Long-Term Outcomes in Survivors of Childhood Cancer: A 30-Year Experience From India

Despite an increasing number of survivors of childhood cancer (CCS) in low- and middle-income countries, survivorship care is in its nascent stages. We describe the spectrum of late effects seen, challenges faced, and lessons learnt over three decades of a late effects program in India.

We describe the demographics and profile of late effects of all CCS survivors enrolled in our After Completion of Treatment Clinic from February 5, 1991 (inception) to February 4, 2021. We analyzed the trends by the decade of diagnosis.

There were 3,067 CCS survivors, the median age was 18 years (range, 3-57 years), and the median follow-up was 11 years (range, 2-46 years). Two thirds (62.4%) had either no or mild late effects, 480 (15.6%), 497 (16.2%), and 162 (5.3%) had grades 2, 3, and 4 late effects, with 67 deaths reported. Notable late effects were chronic viral hepatitis (7.8%), thyroid dysfunction (7.5%), other endocrine issues (13.6%), psychosocial issues (57%), neurocognitive impairment (4.1%), and metabolic syndrome (4%). The cumulative incidence and severity of late effects showed a consistent decline by the decade of diagnosis. Twenty-two percent of survivors are lost to follow-up.

Survivors of childhood cancer treated on contemporary treatment protocols have a significantly lower side-effect profile. Attrition to long-term follow-up and psychosocial issues are significant concerns. Understanding the unique spectrum of late effects and establishing a holistic support system go a long way in ensuring the long-term physical and mental health and psychosocial concerns of childhood cancer survivors in low- and middle-income countries.

Embracing robotic surgery in low- and middle-income countries: Potential benefits, challenges, and scope in the future

Robotic surgery has applications in many medical specialties, including urology, general surgery, and surgical oncology. In the context of a widespread resource and personnel shortage in Low- and Middle-Income Countries(LMICs), the use of robotics in surgery may help to reduce physician burnout, surgical site infections, and hospital stays. However, a lack of haptic feedback and potential socioeconomic factors such as high implementation costs and a lack of trained personnel may limit its accessibility and application. Specific improvements focused on improved financial and technical support to LMICs can help improve access and have the potential to transform the surgical experience for both surgeons and patients in LMICs. This review focuses on the evolution of robotic surgery, with an emphasis on challenges and recommendations to facilitate wider implementation and improved patient outcomes.

Directly observed and reported respectful maternity care received during childbirth in public health facilities, Ibadan Metropolis, Nigeria

Respectful maternity care (RMC) is believed to improve women’s childbirth experience and increase health facility delivery. Unfortunately, few women in low- and middle-income countries experience RMC. Patient surveys and independent observations have been used to evaluate RMC, though seldom together. In this study, we assessed RMC received by women using two methodologies and evaluated the associated factors of RMC received. This was a cross-sectional study conducted in nine public health facilities in Ibadan, a large metropolis in Nigeria. We selected 269 pregnant women by cluster sampling. External clinical observers observed them during childbirth using the 29-item Maternal and Child Health Integrated Program RMC observational checklist. The same women were interviewed postpartum using the 15-item RMC scale for self-reported RMC. We analysed total RMC scores and RMC sub-category scores for each tool. All scores were converted to a percentage of the maximum possible to facilitate comparison. Correlation and agreement between the observed and reported RMC scores were determined using Pearson’s correlation and Bland-Altman analysis respectively. Multiple linear regression was used to identify factors associated with observed RMC. No woman received 100% of the observed RMC items. Self-reported RMC scores were much higher than those observed. The two measures were weakly positively correlated (rho = 0.164, 95%CI: 0.045–0.278, p = 0.007), but had poor agreement. The lowest scoring sub-categories of observed RMC were information and consent (14.0%), then privacy (28.0%). Twenty-eight percent of women (95%CI: 23.0% -33.0%) were observed to be hit during labour and only 8.2% (95%CI: 4.0%-18.0%) received pain relief. Equitable care was the highest sub-category for both observed and reported RMC. Being employed and having completed post-secondary education were significantly associated with higher observed RMC scores. There were also significant facility differences in observed RMC. In conclusion, the women reported higher levels of RMC than were observed indicating that these two methodologies to evaluate RMC give very different results. More consensus and standardisation are required in determining the cut-offs to quantify the proportion of women receiving RMC. The low levels of RMC observed in the study require attention, and it is important to ensure that women are treated equitably, irrespective of personal characteristics or facility context.

Abortion decision-making process trajectories and determinants in low- and middle-income countries: A mixed-methods systematic review and meta-analysis

About 45.1% of all induced abortions are unsafe and 97% of these occur in low- and middle-income countries (LMICs). Women’s abortion decisions may be complex and are influenced by various factors. We aimed to delineate women’s abortion decision-making trajectories and their determinants in LMICs.

We searched Medline, EMBASE, PsychInfo, Global Health, Web of Science, Scopus, IBSS, CINAHL, WHO Global Index Medicus, the Cochrane Library, WHO website, ProQuest, and Google Scholar for primary studies and reports published between January 1, 2000, and February 16, 2021 (updated on June 06, 2022), on induced abortion decision-making trajectories and/or their determinants in LMICs. We excluded studies on spontaneous abortion. Two independent reviewers extracted and assessed quality of each paper. We used “best fit” framework synthesis to synthesise abortion decision-making trajectories and thematic synthesis to synthesise their determinants. We analysed quantitative findings using random effects model. The study protocol is registered with PROSPERO number CRD42021224719.

Of the 6960 articles identified, we included 79 in the systematic review and 14 in the meta-analysis. We identified nine abortion decision-making trajectories: pregnancy awareness, self-reflection, initial abortion decision, disclosure and seeking support, negotiations, final decision, access and information, abortion procedure, and post-abortion experience and care. Determinants of trajectories included three major themes of autonomy in decision-making, access and choice. A meta-analysis of data from 7737 women showed that the proportion of the overall women’s involvement in abortion decision-making was 0.86 (95% CI:0.73–0.95, I2 = 99.5%) and overall partner involvement was 0.48 (95% CI:0.29–0.68, I2 = 99.6%).

Policies and strategies should address women’s perceptions of safe abortion socially, legally, and economically, and where appropriate, involvement of male partners in abortion decision-making processes to facilitate safe abortion. Clinical heterogeneity, in which various studies defined “the final decision-maker” differentially, was a limitation of our study.

Nuffield Department of Population Health DPhil Scholarship for PL, University of Oxford, and the Medical Research Council Career Development Award for MN (Grant Ref: MR/P022030/1).

Identification of risk factors for postoperative pulmonary complications in general surgery patients in a low-middle income country

Postoperative pulmonary complications (PPCs) are an important cause of perioperative morbidity and mortality. Although risk factors for PPCs have been identified in high-income countries, less is known about PPCs and their risk factors in low- and middle-income countries, such as South Africa. This study examined the incidence of PPCs and their associated risk factors among general surgery patients in a public hospital in the province of KwaZulu-Natal, South Africa to inform future quality improvement initiatives to decrease PPCs in this clinical population.

A retrospective secondary analysis of adult patients with general surgery admissions from January 1, 2013 to December 31, 2017 was conducted using data from the health system’s Hybrid Electronic Medical Registry. The sample was comprised of 5352 general surgery hospitalizations. PPCs included pneumonia, atelectasis, acute respiratory distress syndrome, pulmonary edema, pulmonary embolism, prolonged ventilation, hemothorax, pneumothorax, and other respiratory morbidity which encompassed empyema, aspiration, pleural effusion, bronchopleural fistula, and lower respiratory tract infection. Risk factors examined were age, tobacco use, number and type of pre-existing comorbidities, emergency surgery, and number and type of surgeries. Bivariate and multivariable logistic regression models were conducted to identify risk factors for developing a PPC.

The PPC rate was 7.8%. Of the 418 hospitalizations in which a patient developed a PPC, the most common type of PPC was pneumonia (52.4%) and the mortality rate related to the PPC was 11.7%. Significant risk factors for a PPC were increasing age, greater number of comorbidities, emergency surgery, greater number of general surgeries, and abdominal surgery.

PPCs are common in general surgery patients in low- and middle-income countries, with similar rates observed in high-income countries. These complications worsen patient outcomes and increase mortality. Quality improvement initiatives that employ resource-conscious methods are needed to reduce PPCs in low- and middle-income countries.

Standardization of Trauma, General Surgical Morbidity and Mortality Conferences: Development and Dissemination of a “Toolkit” in Peru

Morbidity and Mortality (M&M) conferences allow clinicians to review adverse events and identify areas for improvement. There are few reports of structured M&M conferences in low- and middle-income countries and no report of collaborative efforts to standardize them.

The present study aims to gather general surgeons representing most of Peru’s urban surgical care and, in collaboration, with trauma quality improvement experts develop a M&M conferences toolkit with the expectation that its diffusion impacts their reported clinical practice. Fourteen general surgeons developed a toolkit as part of a working group under the auspices of the Peruvian General Surgery Society. After three years, we conducted an anonymous written questionnaire to follow-up previous observations of quality improvement practices.

A four-component toolkit was developed: Toolkit component #1: Conference logistics and case selection; Toolkit component #2: Documenting form; Toolkit component #3: Presentation template; and Toolkit component #4: Code of conduct. The toolkit was disseminated to 10 hospitals in 2016. Its effectiveness was evaluated by comparing the results of surveys on quality improvement practices conducted in 2016, before toolkit dissemination (101 respondents) and 2019 (105 respondents). Lower attendance was reported by surgeons in 2019. However, in 2019, participants more frequently described “improve the system” as the perceived objective of M&M conferences (70.5% vs. 38.6% in 2016; p < 0.001).

We established a toolkit for the national dissemination of a standardized M&M conference. Three years following the initial assessment in Peru, we found similar practice patterns except for increased reporting of “system improvement” as the goal of M&M conferences.

Nutritional intake in acute care surgery patients in Kigali, Rwanda- A single institution descriptive analysis

INTRODUCTION: Nutrition is essential for health and healing, especially in the perioperative period. However, little is known about the nutritional intake of hospitalized patients in low and middle-income countries.
This paper aimed to characterize the composition and quantity of food in acute care surgery patients at a tertiary referral hospital in Rwanda.

METHODS: Acute care surgery patients were queried about nutritional intake during hospitalization from May 21, 2018, to June 3, 2018, for 100 patient days. Calorie and protein intake were estimated and compared to standards for an average Rwandan adult.
RESULTS: Median daily calorie intake was 1472 kcal/day (Interquartile range (IQR): 662, 2116). The median daily protein intake was 45.99 g (IQR: 24.38, 70.22). Assuming a calorie need of 25 kcal/kg/day and a protein need of 1g/kg/day, this is 98.1% of the estimated daily calorie needs and 76.7% of estimated daily protein needs. Estimating higher energy needs for a surgical patient, the daily intake is 70.0-81.9% of calorie needs and 51.1-63.9% of protein needs.

CONCLUSION: Overall, the calorie and protein intake for the average Rwandan acute care surgery patient were low compared to the needs of a 60 kg surgical patient. More education and accessibility to high-quality foods are needed to ensure adequate nutrition in the postoperative period to optimize clinical outcomes.

Self-reported involvement in road traffic crashes in Kenya: A cross-sectional survey of a nationally representative sample

Road traffic crashes (RTCs) are a global public health burden whose resulting morbidity and mortality disproportionately impact low- and middle-income countries with stressed health systems. There is a paucity of published studies that evaluate the sociodemographic distribution of RTCs using nationally representative samples from the African region.

To examine population-wide associations between sociodemographic factors and involvement in RTCs in Kenya.

Data were obtained from the 2014 Kenyan Demographic Health Survey, representing all 47 counties in Kenya, from May to October of 2014. We estimated the prevalence of RTCs and utilized logistic regression for bivariate and multivariable analyses to determine the sociodemographic factors associated with RTCs. Study variables included age, place of residence, household wealth index, educational attainment, and history of alcohol consumption. We computed odds ratios (ORs) and their corresponding 95% confidence intervals (CIs).

A higher prevalence was reported among men (8.76%) versus women (3.22%). The risk factors among men included being 20−34 years of age, living in a rural area (OR 1.38, 95% CI 1.09, 1.74), drinking alcohol (OR 1.33, 95% CI 1.11, 1.59), and having not higher than a primary (OR 1.90, 95% CI 1.19, 3.03) or secondary (OR 1.68, 95% CI 1.04, 2.71) education. The strongest risk factors for women included the being aged 45−49 (OR 2.30, 95% CI 1.44, 3.67) and 20−24 years (OR 1.81, 95% 1.17, 2.79) as well as being in the fourth wealth quintile (OR 1.83, 95% CI 1.15, 2.91).

Men and the most economically productive age groups were more likely to report being involved in RTCs. Strategies to reduce the occurrences of RTCs should prioritize the most vulnerable sociodemographic groups.

Cancer Medicines: What Is Essential and Affordable in India?

PURPOSE The WHO essential medicines list (EML) guides selection of drugs for national formularies. Here, we evaluate which medicines are considered highest priority by Indian oncologists and the extent to which they are
available in routine practice. METHODS This is a secondary analysis of an electronic survey developed by the WHO EML Cancer Medicine Working Group. The survey was distributed globally using a hierarchical snowball method to physicians who prescribe systemic anticancer therapy. The survey captured the 10 medicines oncologists considered highest priority for population health and their availability in routine practice.
RESULTS The global study cohort included 948 respondents from 82 countries; 98 were from India and 67 were from other low- and middle-income countries. Compared with other low- and middle-income countries, the Indian cohort was more likely to be medical oncologist (70% v 31%, P , .001) and work exclusively in the private health system (52% v 17%, P , .001). 14/20 most commonly selected medicines were conventional
cytotoxic drugs. Universal access to these medicines was reported by a minority of oncologists; risks of significant out-of-pocket expenditures for each medicine were reported by 19%-58% of oncologists. Risk of catastrophic expenditure was reported by 58%-67% of oncologists for rituximab and trastuzumab. Risks of financial toxicity were substantially higher within the private health system compared with the public system.
CONCLUSION Most high-priority cancer medicines identified by Indian oncologists are generic chemotherapy agents that provide substantial improvements in survival and are already included in WHO EML. Access to these
treatments remains limited by major financial burdens experienced by patients. This is particularly acute within the private health system. Strategies are urgently needed to ensure that high-quality cancer care is affordable and accessible to all patients in India

Community-based adult hearing care provided by community healthcare workers using mHealth technologies

The rising prevalence of hearing loss is a global health concern. Professional hearing services are largely absent within low- and middle-income countries where appropriate skills are lacking. Task-shifting to community healthcare workers (CHWs) supported by mHealth technologies is an important strategy to address the problem.

To evaluate the feasibility of a community-based rehabilitation model providing hearing aids to adults in low-income communities using CHWs supported by mHealth technologies.

Between September 2020 and October 2021, hearing aid assessments and fittings were implemented for adults aged 18 and above in two low-income communities in the Western Cape, South Africa, using trained CHWs. A quantitative approach with illustrative open-ended questions was utilised to measure and analyse hearing aid outcomes. Data were collected through initial face-to-face interviews, telephone interviews, and face-to-face visits post-fitting. Responses to open-ended questions were analysed using inductive thematic analysis. The International Outcome Inventory – Hearing Aids questionnaire determined standardised hearing aid outcomes.

Of the 152 adults in the community who self-reported hearing difficulties, 148 were successfully tested by CHWs during home visits. Most had normal hearing (39.9%), 24.3% had bilateral sensorineural hearing loss, 20.9% had suspected conductive hearing loss, and 14.9% had unilateral hearing loss, of which 5.4% had suspected conductive loss. Forty adults met the inclusion criteria to be fitted with hearing aids. Nineteen of these were fitted bilaterally. Positive hearing aid outcomes and minimal device handling challenges were reported 45 days post-fitting and were maintained at six months. The majority (73.7%) of participants fitted were still making use of their hearing aids at the six-month follow-up.

Implementing a hearing healthcare service-delivery model facilitated by CHWs in low-income communities is feasible. mHealth technologies used by CHWs can support scalable service-delivery models with the potential for improved access and affordability in low-income settings.