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

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

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

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

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

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

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

Psychoeducation for psychological issues and birth preparedness in LMICs: A systematic review

Background
Psychological issues usually accompany the pregnancy of first-time mothers and psychoeducational interventions might be effective in addressing these concerns and preparing first-time mothers for childbirth and the postnatal period. This study aimed to identify, analyse and synthesise the components as well as determine the effectiveness of psychoeducational interventions that are used for managing psychological issues and enhancing birth preparedness among primigravid women or couples in LMICs.

Method
A systematic search of 12 databases (APA PsycINFO, Emcare, Embase, MEDLINE(R), Ovid Nursing, British Nursing Index, Health and Medical Collection, ProQuest, CINAHL, Cochrane, Hinari and PubMed) was conducted to identify relevant studies published between 1946 and October 2021. Quality of the included studies was appraised by the JBI critical appraisal tool and a narrative synthesis was conducted to analyse data extracted from included articles. The systematic review protocol is registered with PROSPERO (CRD42021237896).

Findings
The initial search yielded 8,658 articles. Sixteen articles including seven randomised controlled trials and nine non-randomised trials met the inclusion criteria and were selected and reviewed for quality. Thirty-nine outcomes were measured in the studies including psychological outcomes, birth preparedness outcomes and other outcomes. The design of the interventions included antenatal education that was delivered through lectures, role plays, trainings, and antenatal counselling. All the psychoeducational interventions had a significant effect (p <. 05; Cohen's d or Hedge’ g = 0.2 to 1.9) on certain psychological outcomes including childbirth attitude, fear of childbirth, depression, fear, and anxiety and birth preparedness outcomes.

Interpretation
Although first-time mothers experience a range of psychological issues during pregnancy, psychoeducational interventions were beneficial in addressing their psychological concerns. It would appear that these interventions are less expensive and could be easily implemented in LMICs. However, rigorous research like RCTs are hereby warranted to standardise the interventions and outcome assessment tools.

Implementing a Neurotrauma Registry in Latin America and the Caribbean

Background Traumatic brain injury (TBI) has a disproportionately greater impact in low- and middle-income countries (LMICs). One strategy to reduce the burden of disease in LMICs is through the implementation of a trauma registry that standardizes the assessment of each patient’s management of care.

Objective This study aims to ascertain the interest of Latin America and the Caribbean (LAC) nations in establishing a shared neurotrauma registry in the regional block, based on an existing framework for collaboration.

Methods A descriptive review was performed regarding the interests of LAC nations in implementing a shared neurotrauma registry in their region. We convened a meeting with seven Caribbean and five Latin American nations.

Results One hundred percent (n = 12) of the LAC representatives including neurosurgeons, neurointensivists, ministers of health, and chief medical officers/emergency medical technicians (EMTs) agreed to adopt the registry for tracking the burden of TBI and associated pathologies within the region.

Conclusion The implementation of a neurotrauma registry can benefit the region through a shared database to track disease, improve outcomes, build research, and ultimately influence policy

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Fetal movement trials: where is the evidence in settings with high-burden of stillbirths?

Fetal movement (FM) is a sign of fetal life and wellbeing that is felt by the pregnant woman, and reduced FM is known to precede stillbirths (1,2). Therefore, women may be instructed to monitor and report if movements are fewer than usual (2). In high-income countries, there has been a renewed interest in FM with a recent wave of large-scale randomised controlled clinical trials investigating FM as a potential stillbirth reduction strategy. As published in BJOG, My Baby’s Fetal Movement trial was carried out in Australia/New Zealand, and the Mindfetalness trial in Sweden (3,4). Also, the AFFIRM trial published in the Lancet was conducted in UK and the CEPRA study is ongoing in the Netherlands, UK and Australia (5). None of the completed trials, however, found significant reductions in stillbirths, and they showed conflicting results on some potential harmful consequences such as increased rates of obstetric interventions. In this commentary, we reflect on these trials through a global lens, and we urgently call for more trials; but this time in settings suffering from the vast majority (98%) of the world’s 2 million annual stillbirths

Real-time diabetic retinopathy screening by deep learning in a multisite national screening programme: a prospective interventional cohort study

Background
Diabetic retinopathy is a leading cause of preventable blindness, especially in low-income and middle-income countries (LMICs). Deep-learning systems have the potential to enhance diabetic retinopathy screenings in these settings, yet prospective studies assessing their usability and performance are scarce.

Methods
We did a prospective interventional cohort study to evaluate the real-world performance and feasibility of deploying a deep-learning system into the health-care system of Thailand. Patients with diabetes and listed on the national diabetes registry, aged 18 years or older, able to have their fundus photograph taken for at least one eye, and due for screening as per the Thai Ministry of Public Health guidelines were eligible for inclusion. Eligible patients were screened with the deep-learning system at nine primary care sites under Thailand’s national diabetic retinopathy screening programme. Patients with a previous diagnosis of diabetic macular oedema, severe non-proliferative diabetic retinopathy, or proliferative diabetic retinopathy; previous laser treatment of the retina or retinal surgery; other non-diabetic retinopathy eye disease requiring referral to an ophthalmologist; or inability to have fundus photograph taken of both eyes for any reason were excluded. Deep-learning system-based interpretations of patient fundus images and referral recommendations were provided in real time. As a safety mechanism, regional retina specialists over-read each image. Performance of the deep-learning system (accuracy, sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) were measured against an adjudicated reference standard, provided by fellowship-trained retina specialists. This study is registered with the Thai national clinical trials registry, TCRT20190902002.

Findings
Between Dec 12, 2018, and March 29, 2020, 7940 patients were screened for inclusion. 7651 (96·3%) patients were eligible for study analysis, and 2412 (31·5%) patients were referred for diabetic retinopathy, diabetic macular oedema, ungradable images, or low visual acuity. For vision-threatening diabetic retinopathy, the deep-learning system had an accuracy of 94·7% (95% CI 93·0–96·2), sensitivity of 91·4% (87·1–95·0), and specificity of 95·4% (94·1–96·7). The retina specialist over-readers had an accuracy of 93·5 (91·7–95·0; p=0·17), a sensitivity of 84·8% (79·4–90·0; p=0·024), and specificity of 95·5% (94·1–96·7; p=0·98). The PPV for the deep-learning system was 79·2 (95% CI 73·8–84·3) compared with 75·6 (69·8–81·1) for the over-readers. The NPV for the deep-learning system was 95·5 (92·8–97·9) compared with 92·4 (89·3–95·5) for the over-readers.

Interpretation
A deep-learning system can deliver real-time diabetic retinopathy detection capability similar to retina specialists in community-based screening settings. Socioenvironmental factors and workflows must be taken into consideration when implementing a deep-learning system within a large-scale screening programme in LMICs.

High value and cheap musculoskeletal health care interventions: lessons for low- and middle-income countries

To the Editor,

The Global Burden of Disease Study 2019 reported low back pain and other musculoskeletal disorders constitute the top ten cause of disability-adjusted life-year and are common from teenage years into old age [1]. The number of people experiencing musculoskeletal conditions in the coming decades will increase in low- and middle-income countries (LMICs) [2]. In addition to the likelihood of risk factors such as increased life expectancy and obesity associated with musculoskeletal conditions in high-income countries becoming more common in LMICs, the burden of musculoskeletal conditions will increase as a result of physically demanding agrarian work, and arduous portering due to poor access to modern transportation system [2].

In the past decades, the largest increase in disability due to low back pain occurred in LMICs, including Asia, Africa, and the Middle East region [2], where resource-constrained health and social systems are stressed by other burdens including infectious diseases, child and maternal health, and non-communicable diseases. The Lancet series on low back pain reported healthcare professionals in LMICs are providing wrong care for low back pain [3], resulting not only in burdens to individuals, communities, and health care systems but also contravening the 2010 Declaration of Montreal, which recognises pain relief as fundamental human right. Therefore, LMICs should develop innovative health policies to address this concern with fiscally cheaper but high value care. In this paper, the musculoskeletal conditions refer to the chronic, non-traumatic musculoskeletal pain disorders.

The impact of COVID-19 on healthcare-associated infections in intensive care units in low and middle income countries: International Nosocomial Infection Control Consortium (INICC) findings

Background
: This study examines the impact of the COVID-19 pandemic on healthcare-associated infection (HAI) incidence in low-to-middle-income countries (LMICs).

Methods
: Patients from 7 LMICs were followed during hospital intensive care unit (ICU) stays throughout January 2019 to May 2020. HAI rates were calculated using the INICC Surveillance Online System applying CDC-NHSN criteria. Pre-COVID-19 rates for 2019 were compared to COVID-19 era rates for 2020 for central line associated bloodstream infections (CLABs), catheter associated urinary tract infections (CAUTIs), ventilator associated events (VAEs), mortality and lengths of stay (LOS).

Results
: 7,775 patients were followed for 49,506 bed-days. 2019 to 2020 rate comparisons: 2.54 and 4.73 CLABSIs per 1,000 central line days (RR=1.85, p = 0.0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR=1.29, p = 0.10), 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR=1.14; p = 0.69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR=1.42; p < 0.0001). Mean LOS were 6.02 and 7.54 days (RR=1.21, p < 0.0001). Discussion : This report documents a rise in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices.

Development of a remote learning educational model for international Emergency Medicine trainees in the era of COVID-19

Background
The COVID-19 pandemic has pressured post-graduate medical education programs to shift from traditional in-person teaching to remote teaching and learning. Remote learning in medical education has been described in the literature mostly in the context of local in-country teaching. International remote medical education poses unique challenges for educators, especially in low-middle income countries (LMICs) who need continued Emergency Medicine (EM) specialty development. Our objective is to describe the development and implementation of our remote educational curriculum for EM trainees in West Bengal, India, and to assess trainee satisfaction with our remote learning curriculum.

Methods
Our curriculum was developed by adapting remote learning techniques used in Western post-graduate medical education, conducting literature searches on remote learning modalities, and through collaboration with local faculty in India. We assessed resident satisfaction in our curriculum with feedback surveys and group discussions.

Results
The remote educational curriculum had overall high trainee satisfaction ratings for weekly livestream video lectures and throughout our monthly educational modules (median ratings 9-10 out of a 10-point Likert scale). Qualitative feedback regarding specific lecture topics and educational modules were also received.

Conclusions
International remote education in LMICs poses a unique set of challenges to medical educators. Residents in our study reported high satisfaction with the curriculum, but there is a lack of clarity regarding how a remote curriculum may impact academic and clinical performance. Future studies are needed to further evaluate the efficacy and academic and clinical implications of remote medical education in LMICs.