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INTRODUCTION: Post-exposure prophylaxis (PEP) is an efficacious prevention method when initiated promptly after an HIV exposure. Yet, PEP has been underutilized, even among healthcare workers (HCWs) with occupational exposure in sites with PEP policies and procedures and access to PEP medications. It is important to understand the dynamics of uneven PEP use in what appears to be an optimal context to better protect the health and wellbeing of HCWs. METHODS: We conducted a scoping review to elucidate factors influencing HCWs use of PEP after occupational exposure. We searched PubMed, PsychInfo and Google Scholar for peer-reviewed literature published in English from 2014 to 2022 using the terms HIV, postexposure/post-exposure prophylaxis, acceptability, healthcare workers, and values and preferences. An inductive narrative review of the resulting 53 studies identified core themes. RESULTS: Nearly all studies (96%) with various HCW types and settings occurred in low- and middle-income countries (LMICs) in Africa and Asia. Identified themes arrayed along a trajectory of PEP use experience: awareness/knowledge; acceptability; availability/access; uptake/use; adherence/completion. Across studies, awareness of PEP for HIV prevention was high, knowledge about drug regimens and healthcare facility policies was moderate to low; acceptability of PEP was moderate to high; PEPs perceived accessibility/availability was inconsistent and varied by geographic location and setting; HCWs uptake of PEP was low, affected by not knowing how to report an exposure and being unaware of PEP availability; and adherence/completion of PEP regimens was moderate to low, impeded by side effects and a belief that completing regimens was unnecessary to avert seroconversion. HCWs consistently expressed concern about HIV stigma. DISCUSSION: Findings are limited by the inconsistent use of constructs across studies and a lack of clarity about reporting exposure events. Multi-level approaches are needed to address the interplay of individual, social and structural barriers that diminish HCWs PEP use. Improved training, incident reporting, 24-hour access to non-stigmatizing PEP services and monitoring of adherence/completion are essential to optimizing HCWs PEP use. CONCLUSIONS: Lessons from HCWs experience in LMICs may inform understanding of PEP under-use among people in these settings with non-occupational exposures.

BACKGROUND: Safer conception services are needed to minimize HIV transmission among HIV sero-discordant couples desiring pregnancy. Few studies have evaluated the choices couples make when they are offered multiple safer conception methods or real-world method acceptability. This paper addresses an important knowledge gap regarding factors that influence the choice of safer conception methods, couples actual experiences using safer conception methods, and why some couples switch safer conception methods. METHODS: Between February and June 2019, we conducted semi-structured in-depth interviews among 14 men and 17 women, representing 17 couples who exited the SAFER study-a pilot safer conception study for HIV sero-discordant couples in Zimbabwe that offered couples a choice of ART with monthly viral load monitoring (ART/VL), oral PrEP, vaginal insemination, and semen washing. All couples in SAFER had used at least two safer conception methods. RESULTS: We found that safer conception method choice often centered around a desire for intimacy, condomless sex, and certainty in the conception process, particularly for men. Method-related attributes such as familiarity, perceived ease of use, side effects, and perceived level of effectiveness in preventing HIV and achieving pregnancy influenced method choice, switching, and satisfaction. Concerns were expressed about each safer conception method and couples were willing to try different methods until they found method(s) that worked for them. The majority of participants reported having positive experiences using safer conception, especially those using ART/VL + PrEP, citing that they were able to attempt pregnancy for the first time with peace of mind and experienced joy and satisfaction from being able to achieve pregnancy safely. CONCLUSIONS: The differences in method preferences and experiences voiced by participants in this study and in other studies from the region point to the importance of having a variety of safer conception options in the service delivery package and addressing concerns about paternity, intimacy, and method-related attributes to enable HIV sero-discordant couples to safely achieve their reproductive goals.

Objective: In this document, 9 Indian experts have evaluated the factors specific to LMICs when it came to Severe Asthma (SA) diagnosis, evaluation, biologic selection, non-biologic treatment options, and follow-up. Data sources: A search was performed using 50 keywords, focusing on the Indian/LMICs perspective, in PubMed, Cochrane Library, and Google Scholar. The key areas of the search were focused on diagnosis, phenoendotyping, non-biological therapies, selecting a biologic, assessment of treatment response, and management of exacerbation. Study selections: The initial search revealed 1826 articles, from these case reports, observational studies, cohort studies, non-English language papers, etc., were excluded and we short-listed 20 articles for each area. Five relevant articles were selected by the experts for review. Results: In LMICs, SA patients may be referred to the specialist for evaluation a little late for Phenoendotyping of SA. While biologic therapy is now a standard of care, pulmonologists in LMICs may not have access to all the investigations to phenoendotype SA patients like fractional exhaled nitric oxide (FeNO), skin prick test (SPT), etc., but phenotyping of SA patients can also be done with simple blood investigations, eosinophil count and serum immunoglobulin E (IgE). Choosing a biologic in the overlapping phenotype of SA and ACO patients is also a challenge in the LMICs. Conclusions: Given the limitations of LMIC, it is important to select the right patient and explain the potential benefits of biological therapy. Non-biologic add-on therapies can be attempted in a resource-limited setting where biological therapy is not available/feasible for patients. [ABSTRACT FROM AUTHOR]

Introduction: Cancer rates are rising in low- and middle-income countries. While point-of- care ultrasound is now available globally and could serve to mitigate against this rise, its use in diagnosing cancers is inconsistent in lower-resourced healthcare contexts. This proof-of-concept study investigates the feasibility of an ultrasound training concept in a low-resource setting. It evaluates whether this educational concept led to improved knowledge and application of ultrasound diagnostics, cancer screening and staging and patient care. Material and methods: The curriculum was developed through expert exchange and is based on the World Health Organisation's Manual of Diagnostic Ultrasound. It consisted of two didactic components: an on-site training phase across 5 days for a total of 24 hours, and a digital follow-up phase involving the meeting of a bi-weekly tumor board online. The learning objectives of the on-site training were normal imaging and recognition of common pathologies of the abdominal organs, vessels, lymph nodes, female breasts and lungs. The virtual tumour boards met to discuss cases and ultrasound findings, thus aiding continuing professional development after the training sessions had concluded. The face-to-face course component was accompanied by tests given before and after training as well as an evaluation sheet (Likert-scale with 1 = 'completely/very good' and 7 'not at all/very poor'). Results: Of 20 participants from a rural hospital in Tanzania, a total of 16 were included in the analysis (clinical officers n = 6; medical officers n = 10). A significant increase in knowledge (p < 0.01) was measured both in the subjective self-assessment and in the theoretical competence tests. In multivariate linear regression, the status 'medical officers yes' (β = 5.4; p = 0.04) had a significant influence on theory test results at T2. During the 24 virtual tumour board meetings, 28 cases were discussed and a continuous improvement in image acquisition quality was observed. Conclusion: The ultrasound education concept comes with a sustainable increase in clinical competence and improved oncological ultrasound screening locally. There is potential for the transfer of the concept to other locations, which can be explored in the future. [ABSTRACT FROM AUTHOR]

Introduction: Osimertinib is more efficacious and as safe as first-generation epidermal growth factor receptor (EGFR)-directed tyrosine kinase inhibitors. However, osimertinib is not affordable for most patients in developing nations. Moreover, the minimum biologically effective dose of osimertinib may be less than the approved dose. Materials and methods: This was a retrospective observational multicentric study aimed to describe the efficacy (objective response rate (ORR), disease control rate (DCR), progression free survival (PFS), overall survival (OS)) and toxicity of osimertinib 80 mg orally administered less frequently than daily (ranging from every other day to once-a-week) in patients with EGFR-mutated non-small cell lung cancer. Results: Between January 2021 and August 2023, we enrolled 22 patients. Six received osimertinib 80 mg once-a-week, nine received 80 mg once-in-3-days and seven received 80 mg on alternate days. Responses included 0 complete responses, 7 (31.8%) partial responses, 9 (40.9%) stable disease and 5 (22.7%) progressive disease. ORR was 31.8%, and DCR was 72.7%. Median PFS was 9.2 months (95% confidence interval (CI) 2.9-15.7), and median OS was 17.8 months (95% CI, 3.2-32.6). In patients who received reduced frequency osimertinib in the second line and beyond, the ORR was 29.4%, DCR was 70.5%, median PFS was 5.9 months (95% CI, 1.1-10.6) and median OS was 17.6 months (95% CI, 2.9-32.2). Grade 3 and higher toxicities were noted in 8 (36.3%) patients. Conclusion: Less frequent dosing of osimertinib may be a valid treatment option, especially in the second line and beyond setting in patients who cannot afford full dose daily osimertinib. This may provide an additional treatment option with a similar toxicity profile as that of standard dose osimertinib. [ABSTRACT FROM AUTHOR]

Background: In this article we analyzed the extent of the usage of Theories of Change (TOCs) and causal pathways in the evaluation of immunization programs to identify the challenges to generating evidence on how interventions improve immunization. Methods: We analyzed the use of the TOC in impact evaluations (IEs) of immunization interventions published after 2010, and its associated articles. The review includes studies from Evidence Gap Map and Yale review that were conducted in May and March of 2020, respectively. We synthesized data on six domains using NVIVO — program theory, context, assumptions, usage of TOC, use in evaluation, and description causal pathways. Results: Our review included 47 large-scale and 45 small-to medium-scale interventions. Of the included studies, 19% used a TOC, 56% described a causal pathway or used a conceptual diagram with varying degrees of detail, and 25% of the IEs did not provide any information on how their intervention was expected to affect change. Only 19 of the 92 IEs explicitly outlined any assumptions associated with the implementation of the interventions. Forty studies measured the outputs or intermediate outcomes leading to improved immunization coverage. Conclusion: Future implementers and evaluators need to develop clear TOCs that are based on established theory and have clearly articulated the underlying assumptions. Large-scale health system strengthening initiatives implemented by governments, also need to build TOCs and integrate them into their results frameworks. Additionally, there is a need to combine both impact and process evaluations to understand the how context affects the causal pathways. [ABSTRACT FROM AUTHOR]

Background: Traumatic 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. Methods: All 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 design: A prospective, open-ended, cohort study design. Setting: All referral hospitals within the Republic of Rwanda. Results: Overall, 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%). Conclusion: The 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. [ABSTRACT FROM AUTHOR]

Low-income countries (LICs) and lower-middle-income countries (LMICs) are presented with unique challenges and opportunities when performing awake craniotomy (AC) for brain tumors. These circumstances arise from factors that are financial, infrastructural, educational, personnel, and sociocultural in nature. We performed a systematic narrative review of series on AC for intra-axial brain tumors in LICs/LMICs using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, focusing on the challenges and opportunities in these settings. The PubMed, Scopus, and Web of Science databases were searched. After initially identifying 74 studies, inclusion-exclusion criteria were applied, leaving a total of 14 studies included in the review. These involved 409 patients who underwent AC in LICs/LMICs. These series were from India, Ghana, Nigeria, Iran, Pakistan, Morocco, the Philippines, and Egypt. The most common pathology encountered were gliomas (10–70%). Most studies (11/14, 78.5%) reported on their technique of cortical-subcortical mapping. All reported on motor mapping and 8 of these performed language mapping. The most common outcomes reported were seizure and neurologic deficits, and longest follow-up was at 1 year. Challenges noted were lack of equipment and trained personnel, need for validated tests for the local setting, and sociocultural factors. Opportunities identified were volume for training, technique innovation, and international collaboration. There are numerous challenges and opportunities that arise when performing AC in LICs/LMICs. A collaborative approach toward harnessing the opportunities, and seeking creative solutions to address the challenges, would provide an ideal mechanism toward advancing neurosurgical care and specialty worldwide. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the present study was to compare birth weight (BW) distribution and proportion of BWs below or above specified percentiles in low‐risk singleton pregnancies in healthy South African (SA) women of mixed ancestry with expected values according to four BW references and to determine the physiological factors affecting BW. Methods: This was an ancillary study of a prospective multinational cohort study, involving 7060 women recruited between August 2007 and January 2015 in two townships of Cape Town, characterized by low socioeconomic status, and high levels of drinking and smoking. Detailed information about maternal and pregnancy characteristics, including harmful exposures, was gathered prospectively, allowing us to select healthy women with uncomplicated pregnancies without any known harmful exposures. In this cohort we compared the median BW and the proportion of BWs P90, 95 and 97 according to four reference standards (INTERGROWTH‐21st, customized according to the method described by Mickolajczyk, Fetal Medicine Foundation and revised Fenton reference) with expected values. Appropriate parametric and nonparametric tests were used, and sensitivity analysis was performed for infant sex, first trimester bookings and women of normal body mass index (BMI). Multiple regression was used to explore effects of confounders. Written consent and ethics approval was obtained. Results: The cohort included 739 infants. The INTERGROWTH‐21st standard was closest for the actual BW‐distribution and categories. Below‐expected BW was associated with boys, younger, shorter, leaner women, lower parity and gravidity. Actual BW was significantly influenced by maternal weight, BMI, parity and gestational age. Conclusion: Of the four references assessed in this study, the INTERGROWTH‐21st standard was closest for the actual BW distribution. Maternal variables significantly influence BW. Synopsis: The INTERGROWTH‐21st birth weight standard was the best of four references for this population, but maternal variables affect the actual birth weight (BW) and its deviation from the expected median. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to ascertain the personal characteristics of a group of successful academic entrepreneurs in a South African university enterprise and the prevalent barriers and enablers to their entrepreneurial endeavour. Design/methodology/approach: The authors used a Delphi process to identify and rank the characteristics, enablers, barriers and behaviours of entrepreneurial academics, with a Nominal Group Technique applied to establish challenges they encounter managing their enterprise and to propose solutions. Findings: Perseverance, resilience and innovation are critical personal characteristics, while collaborative networks, efficient research infrastructure and established research competence are essential for success. The university's support for entrepreneurship is a significant enabler, with unnecessary bureaucracy and poor access to project and general enterprise funding an impediment. Successful academic entrepreneurs have strong leadership, and effective management and communication skills. Research limitations/implications: The main limitation is the small study participant group drawn from a single university enterprise, which complicates generalisability. The study supported the use of Krueger's (2009) entrepreneurial intentions model for low- and middle-income country (LMIC) academic entrepreneur investigation but proposed the inclusion of mitigators to entrepreneurial activation to recognise contextual deficiencies and challenges. Practical implications: Skills-deficient LMIC universities should extensively and directly support their entrepreneurial academics to overcome their contextual deficiencies and challenging environment. Originality/value: This study contributes to addressing the paucity of academic entrepreneur research in LMIC contexts by identifying LMIC-specific factors that inhibit the entrepreneur's movement from entrepreneurial intention to entrepreneurial action. [ABSTRACT FROM AUTHOR]

Objectives: Caring for children in low- and middle-income countries (LMIC) can be challenging. This review article aims to explore role of telemedicine in supporting pediatric care in LMIC. Methodology: A narrative review of existing English and Spanish literature was conducted to assess role of telemedicine to support pediatric care in LMIC. Results: Beside medical education and direct pediatric care, telemedicine can provide sub-specialties consultations without extra burden on families. Additionally, telemedicine can help in lowering under-5 mortality by supporting neonatal care, infectious illnesses, and non-communicable diseases (NCDs). Telemedicine can be a gate for universal coverage for all children at a lower cost. For over a decade, it has been implemented successfully and sustained in a few LMIC. However, challenges in implementing telemedicine are enormous. Still, opportunities arise by using simpler technology, low-width band internet, smartphones, instant messaging applications and solar energy. COVID-19 pandemic facilitated acceptance and applicability of telemedicine worldwide including LMIC. Nevertheless, governments must regulate telemedicine by issuing policies and ensuring employment of local experts when possible to meet local resources and cultural competency. Conclusion: Telemedicine has proven successful in improving pediatrics care. Many LMIC should take advantage of this innovation to promote equity and access to high quality pediatric care. [ABSTRACT FROM AUTHOR]

Quality data collection is a key aspect of every research. The data is often collected by surveyors who are exposed to multiple risks and difficult situations, particularly in low- and middle-income countries (LMICs). Evidence generation needs to be ethical and essentially comprise the best practices to ensure the health and safety of the surveyors. While the ethics discourse mostly focuses on the rights of the human subject research participants, it is also important to emphasise and focus on the processes around ensuring the well-being of the field research staff engaged in data collection. In this descriptive study, we systematically document some of the key health and safety challenges of surveyors during primary data collection in India. Identified challenges, some of which disproportionately affected female surveyors, included the risk of physical illness, anxiety due to productivity targets, the risk of harassment and limiting hygiene practices. Based on these findings, we propose some best practices around institutional and context-specific measures that can be adopted to mitigate the challenges. Through this, we aim to help strengthen the ethical practices in research, further promoting the rigour and credibility of evidence generated towards sustainable development. [ABSTRACT FROM AUTHOR]

Introduction: Global inequality in clinical research capacity and service delivery can be indicated simply by the proportion of clinical trials that a country or region has registered in clinical trial registry databases. The proportion of clinical trials registered in Africa is very low at 0.02%, even though the region accounts for approximately 15% of the world's population. Despite the economic challenges in most African countries, they have shown potential for growth and change in recent years. Methods: We conducted desk reviews on the interventional clinical trials done in Kenya, Ethiopia, and Nigeria between 2015 to May 2023. The search was done in clinical trials repositories, and journal repositories. The search focused on intervention clinical trials. Data was extracted by screening through the publications and clinical trial platforms. The data extracted from the publications included the type of clinical trial, clinical trial phase, diseases, etc. The data extracted from the reports included: challenges in conducting clinical trials, capacity-building efforts, and the impact of the clinical trial. Results: The number of clinical trial studies identified in Kenya was 113 (28 were on infant clinical trials). The study identified 97 clinical trials in Nigeria, of which 11 studies were on infant clinical trials. In Ethiopia, there were 28 clinical trials and only five were on infant clinical trials. The landscape review also expanded to capacity and gaps in clinical trials in the three countries. The largest proportion of clinical trials carried out in Kenya was on injury, occupational disease, and poisoning, 30.5% (n = 18) and the smallest proportion was on kidney disease, neonatal disease, obstetrics, and gynecology. Most Infant clinical trials were carried out in the area of infections and infestations 33.3% (n=7). Most of the challenges faced by clinical trials in the three countries include a lack of infrastructure, a lack of human resources, and a lack of financial resources. Implications: There is a need to map clinical trials done by African researchers based in Africa to exclude the trials done by non-African researchers based in Africa. Opportunities for clinical trials should be supported and challenges addressed. [ABSTRACT FROM AUTHOR]

Digital health technology interventions have shown promise in enhancing self-management practices among adolescents living with Human Immunodeficiency Virus (ALHIV). The objective of this scoping review was to identify the preferences of ALHIV in low- and middle-income countries (LMICs) concerning the use of digital health technology for the self-management of their chronic illness. Electronic databases, including PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Plus with Full Text), Central (Cochrane Library), Epistemonikos, and Medline (EbscoHost), were searched. The review focused on English articles published before June 2023, that described a technology intervention for ALHIV specifically from LMIC. The screening and data extraction tool Covidence facilitated the scoping review process. Of the 413 studies identified, 10 were included in the review. Digital health technology interventions can offer enhanced support, education, and empowerment for ALHIV in LMICs. However, barriers like limited access, stigma, and privacy concerns must be addressed. Tailoring interventions to local contexts and integrating technology into healthcare systems can optimize their effectiveness.Review registration: OSF REGISTRIES (https://archive.org/details/osf-registrations-eh3jz-v1) [ABSTRACT FROM AUTHOR]

Introduction: Having more "autistic traits" is associated with an increased risk of mental health conditions. However, few studies have examined autistic traits in nonclinical samples. This study aims to analyze the relationship between autistic traits and internalizing symptoms among early adolescents and to examine the moderating effect of self‐efficacy. Methods: Survey data were collected from early adolescents ages 10–14 living in Darjeeling, India (n = 274) to assess autistic traits, self‐efficacy, and internalizing symptoms. Results: Higher internalizing symptoms were significantly associated with a higher report of autistic traits. Academic, social, and emotional dimensions of self‐efficacy moderated the relationship between autistic traits and internalizing symptoms. Conclusion: The moderation effects between social and emotional self‐efficacy among youth with high versus low autism trait scores suggest the need for social‐emotional learning interventions designed for and with neurodivergent youth. Such interventions aim to reduce internalizing symptoms during early adolescence and improve future mental health trajectories. [ABSTRACT FROM AUTHOR]

Abstract Background In this article we analyzed the extent of the usage of Theories of Change (TOCs) and causal pathways in the evaluation of immunization programs to identify the challenges to generating evidence on how interventions improve immunization. Methods We analyzed the use of the TOC in impact evaluations (IEs) of immunization interventions published after 2010, and its associated articles. The review includes studies from Evidence Gap Map and Yale review that were conducted in May and March of 2020, respectively. We synthesized data on six domains using NVIVO — program theory, context, assumptions, usage of TOC, use in evaluation, and description causal pathways. Results Our review included 47 large-scale and 45 small-to medium-scale interventions. Of the included studies, 19% used a TOC, 56% described a causal pathway or used a conceptual diagram with varying degrees of detail, and 25% of the IEs did not provide any information on how their intervention was expected to affect change. Only 19 of the 92 IEs explicitly outlined any assumptions associated with the implementation of the interventions. Forty studies measured the outputs or intermediate outcomes leading to improved immunization coverage. Conclusion Future implementers and evaluators need to develop clear TOCs that are based on established theory and have clearly articulated the underlying assumptions. Large-scale health system strengthening initiatives implemented by governments, also need to build TOCs and integrate them into their results frameworks. Additionally, there is a need to combine both impact and process evaluations to understand the how context affects the causal pathways.

Abstract Background Safer conception services are needed to minimize HIV transmission among HIV sero-discordant couples desiring pregnancy. Few studies have evaluated the choices couples make when they are offered multiple safer conception methods or real-world method acceptability. This paper addresses an important knowledge gap regarding factors that influence the choice of safer conception methods, couples' actual experiences using safer conception methods, and why some couples switch safer conception methods. Methods Between February and June 2019, we conducted semi-structured in-depth interviews among 14 men and 17 women, representing 17 couples who exited the SAFER study—a pilot safer conception study for HIV sero-discordant couples in Zimbabwe that offered couples a choice of ART with monthly viral load monitoring (ART/VL), oral PrEP, vaginal insemination, and semen washing. All couples in SAFER had used at least two safer conception methods. Results We found that safer conception method choice often centered around a desire for intimacy, condomless sex, and certainty in the conception process, particularly for men. Method-related attributes such as familiarity, perceived ease of use, side effects, and perceived level of effectiveness in preventing HIV and achieving pregnancy influenced method choice, switching, and satisfaction. Concerns were expressed about each safer conception method and couples were willing to try different methods until they found method(s) that worked for them. The majority of participants reported having positive experiences using safer conception, especially those using ART/VL + PrEP, citing that they were able to attempt pregnancy for the first time with peace of mind and experienced joy and satisfaction from being able to achieve pregnancy safely. Conclusions The differences in method preferences and experiences voiced by participants in this study and in other studies from the region point to the importance of having a variety of safer conception options in the service delivery package and addressing concerns about paternity, intimacy, and method-related attributes to enable HIV sero-discordant couples to safely achieve their reproductive goals.

Abstract Background The ideal approach for treating anterior cruciate ligament (ACL) injury is still disputed. This study aimed to determine the more cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery to conservative treatment (rehabilitation with optional delayed reconstruction) for ACL injury in a lower/middle-income country (LMIC), Indonesia. Methods A decision tree model was constructed for cost-utility analysis of early ACLR versus conservative treatment. The transition probabilities between states were obtained from the literature review. Utilities were measured by the EQ-5D-3 L from a prospective cohort study in a local hospital. The costs were obtained from a previous study that elaborated on the burden and cost of ACLR in Indonesia. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measure was the incremental cost-effectiveness ratios (ICER). Willingness-to-pay was set at US$12,876 — three times the Indonesian GDP per capita in 2021 — the currently accepted standard in Indonesia as suggested by the World Health Organization Choosing Interventions that are Cost-Effective criterion (WHO-CHOICE). Results The early ACLR group showed an incremental gain of 0.05 QALYs over the conservative treatment group, with a higher overall cost to society of US$976. The ICER of ACLR surgery was US$19,524 per QALY, above the WTP threshold of US$12,876. The ICER was sensitive to cost of conservative treatment, cost of ACLR, and rate of cross-over to delayed ACLR numbers in the conservative treatment group. Using the WTP threshold of US$12,876, the probability of conservative treatment being preferred over early ACLR was 64%. Conclusions Based on the current model, early ACLR surgery does not seem more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. Because the result was sensitive to the rate of cross-over probabilities from the conservative treatment alone to delayed ACLR, a future study with a long-term perspective is needed to further elucidate its impact.

Background: The experiences of trauma patients referred from Ghanaian non-tertiary hospitals for definitive care at higher levels is not well-known. Understanding the motivations of injured patients who do not attend their referral for definitive management may inform interventions to improve injury outcomes. Methods: This study is a follow-up survey of participants of a larger study involving initial management of injured patients presenting to 8 non-tertiary hospitals in Ghana from October 2020 to March 2022. Injured patients referred to higher levels of care were surveyed by phone using a structured questionnaire and patients who could not be reached were excluded. The main outcome was referral non-attendance and differences between patients who attended the referral and those who did not were determined with chi squared tests. Variables with intergroup differences were included in a multivariable logistic regression. Open-ended survey responses were analyzed using thematic content analysis. Results: Of 335 referred patients surveyed, 17 % did not attend the referral. Factors associated with referral non-attendance included being male (Adjusted odds ratio (AOR)=2.70, p = 0.013), sustaining a fracture (AOR=2.83, p = 0.003), and having less severe injury (AOR 2.84, p = 0.017). Primary drivers of referral non-attendance included financial problems (59 %), family influence (45 %), and lack of transportation (20 %). The majority of patients (77 %) not attending the referral sought treatment from traditional healers, citing lower cost, faster service, and a perception of equivalent outcomes. Reported facilitators of referral attendance included positive hospital staff experiences and treatment while barriers included higher hospital costs, lack of bed space, and poor interhospital communication. Conclusions: An important proportion of injured patients in Ghana do not attend referrals for definitive management, with many seeking care from traditional healers. Our study identified possible targets for interventions aimed at maintaining the continuum of hospital-based care for injured patients in order to improve outcomes.

Background: Acute promyelocytic leukemia (APL) is one of the most curable subtypes of acute myeloid leukemia in childhood. It usually presents with a characteristic coagulopathy. The aim of the study was to determine the extent and outcome of this coagulation disorder. Methods: This prospective observational study was conducted at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, and included PML:RAR-α (Promyelocytic Leukemia-Retinoic Acid Receptor-α) positive APL cases. At presentation, all patients were assessed with coagulation parameters and followed up clinically and hematologically while treated with ATRA (all-trans-retinoic acid)-based chemotherapy. The presence of disseminated intravascular coagulation (DIC) was determined using the DIC scoring system of the International Society on Thrombosis and Hemostasis (ISTH). Results: Among 20 APL cases, the mean DIC score was 5.75 ± 0.6. DIC was detected in 90% (n = 18/20) of the patients. The incidence of fatal thrombo-hemorrhagic complications was 15% (n = 3/20). Though hemorrhagic complications are common, thrombosis may also occur in pediatric APL.

Introduction: Pulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram. Method: This study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality. Results: Of the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality. Conclusion: Early identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised.

Abstract The term ‘perspective’ in the context of economic evaluations and costing studies in healthcare refers to the viewpoint that an analyst has adopted to define the types of costs and outcomes to consider in their studies. However, there are currently notable variations in terms of methodological recommendations, definitions, and applications of different perspectives, depending on the objective or intended user of the study. This can make it a complex area for stakeholders when interpreting these studies. Consequently, there is a need for a comprehensive overview regarding the different types of perspectives employed in such analyses, along with the corresponding implications of their use. This is particularly important, in the context of low-and-middle-income countries (LMICs), where practical guidelines may be less well-established and infrastructure for conducting economic evaluations may be more limited. This article addresses this gap by summarising the main types of perspectives commonly found in the literature to a broad audience (namely the patient, payer, health care providers, healthcare sector, health system, and societal perspectives), providing their most established definitions and outlining the corresponding implications of their uses in health economic studies, with examples particularly from LMIC settings. We then discuss important considerations when selecting the perspective and present key arguments to consider when deciding whether the societal perspective should be used. We conclude that there is no one-size-fits-all answer to what perspective should be used and the perspective chosen will be influenced by the context, policymakers'/stakeholders’ viewpoints, resource/data availability, and intended use of the analysis. Moving forward, considering the ongoing issues regarding the variation in terminology and practice in this area, we urge that more standardised definitions of the different perspectives and the boundaries between them are further developed to support future studies and guidelines, as well as to improve the interpretation and comparison of health economic evidence.

Background: The ideal approach for treating anterior cruciate ligament (ACL) injury is still disputed. This study aimed to determine the more cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery to conservative treatment (rehabilitation with optional delayed reconstruction) for ACL injury in a lower/middle-income country (LMIC), Indonesia. Methods: A decision tree model was constructed for cost-utility analysis of early ACLR versus conservative treatment. The transition probabilities between states were obtained from the literature review. Utilities were measured by the EQ-5D-3 L from a prospective cohort study in a local hospital. The costs were obtained from a previous study that elaborated on the burden and cost of ACLR in Indonesia. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measure was the incremental cost-effectiveness ratios (ICER). Willingness-to-pay was set at US$12,876 — three times the Indonesian GDP per capita in 2021 — the currently accepted standard in Indonesia as suggested by the World Health Organization Choosing Interventions that are Cost-Effective criterion (WHO-CHOICE). Results: The early ACLR group showed an incremental gain of 0.05 QALYs over the conservative treatment group, with a higher overall cost to society of US$976. The ICER of ACLR surgery was US$19,524 per QALY, above the WTP threshold of US$12,876. The ICER was sensitive to cost of conservative treatment, cost of ACLR, and rate of cross-over to delayed ACLR numbers in the conservative treatment group. Using the WTP threshold of US$12,876, the probability of conservative treatment being preferred over early ACLR was 64%. Conclusions: Based on the current model, early ACLR surgery does not seem more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. Because the result was sensitive to the rate of cross-over probabilities from the conservative treatment alone to delayed ACLR, a future study with a long-term perspective is needed to further elucidate its impact. [ABSTRACT FROM AUTHOR]

Introduction: Approximately 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. Methods: A 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 discussion: Seventy 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). [ABSTRACT FROM AUTHOR]

Background: The 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. Methods: A 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. Results: Responses 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. Conclusions: This 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. [ABSTRACT FROM AUTHOR]

Background: It has been proposed that children and young people living in low‐ and middle‐income countries (LMICs) are not only exposed more frequently to trauma but also have a higher likelihood of encountering traumas of greater severity than those living in high‐income countries (HICs). This may lead to higher rates of post‐traumatic stress symptoms (PTSS). However, developmental pathways to risk or resilience after trauma exposure in LMICs are underresearched. Methods: We examined early parenting and attachment as potentially important formative factors for later stress reactivity in a longitudinal cohort of South African children (N = 449). Parenting and attachment were assessed at child age 18 months, and interpersonal trauma exposure, PTSS and parenting stress were measured at 13 years (N = 333; core sample with data on all measures: N = 213). Following a vulnerability‐stress approach, separate regression models were run to investigate whether parent–child attachment at 18 months, parental sensitivity and intrusiveness during play at 12 months, and current parenting stress at 13 years, interacted with adolescents' extent of interpersonal trauma exposure to predict their PTSS levels at 13 years. Results: We found no predictive effects of either early attachment or current parenting stress in relation to child PTSS. There was some evidence for predictive influences of parental early intrusiveness and sensitivity on adolescent outcomes, though associations were unexpectedly positive for the latter. No interaction effects supporting a vulnerability‐stress model were found. Conclusions: Overall, we found limited evidence that elements of the early parent–child environment predict child risk/resilience to trauma in LMIC children. Future studies should include more frequent assessments of relevant constructs to capture changes over time and consider further what comprises adaptive parenting in high‐risk contexts. [ABSTRACT FROM AUTHOR]

Reports on the management and survival of children with myelomeningocele defects in Bangladesh are limited. This study describes the characteristics and outcomes of these children, focusing on the timing of surgical repair and factors affecting survival. We enrolled patients with myelomeningoceles in a case-control study on arsenic exposure and spina bifida in Bangladesh. Cases were subsequently followed at regular intervals to assess survival. Demographic, clinical, and surgical characteristics were reviewed. Univariate tests identified factors affecting survival. Between 2016 and 2022, we enrolled 272 patients with myelomeningocele. Postnatal surgical repair was performed in 63% of cases. However, surgery within 5 days after birth was infrequent (<10%) due to delayed presentation, and there was a high rate (29%) of preoperative deaths. Surgical repair significantly improved patient survival (P < 0.0001). Older age at time of surgery was also associated with improved survival rates, which most likely represents that those who survived to older ages prior to surgery accommodated better with their lesions. Patients who presented with ruptured lesions had lower survival rates. Timely neurosurgical repair of myelomeningoceles in Bangladesh is hindered by late patient presentation, resulting in a high preoperative patient death rate. Neurosurgical intervention remains a significant predictor of survival. Increased access to neurosurgical care and education of families and non-neurosurgical providers on the need for timely surgical intervention are important for improving the survival of infants with myelomeningoceles. [ABSTRACT FROM AUTHOR]

Introduction: Improving surgical access in low- and middle-income countries is vital for the 5 billion people who lack safe surgical care. Tailoring a culturally sensitive approach to consent is essential for patient comprehension and comfort, thereby alleviating the effects of resource constraints and advancing equitable care. This study examines the consenting process for endoscopy at Kyabirwa Surgical Center in Kyabirwa, Jinja, Uganda, to assess patients' knowledge and attitudes as a potential barrier to participating in endoscopic procedures. Methods: All adult upper endoscopy (EGD) and colonoscopy patients were recruited to participate in a survey of their demographics, knowledge, and attitudes toward their procedure. All patients received a standard consultation explaining the procedure and its risks and benefits. Results: 75 patients were included; median age was 54 years and 56% (n = 42) were women. 92% (n = 69) of patients had never had an endoscopy before and 73% (n = 55) of patients were scheduled for an EGD while the remaining 27% (n = 20) were scheduled for a colonoscopy. Most patients 80% (n = 60) had a basic understanding of what an endoscopy is and 87% (n = 65) its diagnostic purpose. Few patients 15% (n = 11) knew of the most common side effects or if they would have a surgical scar 27% (n = 20). Overall, 46.7% (n = 35) of patients were moderately or severely fearful of getting an endoscopy. Additionally, 45.3% (n = 34) of patients were moderately or severely fearful of receiving anesthesia during their endoscopic procedure. Despite this fear, most patients 85.3% (n = 64) stated that they understood the benefits of the procedure either very well or extremely well. Conclusions: Most patients understood the role that an endoscopic procedure plays in their care and its potential benefits. Despite this, many patients continued to have high levels of fear associated with both the endoscopic procedure and with receiving anesthesia during their procedure. Future patient education should focus on addressing patients' fears and the risks of undergoing an endoscopy, which may improve the utilization of surgical services. [ABSTRACT FROM AUTHOR]

Objectives This article describes Pathologists Overseas (PO) experience supporting external quality assessment (EQA) programs in 10 clinical laboratories across 3 countries between 2009 and 2017. Methods Laboratories were enrolled in the condensed chemical pathology EQA program provided by the Royal College of Pathologists of Australasia Quality Assurance Program. Participants were given an initial 2- to 4-day in-person training, followed by 1 year of active feedback on performance via emails or phone calls by a PO volunteer. Results There were 2 performance metrics: percentage of reported results as a measure of compliance and percentage of acceptable reported results as a measure of accuracy. Laboratories demonstrated high compliance with result reporting, with medians of 69.9%, 71.7%, and 81.3% before, during, and after feedback, respectively. Concomitant medians for the percentage of acceptable reported results were 41.2%, 57.3%, and 53.5%, respectively. Six laboratories had low performance in terms of accuracy at baseline (<60%). Active feedback improved the percentage of acceptable reported results for these lower-performing laboratories. Conclusions External quality assessment programs can be successfully adopted long term by laboratories in low-resource settings. Active feedback requires significant time and effort but could be especially beneficial for laboratories with poor baseline performance. [ABSTRACT FROM AUTHOR]

In order to discern the causes of the health and developmental problems of children, and thence develop preventative strategies, longitudinal cohort studies offer major advantages. They can monitor the consequences of exposure to physical and psychological events and thence identify antecedents of various disorders. We describe the historical background to the development in the UK of this study design, and the uptake of longitudinal birth cohorts in low- and middle-income countries (LMICs), using the cohorts in Jamaica, South Africa and Brazil as exemplars. We describe the benefits of such studies and show how undertaking longitudinal cohort studies can have major health and financial benefits to the populations concerned. Additionally, the paper outlines the advantages of collaboration between studies and the pooling of data. [ABSTRACT FROM AUTHOR]

Surgical stabilization of rib fractures (SSRF) using standard rib plating systems has become a norm in developed countries. However, the procedure has not garnered much interest in low–middle-income countries, primarily because of the cost. This was a single-center pilot randomized trial. Patients with severe rib fractures were randomized into two groups: SSRF and nonoperative management. SSRF arm patients underwent surgical fixation in addition to the tenets of nonoperative management. Low-cost materials like stainless steel wires and braided polyester sutures were used for fracture fixation. The primary outcome was to assess the duration of hospital stay. Twenty-two patients were randomized, 11 in each arm. Per-protocol analysis showed that the SSRF arm had significantly reduced duration of hospital stay (22.6 ± 19.1 d versus 7.9 ± 5.7 d, P value 0.031), serial pain scores at 48 h and 5 d (median score 5, IQR (3-6) versus median score 7, IQR (6.5-8), P value 0.004 at 48 h and median score 2 IQR (2-3) versus median score 7 IQR (4.5-7) P value 0.0005 at 5 d), significantly reduced need for injectable opioids (9.9 ± 3.8 mg versus 4.4 ± 3.4 mg, P value 0.003) and significantly more ventilator-free days (19.9 ± 8.7 d versus 26.4 ± 3.2 d, P value 0.04). There were no statistically significant differences in the total duration of ICU stay (median number of days 2, IQR 1-4.5 versus median number of days 7, IQR 1-14, P value 0.958), need for tracheostomy (36.4% versus 0%, P value 0.155), and pulmonary and pleural complications. SSRF with low-cost materials may provide benefits similar to standard rib plating systems and can be used safely in resource-poor settings. [ABSTRACT FROM AUTHOR]

Artificial intelligence (AI) is the ability of a digital computer or computer-controlled robot to perform tasks commonly associated with intelligent beings. Artificial intelligence can be both a blessing and a curse, and potentially a double-edged sword if not carefully wielded. While it holds massive potential benefits to humans—particularly in healthcare by assisting in treatment of diseases, surgeries, record keeping, and easing the lives of both patients and doctors, its misuse has potential for harm through impact of biases, unemployment, breaches of privacy, and lack of accountability to mention a few. In this article, we discuss the fourth industrial revolution, through a focus on the core of this phenomenon, artificial intelligence. We outline what the fourth industrial revolution is, its basis around AI, and how this infiltrates human lives and society, akin to a transcendence. We focus on the potential dangers of AI and the ethical concerns it brings about particularly in developing countries in general and conflict zones in particular, and we offer potential solutions to such dangers. While we acknowledge the importance and potential of AI, we also call for cautious reservations before plunging straight into the exciting world of the future, one which we long have heard of only in science fiction movies. [ABSTRACT FROM AUTHOR]

Background: The HIV care cascade is a framework to examine effectiveness of HIV programs and progress toward global targets to end the epidemic but has been conceptualized as a unidirectional process that ignores cyclical care patterns. We present a dynamic cascade that accounts for patient "churn" and apply novel analytic techniques to readily available clinical data to robustly estimate program outcomes and efficiently assess progress toward global targets. Methods: Data were assessed for 35,649 people living with HIV and receiving care at 78 clinics in East Africa between 2014 and 2020. Patients were aged $15 years and had $1 viral load measurements.We used multi-state models to estimate the probability of being in 1 of 5 states of a dynamic HIV cascade: (1) in HIV care but not on antiretroviral therapy (ART), (2) on ART, (3) virally suppressed, (4) in a gap-in-care, and (5) deceased and compared these among subgroups. To assess progress toward global targets, we summed those probabilities across patients and generated population-level proportions of patients on ART and virally suppressed in mid-2020. Results: One year after enrollment, 2.8% of patients had not initiated ART, 86.7% were receiving ART, 57.4% were virally suppressed, 10.2% were disengaged from care, and 0.3% had died. At 5 years, the proportion on ART remained steady but viral suppression increased to 77.2%. Of those aged 15--25, .20% had disengaged from care and,60% were virally suppressed. In mid-2020, 90.1% of the cohort was on ART, 90.7% of whom had suppressed virus. Conclusions: Novel analytic approaches can characterize patient movement through a dynamic HIV cascade and, importantly, by capitalizing on readily available data from clinical cohorts, offer an efficient approach to estimate population-level proportions of patients on ART and virally suppressed. Significant progress toward global targets was observed in our cohort but challenges remain among younger patients. [ABSTRACT FROM AUTHOR]

This study assessed associations between experiences of physical or sexual violence in childhood and self-harm, suicidal ideation, and suicide attempts among young people in low- and middle-income countries (LMICs) and whether these associations varied by sex and perpetrator identity. We used nationally representative data from the Violence Against Children and Youth Surveys in eight LMICs (2017–2019). The analytic sample included 33,381 young men and women (ages 13–24 years). Multivariable logistic regressions with country-fixed effects were used to estimate the associations between childhood physical and sexual violence and the three outcomes. Stratified analyses were performed by country, participant's sex, and type of perpetrator (parent/caregiver, other adults, peers, and intimate partner). About 40% of the participants reported physical childhood violence, and 10% experienced childhood sexual violence. Childhood violence was associated with increased odds of self-harm (physical violence: adjusted odds ratio [aOR]: 2.2, 95% confidence interval [CI]: 2.0–2.4; sexual violence: aOR: 2.7, 95%, CI: 2.3–3.0), suicidal ideation (physical: aOR: 3.0, 95% CI: 2.7–3.3; sexual: aOR: 4.0, 95%, CI: 3.6–4.5), and suicide attempts (physical: aOR: 3.6, 95% CI: 3.2–4.1; sexual: aOR: 4.9, 95%, CI: 4.3–5.7). Consistent findings were observed in country-specific analyses. The odds of all outcomes were highest among those who experienced childhood physical violence by intimate partners and childhood sexual violence by parents or caregivers. Young women who experienced childhood sexual violence had higher odds for all outcomes than young men. Violence prevention and mental health programs for young people in LMICs should consider the types of violence experienced, the perpetrator, and the sex of the survivor. [ABSTRACT FROM AUTHOR]

Despite significant strides made in childhood survival during the last 75 years, India bears the largest burden of congenital heart disease (CHD) in the world. The care of a child with CHD requires multidisciplinary collaboration and development of distinct training opportunities in developing countries to ensure outcomes similar to those achieved in high-income countries. We present a commentary on the current state of pediatric cardiac critical care in India and propose pathways to fulfil the unmet needs of Indian children. The aim is to achieve self-reliance in pediatric cardiac services and to move towards optimal outcome and intact survival of children with CHD. [ABSTRACT FROM AUTHOR]

Introduction: Postpartum depression negatively impacts maternal mental health and child development. The high prevalence of postpartum depression (PPD) in low and lower middle-income countries raises questions about its predictors. This study examines the association between PPD and breastfeeding experience, child death, unresolved pregnancy, forced displacement, COVID-19 pandemic lockdown, marital, and financial status among Ukrainian women. Methods: This online study recruited 1634 Ukrainian mothers of children aged 0–5 years through non-governmental organizations providing services to them. The Edinburgh Postnatal Depression Scale (EPDS), with a cut-off of ≥13, was used to assess depressive symptoms in the postpartum period. Independent t-tests, chi-squared tests, one-way ANOVA, non-parametric correlations, and logistic regression tests were used to analyze the data. Results: The prevalence of depressive symptoms was 39.0% (n=1631). There was a positive association between EPDS scores and breastfeeding difficulties, pandemic lockdown, and financial difficulties. We did not find an association between PPD symptoms and unresolved pregnancy, death of a child, being affected by COVID-19, and forced displacement. We found that EPDS scores for women who did not experience forced displacement (n=1528) were significantly higher compared to displaced mothers (n=74). Conclusions: The present study of Ukrainian women shows that women experienced depressive symptoms influenced by various factors including breastfeeding difficulties, pandemic lockdown, and financial difficulties. There is a need for additional research into such factors as unresolved pregnancy, the death of a child, being affected by COVID-19, and forced displacement. [ABSTRACT FROM AUTHOR]

Risk stratification andmolecular targeting have been key to increasing cure rates for pediatric cancers in high-income countries. In contrast, precise diagnosis in lowresource 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 realtime will enable the treatment of pediatric cancer tomove toward incorporating risk stratification for optimized therapy. [ABSTRACT FROM AUTHOR]

Based on the lack of differences in progression-free and overall survival after a median follow-up of 93 months in our HOVON-65/GMMG-HD4 trial (German part; n = 395) randomizing VAD induction (vincristin/adriamycin/dexamthasone)/tandem-transplantation/thalidomide-maintenance vs. PAD induction (bortezomib/adriamycin/dexamethasone)/tandem transplantation/bortezomib maintenance, we discern how chromosomal aberrations determine long-term prognosis by different patterns of association with proliferation and treatment-dependent response, whether responses achieved by different regimens are equal regarding prognosis, and whether subpopulations of patients could be defined as treatable without upfront "novel agents" in cases of limited resources, e.g., in low- or middle-income countries. Serum parameters and risk factors were assessed in 395 patients. CD138-purified plasma cells were subjected to fluorescence in situ hybridization (n = 354) and gene expression profiling (n = 204). We found chromosomal aberrations to be associated in four patterns with survival, proliferation, and response: deletion (del) del17p13, del8p21, del13q14, (gain) 1q21+, and translocation t(4;14) (all adverse) associate with higher proliferation. Of these, del17p is associated with an adverse response (pattern 1), and 1q21+, t(4;14), and del13q14 with a treatment-dependent better response (pattern 2). Hyperdiploidy associates with lower proliferation without impacting response or survival (pattern 3). Translocation t(11;14) has no association with survival but a treatment-dependent adverse response (pattern 4). Significantly fewer patients reach a near-complete response or better with "conventional" (VAD) vs. bortezomib-based treatment after induction or high-dose melphalan. These patients, however, show significantly better median progression-free and overall survival. Molecularly, patients responding to the two regimens differ in gene expression, indicating distinct biological properties of the responding myeloma cells. Patients with normal renal function (89.4%), low cytogenetic risk (72.5%), or low proliferation rate (37.9%) neither benefit in progression-free nor overall survival from bortezomib-based upfront treatment. We conclude that response level, the treatment by which it is achieved, and molecular background determine long-term prognosis. Chromosomal aberrations are associated in four patterns with proliferation and treatment-dependent responses. Associations with faster and deeper responses can be deceptive in the case of prognostically adverse aberrations 1q21+ and t(4;14). Far from advocating a return to "outdated" treatments, if resources do not permit state-of-the-art-treatment, normal renal function and/or molecular profiling identifies patient subpopulations doing well without upfront "novel agents". [ABSTRACT FROM AUTHOR]

AbstractBackgroundAimMethodsResultsConclusionRegistrationThe positive impact of breastfeeding against postpartum depression has been increasingly reported. However, no studies have systematically and critically examined current evidence on breastfeeding practices’ influences on postpartum depression in LMICs.To review the influence of breastfeeding on postpartum depression in LMICs.We searched original research in English published over the last ten years (2012 – 2022) within 8 databases: EBSCOhost, EMBASE, Pubmed, Sage Journals, Science Direct, APA PsycArticles, Taylor & Francis, Google Scholar, and citation tracking. The risk of bias assessment used The Newcastle Ottawa Scale and The Modified Jadad Scale. We followed the PRISMA statement after the protocol had been registered on the PROSPERO. The review included 21 of 11015 articles.Of 21 articles, 16 examined breastfeeding practices, 2 each investigated breastfeeding self-efficacy and breastfeeding education, and 1 each assessed breastfeeding attitude and breastfeeding support. 3 randomized control trials and 5 cohorts revealed that breastfeeding decreased the EPDS scores. However, 4 cross-sectional studies indicated that breastfeeding is nonsignificantly associated with postpartum depression.This review indicated that breastfeeding may alleviate or prevent postpartum depression. Our findings indicated that integrating breastfeeding-related programs and policies into postpartum depression prevention may benefit public health.PROSPERO (CRD42022315143) [ABSTRACT FROM AUTHOR]

AbstractBackgroundAimsMethodsResultsConclusionThe impact of COVID-19 and its mitigation measures have exacerbated the global mental health crisis. Digital mental health interventions (DMHIs) may have the potential to address health system gaps and global health inequalities in low- and middle-income countries (LMICs).This thesis aims to map the current state of DMHIs in Nigeria and illustrate their progress, limitations, and challenges.Twenty interviews were conducted with researchers, healthcare providers, and digital health experts. Interviews were recorded and transcribed. Then data were coded and analyzed using thematic analysis.The majority of DMHIs in Nigeria are private mental health service delivery platforms that connect directly to mental health professionals. The target audience encompasses all mental health conditions and ages. Advantages of DMHIs include increasing efficiency, accessibility, addressing stigma, and filling the mental health service gap. Disadvantages include skepticism, limitations of applicability, lack of accessibility to internet and technology, lack of sustainability and infrastructure, and lack of funding and policies.The lessons learned in the Nigerian context can inform the delivery of DMHIs in other low-resource settings. Future research should examine user and provider feedback of DMHIs to allow for comparative analysis, more conclusive and replicable results to inform DMHI design and implementation. [ABSTRACT FROM AUTHOR]

The experiences of trauma patients referred from Ghanaian non-tertiary hospitals for definitive care at higher levels is not well-known. Understanding the motivations of injured patients who do not attend their referral for definitive management may inform interventions to improve injury outcomes. This study is a follow-up survey of participants of a larger study involving initial management of injured patients presenting to 8 non-tertiary hospitals in Ghana from October 2020 to March 2022. Injured patients referred to higher levels of care were surveyed by phone using a structured questionnaire and patients who could not be reached were excluded. The main outcome was referral non-attendance and differences between patients who attended the referral and those who did not were determined with chi squared tests. Variables with intergroup differences were included in a multivariable logistic regression. Open-ended survey responses were analyzed using thematic content analysis. Of 335 referred patients surveyed, 17 % did not attend the referral. Factors associated with referral non-attendance included being male (Adjusted odds ratio (AOR)=2.70, p = 0.013), sustaining a fracture (AOR=2.83, p = 0.003), and having less severe injury (AOR 2.84, p = 0.017). Primary drivers of referral non-attendance included financial problems (59 %), family influence (45 %), and lack of transportation (20 %). The majority of patients (77 %) not attending the referral sought treatment from traditional healers, citing lower cost, faster service, and a perception of equivalent outcomes. Reported facilitators of referral attendance included positive hospital staff experiences and treatment while barriers included higher hospital costs, lack of bed space, and poor interhospital communication. An important proportion of injured patients in Ghana do not attend referrals for definitive management, with many seeking care from traditional healers. Our study identified possible targets for interventions aimed at maintaining the continuum of hospital-based care for injured patients in order to improve outcomes. [ABSTRACT FROM AUTHOR]

Pulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram. This study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality. Of the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality. Early identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised. [ABSTRACT FROM AUTHOR]

The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) trial tested a collaborative care model including electronic clinical decision support (CDS) for treating diabetes and depression in India. We aimed to assess which features of this clinically and cost-effective intervention were associated with improvements in diabetes and depression measures. Post-hoc analysis of the INDEPENDENT trial data (189 intervention participants) was conducted to determine each intervention feature's effect: 1. Collaborative case reviews between expert psychiatrists and the care team; 2. Patient care-coordinator contacts; and 3. Clinicians' CDS prompt modifications. Primary outcome was baseline-to-12-months improvements in diabetes control, blood pressure, cholesterol, and depression. Implementer interviews revealed barriers and facilitators of intervention success. Joint displays integrated mixed methods' results. High baseline HbA1c≥ 74.9 mmol/mol (9%) was associated with 5.72 fewer care-coordinator contacts than those with better baseline HbA1c (76.8 mmol/mol, 9.18%, p < 0.001). Prompt modification proportions varied from 38.3% (diabetes) to 1.3% (LDL). Interviews found that providers' and participants' visit frequencies were preference dependent. Qualitative data elucidated patient-level factors that influenced number of clinical contacts and prompt modifications explaining their lack of association with clinical outcomes. Our mixed methods approach underlines the importance of the complementarity of different intervention features. Qualitative findings further illuminate reasons for variations in fidelity from the core model. • Parent trial showed effectiveness in improving cardiometabolic and mental health. • Variability in the number of care-coordinator contacts was not associated with outcomes. • Variability in the adherence to CDS was not associated with health outcomes. • Unexplained variability was elucidated by qualitative data on contextual factors. • Studying implementation outcomes provides value for future scale-up and scale-out. [ABSTRACT FROM AUTHOR]

Background: How pediatric medulloblastoma patients fare in Lower Middle-Income Country (LMICs) in South America is not well understood. Correspondingly, the aim of this study was to summarize the pediatric neurosurgical experience of an institution in La Paz, and compare outcomes to that of a generalized High Income Country (HIC) United States (US) experience. Methods: A retrospective review of all pediatric neurosurgical medulloblastoma patients at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2014 and 2023 was conducted and compared to a generalized US experience abstracted from the US National Cancer Database (NCDB) and National Inpatient Sample (NIS) databases. Categorical, continuous and survival data were statistically summarized and compared. Results: A total of 24 pediatric medulloblastoma patients underwent neurosurgical treatment at the Hospital del Niño. In this La Paz cohort, there were 15 (63%) males and 9 (38%) females, with a mean age of 5.6 years old at diagnosis. The majority of patients underwent subtotal resection (STR, 79%), while the remaining patients underwent biopsy only. Ten (42%) patients expired during their hospitalization, and mean length of stay overall was 39 days. Only 8 (33%) patients received adjuvant treatment after surgery. Median overall survival from diagnosis in the La Paz cohort was 1.9 months. Compared to the US databases, the La Paz cohort experienced significantly more emergency room admissions for surgery, less gross total resection, more STR, more return to operating room for ventriculoperitoneal shunting, more bacteremia, more tracheostomy procedures, more percutaneous gastrostomy placements, longer lengths of stay, less adjuvant chemotherapy, less radiation therapy, shorter follow-up, and ultimately, significantly shorter overall survival (all P < 0.050). Conclusions: Pediatric neurosurgical medulloblastoma outcomes at the Children's Hospital of La Paz, Bolivia are significantly inferior to that of a generalized US experience. Future research is required to identify institution- and country-specific initiatives to improve discrepancies between institutions in LMICs in South America compared to HICs. [ABSTRACT FROM AUTHOR]

INTRODUCTION Perinatal mental health defines new mothers, their families, and the social, emotional, and cognitive development of their children. The factors contributing to Ukrainian mothers' mental health are not well-defined in the literature. This study aims to explore how Ukrainian women understand mental health and its psychosocial determinants through their perinatal experience. METHODS This qualitative analysis is part of a larger mixed-methods study exploring perinatal mental health in Ukraine. Five online focus groups (n=30) with Ukrainian mothers of children aged 0-5 years were conducted in June-July 2020. The participants were selected from a pool of 1634 women who completed an online questionnaire and agreed to participate in further research. Informed consent was obtained. The data collected from the focus groups were transcribed verbatim and analyzed thematically using Dedoose software. RESULTS The study identified two themes. The first theme was: 'Understanding perinatal mental health through women's experience', which covers five subthemes. The second theme was 'Psychosocial determinants of maternal mental health', which includes six subthemes. Overall, women's feelings of guilt, blame, and shame during their perinatal journey are influenced by socio-cultural factors and can lead to mental health problems and reluctance to seek proper help. CONCLUSIONS The study has identified some factors that can contribute to the enhancement of mental health and well-being of mothers in Ukraine during their perinatal journey. Negative emotions such as guilt, blame, and shame can have a significant impact on their ability to seek the necessary support, and should be addressed by midwives and other healthcare professionals. [ABSTRACT FROM AUTHOR]

Distracted driving is a major cause of road traffic crashes in Yaoundé. This is partly due to the scarcity of enforcement and a lack of evidence and investigation using the distraction safety performance indicator (SPI), hindering evidence-based interventions. This study aimed to address this evidence gap by evaluating the distraction SPI using a proven methodology. Data on distracted driving (handheld mobile device; interaction; eating/smoking/drinking) were collected from roadside observations on 36 randomly selected road sections carefully spread to cover the city. SPIs were computed and weighted with traffic volume to ensure the representativeness of the values. A total of 41,004 drivers were observed (38,248 in cars; 1116 in vans; 977 in trucks; 663 in buses). The prevalence of distracted driving in Yaoundé is 13.69% for the three distractions type combined. The prevalence is 7.84% for interaction, 4.89% for handled mobile device usage and 0.96% for eating/smoking/drinking. Leveraging these insights, a seven year (2024–2030) fighting strategy aimed at halving the prevalence was developed. The strategy contains interventions including legislation/enforcement, which have been proven to be effective. This study, pioneered in Yaoundé, provides stakeholders with evidence of the issue and measures to implement and can also be used when developing a road safety strategy. Future research should consider investigation at national level. [ABSTRACT FROM AUTHOR]

The term 'perspective' in the context of economic evaluations and costing studies in healthcare refers to the viewpoint that an analyst has adopted to define the types of costs and outcomes to consider in their studies. However, there are currently notable variations in terms of methodological recommendations, definitions, and applications of different perspectives, depending on the objective or intended user of the study. This can make it a complex area for stakeholders when interpreting these studies. Consequently, there is a need for a comprehensive overview regarding the different types of perspectives employed in such analyses, along with the corresponding implications of their use. This is particularly important, in the context of low-and-middle-income countries (LMICs), where practical guidelines may be less well-established and infrastructure for conducting economic evaluations may be more limited. This article addresses this gap by summarising the main types of perspectives commonly found in the literature to a broad audience (namely the patient, payer, health care providers, healthcare sector, health system, and societal perspectives), providing their most established definitions and outlining the corresponding implications of their uses in health economic studies, with examples particularly from LMIC settings. We then discuss important considerations when selecting the perspective and present key arguments to consider when deciding whether the societal perspective should be used. We conclude that there is no one-size-fits-all answer to what perspective should be used and the perspective chosen will be influenced by the context, policymakers'/stakeholders' viewpoints, resource/data availability, and intended use of the analysis. Moving forward, considering the ongoing issues regarding the variation in terminology and practice in this area, we urge that more standardised definitions of the different perspectives and the boundaries between them are further developed to support future studies and guidelines, as well as to improve the interpretation and comparison of health economic evidence. [ABSTRACT FROM AUTHOR]

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: 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]