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Background More than half of childhood tuberculosis cases remain undiagnosed yearly. The World Health Organization recommends the Xpert-Ultra assay as a first pediatric diagnosis test, but microbiological confirmation remains low. We aimed to determine the diagnostic performance of Xpert-Ultra with stool and urine samples in presumptive pediatric tuberculosis cases in 2 high-tuberculosis-burden settings. Methods This Médecins Sans Frontières cross-sectional multicentric study took place at Simão Mendes Hospital, Guinea-Bissau (July 2019 to April 2020) and in Malakal Hospital, South Sudan (April 2021 to June 2023). Children aged 6 months to 15 years with presumptive tuberculosis underwent clinical and laboratory assessment, with 1 respiratory and/or extrapulmonary sample (reference standard [RS]), 1 stool, and 1 urine specimen analyzed with Xpert-Ultra. Results A total of 563 children were enrolled in the study, 133 from Bissau and 400 from Malakal; 30 were excluded. Confirmation of tuberculosis was achieved in 75 (14.1%), while 248 (46.5%) had unconfirmed tuberculosis. Of 553 with an RS specimen, the overall diagnostic yield was 12.4% (66 of 533). A total of 493 stool and 524 urine samples were used to evaluate the performance of Xpert-Ultra with these samples. Compared with the RS, the sensitivity and specificity of Xpert-Ultra were 62.5% (95% confidence interval, 49.4%–74%) and 98.3% (96.7%–99.2%), respectively, with stool samples, and 13.9% (7.5%–24.3%) and 99.4% (98.1%–99.8%) with urine samples. Nine patients were positive with stool and/or urine samples but negative with the RS. Conclusions Xpert-Ultra in stool samples showed moderate to high sensitivity and high specificity compared with the RS and an added diagnostic yield when RS results were negative. Xpert-Ultra in stool samples was useful in extrapulmonary cases. Xpert-Ultra in urine samples showed low test performance. Clinical Trials Registration NCT06239337 [ABSTRACT FROM AUTHOR]

Background & objectives Medication-related harm is known to be the cause for about 1/10th of hospitalizations. Some estimates from India show that about 90 per cent of medicines consumed are inessential or irrational and contribute towards high out-of-pocket expenditure on health. In this context, the Indian Council of Medical Research in 2022 constituted a National Task Force (NTF) to explore possible solutions that could improve safe and rational use of medicines (SRUMs). The objective of this study was to identify research ideas in the field of SRUM through a survey of relevant stakeholders, and further to prioritize the research ideas using a pre-identified set of criteria. Methods The responses from the identified stakeholders were assessed using the Child Health and Nutrition Research Initiative method, which is an established research priority-setting methodology. First, the NTF asked for two to six research ideas from relevant Indian and global stakeholders on solutions to improve SRUM. The ideas were checked for duplicates, re-phrased where necessary and classified into various sub-themes. Subsequently, the research ideas were scored by Indian experts with relevant technical expertise using a pre-defined set of five criteria: innovativeness, effectiveness, translational value, answerability and applicability. Each research idea received from a stakeholder was assigned a score under each of the five criteria. The overall research priority score was calculated as a mean of all five criteria-specific scores and converted into a percentage. Results The final output of the prioritization process was a list of research ideas or questions, ranked by their scores. Total 209 unique ideas were received from 190 respondents, which were scored by 27 experts. The top three research topics on medication safety focused on cost-effective strategies for improving antimicrobial stewardship, safe use of poly-pharmacy in geriatric patients and drug take-back policy interventions. Regarding the rational use of medicine, the top three topics included testing mobile application-based antimicrobial stewardship interventions, development of diagnostics for antimicrobial resistance, and behavioural interventions. Interpretation & conclusions Several priority ideas found in this study also align with those of global priority, e.g., safe disposal practices and enhanced pharmacovigilance, rational use of medicines. Patient engagement, which underlines many of the top scoring ideas found in this study, is also inclined with the top research priorities reported by the WHO priority exercise on research into the safe use of medicines. However, to the best of our knowledge, this is the first such work from a low- and middle- income country on medication safety and rational use of medicines. The findings of this research priority-setting exercise can help to guide research for the development of policy-relevant and novel interventions to improve SRUM in India. [ABSTRACT FROM AUTHOR]

Background: In 2023 FIGO revised the endometrial cancer staging system after 13 years. There is a lacuna of data regarding the performance and practicality of the revised 2023 FIGO staging schema for endometrial cancer from Low Middle-Income Countries (LMIC). Objective: To estimate the shift of stage and adjuvant management of endometrial cancer based on the FIGO 2023 system compared to the FIGO 2009 system and assess the predictive potential of the FIGO 2023 system. Material and methods: A retrospective study was conducted from 1st January 2017 to 31st December 2022. All patients with endometrial cancer were staged according to the FIGO 2023 and FIGO 2009 staging system. Follow-up of patients was done to determine recurrence. Results: A total of 152 patients were included. Aggressive histology was seen in 66 (45%) patients. Eighteen (11%) had subserosal involvement. Substantial LVSI was noted in 23 (15%) of patients. Twenty-four (47%) patients of FIGO 2009 Stage IA and 26 patients (63%) of FIGO 2009 Stage IB were upstaged. Eleven (50%) patients of FIGO 2009 Stage IIIA were down staged to IA3. Overall 23 patients (15%) had a shift of stage. Fifteen out of 152 patients (15%) would have had a possible risk stratification change which would imply 23 patients (15%) would have needed a more radical treatment. Molecular classification was done in 32 patients; however, only 2 patients could afford POLE testing. Kaplan–Meier curves showed significant PFS differences in FIGO 2009 Stage IB and Stage IIIA when restaged according to the FIGO 2023 system. Conclusion: The FIGO 2023 endometrial staging is a more robust prognosticator; however, the practicality of molecular classification in LMICs is still a distant dream. [ABSTRACT FROM AUTHOR]

Diagnostics are an essential, undervalued part of the health-care system. For many diseases, molecular diagnostics are the gold standard, but are not easy to implement in Low- and Middle-Income Countries (LMIC). Sample-to-result (S2R) platforms combining all procedures in a closed system could offer a solution. In this paper, we investigated their suitability for implementation in LMIC. A scorecard was used to evaluate different platforms on a range of parameters. Most platforms scored fairly on the platform itself, ease-of-use and test consumables; however, shortcomings were identified in cost, distribution and test panels tailored to LMIC needs. The diagnostic coverage for common infectious diseases was found to have a wider coverage in high-income countries (HIC) than LMIC. A literature study showed that in LMIC, these platforms are mainly used as diagnostic tools or evaluation of diagnostic performance, with a minority assessing the operational characteristics or the clinical utility. In this narrative review, we identified various points for adaptation of S2R platforms to LMIC conditions. For S2R platforms to be suitable for implementation in LMIC some modifications by the manufacturers could be considered. Furthermore, strengthening health systems and digitalization are vital; as are smaller, cheaper, faster, and sustainable technologies. [ABSTRACT FROM AUTHOR]

Background: As crises escalate worldwide, there is an increasing demand for innovative solutions to enhance humanitarian outcomes. Within this landscape, digital health tools have emerged as promising solutions to tackle certain health challenges. The integration of digital health tools within the international humanitarian system provides an opportunity to reflect upon the system's paternalistic tendencies, driven largely by Global North organisations, that perpetuate existing inequities in the Global South, where the majority of crises occur. The Participation Revolution, a fundamental pillar of the Localisation Agenda, seeks to address these inequities by advocating for greater participation from crisis-affected people in response efforts. Despite being widely accepted as a best practice; a gap remains between the rhetoric and practice of participation in humanitarian response efforts. This study explores the extent and nature of participatory action within contemporary humanitarian digital health projects, highlighting participatory barriers and tensions and offering potential solutions to bridge the participation gap to enhance transformative change in humanitarian response efforts. Methods: Sixteen qualitative interviews were conducted with humanitarian health practitioners and experts to retrospectively explored participatory practices within their digital health projects. The interviews were structured and analysed according to the Localisation Performance Measurement Framework's participation indicators and thematically, following the Framework Method. The study was guided by the COREQ checklist for quality reporting. Results: Varied participatory formats, including focus groups and interviews, demonstrated modest progress towards participation indicators. However, the extent of influence and power held by crisis-affected people during participation remained limited in terms of breadth and depth. Participatory barriers emerged under four key themes: project processes, health evidence, technology infrastructure and the crisis context. Lessons for leveraging participatory digital health humanitarian interventions were conducting thorough pre-project assessments and maintaining engagement with crisis-affected populations throughout and after humanitarian action. Conclusion: The emerging barriers were instrumental in shaping the limited participatory reality and have implications: Failing to engage crisis-affected people risks perpetuating inequalities and causing harm. To advance the Participation Revolution for humanitarian digital health response efforts, the major participatory barriers should be addressed to improve humanitarian efficiency and digital health efficacy and uphold the rights of crisis-affected people. [ABSTRACT FROM AUTHOR]

Introduction: To effectively regulate and reduce antibiotic use, in the livestock sector, a thorough understanding of the flow of veterinary antibiotics will help to identify key nodes in the chain for targeted interventions. The aim of this study was to understand the flow of antibiotics from import to end-user, and identify relevant governance mechanisms. Methods: A mixed methods approach was used to collect data in three Kenyan counties (Nairobi, Kiambu, and Kajiado). Focus group discussions (n = 23), individual interviews (n = 148), and key informant interviews (n = 10) were conducted. Results: The key actors identified include primary wholesalers, secondary wholesalers, retailers, animal health service providers (AHSPs), and farmers. Kenya imports 100% of its veterinary antibiotics: primary wholesalers legally import antibiotics as finished pharmaceutical products (90%) or active pharmaceutical ingredients (10%) after approval by the Veterinary Medicines Directorate. Secondary wholesalers play a major role in the distribution of antibiotics (60% of antibiotics) from importers to farmers, AHSPs, and retailers. Some of the illegal sources of antibiotics include unlicenced/unauthorized middlemen and online platforms that sell directly to retailers, AHSPs, and farmers. Discussion: Despite the presence of various laws and regulations governing the antibiotic value chain, implementation has been a challenge due to financial and human resource constraints. This contributes to over-the-counter sale of antibiotics without prescription, unlicensed businesses selling antibiotics, illegal importation, and presence of poor-quality drugs. There is a need to review the applicability of existing policies and address policy gaps (e.g., product containing antibiotic combinations, and use of human critically important antibiotics) to ensure the prudent sale and use of antibiotics, pharmacovigilance, antimicrobial use surveillance, and developing a business model that aligns with antibiotic stewardship. Additional interventions include awareness raising and capacity building of the different stakeholders along the antibiotic distribution chain to reduce antibiotic mis- and overuse. [ABSTRACT FROM AUTHOR]

Staphylococcus aureus is the leading cause of skin and soft tissue infections (SSTIs) in the U.S. as well as more serious invasive diseases, including bacteremia, sepsis, endocarditis, surgical site infections, osteomyelitis, and pneumonia. These infections are exacerbated by the emergence of antibiotic-resistant clinical isolates such as methicillin-resistant S. aureus (MRSA), highlighting the need for alternatives to antibiotics to treat bacterial infections. We have previously developed a multi-component toxoid vaccine (IBT-V02) in a liquid formulation with efficacy against multiple strains of Staphylococcus aureus prevalent in the industrialized world. However, liquid vaccine formulations are not compatible with the paucity of cold chain storage infrastructure in many low-to-middle income countries (LMICs). Furthermore, whether our IBT-V02 vaccine formulations are protective against S. aureus isolates from LMICs is unknown. To overcome these limitations, we developed lyophilized and spray freeze-dried formulations of IBT-V02 vaccine and demonstrated that both formulations had comparable biophysical attributes as the liquid formulation, including similar levels of toxin neutralizing antibodies and protective efficacy against MRSA infections in murine and rabbit models. To enhance the relevancy of our findings, we then performed a multi-dimensional screen of 83 S. aureus clinical isolates from LMICs (e.g., Democratic Republic of Congo, Palestine, and Cambodia) to rationally down-select strains to test in our in vivo models based on broad expression of IBT-V02 targets (i.e., pore-forming toxins and superantigens). IBT-V02 polyclonal antisera effectively neutralized toxins produced by the S. aureus clinical isolates from LMICs. Notably, the lyophilized IBT-V02 formulation exhibited significant in vivo efficacy in various preclinical infection models against the S. aureus clinical isolates from LMICs, which was comparable to our liquid formulation. Collectively, our findings suggested that lyophilization is an effective alternative to liquid vaccine formulations of our IBTV02 vaccine against S. aureus infections, which has important implications for protection from S. aureus isolates from LMICs. [ABSTRACT FROM AUTHOR]

Background Equitable access to quality care after injury is an essential step for improved health outcomes in low and middle-income countries (LMICs). We introduce the Equi-Injury project, in which we will use integrated frameworks to understand how to improve equitable access to quality care after injury in four LMICs: Ghana, Pakistan, Rwanda and South Africa. Methods This project has 5 work packages (WPs) as well as essential cross-cutting pillars of community engagement, capacity building and cross-country learning. In WP1, we will identify needs, barriers, and facilitators to impactful stakeholder engagement in developing and prioritising policy solutions. In WP2, we will collect data on patient care and outcomes after injuries. In WP3, we will develop an injury pathway model to understand which elements in the pathway of injury response, care and treatment have the biggest impact on health and economic outcomes. In WP4, we will work with stakeholders to gain consensus on solutions to address identified issues; these solutions will be implemented and tested in future research. In WP5, in order to ascertain where learning is transferable across contexts, we will identify which outcomes are shared across countries. The study has received approval from ethical review boards (ERBs) of all partner countries in South Africa, Rwanda, Ghana, Pakistan and the University of Birmingham. Discussion This health system evaluation project aims to provide a deeper understanding of injury care and develop evidence-based interventions within and across partner countries in four diverse LMICs. Strong partnership with multiple stakeholders will facilitate utilisation of the results for the co-development of sustainable interventions. [ABSTRACT FROM AUTHOR]

This article explores the disparities in pediatric neuro-oncology care between high-income countries (HIC) and low- and middle-income countries (LMIC) in Latin America and the Caribbean. It highlights the need for improved access to resources and specialized care in LMIC, where the majority of childhood cancer cases and deaths occur. The article discusses regional and international interventions aimed at improving pediatric cancer care and outcomes in the region, such as the Global Initiative for Childhood Cancer and the Latin American Brain Tumor Board. It emphasizes the importance of comprehensive care, timely diagnosis, and collaboration among healthcare providers to address the challenges in pediatric neuro-oncology in Latin America and the Caribbean. [Extracted from the article]

Disparities in scholarship exist between authors in low- or middle-income countries (LMIC) and high-income countries. Recognizing these disparities in our global network providing pediatric, adolescent, and maternal healthcare to vulnerable populations in LMIC, we sought to improve access and provide resources to address educational needs and ultimately impact the broader scholarship disparity. We created a virtual community of practice (CoP) program underpinned by principles from starling murmuration to promote interdisciplinary scholarship. We developed guiding principles- autonomy, mastery and purpose- to direct the Global Health Scholarship Community of Practice Program. Program components included a continuing professional development (CPD) program, an online platform and resource center, a symposium for scholarship showcase, and peer coaching. From February 2021 to October 2022, 277 individuals joined. Eighty-seven percent came from LMIC, with 69% from Africa, 6% from South America, and 13% from other LMIC regions. An average of 30 members attended each of the 21 CPD sessions. Thirty-nine authors submitted nine manuscripts for publication. The symposium increased participation of individuals from LMIC and enhanced scholarly skills and capacity. Early outcomes indicate that members learned, shared, and collaborated as scholars using the online platform. Sharing of knowledge and collaboration globally are feasible through a virtual CoP and offer a benchmark for future sustainable solutions in healthcare capacity building. We recommend such model and virtual platform to promote healthcare education and mentoring across disciplines. [ABSTRACT FROM AUTHOR]

Introduction: Injection drug networks may influence their network members' health‐seeking behaviours. Using data from a sociometric injecting partner network of people who inject drugs (PWID) in New Delhi, India, we assessed the role of injecting partner (alter) behaviours on individual engagement in HIV prevention services. Methods: We enumerated injecting partner linkages among 2512 PWID using coupon referrals and biometric data from November 2017 to March 2020. Participants completed interviewer‐administered questionnaires and provided information on injection behaviours, injecting partners, HIV/hepatitis C (HCV) testing and service engagement. Multilevel multiple‐membership models (MMMM) evaluated individual PWID HIV testing, medication for opioid use disorder (MOUD) and syringe service engagement as a function of alter attributes, accounting for membership across multiple ego‐networks. Logistic regression models assessed parallel associations among socially proximal injecting peers, defined as PWID ≤3 path length from ego. Results: Median age was 26 years; 99% were male. PWID had median 2 injecting partners and 8 socially proximal peers; 14% reported HIV testing, 33% accessed MOUD and 13% used syringe services 6 months prior. In MMMM analyses, PWID with ≥1 versus 0 injecting partners who received HIV testing were significantly more likely to report HIV testing (adjusted odds ratio [aOR]: 2.27, 95% confidence interval [CI]: 1.68–3.16), MOUD (aOR: 1.99, 95% CI: 1.60–2.53) and syringe service use (aOR: 1.66, 95% CI: 1.21–2.39). We observed similar findings for individual MOUD and syringe service use. Having ≥1 versus 0 HIV‐positive partners was associated with decreased HIV testing and MOUD but increased syringe service use (aOR: 1.54, 95% CI: 1.09–2.17). PWID with ≥1 versus 0 socially proximal peers who used non‐sterile injection equipment reported increased HIV testing (aOR: 1.39, 95% CI: 1.01–1.92), MOUD (aOR: 1.40, 95% CI: 1.10–1.77) and syringe service use (aOR: 1.82, 95% CI: 1.23–2.68). Conclusions: We found differential associative relationships between individual HIV prevention service engagement and the health or risk behaviours of direct and indirect alters. Characterizing network exposure beyond direct injecting partnerships provided important context on possible mechanisms of behavioural influence. Findings could be leveraged to design peer‐based interventions that promote network diffusion of health‐seeking behaviours. [ABSTRACT FROM AUTHOR]

Engagement with genomic medicine and research has increased globally during the past few decades, including rapid developments in Sri Lanka. Genomic research is carried out in Sri Lanka on a variety of scales and with different aims and perspectives. However, there are concerns about participants' understanding of genomic research, including the validity of informed consent. This article reports a qualitative study aiming to explore the understanding, knowledge, and attitudes of the Sri Lankan public towards genomic medicine and to inform the development of an effective and appropriate process for informed consent in that setting. Purposive sampling was employed. Participants were recruited from a sub-group of the public in Colombo, Sri Lanka who had either consented or refused to donate genetic material for a biobank. Data were collected using face-to-face semi-structured interviews. Interview data were transcribed verbatim and translated into English. Conventional content analysis was used. The analysis developed three key themes: a) 'Scientific literacy' describes an apparent lack of scientific knowledge that seems to affect a participant's ability to understand the research, b) 'Motivation' describes narratives about why participants chose (not) to take part in the research, despite not understanding it, and c) 'Trust' describes how trust served to mitigate the apparent ethical deficit created by not being fully informed. In this article, we argue that informed trust is likely an acceptable basis for consent, particularly in settings where scientific literacy might be low. However, researchers must work to be worthy of that trust and ensure that misconceptions are actively addressed. [ABSTRACT FROM AUTHOR]

Objective: To determine the diagnostic accuracy of MCHAT-R/F, RBSK-ASQ and TABC for screening children aged 16 to 30 months for autism spectrum disorder (ASD). Method: Children aged 16 to 30 months were recruited from the pediatrics department. Those with known neurodevelopmental disorders, disabilities, severe medical illnesses, unavailable mothers, or lack of maternal understanding of Hindi, were excluded. The three index tools were translated into Hindi; each tool was piloted on 25 mothers and modified accordingly. The researcher was trained in administration, scoring and interpretation of the three tools. After enrollment the index tools and Developmental Profile (DP-3) were administered to each participant. The reference tool was a comprehensive assessment by experts that included clinical evaluation, computation of DP-3 scores, and application of diagnostic criteria of ASD; the final diagnosis being ASD or Non-ASD. Results: Sensitivity and specificity of M-CHAT-R/F were 95.2% and 94.4%, of RBSK-ASQ were 100% and 93.9%, and of TABC were 100% and 94.4%, respectively. Convergent validity was high (Spearman's correlation coefficient 0.98). Test-retest and inter-rater reliability of each tool was excellent (Intra-class correlation coefficient 1.00). Conclusion: All three tools had acceptable psychometric properties, high convergent validity and excellent test-retest and inter-rater reliability. [ABSTRACT FROM AUTHOR]

HIV-related stigma in healthcare settings remains a key barrier to engaging people living with HIV (PLHIV) in care. This study investigated the association between clinical encounter frequency and HIV-related anticipated, enacted, and internalized stigma among newly-diagnosed PLHIV in Rwanda. From October 2020 to May 2022, we collected data from adult PLHIV on antiretroviral therapy (ART) in Kigali, Rwanda who were participating in a randomized, controlled trial testing early entry into differentiated care at 6 months after ART initiation. We measured anticipated HIV stigma with five-point Likert HIV Stigma Framework measures, enacted stigma with the four-point Likert HIV/AIDS Stigma Instrument, and internalized stigma with the four-point Likert HIV/AIDS Stigma Instrument. We used multivariable linear regression to test the associations between clinical encounter frequency (average inter-visit interval ≥ 50 days vs. < 50 days) and change in mean anticipated, enacted and internalized HIV stigma over the first 12 months in care. Among 93 individuals enrolled, 76 had complete data on encounter frequency and stigma measurements and were included in the present analysis. Mean internalized stigma scores of all participants decreased over the first 12 months in care. Anticipated and enacted stigma scores were low and did not change significantly over time. There was no association between encounter frequency and change in internalized stigma. In this pilot study of newly-diagnosed Rwandan PLHIV with relatively low levels of HIV-related stigma, clinical encounter frequency was not associated with change in stigma. Additional research in diverse settings and with larger samples is necessary to further explore this relationship. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of hyperthyroidism in Pakistan is 2.9%, which is two times higher than in the United States. Most high-quality hyperthyroidism clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of hyperthyroidism in Pakistan. Methods: We employed the GRADE-ADOLOPMENT approach utilizing the 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context. Results: The source guideline included a total of 124 recommendations, out of which 71 were adopted and 49 were excluded. 4 recommendations were carried forward for adaptation via the ETD process, with modifications being made to 2 of these. The first addressed the need for liver function tests (LFTs) amongst patients experiencing symptoms of hepatotoxicity while being treated with anti-thyroid drugs (ATDs). The second pertained to thyroid status testing post-treatment by radioactive iodine (RAI) therapy for Graves' Disease (GD). Both adaptations centered around the judicious use of laboratory investigations to reduce costs of hyperthyroidism management. Conclusion: Our newly developed hyperthyroidism CPGs for Pakistan contain two context-specific modifications that prioritize patients' finances during the course of hyperthyroidism management and to limit the overuse of laboratory testing in a resource-constrained setting. Future research must investigate the cost-effectiveness and risk-benefit ratio of these modified recommendations. [ABSTRACT FROM AUTHOR]

Simple Summary: In the face of significant hurdles stemming from conflicts and resource constraints, Jordan has emerged as an exemplary paradigm, solidifying cancer care both locally and regionally. Despite the positive progress being made, a significant obstacle is emerging in the form of increasing rates of cancer, which is representative of a larger upsurge in non-communicable diseases. However, a thorough grasp of the various contributing factors is still lacking. Therefore, we aimed to carefully examine and discuss the current identified barriers that are hindering the achievement of optimal cancer care in Jordan. This narrative review explores the multifaceted barriers hindering access to quality cancer care in Jordan. A literature-based narrative review was undertaken to explore the current identified barriers to cancer care in Jordan. Four databases were searched using relevant keywords to identify key insights on barriers and proposed solutions. Key challenges and potential solutions were identified based on evidence from studies, reports, and initiatives. Medical services and infrastructure exhibit centralized disparities, impacting rural and underserved areas. Human resources shortages, geopolitical instability, and quality management issues pose significant challenges. Public awareness campaigns face hurdles in addressing the tobacco epidemic and late-stage diagnosis. Socioeconomic disparities, particularly in health insurance and urban–rural divides, further compound barriers. Refugees encounter distinct challenges, including late-stage diagnosis, financial barriers, and psychological distress. Despite multiple challenges, Jordan presents a model for regional development and health equity. This study not only contributes to improving cancer care in Jordan but also offers a roadmap for policymakers, healthcare practitioners, and researchers in similar contexts globally. Government initiatives, financial aspects, and proposed policy measures are examined as potential solutions. Recommendations include coordinated prevention strategies, enhanced screening uptake, training programs, the equitable distribution of facilities, and policy directives aligned with global commitments. The role of digital technologies, telemedicine, and community engagement models is emphasized. [ABSTRACT FROM AUTHOR]

Mexico is the third Latin American country with the most children and adolescents living with human immunodeficiency virus (ALHIV). There is a lack of information on the characteristics of this population. We aimed to describe the social and mental health characteristics of Mexican ALHIV. A census was conducted of all adolescent patients with HIV at a pediatric hospital (n = 47; mean age 14.39, S.D. = 3.65) and their caregivers. We collected data on socio-demographic characteristics, family, intelligence, mental health, adverse life events, substance use, treatment, knowledge of Antiretroviral Treatment (ART) and HIV, and biomarkers. Most cases were transmitted vertically and self-reported ART adherence was above 90%. Some obstacles to adherence were medicine discomfort, believing that they did not need it, and forgetfulness. The vulnerabilities were intellectual disability, adverse life events, possible mental health problems, and little knowledge of their illness and treatment. These findings suggest the importance of interventions to improve the perception and knowledge of HIV and ART to increase ART adherence. [ABSTRACT FROM AUTHOR]

The growing importance of Universal Design for Learning (UDL) as a framework for implementing inclusive education is acknowledged in the Global Education Monitoring report of 2020. There is a lack of evidence and little guidance on how to effectively implement UDL in low- and middle-income countries (LMIC). In this context, a scoping review of the literature was commissioned by CBM Christian Blind Mission, an international non-governmental organisation, to look for evidence of current UDL practices in LMIC. The aim was to identify existing research and current gaps, and make recommendations for capacity-development resources and materials in implementing UDL in LMIC. Twenty-one articles were included in this review, of which 13 were from the African continent. While eight of these 13 articles came from South Africa, other LMIC were represented by one or two papers each. The following themes emerged deductively: capacity building of teachers, levels of technology, diversity of target audience, role of communities and families, addressing systemic inequality, and policy supporting implementation. Inductive analysis was used to consider areas that did not fit into these predetermined themes, and additional themes emerged: disability and UDL, and challenges of implementing UDL. These themes are discussed and recommendations made. [ABSTRACT FROM AUTHOR]

A guideline for the management of hyperbilirubinemia in infants has recently been established in Indonesia, but physician acceptance and adherence to these standards are unknown. The objective of this study was to assess the current state of phototherapy practice and to determine if this was in-line with the Indonesian Hyperbilirubinemia Guideline. The study was done in the neonatal care units of Dr. Soetomo Hospital in Surabaya, Indonesia. We evaluated all babies on phototherapy between September 2019 and September 2020. The conformity to core elements in the national guideline was assessed on hyperbilirubinemia management for 89 infants, two-third of these being preterm and low birth weight. One-third of infants were commenced on phototherapy just based on transcutaneous bilirubin measurement. A significant proportion of infants had phototherapy ceased without bilirubin level assessment or confirmation that jaundice had significantly resolved. Almost all (95.9%) of the phototherapy sessions did not conform to guidelines, with the most common being inadequate exposure of the body surface area to light. In spite of a guideline adapted to be pragmatic and applicable to the local setting, healthcare practitioners were not sufficiently aligned, thus an urgent reassessment of the implementation and adoption of the current hyperbilirubinemia guideline is required. [ABSTRACT FROM AUTHOR]

The number of government institutes offering affordable super specialty and tertiary healthcare in India has traditionally not been able to keep pace with the growth in population, most of whom are too poor to be able to afford private healthcare services. To meet this mandate, 6 new institutes built on the template of the premier institute of the country—the All India Institute of Medical Sciences, New Delhi—were founded and began operations in 2012. Using the progress of our department as an example, the aim of this report is to outline the principles that were followed to set up the department of neurosurgery. The Department of Neurosurgery at All India Institute of Medical Sciences, Jodhpur, began providing services in August 2017. Data related to the inception and development of the department were collected. The department has grown during the past 5 years from 400 outpatients and 79 inpatients in 2017 to 11,144 outpatients and 1624 inpatients in 2022. Only 59 surgeries were performed in 2017 compared with 597 routine and 311 emergency procedures performed in 2022. Currently, the department has 7 faculty members performing all forms of complex skull base, craniovertebral junction, vascular, endovascular, epilepsy, and functional surgeries. A total of 134 studies have been reported in national and international journals, and 8 patents have been granted. We report the unique experiences of one department that could be useful as a template and as guidelines for the establishment process of a new department. [ABSTRACT FROM AUTHOR]

Background and aims: Network centrality, an indicator of an individual's importance and potential to drive behavioral change, is rarely used to select peer educators. Individual‐level predictors of network centrality might be useful to identify people who inject drugs (PWID) for potential roles as peer navigators or change agents in network‐based interventions in settings where sociometric data are unavailable. We assessed the relationship between network centrality and HIV prevention service engagement to determine whether centrally‐positioned PWID share measurable commonalities. Design: Observational study and survey using baseline data from a sociometric network cohort of PWID, enumerated using network software and biometric data (2017‐2020). Network ties corresponded to direct injection partnerships in the prior month. Setting: New Delhi, India. Participants: A total of 2512 PWID who were ≥18 years, provided written informed consent, and reported illicit injection drug use within the 24 months before study enrollment. Measurements Interviewer‐administered questionnaires measured demographics and substance use behaviors. Central versus peripheral network position was categorized using betweenness centrality 75th%ile. Logistic regression was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals (95%CI) between network position and HIV testing, medication for opioid use disorder (MOUD), or syringe service use. Lasso models selected predictors of central network position among 20 covariates detailing demographic, biologic, and substance use information. Predictive accuracy was evaluated using model performance metrics. Findings Overall, median age was 26 years (interquartile range 22–34); 99% were male; 628 were classified as central. Compared with PWID at the periphery, central PWID were more likely to use MOUD (aOR: 1.59, 95%CI: 1.30–1.94) and syringe services (aOR: 2.91, 95%CI: 2.25, 3.76) in the prior six months. Findings for HIV testing were inconclusive (aOR: 1.30, 95%CI: 1.00–1.69). The lasso variable selector identified several predictors of network centrality: HIV and hepatitis C infection, number of PWID seen in the prior month, injecting heroin and buprenorphine (vs. heroin only) six months prior, sharing injection equipment six months prior, experiencing drug overdose in the past year, and moderate/severe depression (vs. none/mild). Average agreement between model‐predicted vs. observed values was 0.75; area under the receiver operator curve was 0.69. Conclusions: In a socioeconomic network of people who inject drugs (PWID) in New Delhi, India, there are common characteristics among individuals based on their network position (central vs. peripheral) but individual‐level predictors have only moderate predictive accuracy. Although central network members appear to be more likely to use HIV prevention services than peripheral network members, their potential as change agents may be limited by other factors that impede their ability to adopt or promote HIV prevention service use. [ABSTRACT FROM AUTHOR]

Background & objectives Traumatic injuries, especially in low- and middle- income countries (LMICs), present significant challenges in patient resuscitation and healthcare delivery. This study explores the role of trauma training programmes in improving patient outcomes and reducing preventable trauma-related deaths. Methods A dual approach was adopted, first a literature review of trauma training in LMICs over the past decade, along with a situational assessment survey. For the review of literature, we searched the PubMed database to identify key challenges and innovative practices in trauma training programmes in LMIC's. The survey, conducted among healthcare professionals in various LMICs, collected direct insights into the challenges and the status of trauma training programmes in these countries. Results The literature review analysed 68 articles, with a significant focus on the African subcontinent (36 studies), underscoring the region's emphasis on research on trauma training programmes. These studies mainly targeted physicians, clinicians, postgraduate trainees in surgical or anaesthesia fields and medical students (86.8%), highlighting innovations like simulation-based training and the cascading training model. In our survey, we received 34 responses from healthcare professionals in India, Belarus, Azerbaijan, Nepal and Pakistan. Around 52.9 per cent reported the absence of established trauma training programmes in their settings. The majority of respondents advocated for hands-on, simulation-based training (94.1%) and emphasised the need for structured training programmes (85.3%), feedback sessions (70.6%) and updated protocols (61.8%). This combined data underlined the critical gaps and potential improvements in trauma training programmes and resuscitation practices in LMICs. Interpretation & conclusions Effective trauma care in LMICs requires the establishment of comprehensive, tailored training programmes. Key interventions should include subsidization of pre-existing trauma courses and the adoption of World Health Organization Guidelines for essential trauma care, implementation of trauma quality improvement and review processes and the incorporation of focused assessment with sonography in trauma (FAST) in emergency departments. These steps are crucial for equipping healthcare workers with vital skills and knowledge, fostering a culture of continuous learning and improvement in the realm of trauma care. [ABSTRACT FROM AUTHOR]

Distraction osteogenesis is utilized to increase intracranial volume in the treatment of restrictive pathologies, most commonly syndromic synostosis. Children too young for open calvarial vault expansion or other systemic or local contraindications to a direct reconstructive approach benefit greatly from distraction osteogenesis, typically addressing posterior vault expansion. Wound infection, cerebrospinal fluid (CSF) leak, device failure, need for a second surgery for removal, and cost, are issues that can limit the use of this approach. These challenges are more pronounced in low- and middle-income countries (LMICs) due to lack of access to the device, the financial burden of the need for a second surgery, and the severity of the implications of infection and CSF leak. Over the last five decades, there has been an increased acceptance of bioresorbable instrumentation in craniofacial surgery. Poly L-lactic acid, polyglycolic acid, and polydioxanone are the most commonly used polymers. New resorbable fixation tools such as ultrasound-activated pins and heat-activated pins are superior to conventional bioresorbable screws in allowing attachment to thinner bone plates. In this paper, we present a review of the literature on cranial vault distraction and the use of bioresorbable materials and propose a novel design of a fully absorbable cranial distractor system using external magnetic distraction control, eliminating the need for external activation ports and a second surgery to remove the hardware. The application of this technology in LMIC settings could advance access to care and treatment options for patients with syndromic synostosis. [ABSTRACT FROM AUTHOR]

Rare diseases (RD) pose significant challenges for healthcare systems globally, necessitating the establishment of disease registries to facilitate research, diagnosis, and treatment. This article explores the development of a comprehensive national RD registry for India, informed by insights gained through interactions with experts from India and the Asia-Pacific Economic Cooperation (APEC) region. The social and technological challenges involved in creating and maintaining a national RDs registry are highlighted. Moreover, the roles and responsibilities of different stakeholders are discussed. Additionally, the RD-RAP (Registry and Analytics Platform) framework is also discussed, which is an analytics-based RD registry model with multi-stakeholder end-user utility. Although developed for the APEC region, the RD-RAP framework holds promise in the Indian context. This article discusses the key features of the RD-RAP framework that are relevant and applicable to the Indian setting. By leveraging these insights, this research aimed to provide valuable guidance for the development and operation of a comprehensive national RD registry in India. [ABSTRACT FROM AUTHOR]

A diagnosis of autism typically depends on clinical assessments by highly trained professionals. This high resource demand poses a challenge in low-resource settings. Digital assessment of neurodevelopmental symptoms by non-specialists provides a potential avenue to address this challenge. This cross-sectional case-control field study establishes proof of principle for such a digital assessment. We developed and tested an app, START, that can be administered by non-specialists to assess autism phenotypic domains (social, sensory, motor) through child performance and parent reports. N = 131 children (2–7 years old; 48 autistic, 43 intellectually disabled and 40 non-autistic typically developing) from low-resource settings in Delhi-NCR, India were assessed using START in home settings by non-specialist health workers. The two groups of children with neurodevelopmental disorders manifested lower social preference, greater sensory interest and lower fine-motor accuracy compared to their typically developing counterparts. Parent report further distinguished autistic from non-autistic children. Machine-learning analysis combining all START-derived measures demonstrated 78% classification accuracy for the three groups. Qualitative analysis of the interviews with health workers and families of the participants demonstrated high acceptability and feasibility of the app. These results provide feasibility, acceptability and proof of principle for START, and demonstrate the potential of a scalable, mobile tool for assessing neurodevelopmental conditions in low-resource settings. Autism is diagnosed by highly trained professionals– but most autistic people live in parts of the world that harbour few or no such autism specialists and little autism awareness. So many autistic people go undiagnosed, misdiagnosed, and misunderstood. We designed an app (START) to identify autism and related conditions in such places, in an attempt to address this global gap in access to specialists. START uses computerised games and activities for children and a questionnaire for parents to measure social, sensory, and motor skills. To check whether START can flag undiagnosed children likely to have neurodevelopmental conditions, we tested START with children whose diagnoses already were known: Non-specialist health workers with just a high-school education took START to family homes in poor neighbourhoods of Delhi, India to work with 131 two-to-seven-year-olds. Differences between typically and atypically developing children were highlighted in all three types of skills that START assesses: children with neurodevelopmental conditions preferred looking at geometric patterns rather than social scenes, were fascinated by predictable, repetitive sensory stimuli, and had more trouble with precise hand movements. Parents' responses to surveys further distinguished autistic from non-autistic children. An artificial-intelligence technique combining all these measures demonstrated that START can fairly accurately flag atypically developing children. Health workers and families endorsed START as attractive to most children, understandable to health workers, and adaptable within sometimes chaotic home and family environments. This study provides a proof of principle for START in digital screening of autism and related conditions in community settings. [ABSTRACT FROM AUTHOR]

• Several obstacles exist limiting research within emergency care from low- and middle-income countries (LMICs) therefore research effort must be targeted towards addressing priorities. • Measures to increase research addressing priority questions within LMICs are needed as evidence derived from vastly different high-income country settings is not directly applicable to LMIC populations. • Establishing research priorities can ensure the limited studies carried out in LMICs are targeted towards existing emergency care knowledge gaps and result in efficient coordinated work. Low- and middle-income countries (LMICs) are disproportionally affected by conditions requiring emergency care but there are limited contextually appropriate studies performed within these settings involving the patient population and healthcare systems they aim to benefit. Over the past five years, researchers in the Western Cape of South Africa have produced approximately 20 % of all emergency care publications from Africa, yet no agreed list of research priorities exists. Establishing research priorities, via recognised consensus methods, can ensure that efforts and resources in LMICs are more appropriately targeted to the need. Using a modified Delphi study, we invited a range of public and private representatives from different professional emergency care cadres within the Western Cape to identify current evidence gaps and consensus research priorities across the four areas of the WHO Emergency Care Systems framework: scene care, prehospital care, facility-based care, and the emergency care system itself. We then purposively selected eleven experts holding key academic and management positions to form a panel and perform a nominal group technique process to discuss these identified research priorities and establish a final list of priority research questions. Forty of the sixty-six (61 %) emergency care professionals invited contributed to the Delphi phase of the study, with representation from all professional cadres. After deduplication, 154 research topics were identified in the first round. In the second round, 94 (61 %) topics were considered research priorities by at least 80 % of participants. Following the nominal group technique discussion, 26 questions were established as consensus research priorities having been ranked as a top ten priority by over 50 % of panellists. We were able to successfully collate expert opinion and identify existing emergency care knowledge gaps within the Western Cape province of South Africa. Key topics identified for future work included questions on current health-seeking behaviour, dispatch, interfacility transfer, and staff burnout. [ABSTRACT FROM AUTHOR]

Plastic waste management is a complicated challenge that in recent years has gained attention as a global policy priority. In low- and middle-income countries (LMIC), waste management is heterogeneous and context-specific and many organizations provide needed waste management services, including entrepreneurs. Sustainable entrepreneurs are uniquely positioned to provide these services; however, they face challenges such as limited support system and lack of capacity. The goal of this paper is to understand critical characteristics of successful plastic waste management ventures in LMIC and operationalize those insights into a strategic tool. A wide variety of successful ventures from diverse LMIC contexts are systematically analyzed to identify which factors contribute to their business viability and ability to deliver services. The identified success factors were built into a tool, the Plastic Venture Builder (PVB), based on the multi-criteria analysis methodology. This is validated using empirical cases, tested on projects currently in development and discussed with experts in the field. The results show that political, economic, financial, technological, operational, social, team and legal factors contribute to success; however pathways to success are diverse. We identify a strong team as the most critical factor, whereas financial, political and social factors have the least impact. The PVB can be used by entrepreneurs who want to set up or improve plastic waste management ventures by identifying weak spots or avenues for improvement. The assessment framework can also be used by policy makers, development agencies and financing organizations who want to support or assess waste management initiatives by prioritizing their resources to match the identified critical factors. [ABSTRACT FROM AUTHOR]

Background: Low and middle-income countries like India anticipate rapid population aging and increases in dementia burden. In India, dementia screening scales originally developed in other contexts need to be assessed for feasibility and validity, given the number of different languages and varying levels of literacy and education. Method: Using data from the Longitudinal Aging Study in India-Diagnostic Assessment of Dementia (N = 4,028), we characterize the performance of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). We described patterns and correlates of missingness, evaluated the psychometric properties of the scale, and assessed criterion validity against the Hindi Mental State Examination (HMSE) using linear regression. Results: Several IQCODE items had high levels of missingness, which was associated with urbanicity, respondent's gender, and informant's generation (same vs. younger generation). Full IQCODE scores showed strong criterion validity against the HMSE; each 1-point increase in IQCODE score was associated with a 3.03-point lower score on the HMSE, controlling for age, gender, and urbanicity. The statistically significant association between IQCODE and HMSE was stronger in urban than rural settings (p-value for interaction = 0.04). Associations between IQCODE and HMSE remained unchanged after removing the three items with the highest levels of differential missingness (remembering addresses and telephone numbers, ability to work with familiar machines, ability to learn to use new gadget or machine). Conclusion: Findings raise questions about the value of including items with high proportions of missingness, which may signal cultural irrelevance, while removing them did not affect criterion validity. [ABSTRACT FROM AUTHOR]

BackgroundTraumatic spinal cord injury (TSCI) is not only a life-threatening but also life changing event that happens suddenly, the effects extends beyond the TSCI survivors to include their families. In Rwanda to the best knowledge of authors, there is no published information on the epidemiology of TSCI. The aim of this study was therefore to determine the incidence rate, etiology and injury characteristics of TSCI.MethodsAll survivors of acute TSCI who met the inclusion criteria were prospectively recruited for a one-year period. The International Spinal Cord Injury Core Data Set was used to collect the minimum set of variables to facilitate worldwide comparison of epidemiological data, while the International Standards for the Neurological Classification was used to categorize TSCI according to the American Spinal Injury Association Impairment Scale (AIS). Data were collected by trained physiotherapists.Study designA prospective, open-ended, cohort study design.SettingAll referral hospitals within the Republic of Rwanda.ResultsOverall, 122 adult individuals sustained a TSCI between 10th October 2019 until 9th October 2020 and all consented to take part in the study. The male-to-female ratio was 3.9:1, and the mean age was 42.5 (SD = ±14.8) years. The crude incidence rate of TSCI was 22.2 per million people (95% CI, 18.4–26.5) with significant differences in sex-adjusted rates for all age groups while men 46 years of age and older presented with the highest incidence. The leading causes of TSCI were falls (73.8%), followed by road traffic accidents (18.9%). Moreover, SCI lesions of the cervical region (n = 69) were the most common, followed by the lumbosacral region (n = 27). Fifty-one (41.8%) participants were diagnosed as complete injury, i.e., AIS A, while incomplete injury category C constituted 35 (28.7%).ConclusionThe incidence and etiology of TSCI in Rwanda are comparable to worldwide estimates and figures. Largely, the etiology of TSCI are preventable as it is caused due to falls and road traffic accidents. There is a need to consider preventive strategies and policies on activities that predispose people to falls. Policies should focus largely on occupational health and safety in both formal and informal sectors of work.

Hypertension is the leading preventable cause of death worldwide. Two-thirds of people with hypertension live in Low- and Middle-Income Countries (LMIC). However, epidemiological data necessary to address the growing burden of hypertension and other Non-Communicable Diseases (NCDs) in LMICs are severely lacking. Electronic Health Records (EHRs) are an emerging source of epidemiological data for LMICs, but have been underutilized for NCD monitoring. The objective of this study was to estimate the prevalence of hypertension in a rural Indigenous community in Guatemala using EHR data, describe hypertension risk factors and current treatment in this population, and demonstrate the feasibility of using EHR data for epidemiological surveillance of NCDs in LMIC. We conducted a cross-sectional analysis of 3646 adult clinic visits. We calculated hypertension prevalence using physician diagnosis, antihypertensive treatment, or Blood Pressure (BP) ≥140/90 mmHg. We noted antihypertensives prescribed and BP control (defined as BP

Background: Breast cancer (BC) is the most incident tumor and, consequently, any new intervention can potentially promote a considerable budget impact if incorporated. Cost-effectiveness (CE) studies assist in the decision-making process but may be influenced by the country's perspective of analysis and pharmaceutical industry funding. Methods: A systematic review of Medline, Scopus, and Web of Science from January 1st, 2012 to July 8th, 2022 was conducted to identify CE studies of tumor-targeted systemic-therapies for advanced BC. Articles without incremental cost-effectiveness ratio calculations were excluded. We extracted information on the country and class of drug studied, comparator type, authors’ conflicts of interest (COI), pharmaceutical industry funding, and authors' conclusions. Results: 71 studies comprising 204 CE assessments were included. The majority of studies were from the United States and Canada (44%), Asia (32%) and Europe (20%). Only 8% were from Latin America and none from Africa. 31% had pharmaceutical industry funding. The most studied drug classes were cyclin-dependent-kinase inhibitors (29%), anti-HER2 therapy (23%), anti-PD(L)1 (11%) and hormone therapy (11%). Overall, 34% of CE assessments had favorable conclusions. Pharmaceutical industry-funded articles had a higher proportion of at least one favorable conclusion (82% vs. 24%, p-value

Risk stratification and molecular targeting have been key to increasing cure rates for pediatric cancers in high-income countries. In contrast, precise diagnosis in low-resource settings is hindered by insufficient pathology infrastructure. The Global HOPE program aims to improve outcomes for pediatric cancer in Sub-Saharan Africa (SSA) by building local clinical care and diagnostic capacity. This study aimed to assess the feasibility of implementing molecular assays to improve leukemia diagnoses in SSA. Custom NanoString nCounter gene fusion assays, previously validated in the US, were used to test samples from suspected leukemia patients. The NanoString platform was chosen due to relatively low cost, minimal technical and bioinformatics expertise required, ability to test sub-optimal RNA, and rapid turnaround time. Fusion results were analyzed blindly, then compared to morphology and flow cytometry results. Of 117 leukemia samples, 74 were fusion-positive, 30 were negative, 7 were not interpretable, and 6 failed RNA quality. Nine additional samples were negative for leukemia by flow cytometry and negative for gene fusions. All 74 gene fusions aligned with the immunophenotype determined by flow cytometry. Fourteen samples had additional information available to further confirm the accuracy of the gene fusion results. The testing provided a more precise diagnosis in >60% of cases, and 9 cases were identified that could be treated with an available tyrosine kinase inhibitor, if detected at diagnosis. As risk-stratified and targeted therapies become more available in SSA, implementing this testing in real-time will enable the treatment of pediatric cancer to move toward incorporating risk stratification for optimized therapy.

Livestock associated antimicrobial resistance (AMR) can reduce productivity and cause economic losses, threatening the livelihoods of poor farming communities in low-income settings. We investigated the practices and risk factors for increased antibiotic use, and AMR in Escherichia coli including resistance to human critically important antibiotics like cefotaxime and colistin in semi-intensive and free-range poultry farms in Uganda. Samples and farm management data were collected from 402 poultry farms in two districts between October 2021 to March 2022. Samples were processed to isolate E. coli and to quantify cefotaxime (CTX) and colistin (COL) resistant coliforms. The identification of presumptive E. coli isolated on MacConkey agar without antibiotics, was confirmed by matrix-assisted laser desorption/ionization-time of flight mass spectrometry and subjected to antimicrobial susceptibility testing by disk diffusion using EUCAST guidelines. Our models indicated that antibiotic use was associated with production intensity, and type of feed used. Moreover, semi-intensive farmers had better knowledge on antibiotic use compared to farmers in the free-range system. In semi-intensive farms, 52% harbored COLR and 57% CTXR coliforms. In free-range farms, 54% had COLR and 67% CTXR coliforms. Resistance to tetracycline, ampicillin and enrofloxacin were more frequent in semi-intensive farms compared to the free-range farms. Multi-drug resistant E. coli were identified in both poultry production systems despite different management and antibiotic use practices. There was no significant relationship between antibiotic use and resistance for the six antibiotics tested.

BackgroundThe evaluation of existing resources and services is key to identify gaps and prioritize interventions to expand care capacity for children with central nervous system (CNS) tumors. We sought to evaluate the resources for pediatric neuro-oncology (PNO) in Mexico.MethodsA cross-sectional online survey with 35 questions was designed to assess PNO resources and services, covering aspects including number of patients, infrastructure, human resources, and diagnostic and treatment time intervals. The survey was distributed to the members of the Mexican Association of Pediatric Oncology and Hematology (AMOHP) who belong to the nation’s many different health systems.ResultsResponses were obtained from 33 institutions, distributed throughout the country and part of the many health systems that exist in Mexico. Twenty-one (64%) institutions had less than 10 new cases of pediatric CNS tumors per year. Although 30 (91%) institutions saw pediatric patients up to the age of 18 years, 2 (6%) had a cutoff of 15 years. Twenty-four (73%) institutions had between 1 and 3 pediatric oncologists providing care for children with CNS tumors. Six (18%) institutions did not have a neurosurgeon, while 19 (57%) institutions had a pediatric neurosurgeon. All centers had a pathology department, but 13 (39%) institutions only had access to basic histopathology. Eleven (33%) institutions reported histopathological diagnoses within one week, but 3 (9%) took more than 4 weeks. Radiotherapy for pediatric CNS tumors was referred to outside centers at 18 (55%) institutions. All centers had access to conventional cytotoxic chemotherapy, but only 6 (18%) had access to targeted therapy. Eighteen (55%) respondents estimated a survival rate of less than 60%. Fifteen (45%) centers attributed the main cause of mortality to non-tumor related factors, including infection and post-surgical complications.ConclusionsThis is the first national assessment of the resources available in Mexico for the treatment of CNS tumors. It shows disparities in resource capacity and a lack of the specific and efficient diagnoses that allow timely initiation of treatment. These data will enable the prioritization of collaborative interventions in the future.

IntroductionApproximately 70% of diarrheal cases in Kenya are attributed to ingestion of contaminated food and water and costs an estimated $ 1 billion USD due to morbidity and cost of treatment. This study aimed to assess the levels of microbiological contamination of meat sold in selected butcheries in Nairobi and the handling practices of butcher shop attendants.MethodsA cross-sectional study design was used during which 200 meat samples were collected, and meat handling practices were observed. Total coliforms and Escherichia coli were enumerated using 3M™ Petrifilm® count plates. Additionally, quantification of tetracycline- and cefotaxime-resistant Enterobacteriaceae was done on agar plates containing the respective antibiotics. Bacterial species were confirmed by Matrix-Assisted Laser Desorption/Ionization-Time of Flight mass spectrometry.Results and discussionSeventy two percent and 84% of the samples had E. coli and total coliforms respectively above the acceptable regulatory limits (i.e. E. coli >100 CFU/g, Total coliforms >361 CFU/g,) respectively as per the Kenya Bureau of Standards South African microbiological standards the European Union. Enterobacteriaceae resistant to tetracycline and cefotaxime were detected in 35% and 9.5% of the samples respectively. Eighty-five percent of the butcher shop attendants neither washed their hands before nor after handling the meat, 91% handled money while selling meat concurrently, and 99% did not wear gloves while handling meat. These poor meat handling practices coupled with the presence of microbial loads above the regulatory acceptable limits imply an increased risk of foodborne illness to consumers. Therefore, there is an urgent need for education of butcher shop attendants on appropriate handling of meat, highlighting the importance of good hygienic practices and their relationship to food safety, and provision of incentives for behavior change. This study is important and serves to inform policymakers in the identification of key control points for designing meat safety intervention(s).

Emma R Lawrence,1 Bela J Parekh,2 Ruth Owusu-Antwi,3 Noah Newman,2 Colin B Russell,1 Titus K Beyuo,4,5 Michael Yeboah,6 Samuel A Oppong,4,5 Cheryl A Moyer1,7 1Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA; 2University of Michigan Medical School, Ann Arbor, MI, USA; 3Department of Behavioural Sciences, Kwame Nkrumah University of Science and Technology/ Psychiatry Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana; 4Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana; 5Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Korle Bu, Accra, Ghana; 6Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana; 7Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USACorrespondence: Ruth Owusu-Antwi, Department of Behavioural Sciences, Kwame Nkrumah University of Science and Technology/ Psychiatry Unit, Komfo Anokye Teaching Hospital, Accra Road, Kumasi, Ashanti Region, Ghana, Tel +233244650245, Email rucha_2001@yahoo.comPurpose: Globally, the COVID-19 pandemic has brought attention to the impact of negative patient outcomes on healthcare providers. In Ghana, obstetric providers regularly face maternal and neonatal mortality, yet limited research has focused on provision of mental health support for these providers. This study sought to understand how obstetric providers viewed seeking mental health support after poor clinical outcomes, with a focus on the role of mental health stigma.Patients and Methods: Participants were 52 obstetric providers (20 obstetrician/gynecologists and 32 midwives) at two tertiary care hospitals in Ghana. Five focus groups, led by a trained facilitator and lasting approximately two hours, were conducted to explore provider experiences and perceptions of support following poor maternal and neonatal outcomes. Discussions were audiotaped and transcribed verbatim, then analyzed qualitatively using grounded theory methodology.Results: Most participants (84.3%, N=43) were finished with training, and 46.2% (N=24) had been in practice more than 10 years. Emerging themes included pervasive stigma associated with seeking mental health care after experiencing poor clinical outcomes, which was derived from two overlapping dimensions. First, societal-level stigma resulted from a cultural norm to keep emotions hidden, and the perception that psychiatry is equated with severe mental illness. Second, provider-level stigma resulted from the belief that healthcare workers should not have mental health problems, a perception that mental health care is acceptable for patients but not for providers, and a fear about lack of confidentiality. Despite many providers acknowledging negative mental health impacts following poor clinical outcomes, these additive layers of stigma limited their willingness to engage in formal mental health care.Conclusion: This study demonstrates that stigma creates significant barriers to acceptance of mental health support among obstetric providers. Interventions to support providers will need to respect provider concerns without reinforcing the stigma associated with seeking mental health care.Keywords: provider burnout, therapy, sub-Saharan Africa, LMIC

Introduction: Burundi, like many African nations, faces challenges in providing accessible emergency care. The aim of this study was to assess the type of staff training, accessibility to imaging, and availability of essential equipment in the district hospitals of Burundi in order to inform strategic planning for healthcare delivery. Methods: In June 2022 an online survey was sent to each district hospital of the country. Complete responses were analysed and, where appropriate, significance determined by chi-square analysis, with p

Danai T Zhou,1 Taona E Mudhluli,1,2 Lindsay J Hall,3– 5 Justen Manasa,1,6 Shungu Munyati6 1Department of Laboratory Diagnostic and Investigative Sciences, University of Zimbabwe, Harare, Zimbabwe; 2Department of Biochemistry, Midlands State University, Gweru, Zimbabwe; 3Gut Microbes & Health, Quadram Institute Bioscience, Norwich, UK; 4Norwich Medical School, University of East Anglia, Norwich, UK; 5Intestinal Microbiome, Technical University of Munich, Freising, Germany; 6Department of Laboratory Sciences, Biomedical Research and Training Institute, Harare, ZimbabweCorrespondence: Danai T Zhou, Department of Laboratory Diagnostic and Investigative Sciences, University of Zimbabwe, Box A 178, Avondale, Harare, Zimbabwe, Email dzhou@medsch.uz.ac.zw; danaizh@yahoo.co.ukBackground: Gut microbiota play a key role in host health, with certain Bifidobacterium strains critical for immune development. The healthy gut of breastfed infants is dominated by these pioneer microbes, especially the strains that feed on human milk oligosaccharides.Objective: This is a scoping review of gut microbiome research from Zimbabwe. It focuses on distribution and dynamic changes of bifidobacteria, and milk components that promote growth of microbes in infants, together with the distribution of associated gut microbes in adults.Design: Online databases were searched for publications from 2000 to 2023.Results and Analysis: Fourteen publications on microbiota of infants and adults were included in this scoping review. Most were cross-sectional, while three were clinical trials/cohort protocols. Publications focused on pediatrics (78.5%), pregnant women (14.3%), and men (7.2%). Zimbabwe has a high burden of HIV; hence 35.7% of study populations were delineated by HIV status. The laboratory methods used included shotgun metagenomics (62%) or 16S rRNA gene amplicon sequencing. Almost 85% of the studies focused on total microbiome profiles and rarely reported the distribution of different Bifidobacterium species and variants. None of the papers studied human breast milk composition. There were reports of reduced abundance of beneficial genera in pregnant women, children, and adolescents living with HIV. Additionally, gut microbiota was reported to be poorly predictive of child growth and vaccine response, though this was not conclusive.Conclusion: There are few studies that characterize the gut microbiome by Zimbabwe-based researchers. However, studies on strain level diversity of Bifidobacterium and other key microbes, and their role in health during and beyond infancy, lag behind in Zimbabwe and other low- and middle-income countries. Such cohorts are needed to inform future mechanistic studies and downstream translational work such as next-generation probiotics and prebiotics.Keywords: Bifidobacterium, gut microbiome, human milk oligosaccharides, LMIC, prebiotics, probiotics, Zimbabwe

UNESCO’s Global Education Monitoring Report (2020) strongly recommends the adoption of Universal Design for Learning (UDL) at the government level so that it becomes an integral part of countries’ inclusive education policies. However, UDL has largely been developed in high-income countries with technology as a central theme. The question is whether the purported benefits of the UDL approach can translate into low and middle-income country (LMIC) contexts. This study explores the relevance and fit of UDL to LMIC contexts by use of interviews (either individual or group) with 12 representatives of international agencies, non-governmental organizations (NGOs), and UDL experts who have experience in providing inclusive education services in LMICs. Three themes are reported: understanding of UDL, UDL supporting inclusive education, and UDL in teacher-training initiatives and capacity building. The concept of UDL is not new in LMICs, although the name may be. The potential for UDL to support inclusive education in LMICs is recognized. UDL needs to be mainstreamed in teacher training programs, and its implementation should be adapted to respond to the contextual realities of LMICs. The encounter between UDL proponents from high-income countries and education stakeholders in LMICs should be mutually enriching rather than imposing the approach from high-income countries on those in LMICs.

Background: Data on outcomes in children with acute lymphoblastic leukaemia (ALL) who are on Berlin-Frankfurt-Munster (BFM)-based chemotherapy protocol is scarce from India. We share experience on the survival of children with ALL treated on the modified IC BFM 2002 protocol. Methods: Children (1–18 years) diagnosed with ALL between January 1, 2011 and January 1, 2021 at BLK-MAX Super Specialty Hospital were analyzed retrospectively. Patients were treated with modified IC BFM 2002 protocol. Data on the type of leukaemia, risk status, minimal residual disease (MRD), cytogenetic, and molecular genetics were collected. Disease free survival (DFS) and overall survival (OS) were calculated. Results: Hundred (88 B-cell, 12 T-cell) patients with ALL were evaluated. The median age at presentation was 6.5 years. According to the BFM risk stratification, 35 children were standard-risk, 45 were intermediate and 20 were high-risk. Bone marrow aspiration for MRD by flow cytometry on day 33 of induction chemotherapy was performed in 61 patients. One patient died on day 50 of induction. Day 78 MRD was performed in 60 patients. Day 78 MRD positivity was used for treatment escalation. There were 18 deaths. DFS as on 1st July 2023 for standard, intermediate and high-risk patients was 89%, 85% and 55% respectively. Overall survival in all risk groups was 82%. Conclusion: Treating childhood ALL with BFM-based chemotherapy protocol is feasible in developing countries without major modifications and with results comparable to those reported in Western literature.

Background: Wilms Tumor (WT) is a highly curable cancer if treatment is appropriate and timely. The outcomes and prognostic factors in a large low- and middle-income country (LMIC) tertiary center were assessed. Materials and methods: Retrospective review of data of all patients, 0–15 years diagnosed between 2010 and 2020 with WT. Kaplan Meier curves were used for survival analysis, and the chi-square test was used for multivariate analysis. Results: Of the 40 patients enrolled (median age: 38 months) in the cohort, 10 had metastatic disease. The most common site of metastasis was lungs (6/10). Nine (22.5%) abandoned treatment. Large tumor (>500 ml) volume was found in half the patients at diagnosis. The majority of patients were treated per the SIOP approach. Out of 34 who went for surgery, 31 received neoadjuvant chemotherapy with tumor shrinkage to less than 500 ml in 26/31 (80%). Maximum tumor shrinkage was observed in the SIOP low-risk group (p

Understanding the impact of neighborhood context on viral suppression outcomes may help explain health disparities and identify future interventions. We assessed the relationship between individual characteristics, neighborhood socioeconomic context, and viral suppression using multilevel logistic regression models. Adults with HIV initiating antiretroviral therapy (ART) between 2000 and 2017, who resided in Rio de Janeiro and had an HIV-1 RNA level (viral load) measured 90-270 days after ART initiation were included. Overall, 83.9% achieved viral suppression. Participants who were older, had a higher level of education, and identified as heterosexual cisgender men and cisgender men-who-have-sex-with-men had increased odds of viral suppression. Later calendar year of ART initiation carried the strongest association with viral suppression, reflecting the increased effectiveness and tolerability of ART over time. Neighborhood socioeconomic indicators did not predict viral suppression in unadjusted or adjusted analyses, which may result from the integrated care provided in our health care facility together with Brazil's universal treatment.

BackgroundDrug overdoses are prevalent in low- and middle-income countries but are scarcely reported in the literature. We report on an opioid overdose reversal and naloxone distribution program that was instituted at the first safe consumption site in Latin America.MethodsA cross-sectional analysis of witnessed drug overdoses and naloxone distribution between 1 June 2019 and 31 May 2021 in Mexicali, Mexico. Case report forms were entered in an electronic database. Trends in overdose and naloxone distribution were described. Comparisons were made before and after the COVID-19 pandemic was declared in the city. Maps were created to represent the geographic distribution of overdose in the city.ResultsDuring the study period 1,534 doses of naloxone were distributed throughout the community. In addition, there were 464 overdoses reported during this period, of which 4 were fatal. There was a 30% increase in reported overdoses from the period before the COVID-19 pandemic to the period after the pandemic was declared (p = 0.03). Most common substance reported included heroin (93%), sedatives (21%), methamphetamine (16%) and fentanyl (14%). Naloxone was given in 96% of cases (median 1 dose, IQR 1-2 doses) and emergency services were called in 20% of cases.ConclusionsAn opioid overdose reversal program in Mexicali, Mexico was able to distribute naloxone and register drug overdoses between 2019 and 2021 as a harm reduction strategy. This adds to the growing body of literature on the impact of community-based programs on preventing fatal overdoses and the potential for implementation in low-resource settings.

BackgroundPre-exposure prophylaxis (PrEP) use in Brazil remains low despite free national access. We explored associations of HIV knowledge and internalized homonegativity with PrEP use among PrEP-eligible men who have sex with men (MSM).MethodsBrazilian Hornet users completed an online, cross-sectional survey in February-March 2020. We included cis-men ≥18 years old who reported recent sex with men and were PrEP-eligible per the following: condomless anal intercourse, partner(s) living with HIV, transactional sex, and/or sexually transmitted infection. Our outcome was current PrEP use, defined by the response, "I am currently taking PrEP." Key predictors included the HIV/AIDS Knowledge Assessment (HIV-KA) and Reactions to Homosexuality Scale (RHS); higher scores indicate greater knowledge and greater internalized homonegativity, respectively. Scales were standardized for analysis. Associations with current PrEP use were estimated using adjusted odds ratios (aOR) with 95% confidence intervals (95%CI).FindingsAmong 2398 PrEP-eligible MSM, n = 370 (15·4%) reported current PrEP use. Increasing HIV-KA scores were associated with greater odds of PrEP use (aOR 1·70 [95%CI 1·41-2·04], p < 0·001), and increasing RHS scores with lower odds of PrEP use (aOR 0·83 [95%CI 0·73-0·96], p = 0·010). PrEP use was lower among 18-24 versus 40+-years-old MSM (aOR 0·43 [95%CI 0·27-0·69], p = 0·005), and in Black versus White/Asian respondents (aOR 0·51 [95%CI 0·31-0·85], p = 0·040).InterpretationAmong PrEP-eligible Brazilian MSM, HIV knowledge was associated with increased PrEP use and internalized homonegativity with decreased use. Wider dissemination of HIV prevention knowledge and addressing stigma experienced by MSM could promote increased PrEP use.FundingNational Institute of Mental Health, Fiocruz, Conselho Nacional de Desenvolvimento Científico e Tecnológico.

BackgroundEggs are a rich source of choline, an essential nutrient important for child growth and development. In a randomized trial of 1 egg/d in young children in Ecuador, an egg intervention led to significant improvements in growth, which were partially mediated by increased plasma choline concentration. A similar trial in Malawi (clinicaltrials.gov: NCT03385252) found little improvement in child growth or development.ObjectivesWe aimed to evaluate the effect of 1 egg/d for 6 mo on plasma choline concentrations in Malawian children enrolled in a randomized trial.MethodsInfants aged 6-9 mo in rural Malawi were randomly assigned to receive 1 egg/d (n = 331) or serve as a nonintervention control (n = 329) for 6 mo. Anthropometric, developmental, and dietary data were collected at baseline and 6-mo follow-up, along with a blood draw. Plasma choline, betaine, dimethylglycine, trimethylamine N-oxide (TMAO), and DHA were measured at both time points using ultrahigh performance liquid chromatography-tandem MS (n = 200 per group). Linear regression analysis was used to determine the difference in plasma choline and related metabolites between groups after 6 mo of intervention.ResultsPlasma choline, betaine, dimethylglycine, and DHA concentrations did not differ between groups at 6-mo follow-up. Plasma TMAO was significantly (26%; 95% CI: 7%, 48%) higher in the egg intervention group in a fully adjusted model.ConclusionsProvision of 1 egg/d for 6 mo did not result in increases in plasma choline or related metabolites, except TMAO. This could partially explain the lack of effect on growth and development. Additional interventions are needed to improve choline status, growth, and development in this population.

Cancer incidence and mortality rates continue to rise globally, a trend mostly driven by preventable cancers occurring in low-and middle-income countries (LMICs). There is growing concern that many LMICs are ill-equipped to cope with markedly increased burden of cancer due to lack of comprehensive cancer control programs that incorporate primary, secondary, and tertiary prevention strategies. Notably, few countries have allocated budgets to implement such programs. In this review, we utilize a socio-ecological framework to summarize primary (risk reduction), secondary (early detection), and tertiary (treatment and survivorship) strategies to reduce the cancer burden in these countries across the individual, organizational, community, and policy levels. We highlight strategies that center on promoting health behaviors and reducing cancer risk, including diet, tobacco, alcohol, and vaccine uptake, approaches to promote routine cancer screenings, and policies to support comprehensive cancer treatment. Consistent with goals promulgated by the United Nations General Assembly on Noncommunicable Disease Prevention and Control, our review supports the development and implementation of sustainable national comprehensive cancer control plans in partnership with local communities to enhance cultural relevance and adoption, incorporating strategies across the socio-ecological framework. Such a concerted commitment will be necessary to curtail the rising cancer and chronic disease burden in LMICs.