-item survey included questions pertaining to ED characteristics, including visit volume, physical and administrative structure, clinical capabilities, technological resources, and consult personnel availability. This study included all EDs in Quito operating 24 hours/day, 7 days/week, and serving all patients seeking care. One representative from each ED was asked to complete the survey based on calendar year 2017.
Findings: Thirty EDs met the inclusion criteria, and 26 completed the survey (87% response). The median number of ED beds was 17 (range 2–61). Median annual visit
volume was 22,580 (range 1,680 to 129,676). All but two EDs provided care for both children and adults. Cardiac monitors were available in 88% of EDs, CT scanners in 68%,
and rooms for respiratory isolation in 31%. Most EDs could manage patients with general medicine (92%), general surgery (92%), and gynecology (88%) emergencies 24/7. Fewer were able to provide hand surgery (45%) and dental (28%) care 24/7. Typical length of stay was 1–6 hours in 65% and >6 hours in 31% of EDs. Half of EDs reported operating at full capacity and 27% reported operating over their capacity. When compared to private EDs, government EDs (public and social security) had a higher mean number of visits per year (50,090 government vs. 13,968 private, p 6 hours in government EDs vs. 86% of patient stays 1–6 hours in private EDs, p = 0.009).
Conclusions: EDs in Quito varied widely with respect to annual visit volume, the ability to treat different pathologies 24/7, and resources. Most EDs are functioning at or over capacity, and a substantial number have long lengths of stay. Further research and investment in emergency care could help increase the capacity and efficiency of EDs in Ecuador.


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303. User Experience With Low-Cost Virtual Reality Cancer Surgery Simulation in an African Setting

JCO Global Oncology


Authors: Eric G. Bing , Megan L. Brown , Anthony Cuevas,Richard Sullivan , Groesbeck P. Parham
Region / country: Southern Africa – Zambia
Speciality: Surgical Education, Surgical oncology

PURPOSE
Limited access to adequate cancer surgery training is one of the driving forces behind global inequities in surgical cancer care. Affordable virtual reality (VR) surgical training could enhance surgical skills in low- and middle-income settings, but most VR and augmented reality systems are too expensive and do not teach open surgical techniques commonly practiced in these contexts. New low-cost VR can offer skill development simulations relevant to these settings, but little is known about how knowledge is gained and applied by surgeons training and working in specific resource-constrained settings. This study addresses this gap, exploring gynecologic oncology trainee learning and user experience using a low-cost VR simulator to learn to perform an open radical abdominal hysterectomy in Lusaka, Zambia.

METHODS
Eleven surgical trainees rotating through the gynecologic oncology service were sequentially recruited from the University Teaching Hospital in Lusaka to participate in a study evaluating a VR radical abdominal hysterectomy training designed to replicate the experience in a Zambian hospital. Six participated in semi-structured interviews following the training. Interviews were analyzed using open and axial coding, informed by grounded theory.

RESULTS
Simulator participation increased participants’ perception of their surgical knowledge, confidence, and skills. Participants believed their skills transferred to other related surgical procedures. Having clear goals and motivation to improve were described as factors that influenced success.

CONCLUSION
For cancer surgery trainees in lower-resourced settings learning medical and surgical skills, even for those with limited VR experience, low-cost VR simulators may enhance anatomical knowledge and confidence. The VR simulator reinforced anatomical and clinical knowledge acquired through other modalities. VR-enhanced learning may be particularly valuable when mentored learning opportunities are limited.


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304. The treatment challenges and limitation in high-voltage pediatric electrical burn at rural area: A case report

International Journal of Surgery Case Reports


Authors: Adi Basukia , Agustini Songb Nabila, Viera Yovitad Kevin , Leonard Suryadinatac Asian, Edward Sagala
Region / country: South-eastern Asia – Indonesia
Speciality: Emergency surgery, Plastic surgery, Trauma surgery

Introduction
Although rare, electrical injury in pediatrics is potentially life threatening and has significant and long-term impact in life. It is challenging to manage such cases in rural areas.

Presentation of case
A fully conscious 13-year-old boy was admitted to the emergency room after being electrocuted by high-voltage power cable, with superficial partial thickness burn over right arm, trunk, and left leg (26 % of total body surface area). Tachycardia and non-specific ST depression was found on ECG examination and was diagnosed with high-voltage electrical injury. Treatments were based on ANZBA algorithm with several modifications, i.e., administering lower concentration of oxygen with nasal cannula instead of non-rebreathing mask as well as Ketorolac and Antrain® for analgesic instead of morphine.

Discussion
Different choices of treatments were given due to limited resources. Despite possible cardiac and renal complication, further tests could not be done. Fortunately, after strict monitoring, no signs of abnormality were found. We used silver sulfadiazine, Sofratulle® and dry sterile gauze as a dressing of choice following immediate surgical debridement. The patient was observed daily through 7 days of hospitalization and followed-up for 1 year, achieving normal physiologic function of the affected area but unsatisfactory esthetic result.

Conclusion
Lack of infrastructure, drugs, and trained personnel are some of the challenges that still exist in most rural areas. Thus, implementation of available standardized guidelines such as ANZBA, and giving similar training to personnel as well as providing feasible equipment followed by strict monitoring for the patient are needed to achieve maximum results.


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305. The availability and utilization of psychosocial services for breast cancer 2 patients in Addis Ababa, Ethiopia: a mixed method study

Research Square


Authors: Abigiya Wondimagegnehu , Workeabeba Abebe, Selamawit Hirpa , Aynalem Abraha, Eva J. Kantelhardt, Adamu Addissie, Bradley Zebrack , Solomon Teferra
Region / country: Eastern Africa – Ethiopia
Speciality: Other, Surgical oncology

Background: Provision of psychosocial services has substantial impact in cancer care by reducing emotional distress and improving both the quality of life and survival of patients, but the availability and utilization of the services have been not well-studied in developing countries, particularly in Ethiopia. The aim of this study was to explore the types of psychosocial services available for breast cancer patients and utilization in selected health facilities in Addis Ababa, Ethiopia.
Methods: A mixed method study was conducted using a cross-sectional survey involving a sample of 428 patients with breast cancer, followed by a qualitative study in seven health facilities in Addis Ababa, Ethiopia. A total of nine in-depth interviews (IDIs) were conducted with purposefully selected four breast cancer patients and five key informants using two separate interview guides. Descriptive statistics were calculated using SPSS software, and both bivariate and multivariate logistic regressions were done to identify factors associated with provision of psychosocial services. Thematic analysis was used for the qualitative data using NVivo 12 plus software.
Result: Only 47 (11.1%) patients received psychosocial services, either in the form of counseling, emotional support or provision of information. Addis Ababa residency, severity of pain and longer duration since diagnosis were factors associated with provision of psychosocial services. Health professionals reportedly provided such services along with their routine activities, and patients predominantly received social/emotional support from family members, friends and colleagues. There was no well-structured counseling service, emotional support or group discussion sessions for breast cancer patients in these health facilities. The main reasons reported by health professionals for not providing these services were high patient flow/workload, inadequate space, lack of training and not having qualified professionals to organize and deliver psychosocial services in those hospitals in Addis Ababa, Ethiopia.
Conclusion: This study revealed that very few breast cancer patients received psychosocial services from health professionals, and the services were not integrated and delivered in a structured way. Therefore, integrating and implementing psychosocial services in cancer care is recommended both in private and government health facilities in Ethiopia


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306. Expert commentary on the challenges and opportunities for surgical site infection prevention through implementation of evidence-based guidelines in the Asia–Pacific Region

Antimicrobial Resistance and Infection Control


Authors: K. Morikane, P. L. Russo, K. Y. Lee, M. Chakravarthy, M. L. Ling, E. Saguil, M. Spencer, W. Danker, A. Seno & E. Edmiston Charles Jr
Region / country: Eastern Asia, South-eastern Asia
Speciality: General surgery, Health policy, Other

Introduction
Surgical site infections (SSIs) are a significant source of morbidity and mortality in the Asia–Pacific region (APAC), adversely impacting patient quality of life, fiscal productivity and placing a major economic burden on the country’s healthcare system. This commentary reports the findings of a two-day meeting that was held in Singapore on July 30–31, 2019, where a series of consensus recommendations were developed by an expert panel composed of infection control, surgical and quality experts from APAC nations in an effort to develop an evidence-based pathway to improving surgical patient outcomes in APAC.

Methods
The expert panel conducted a literature review targeting four sentinel areas within the APAC region: national and societal guidelines, implementation strategies, postoperative surveillance and clinical outcomes. The panel formulated a series of key questions regarding APAC-specific challenges and opportunities for SSI prevention.

Results
The expert panel identified several challenges for mitigating SSIs in APAC; (a) constraints on human resources, (b) lack of adequate policies and procedures, (c) lack of a strong safety culture, (d) limitation in funding resources, (e) environmental and geographic challenges, (f) cultural diversity, (g) poor patient awareness and (h) limitation in self-responsibility. Corrective strategies for guideline implementation in APAC were proposed that included: (a) institutional ownership of infection prevention strategies, (b) perform baseline assessments, (c) review evidence-based practices within the local context, (d) develop a plan for guideline implementation, (e) assess outcome and stakeholder feedback, and (f) ensure long-term sustainability.

Conclusions
Reducing the risk of SSIs in APAC region will require: (a) ongoing consultation and collaboration among stakeholders with a high level of clinical staff engagement and (b) a strong institutional and national commitment to alleviate the burden of SSIs by embracing a safety culture and accountability.


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307. Measuring barriers to fistula care: investigating composite measures for targeted fistula programming in Nigeria and Uganda

BMC Women’s Health


Authors: Pooja Sripad, Elly Arnoff, Charlotte Warren & Vandana Tripathi
Region / country: Eastern Africa, Western Africa – Nigeria, Uganda
Speciality: General surgery, Obstetrics and Gynaecology

Background
Accessing surgical repair poses challenges to women living with female genital fistula who experience intersectional vulnerabilities including poverty, gender, stigma and geography. Barriers to fistula care have been described qualitatively in several low- and middle-income countries, but limited effort has been made to quantify these factors. This study aimed to develop and validate composite measures to assess barriers to accessing fistula repair in Nigeria and Uganda.

Methods
This quantitative study built on qualitative findings to content validate composite measures and investigates post-repair client surveys conducted at tertiary hospitals in Northern and Southern Nigeria and Central Uganda asking women about the degree to which a range of barriers affected their access. An iterative scale development approach included exploratory and confirmatory factor analyses of two samples (n = 315 and n = 142, respectively) using STATA 13 software. Reliability, goodness-of-fit, and convergent and predictive validity were assessed.

Results
A preliminary 43-item list demonstrated face and content validity, triangulated with qualitative data collected prior to and concurrently with survey data. The iterative item reduction approach resulted in the validation of a set of composite measures, including two indices and three sub-scales. These include a Financial/Transport Inaccessibility Index (6 items) and a multidimensional Barriers to Fistula Care Index of 17 items comprised of three latent sub-scales: Limited awareness (4 items), Social abandonment (6 items), and Internalized stigma (7 items). Factor analyses resulted in favorable psychometric properties and good reliability across measures (ordinal thetas: 0.70–0.91). Higher levels of barriers to fistula care are associated with a woman living with fistula for longer periods of time, with age and geographic settings as potential confounders.

Conclusions
This set of composite measures that quantitatively captures barriers to fistula care can be used separately or together in research and programming in low- and middle-income countries.


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308. SURGE: Survey of Undergraduate Respondents on Global surgery Education

BJS Open


Authors: InciSioN UK Collaborative, Michal Kawka
Region / country: Global
Speciality: Surgical Education

Introduction
It is estimated that over 10% of the global burden of disease can be treated with surgery, most of which is located in low and middle-income countries (LMICs), underpinning the importance of the topic of global surgery (GS). The multidisciplinary principles of GS are increasingly recognised as being key to modern practice and as such, must be fostered at early stages of medical training. However, it is unclear whether medical students are being exposed to GS. This study aimed to assess the importance of GS and its presence in medical curricula.

Methods
A novel, 22-item online questionnaire was developed and disseminated to medical students and faculty members using social media. Data collection was conducted by a collaboration of medical students, who acted as regional leads at their institutions.

Results
795 medical students and 141 faculty members representing 38/42 of UK medical schools (90.4%) completed the questionnaire. Only 84 students (10.6%) were previously exposed to GS. Most students (66.3%) and faculty (60.6%) agreed that GS should be an integral part of the curriculum. Only 20 students (2.5%) were or familiar with what a career in GS means.

Conclusion
Approximately 2/3 of students and faculty agree that global surgery should be an integral part of the mandatory curriculum. Findings of this study should underpin further incorporation of GS into curricula, as high-income countries can decisively contribute to achieving the global surgery 2030 targets, by training a new generation of clinicians who are ready for the challenges of the 21st century.


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

BJS Open


Authors: Priyansh Shah, Bhakti Sarang, Anita Gadgil, Geetu Bhandoria, Monty Khajanchi, Deepa Kizhakke Veetil, Prashant Bhandarkar, Monali Mohan Gupta, Dylan Goh, Nobhojit Roy, Priyansh Shah
Region / country: Southern Asia – India
Speciality: Anaesthesia, Critical care

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.


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310. Is Independent Clinical Research Possible in Low- and Middle-Income Countries? A Roadmap to Address Persistent and New Barriers and Challenges

American Society of Clinical Oncology Educational Book


Authors: Carlos H. Barrios, Max S. Mano
Region / country: Global
Speciality: Health policy, Surgical oncology

Cancer is an increasing and significant problem for both high- and low- and middle-income countries. Basic, translational, and clinical research efforts have been instrumental in generating the outstanding improvements we have witnessed over the last few decades, answering important questions, and improving patient outcomes. Arguably, a substantial portion of currently ongoing research is sponsored by the pharmaceutical industy and specifically addresses questions under industry interests, most of which apply to high-income countries, leaving behind problems related to the much larger and underserved population of patients with cancer in low- and middle-income countries. In this scenario, discussing independent academic research is an important challenge, particularly for these countries. Although different countries and institutions face different problems while establishing independent research agendas, some generalizable barriers can be identified. A solid regulatory and ethical framework, a strong and sustainable technical supporting infrastructure, and motivated and experienced investigators are all paramount to build a viable and productive academic research program. Securing funding for research, although not the only hurdle, is certainly one of the most basic hurdles to overcome. Noticeably, and as an added impediment, public and governmental support for cancer research has been decreasing in high-income countries and is almost nonexistent in the rest of the world. We propose an initial careful diagnostic assessment of the research resource scenario of each institution/country and adjustment of the strategic development plan according to four different research resource restriction levels. Although not necessarily applicable to all situations, this model can be helpful if adjusted to each local or regional situation


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311. Time to recovery from cataract and its predictors among eye cataract patients treated with cataract surgery: A retrospective cohort study in Ethiopia

Annals of Medicine and Surgery


Authors: Asmare Mihret Beyene, Aragaw Eshetie, Yohannes Tadesse, Moges Gashaw Getnet
Region / country: Eastern Africa – Ethiopia
Speciality: Ophthalmology

Background
Cataracts is the major global causes of blindness and a vision-affecting disease of the eye. Cataract surgery is a curative and cost-effective intervention. The number of people who undergo cataract surgery has increased rapidly. Hence, this study was aimed to determine predictors and the time of recovery of cataract patients after cataract surgery by using Simi parametric models of survival analysis.

Methods
A retrospective cohort study was conducted from January/01/2015 and January/30/2019. STATA version14.0 statistical software was used for analysis. The Kaplan-Meier survival method and log-rank test curves were applied. Weibull regression was used and adjusted hazard ratio 95% CI with a value of p less than 0.05 was used to identify a significant association.

Results
Two hundred twenty three cataract patients were recovered from cataract, 72.6% (95% CI 69.8%–75.9%). The overall median survival time was 23 weeks (IQR = 16 to 35) with (95% CI, 21%–25%). aged between 16 and 30year (AHR = 1.20 CI; 1.07–2.36), age 31 to 45 (AHR = 1.24 CI; 1.08–1.54), urban dwellers (AHR = 1.59; 95% CI, 1.18–2.14), medium visual acuity (AHR = 4.14 CI; 2.57–6.67), high visual acuity (AHR = 5.23 CI; 3.06–8.93), Secondary cataract (AHR = 2.59 CI; 1.01–3.02), traumatic cataract (AHR = 1.75 CI; 1.01–3.02), extra capsular cataract extraction surgery (AHR = 1.43 CI; 1.07–1.94),and diabetes mellitus (AHR = 0.75, CI; 0.41–0.96) were notably associated with time to recovery.

Conclusion
Time to recovery in the study area was slightly higher as compared with the global cut of time. Cataract patients with comorbidity of DM had lower recovery time


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312. Impact of COVID-19 on the practice of orthopaedics and trauma—an epidemiological study of the full pandemic year of a tertiary care centre of New Delhi

International Orthopaedics


Authors: Raju Vaishya, Abhishek Vaish , Ashok Kumar
Region / country: Southern Asia – India
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Purpose
In an observational study, we studied the impact of COVID-19 pandemic on our clinical practice of trauma and orthopaedics, in tertiary care hospital of New Delhi.

Methods
We collated the hospital data for 2019 and 2020 and analyzed and compared it extensively. We looked for the effects of the COVID-19 pandemic on several important clinical practice parameters like outpatient attendance, inpatients admissions, and surgery. The correlation of the number of surgeries done during the pandemic time was done with the number of positive cases in Delhi, monthwise. A trend of recovery was also observed.

Results
During the pandemic period, the attendance of outpatients fell by 71.93%, admissions by 59.35%, and surgery by 55.78%. Adult trauma surgery was the least affected (42.21%), followed by arthroscopic surgery (49.81%). Fragility hip fractures requiring bipolar hip arthroplasty were reduced by 34.15%. The maximum adverse impact of the pandemic was seen on arthroplasty surgery (hip > knee), followed by on the paediatric orthopaedic cases, and spinal surgery. We notice a “lazy V-shaped” recovery after the lockdown period.

Conclusion
COVID-19 pandemic has had a severe impact on all aspects of orthopaedics and trauma’s clinical practice in our setup. These adverse effects were maximally seen during the lockdown period, with a reduction of 90.77% in the outpatients, 84.63% in the admissions, and 86.67% in the surgery.


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313. Concurrent manifestations of Horner’s syndrome and esophageal metastasis of breast cancer: case report of a young woman after a period of non-adherence to treatment: a case report

Journal of Medical Case Reports


Authors: Sumadi Lukman Anwar, Widya Surya Avanti, Lina Choridah, Ery Kus Dwianingsih, Herjuna Hardiyanto , Teguh Aryandono
Region / country: South-eastern Asia – Indonesia
Speciality: General surgery, Surgical oncology

Background
Esophageal involvement and Horner’s syndrome are rare manifestations of breast cancer distant metastases that can pose a significant challenge in diagnosis and treatment. In addition to the more aggressive behavior of breast cancer diagnosed in young women, non-adherence to treatment is associated with increased risk of distant metastasis.

Case presentation
A 36-year-old Javanese woman presented to our institution with dysphagia, hoarseness, and frequent hiccups. In the 6 weeks prior to the current admission, the patient also reported tingling in the neck and shoulder, anhidrosis in the left hemifacial region, and drooping of the upper left eyelid. She was previously managed as tuberculoid laryngitis. Plain X-rays showed burst fractures of the cervical vertebrae and slight pleural effusion. Laryngoscopy revealed bowing of the vocal cords and liquid residue in the vallecula that was reduced upon chin tuck. Esophageal metastasis was confirmed with endoscopy showing thickening of the wall and positive cytology swab with ductal malignant cells. The patient had a history of breast cancer with a period of loss to follow-up of 4 years.

Conclusions
Physicians should consider potential distant metastasis of breast cancer to the esophagus and sympathetic nervous system of the neck particularly in a high-risk woman with presentation of dysphagi