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Gestational Diabetes Mellitus (GDM) is associated with adverse maternal and perinatal outcomes and increased risk of developing diabetes in later life. Sri Lanka adopted universal GDM screening at two time points in pregnancy (before 12 weeks and between 24 and 28 weeks) in 2014 and its utilization has not been assessed. This study assessed the utilization of GDM screening services and associated factors among antenatal mothers in Southern Sri Lanka. A cross-sectional study was carried out in a consecutive sample of 420 postpartum mothers who delivered at three major hospitals in Sri Lanka. Data were collected on socio-demographics, pregnancy, availability and utilization of screening services and logistics using an interviewer-administered questionnaire and a data record sheet. Data was analysed using SPSS software. Chi-square test and binary logistic regression was used to assess the association between variables. The coverage of first and second screening tests were 91.4% and 94.5% and timeliness were 72.4% and 59.5%, respectively. The median period of amenorrhoea at the first and second screening were 10.0 (inter-quartile range: 2.5) weeks and 28.0 (inter-quartile range: 1.5) weeks. A higher utilization was associated with higher income (OR = 3.4, 95% CI: 1.1–10.5) and planned pregnancy (OR = 4.9, 95% CI: 2.2–10.7) for the first screening test. Primiparity (OR = 0.3, 95% CI: 0.1–0.9) and proximity of the nearest laboratory (OR = 3.5, 95% CI: 1.0–12.0) were positively associated with the second screening test. The timeliness of both screening tests was associated with planned pregnancy (OR = 2.1, 95% CI: 1.1-4.0 and OR = 2.3, 95% CI: 1.1–4.5) and being non-employed during the pregnancy (OR = 2.5, 95% CI: 1.4–4.3 and OR = 2.3, 95% CI: 1.3–4.1). A high utilization of GDM screening was observed. Timeliness should be ensured through improved availability and accessibility of screening facilities. [ABSTRACT FROM AUTHOR]

The most common cited cause of split-thickness skin graft failure is infection and due to the association between bacterial findings in wound beds an attempt to decrease the bacterial burden before skin-grafting evolved. Thus, preoperative microbiology swabs of the wound bed became routine at some institutions prior to grafting. This is not standard practice in the Pietermaritzburg Burn Service. Emphasis is instead placed on a strict protocol of intraoperative wound bed preparation to promote adequate graft take. This pilot study aims to evaluate whether preoperative wound swabs are appropriate. We performed a prospective observational study to determine if positive wound cultures were associated with graft failure. All patients with a burn surface area of less than 10%, where delayed grafting (later than 28 days from the time of burn injury) was performed, from March to December 2021 were analyzed. Patient demographics, days from burn to graft, %TBSA burn, %TBSA grafted, whether sharp debridement prior to grafting in the same procedure was performed or not, use of topical gentamicin intraoperatively, graft outcome (% graft loss), need for regraft, and organism grown were recorded into an excel spreadsheet for analysis. The sample included 52 patients. Of these, 17 (31.5%) were female. The median %TBSA grafted was 8% (IQR 4%-13%) and similar in both groups. The median days from burn to grafting were 35 days. Thirty-nine patients (75%) had graft Take and 13 (25%) had graft Failure. In the failed group, the median % graft failure was 50% (30%-70%). Of the group with successful graft take, 90% were noted to have had a positive wound culture prior to grafting. A positive wound culture was not found to be a risk factor for graft failure (P =.993). Despite the positive wound cultures graft take was more than 90% in 75% of grafts performed and only 2/52 patients required supplementary grafting. We believe that this demonstrates that our local protocol is reasonable in this setting and that waiting for negative wound swabs prior to grafting should not be a reason to delay grafting. [ABSTRACT FROM AUTHOR]

Abstract Gestational Diabetes Mellitus (GDM) is associated with adverse maternal and perinatal outcomes and increased risk of developing diabetes in later life. Sri Lanka adopted universal GDM screening at two time points in pregnancy (before 12 weeks and between 24 and 28 weeks) in 2014 and its utilization has not been assessed. This study assessed the utilization of GDM screening services and associated factors among antenatal mothers in Southern Sri Lanka. A cross-sectional study was carried out in a consecutive sample of 420 postpartum mothers who delivered at three major hospitals in Sri Lanka. Data were collected on socio-demographics, pregnancy, availability and utilization of screening services and logistics using an interviewer-administered questionnaire and a data record sheet. Data was analysed using SPSS software. Chi-square test and binary logistic regression was used to assess the association between variables. The coverage of first and second screening tests were 91.4% and 94.5% and timeliness were 72.4% and 59.5%, respectively. The median period of amenorrhoea at the first and second screening were 10.0 (inter-quartile range: 2.5) weeks and 28.0 (inter-quartile range: 1.5) weeks. A higher utilization was associated with higher income (OR = 3.4, 95% CI: 1.1–10.5) and planned pregnancy (OR = 4.9, 95% CI: 2.2–10.7) for the first screening test. Primiparity (OR = 0.3, 95% CI: 0.1–0.9) and proximity of the nearest laboratory (OR = 3.5, 95% CI: 1.0–12.0) were positively associated with the second screening test. The timeliness of both screening tests was associated with planned pregnancy (OR = 2.1, 95% CI: 1.1-4.0 and OR = 2.3, 95% CI: 1.1–4.5) and being non-employed during the pregnancy (OR = 2.5, 95% CI: 1.4–4.3 and OR = 2.3, 95% CI: 1.3–4.1). A high utilization of GDM screening was observed. Timeliness should be ensured through improved availability and accessibility of screening facilities.

Abstract Background Opioid use disorder (OUD) among adolescents with sickle cell disease (SCD) patients increases their risk of complications from sickle cell disease, such as infections, stroke, acute chest syndrome, sudden death, and organ failure. This negatively impacts families, communities, the national health system, and the economy. This study aimed to determine the prevalence and factors associated with opioid use disorder among adolescents with SCD at Mulago Hospital Uganda. Methods This study was carried out at the Sickle Cell Clinic of Mulago Hospital, the national referral hospital in Uganda. The study participants were adolescents aged 10 to 19 years. Following informed consent/ assent, a sociodemographic questionnaire, the WHO Alcohol, Smoking and Substance Involvement Screening Test - Young (ASSIST-Y), the Beck Depression Inventory-II (BDI II), and Generalized Anxiety Disorder − 7 (GAD-7) questionnaires were used to collect data. Data was entered in EpiInfo and analyzed in STATA 15. Results The prevalence of opioid use disorder was 5.3%. The significant risk factor was increasing depressive score AOR: 1.11(95% CI: 1.01–1.22, p = 0.035), while living with a family was protective against opioid use disorders AOR: 0.01; (95% CI: 0.0004, 0.27, p = 0.007). Conclusion There was a significant problem of OUD among adolescents with SCD. There is, therefore, needed to integrate screening of OUD and mental illnesses like depression among adolescents with SCD and to emphasize the importance of family support in their care.

Introduction: In low resource settings (LRS), utilization of Computed Tomography scan (CTS) for mild traumatic brain injuries (mTBIs) presents unique challenges and considerations given the limited infrastructure, financial resources, and trained personnel. The Theoretical Domains Framework (TDF) offers a comprehensive theoretical lens to explore factors influencing the decision-making to order CTS for mTBI by imaging referrers (IRs). Objectives: The primary objective was to explore IRs’ beliefs about factors influencing CT utilization in mTBIs using TDF in Uganda.Differences in the factors influencing CTS ordering behavior across specialties, levels of experience, and hospital category were also explored. Materials and Methods: In-depth semi-structured interviews guided by TDF were conducted among purposively selected IRs from 6 tertiary public and private hospitals with functional CTS services. A thematic analysis was performed with codes and emerging themes developed based on the TDF. Results: Eleven IRs including medical officers, non-neurosurgeon specialists and neurosurgeons aged on average 42 years (SD+/-12.3 years) participated.Identified factors within skills domain involved IRs’ clinical assessment and decision-making abilities, while beliefs about capabilities and consequences encompassed their confidence in diagnostic abilities and perceptions of CTS risks and benefits. The environmental context and resources domain addressed the availability of CT scanners and financial constraints. The knowledge domain elicited IRs’ understanding of clinical guidelines and evidence-based practices while social influences considered peer influence and institutional culture. For memory, attention & decision processes domain, IRs adherence to guidelines and intentions to order CT scans were cited. Conclusion: Using TDF, IRs identified several factors believed to influence decision making to order CTS in mTBI in a LRS. The findings can inform stakeholders to develop targeted strategies and evidence-based interventions to optimize CT utilization in mTBI such as; educational programs, workflow modifications, decision support tools, and infrastructure improvements, among others.

Purpose: This study describes the experience with common neonatal surgical conditions and their outcomes at a single center in the Eastern Democratic Republic of the Congo (DRC) over a period of 7 years (2016–2022). Methods: A retrospective review of neonatal surgical admissions and their outcomes was performed for patient admitted between January 2016 and December 2022 at HEAL Africa teaching hospital. Data were collected from the neonatal admission and discharge registry for all patients with a potential surgical condition. Results: 107 neonates potentially requiring surgery were identified. 81.3% were referred from facilities within 10 km of HEAL Africa. The most common diagnosis was myelomeningocele/meningocele (27.1%). 68.2% of patients had an operation. The overall mortality was 29% for all patients and mean length of stay 9.9 days. Operated patients had a lower mortality at 16.4% (p-value < 0.001, OR 0.155, CI 0.062–0.389) while patients with a birth weight of less than 2500 g were more likely to die (p-value < 0.001, OR 5.333, CI 2.062–13.79). Conclusion: The neonatal mortality rate for patients presenting with a potential surgical condition is extremely high. This is multifactorial and largely related to patient selection inherent to resource limitations. [ABSTRACT FROM AUTHOR]

Background: Opioid use disorder (OUD) among adolescents with sickle cell disease (SCD) patients increases their risk of complications from sickle cell disease, such as infections, stroke, acute chest syndrome, sudden death, and organ failure. This negatively impacts families, communities, the national health system, and the economy. This study aimed to determine the prevalence and factors associated with opioid use disorder among adolescents with SCD at Mulago Hospital Uganda. Methods: This study was carried out at the Sickle Cell Clinic of Mulago Hospital, the national referral hospital in Uganda. The study participants were adolescents aged 10 to 19 years. Following informed consent/ assent, a sociodemographic questionnaire, the WHO Alcohol, Smoking and Substance Involvement Screening Test - Young (ASSIST-Y), the Beck Depression Inventory-II (BDI II), and Generalized Anxiety Disorder − 7 (GAD-7) questionnaires were used to collect data. Data was entered in EpiInfo and analyzed in STATA 15. Results: The prevalence of opioid use disorder was 5.3%. The significant risk factor was increasing depressive score AOR: 1.11(95% CI: 1.01–1.22, p = 0.035), while living with a family was protective against opioid use disorders AOR: 0.01; (95% CI: 0.0004, 0.27, p = 0.007). Conclusion: There was a significant problem of OUD among adolescents with SCD. There is, therefore, needed to integrate screening of OUD and mental illnesses like depression among adolescents with SCD and to emphasize the importance of family support in their care. [ABSTRACT FROM AUTHOR]

The provision of specialized spine care in Nigeria presents a pressing challenge amid limited resources and geographical disparities. This correspondence offers a comprehensive roadmap for improving spine surgery and care within the country. We examine the current state of spinal health infrastructure, highlighting barriers such as limited access to specialists and facilities, particularly in rural areas, and financial constraints for patients. Innovations in spinal treatment, including the adoption of minimally invasive techniques and advancements in surgical modalities, are discussed alongside persistent challenges such as disparities in access and equipment costs. Training and education of spine surgeons emerge as critical areas requiring attention, with a shortage of qualified professionals exacerbated by inadequate training programs and resource constraints. We advocate for fostering local and international collaborations to address these gaps, emphasizing the role of partnerships in capacity building and knowledge exchange. Additionally, we explore the potential of public-private partnerships and investments to enhance the Nigerian spine healthcare system, calling for strategic initiatives to modernize infrastructure and improve accessibility. Finally, we propose a strategic blueprint encompassing infrastructure enhancement, training programs, research initiatives, policy advocacy, and public awareness campaigns. Through concerted efforts from local stakeholders and international partners, we envision a future where spine care in Nigeria is comprehensive, accessible, and of high quality, leading to improved health outcomes and a higher quality of life for those affected by spinal conditions. [ABSTRACT FROM AUTHOR]

In low resource settings (LRS), utilization of Computed Tomography scan (CTS) for mild traumatic brain injuries (mTBIs) presents unique challenges and considerations given the limited infrastructure, financial resources, and trained personnel. The Theoretical Domains Framework (TDF) offers a comprehensive theoretical lens to explore factors influencing the decision-making to order CTS for mTBI by imaging referrers (IRs). The primary objective was to explore IRs' beliefs about factors influencing CT utilization in mTBIs using TDF in Uganda. Differences in the factors influencing CTS ordering behavior across specialties, levels of experience, and hospital category were also explored. In-depth semi-structured interviews guided by TDF were conducted among purposively selected IRs from 6 tertiary public and private hospitals with functional CTS services. A thematic analysis was performed with codes and emerging themes developed based on the TDF. Eleven IRs including medical officers, non-neurosurgeon specialists and neurosurgeons aged on average 42 years (SD+/-12.3 years) participated. Identified factors within skills domain involved IRs' clinical assessment and decision-making abilities, while beliefs about capabilities and consequences encompassed their confidence in diagnostic abilities and perceptions of CTS risks and benefits. The environmental context and resources domain addressed the availability of CT scanners and financial constraints. The knowledge domain elicited IRs' understanding of clinical guidelines and evidence-based practices while social influences considered peer influence and institutional culture. For memory, attention & decision processes domain, IRs adherence to guidelines and intentions to order CT scans were cited. Using TDF, IRs identified several factors believed to influence decision making to order CTS in mTBI in a LRS. The findings can inform stakeholders to develop targeted strategies and evidence-based interventions to optimize CT utilization in mTBI such as; educational programs, workflow modifications, decision support tools, and infrastructure improvements, among others. [ABSTRACT FROM AUTHOR]

Carcinoma cervix is one of the leading causes of death among females worldwide. WHO has put forth the 90–70–90 global strategy for elimination of cervical cancer. It calls for 70% women to be screened at least once in their lifetime. This is as low as 1.9% for India and even lower for many other countries. Studying patient journeys, process mapping and counterfactual analysis helped to better understand the problem. Weaknesses of our system include availability, accessibility, affordability, skewed distribution of infrastructure, cost implications and limited specialist manpower. The strengths of our system are the key change drivers like existing network of primary healthcare workers, changes in health seeking behavior due to COVID-19 with increasing role of tele-health, conducive political milieu with initiatives like Digital India Mission and booming start-up ecosystem. On connecting the dots, what we need is a solution that is inexpensive, socially acceptable, does not require women to visit health centers, does not require additional government budgetary allocation and something that the industry/start-ups would be keen on taking up. An artificial intelligence-based solution like "Smart-Colpo" can be a good fit. It can be a potential "Loss-Leader" for industry players, helping them build network, acquire potential customers in rural India and usher in data-driven revenue models and cross-subsidization. Therefore, making it India's first industry-led health program. [ABSTRACT FROM AUTHOR]

Background: The Kitovu Fast Triage (KFT) score predicts imminent mortality from mental status, gait and either respiratory rate or oxygen status. As some non-life-threatening conditions require immediate attention, the South African Triage System (SATS) assigns arbitrary rankings of urgency for specific patient presentations. Aim: Establish the feasibility of determining and then comparing the KFT score and explicitly defined SATS urgency rankings. Methods: A computerized proforma used standardized methods of assessing and measuring mental status and gait, and respiratory rate and collected explicitly defined clinical presentations and SATS urgency rankings on 4,842 patients at the time of their arrival to the hospital. Results: 75 % of patients were awake and able to count the months backwards from December to September. Respiratory rates measured by a computer application had no clustering of values or digit preference; however, oximetry failed in 14 % of patients, making the score based on respiratory rate the most practical in our setting. Determining the SATS acuity ranking and both KFT scores usually took 38 °C. Conclusion: Whilst the KFT score based on respiratory rate could be rapidly determined in all patients, it identified some patients as low acuity who had very urgent SATS rankings. However, most of these patients had non-severe chest pain, which may not be a very urgent presentation in our setting as ischaemic heart disease remains uncommon in sub-Saharan Africa.

Postpartum depression (PPD) affects nearly 20% of postpartum women in Sub-Saharan Africa (SSA), where HIV prevalence is high. Depression is associated with worse HIV outcomes in non-pregnant adults and mental health disorders may worsen HIV outcomes for postpartum women and their infants. PPD is effectively treated with psychosocial or pharmacologic interventions; however, few studies have evaluated the acceptability of treatment modalities in SSA. We analyzed interviews with 23 postpartum women with HIV to assess the acceptability of two depression treatments provided in the context of a randomized trial. Most participants expressed acceptability of treatment randomization and study visit procedures. Participants shared perceptions of high treatment efficacy of their assigned intervention. They reported ongoing HIV and mental health stigma in their communities and emphasized the importance of social support from clinic staff. Our findings suggest a full-scale trial of PPD treatment will be acceptable among women with HIV in Zambia. [ABSTRACT FROM AUTHOR]

Hand hygiene (HH) is challenging in health care, but particularly in resource-limited settings due to a lack of training, resources, and infrastructure. This study aimed to evaluate the implementation of wall-mounted alcohol-based handrub (ABHR) at the point of care (POC) on HH compliance among health care workers in a Cameroon hospital. It was a three-stage before and after study. The first stage involved baseline collection of ABHR utilization and HH compliance data. The second stage included the implementation of ABHR at the POC, supported by an implementation strategy involving HH training, monitoring and feedback, and HH champions. The third stage involved postimplementation data collection on ABHR use and HH compliance. 5,214 HH opportunities were evaluated. HH compliance significantly increased from 33.3% (baseline) to 83.1% (implementation stage) (P <.001) and to 87.2% (postimplementation stage) (P <.001). Weekly ABHR usage increased significantly during implementation (5,670 ml), compared to baseline, (1242.5 ml, P =.001), and remained high in postimplementation (7,740 ml). Continuous availability of ABHR at POC, supported by implementation strategy, significantly increased HH compliance and ABHR use. Learning from this study could be used to implement ABHR at POC in other facilities. • ABHR provision supported with implementation strategy resulted in improved HH. • A significant increase in ABHR usage was also observed. • Learning from this study could be used to improve HH in other facilities. • Further work should focus on developing an infection surveillance system. [ABSTRACT FROM AUTHOR]

The Kitovu Fast Triage (KFT) score predicts imminent mortality from mental status, gait and either respiratory rate or oxygen status. As some non-life-threatening conditions require immediate attention, the South African Triage System (SATS) assigns arbitrary rankings of urgency for specific patient presentations. Establish the feasibility of determining and then comparing the KFT score and explicitly defined SATS urgency rankings. A computerized proforma used standardized methods of assessing and measuring mental status and gait, and respiratory rate and collected explicitly defined clinical presentations and SATS urgency rankings on 4,842 patients at the time of their arrival to the hospital. 75 % of patients were awake and able to count the months backwards from December to September. Respiratory rates measured by a computer application had no clustering of values or digit preference; however, oximetry failed in 14 % of patients, making the score based on respiratory rate the most practical in our setting. Determining the SATS acuity ranking and both KFT scores usually took <90 s; the commonest complaints were pain, dyspnoea, and fever, which often occurred together; overall 3574 (73.8 %) patients had at least one of these symptoms as did 96.4 % of those with the highest KFT score based on respiratory rate. 12 % of patients with the lowest KFT score based on respiratory rate had one or more very urgent SATS rankings, 52 % of whom had non-severe chest pain. Only 5.7 % of patients complaining of fever had a temperature >38 °C. Whilst the KFT score based on respiratory rate could be rapidly determined in all patients, it identified some patients as low acuity who had very urgent SATS rankings. However, most of these patients had non-severe chest pain, which may not be a very urgent presentation in our setting as ischaemic heart disease remains uncommon in sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

An ectopic pregnancy occurs when the fertilized egg is implanted and develops outside the endometrium, i.e. in the fallopian tubes, cervix, ovary, or abdomen. It commonly presents with a history of amenorrhoea, lower abdominal pain, and slight vaginal bleeding. The fallopian tube is the most typical location for ectopic pregnancy. Two percent of reported pregnancies are ectopic pregnancy. Ectopic pregnancy remains a public health threat for women in reproductive age, and a major cause of maternal mortalities in the first trimester. In East Africa, these reports are limited, despite a great need for documentation addressing key considerations for diagnosis and management of ectopic pregnancy in these resource limited settings. In this case study, we report on 26-years-old female Gravida 5 Para 4 Living 4, who reported history of amenorrhoea for 3 months complaining of slight per vagina bleeding and lower abdominal pain for 5 days more marked at left iliac region along with generalized weakness for 2 weeks. Her vitals were stable. Pelvic ultrasound revealed empty uterus and live fetus at the left adnexa corresponding to 14 weeks 6 days with minimal free fluid in the Douglas Cul-de-sac. The patient's final diagnosis was live extra-uterine pregnancy at 14 weeks 6 days that was managed by emergency laparotomy with salpingectomy. The patient recovered completely after surgery and was discharged in a stable condition. Ectopic pregnancy still remains one of the major causes of maternal morbidity and mortality. Early diagnosis and referral in hemodynamically state along with use of minimal access surgery or management can change the scenario of ectopic pregnancy in the developing world. Late attendance to first visit clinics is still a major concern in low resource limited settings as this could have been picked early and intervened. Key message: Management of broad ligament ectopic pregnancy in the second trimester is still challenging especially in low resource settings where the clients do not attend clinics and because of unavailability of ultrasound machines to diagnose it. [ABSTRACT FROM AUTHOR]

Injuries are a public health crisis. Neurotrauma, a specific type of injury, is a leading cause of death and disability globally, with the largest burden in low- and middle-income countries (LMICs). However, there is a lack of quality neurotrauma-specific data in LMICs, especially at the national level. Without standard criteria for what constitutes a national registry, and significant challenges frequently preventing this level of data collection, we argue that singleinstitution or regional databases can provide significant value for context-appropriate solutions. Although granular data for larger populations and a universal minimum dataset to enable comparison remain the gold standard, we must put progress over perfection. It is critical to engage local experts to explore available data and build effective information systems to inform solutions and serve as the foundation for quality and process improvement initiatives. Other items to consider include adequate resource allocation and leveraging of technology as we work to address the persistent but largely preventable injury pandemic.

BackgroundThe burden of pediatric critical illness and resource utilization by children with critical illness in resource limited settings (RLS) are largely unknown. Without specific data that captures key aspects of critical illness, disease presentation, and resource utilization for pediatric populations in RLS, development of a contextual framework for appropriate, evidence-based interventions to guide allocation of limited but available resources is challenging. We present this methods paper which describes our efforts to determine the prevalence, etiology, hospital outcomes, and resource utilization associated with pediatric acute, critical illness in RLS globally.MethodsWe will conduct a prospective, observational, multicenter, multinational point prevalence study in sixty-one participating RLS hospitals from North, Central and South America, Africa, Middle East and South Asia with four sampling time points over a 12-month period. Children aged 29 days to 14 years evaluated for acute illness or injury in an emergency department) or directly admitted to an inpatient unit will be enrolled and followed for hospital outcomes and resource utilization for the first seven days of hospitalization. The primary outcome will be prevalence of acute critical illness, which Global PARITY has defined as death within 48 hours of presentation to the hospital, including ED mortality; or admission/transfer to an HDU or ICU; or transfer to another institution for a higher level-of-care; or receiving critical care-level interventions (vasopressor infusion, invasive mechanical ventilation, non-invasive mechanical ventilation) regardless of location in the hospital, among children presenting to the hospital. Secondary outcomes include etiology of critical illness, in-hospital mortality, cause of death, resource utilization, length of hospital stay, and change in neurocognitive status. Data will be managed via REDCap, aggregated, and analyzed across sites.DiscussionThis study is expected to address the current gap in understanding of the burden, etiology, resource utilization and outcomes associated with pediatric acute and critical illness in RLS. These data are crucial to inform future research and clinical management decisions and to improve global pediatric hospital outcomes.

BackgroundHIV/AIDS is now a manageable chronic illness owing to effective antiretroviral therapy (ART), which involves routine follow-up care, including regular physical visits to the clinic. In the recent past, and in wake of the COVID-19 pandemic, there has been increased need for virtual care and intervention delivery, a modality known as mobile health (mHealth), which includes cell phone-delivered services for medical and public health practice.ObjectiveHere we describe cell phone use and its relationship with alcohol use in a cohort of persons living with HIV and latent tuberculosis (TB).MethodsWe performed a cross-sectional analysis of baseline data from a cohort of persons living with HIV and latent TB in HIV care in southwestern Uganda. We estimated proportions of cell phone and text message use and evaluated their associations with alcohol use-a common modifiable behavior among persons living with HIV. Cell phone use (primary outcome) was defined as owning a cell phone that is turned on at least half of the day. Any alcohol use was defined as any self-reported alcohol use in the prior 3 months or a phosphatidylethanol (an alcohol biomarker) level of ≥8 ng/mL.ResultsA total of 300 participants (median age 40 years; n=146, 48.7% male) were included in the analysis. Most (n=267, 89.0%) participants had access to a phone and of them, 26 (9.7%) shared the phone with someone else. In total, 262/300 (87.3%) of participants owned a cell phone that is turned on at least half of the time; the majority (n=269, 89.7%) rarely or never sent text messages, and over two-thirds (n=200, 66.9%) rarely or never received text messages. Most (n=214, 71.3%) had any alcohol use in the prior 3 months. In adjusted analyses, any alcohol use was not significantly associated with cell phone use (adjusted odds ratio [aOR] 0.48, 95% CI 0.18-1.25; P=.13) or sending (aOR 0.82, 95% CI 0.28-2.37; P=.71) or receiving (aOR 1.31, 95% CI 0.70-2.47; P=.40) text messages.ConclusionsThere is hope that mHealth interventions in this population can be carried out using cell phones owing to their popularity; however, the interventions may need to employ methods that do not rely on the sending and receiving of text messages only.

Introduction. Unlike classroom education, during clinical placements, much of the day-to-day activities are unplanned and unstructured, hence, learning occurs in a complex environment. While a clinical setting may provide a more authentic learning environment, it however does include many challenges for the students. Identifying the challenges experienced by students is of importance so that appropriate mitigation strategies can be put in place. The aim of the study was to explore the challenges experienced by radiography students during their clinical placements. Methods. A qualitative phenomenological design employing three focus group discussions were conducted with second, third, and fourth-year radiography students. Data were managed in Nvivo 12 and analysed according to Giorgi's phenomenological approach. Results. Six themes overlapping from all three focus groups representing the challenges experienced by students emerged. The themes include financial issues, inadequate equipment, unsatisfactory supervision, disruptive behaviours, COVID-19, and a lack of support. Conclusion. Deliberate strategies to tackle the challenges experienced by students are recommended to create an effective clinical environment for radiography students. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopy has a clear patient benefit related to postoperative morbidity but may not be as commonly performed in low-and middle-income countries. The decision to convert to laparotomy can be complex and involve factors related to the surgeon, patient, and procedure. The objective of this work is to analyze the factors associated with conversion in laparoscopic surgery in a low-resource setting. Methods: This is a single-center prospective study of patients who underwent laparoscopic surgery between May 1, 2018 and October 31, 2021. The parameters studied were age, sex, body mass index (BMI), intraoperative complication (e.g., accidental enterotomy, hemorrhage), equipment malfunction (e.g., technical failure of the equipment, break in CO2 supply line), operating time, and conversion rate. Results: A total of 123 laparoscopic surgeries were performed. The average age of patients was 31.2 years (range 11–75). The procedures performed included appendix procedures (48%), followed by gynecological (18.7%), gallbladder (14.6%), digestive (10.56%), and abdominal procedures (4%). The average length of hospitalization was 3 days (range 1–16). Conversion to laparotomy was reported in 8.9% (n = 11) cases. Equipment malfunction was encountered in 9.8% (n = 12) cases. Surgical complications were noted in 11 cases (8.9%). Risk factors for conversion were shown to be BMI > 25 kg/m2 (OR 4.6; p = 0.034), intraoperative complications (OR 12.6; p = 0.028), and equipment malfunction (OR 9.4; p = 0.002). Conclusion: A better understanding of the underlying factors associated with high conversion rates, such as overweight/obesity, intraoperative complications, and equipment failure, is the first step toward surgical planning to reduce postoperative morbidity in low-resource settings. [ABSTRACT FROM AUTHOR]

Inadequate wheelchair provision in children can lead to delays in growth and development, poorer health, and decreased participation. Wheelchair provision for children can be challenging, especially in low-resource settings, due to limited resources. Therefore, the purpose of the scoping review was to gain an understanding of the current state of paediatric wheelchair provision in low resource settings and identify factors, strategies, and gaps that can lead to more successful wheelchair provision. This scoping review used literature published after 2010, related to paediatric wheelchair provision in low resource settings. We searched online databases and grey literature and extracted data based on categories from the World Health Organisation Guidelines to wheelchair provision in low resource settings. 34 articles were used to identify and analyse common themes and successful strategies related to wheelchair provision for children in low resource settings. Aspects of paediatric wheelchair provision were mentioned in the literature but were rarely the focus. End-user outcomes were the least represented category in the literature. Based on the currently available evidence the overall state of a wheelchair for children is inadequate. Improvements in design and production, personnel capacity, and service delivery systems are recommended to promote best practices. The lack of child-focussed wheelchair provision and end-user involvement in the research process urgently needs to be addressed. Identify best practice Identify gaps in knowledge Determine areas of need for future research [ABSTRACT FROM AUTHOR]

Abstract Background An International Health Elective (IHE) can be a unique learning experience for students. However, it has proven difficult to clearly define learning outcomes that capture the complexity of an IHE and are aligned with future professional performance. This study aimed to further define learning outcomes for IHEs in low- to middle-income countries (LMIC) from a student perspective. Methods We conducted a deductive analysis of pre-departure and post-elective reflective reports of fifth-year medical students who participated in an IHE as part of their program. This provided possible learning objectives that were further explored in semi-structured individual interviews with medical students who had recently returned from an IHE. Results We analyzed 33 reports of students participating in an IHE from 2017–2019 and held 19 interviews. Thematic analysis revealed 9 themes: developing intercultural competence, developing appreciation for differences in health care delivery systems, understanding international health, understanding the global burden of disease, developing a career perspective, developing clinical skills in resource low settings, becoming cost conscious, developing social responsibility and self-actualization. Conclusions We identified 9 learning outcomes that are directly and indirectly related to clinical practice. They add to the on-going discourse on the benefits of IHEs. These outcomes can be further developed by investigating the perspectives of home and host supervisors and educationalists, while taking the local context into account. Follow-up studies can evaluate to what extend these outcomes are achieve during an IHE.

Summary: Sri Lanka is representative of challenges faced by low-income and middle-income countries, including the rise in the prevalence of autism and the lack of sufficient autism-specific services in the state sectors. The experience in establishing a Center to provide services for children with autism in Northern Sri Lanka is described. Funding and resourcing were accessed through an innovative partnership-based public/non-governmental organisation/charity model, where service-based outcomes were the main objectives. This model, incorporating state institutions, local and international charity organisations, and volunteers, devised a bespoke approach to care provision using the available resources under the clinical supervision of a consultant psychiatrist and the administrative purview of the Regional Director of Health Services. The evolution of this Center into a Learning Health System is described, reflecting how a minimalistic partnership approach focused on the integration of existing organisations and services could be a feasible model for the delivery of high-quality healthcare in low-resource settings.

Background and aim: Diabetes has become a public health threat. The cost of diabetes care varies in different communities and depends on health-seeking behavior and socio-economic condition of the people. Data on economic and social impact of diabetes treatment among socially weaker section is scanty. Hence, this study was conducted to estimate the direct and indirect cost of treating diabetes among people living in low resource urban setting. Methods: A cross-sectional study was conducted among 1065 households in the two selected areas of North Chennai. Data was collected from individuals who were taking diabetes treatment in private health care facilities. The cost toward diabetes treatment for each participant was calculated using their medical bills, tablet strips and also self-reported cost details. Results: A total of 341 individuals were found to have diabetes and out of them, 230 (M:F, 63:167) individuals who attended private health facilities for their diabetes treatment were studied. Around 73% of them earned a monthly income of < INR 10,000. The study revealed that median annual direct cost of treating diabetes among the study participants was amounted to INR 7540. Annual median indirect cost amounted to INR 1650. Conclusion: People living with diabetes in low resource urban setting spent more toward direct medical cost. The out of pocket expenditure was mainly on hospitalization followed by medicines and investigations. The strengthening and provision of appropriate primary public health care services for diabetes in this setting may reduce out of pocket expenditure toward treatment of diabetes in private health care facilities. Highlights: • Nearly 3/4th of study participants who earn INR 10,000/month monitor their diabetes status rarely, but take medicines alone. • They spend INR 6000 on medicines annually while they spend only INR 400 on lab investigations. • More than 1/4th (28.3%) of them were irregular in taking medication and buying medicines with previous tablet strips from the medical shop. • Hypertension (24.7%) was the most common co-morbid condition prevalent among them than any other diabetic complications. [ABSTRACT FROM AUTHOR]

Background: An International Health Elective (IHE) can be a unique learning experience for students. However, it has proven difficult to clearly define learning outcomes that capture the complexity of an IHE and are aligned with future professional performance. This study aimed to further define learning outcomes for IHEs in low- to middle-income countries (LMIC) from a student perspective. Methods: We conducted a deductive analysis of pre-departure and post-elective reflective reports of fifth-year medical students who participated in an IHE as part of their program. This provided possible learning objectives that were further explored in semi-structured individual interviews with medical students who had recently returned from an IHE. Results: We analyzed 33 reports of students participating in an IHE from 2017–2019 and held 19 interviews. Thematic analysis revealed 9 themes: developing intercultural competence, developing appreciation for differences in health care delivery systems, understanding international health, understanding the global burden of disease, developing a career perspective, developing clinical skills in resource low settings, becoming cost conscious, developing social responsibility and self-actualization. Conclusions: We identified 9 learning outcomes that are directly and indirectly related to clinical practice. They add to the on-going discourse on the benefits of IHEs. These outcomes can be further developed by investigating the perspectives of home and host supervisors and educationalists, while taking the local context into account. Follow-up studies can evaluate to what extend these outcomes are achieve during an IHE. [ABSTRACT FROM AUTHOR]

Cancer-related fatigue can lead to a reduced health-related quality of life among patients with cancer. We explored the experiences of fatigue among women undergoing breast cancer treatment at a public hospital in South Africa. We recruited 12 participants using purposive sampling. In-depth, semi-structured interviews were conducted by registered clinical psychologists. The interviews were audio recorded and transcribed. A thematic analysis of the data produced three themes, namely, fatigue is tiredness, the pervasive impact of fatigue and fatigue management strategies. These strategies included rest, pacing, physical activity, energy drinks, instrumental support and cognitive strategies such as distraction and self-talk. Our recommendation is that healthcare providers need to prioritise communication about fatigue and provide appropriate management strategies. [ABSTRACT FROM AUTHOR]

Purpose Newborn respiratory support using Bubble Continuous positive airway pressure (bCPAP) has become acceptable in Nigeria as many centers are increasingly reporting its usefulness. There is increasing access to CPAP devices although the use of 100% oxygen for bCPAP administration is on the rise as oxygen/air blenders are not commonly available or insufficient. The cost of oxygen has become a significant contributor to hospital bills. The oxygen concentrator driven bCPAP device with blending capacity is expected to save lives and reduce cost of care. Objective To compare the cost saving benefit of the use of oxygen concentrator bCPAP devices for CPAP administration to oxygen based devices in a resource limited setting. Methods This prospective cross sectional study was done between February and December 2019. The oxygen use by CPAP devices-Improvised (IbCPAP), Fisher and Paykel and T-piece were quantified, costed, documented and compared with the same duration of use of concentrator CPAP-Diamedica. Results CPAP services was accessed by 357 babies, 154 males and 203 females of GA range from 22 to 42 weeks and Birthweights range from 264 to 4400 grams. The main indication for CPAP was respiratory distress syndrome 201(56.3%). Oxygen supply were by oxygen pipeline 250 (70%), cylinders 39 (10.9%), concentrator CPAP 44 (12.3%) mixed source 24 (6.7%). Mean duration on the CPAP devices was 5.4 days, mean cost ₦37,645 ($104) or ₦6,971 ($20)/day, highest with IbCPAP, non-existent with concentrator bCPAP. Conclusion The high running cost implication of CPAP use in low resource settings could deter transitioning to quality devices hence the need for non-oxygen dependent devices. [ABSTRACT FROM AUTHOR]

Abstract Background Men’s depression, alcohol use, and family problems commonly co-occur to create of cluster of mental health problems. Yet, few treatments exist to address these problems, especially in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel task-shifted intervention to address this cluster of men’s mental health problems with a focus on engaging and retaining men in treatment. Methods The intervention, Learn, Engage, Act, Dedicate (LEAD), is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop LEAD, we engaged in a community-engaged multi-step, collaborative process with local Kenyan stakeholders. LEAD was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated given engagement of men was key for proof of concept. Semi-structured interviews were conducted with participants and analyzed using thematic content analysis. Results The development process resulted in a weekly 5-session intervention rooted in behavioral activation, motivational interviewing, and masculinity discussion strategies. These approaches were combined and adapted to fit contextually salient constructs, such as the importance of the man as provider, and streamlined for lay providers. Feasibility and acceptability results were promising with high attendance, acceptability of delivery and intervention content, and perceived intervention helpfulness. Conclusion Results describe an acceptable task-shifted treatment that may engage men in care and addresses a cluster of common mental health problems among men in ways that consider social determinants like masculinity. Findings set the stage for a larger trial. Trial registration ISRCTN, ISRCTN130380278. Registered 7 October 2019—Retrospectively registered, http://www.isrctn.com/ISRCTN13038027

Abstract Background Significant improvements in under-five mortality in Malawi have been demonstrated over the past thirty years; however, Malawian healthcare remains with gaps in availability and access to quality pediatric critical care nursing training and education. To improve expertise of pediatric critical care nurses in Malawi, Kamuzu University of Health Sciences (KUHeS), Queen Elizabeth Central Hospital (QECH), and Mercy James Center (MJC) entered a partnership with Seed Global Health, a US non-governmental organization. A needs assessment was conducted to understand the training needs of nurses currently working in pediatric critical care and in preparation for the development of a specialized Master’s in Child Health pathway in Pediatric Critical Care (PCC) Nursing at KUHeS. Methods The needs assessment was completed using a survey questionnaire formatted using an ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) framework. The questionnaire had Likert scale and yes/no questions. Data was manually entered into excel and was analyzed using descriptive statistics. Results One hundred and fifty-three nurses at QECH and MJC responded to the survey. Most nurses were between the ages of 25 and 35 years (N = 98, 64%), female (N = 105, 69%), and held either a Bachelors (N = 72, 47%) or diploma (N = 70, 46%) in nursing. Nurses had high rates of confidence in certain skills: airway management (N = 120, 99%), breathing assessment & management (N = 153, 100%). However, nurses demonstrated little to no confidence in areas such as: mechanical ventilation (N = 68, 44%), ECG evaluation (N = 74, 48%), and arterial blood gas collection & interpretation (N = 49, 32%). Conclusion It is important to identify priority areas for training and skills development to address in the PCC master’s within the child health pathway at KUHeS. Ideally this partnership will produce practice-ready PCC nurses and will establish a recognized PCC nursing workforce in Malawi.

Background High-quality essential newborn care (ENC) can improve newborn health and reduce preventable newborn mortality. The World Health Organization recommends specific ENC interventions. Video recordings have potential as a tool for assessment of clinical care also in low and middle-income countries. Objective To use video observations of healthy newborns to describe ENC practices in a low-income setting and compare actual clinical practice with WHO recommendations. Method This is a cross-sectional observational study. Video records of neonatal interventions to 324 healthy newborns were assessed. They were obtained at baseline of a pre-post intervention study during a 10-week study period in Pemba, Tanzania. Data also included postnatal structured questionnaires. Eight ENC interventions and quality indicators were defined as per the WHO recommendations. Descriptive statistics were used to summarize ENC practices and maternal and neonatal characteristics. Results None of the newborns received all eight recommended ENC interventions. The median duration of separation from the mother was 25 minutes and 15 seconds (ranging from 22 seconds to 3 hours and 36 minutes), 51% of the newborns received proper thermal care during the separation. Twenty-one percent had sufficient umbilical cord care, 8% were stimulated for breathing, 69% were observed at least once by healthcare staff and 9% did undergo suctioning. None of the newborns received antibiotic ointments or vitamin K. Conclusion Video recording of healthy newborns was feasible. The study identified omission of key ENC practices including proper thermal care, skin-to-skin contact and establishment of breastfeeding within the first hour of life, vitamin K administration as well as application of unnecessary practices such as excessive suctioning of breathing newborns.

Cervical cancer is one of the most significant global health inequities of our time and is the fourth most common cancer in women worldwide, disproportionally affecting developing countries where the disease burden is 84%. Sometimes referred to as preventable cancer, it progresses slowly, providing a window of time for routine screening in which pre-cancerous lesions can be identified and treated. The high mortality rate can be attributed to many reasons, including the high cost of cytology-based screening, lack of human resources to conduct screening, and inadequate preventive medicine services and systems. Due to its slow progression, early intervention is feasible with appropriate screening. However, the standard screening procedures require access to lab-based tests and physician expertise. Several imaging devices have been introduced in the literature to aid cervical screening in low-resource settings. This review details the instrumentation and clinical testing of devices currently deployed in low-resource locations worldwide. The devices' imaging, portability, illumination, and power requirements (among other metrics) are documented with specifics of human pilot studies conducted with these tools. [ABSTRACT FROM AUTHOR]

Despite the availability of free pap testing services, Jamaican women have low human papillomavirus (HPV) screening rates; 16% of women in the Kingston Metropolitan Area have been screened within the prior 3 years. This paper discusses the testing of theory-based messages to increase HPV screening uptake in a low-resource setting, using HPV self-test kits designed for this intervention. A total of 163 Jamaican women, aged 30-65 years, who had not had a pap test in at least 3 years, from two low socioeconomic status communities in Kingston, were enrolled and assigned to one of two versions of an HPV self-test kit, either with or without culturally targeted fear appeal messages. The uptake of screening was high across conditions; 95.6% of participants used the HPV self-test and returned their kits. However, surprising variations were observed in self-test acceptability, explained by differing attitudes toward the message conditions. Based on the results, we recommend four key components to increase HPV screening in low-resource settings: 1) focus on perceived threat in message design, 2) avoid written materials due to literacy concerns, 3) use culturally appropriate interpersonal or community-based channels, and 4) consider alternative solutions (such as a self-test) available at no or low cost to address structural barriers. [ABSTRACT FROM AUTHOR]

Introduction: In South Africa, only children considered eligible for transplantation are offered dialysis as bridge to kidney transplantation. Maintenance peritoneal dialysis (PD) is preferred and has several advantages over hemodialysis (HD). While awaiting transplantation, PD may be discontinued due to permanent transfer to HD or death while on PD, of which the occurrence and burden is not known in our setting. We investigated the rate of discontinuation of maintenance PD, and associated factors among children awaiting a kidney transplant under challenging socio-economic circumstances in a low resource setting., Methods: Single center retrospective analysis of children receiving maintenance PD. Outcomes included the proportion of children who discontinued PD before transplantation, associated factors and timing of discontinuation, and the proportion transplanted. Time to discontinuation or transplantation was displayed using a Kaplan-Meier curve., Results: Sixty-seven children who received maintenance automated PD as initial dialysis modality were identified from the kidney transplant waiting list between January 2009 and December 2018. Complete data was available for 52 of the 67 children. Four children had prior failed kidney transplants. The median age was 11 years (interquartile range 6.0, 13.1). Overall, 17/52 (32.7%) children discontinued PD, with 13 (25%) transfers to HD and 4 deaths (7.7%), whereas 29/52 (55.8%) received a kidney transplant. Three of the deaths were PD related. Six children remained on maintenance PD at the end of the study period. Over a half of our patients discontinued PD by 12 months, and 80% by 30 months. Most PD discontinuations were associated with peritonitis., Conclusions: The proportion discontinuing PD was high, highlighting the need to optimize measures to improve retention rates, especially through prevention of peritonitis., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Despite the availability of free pap testing services, Jamaican women have low human papillomavirus (HPV) screening rates; 16% of women in the Kingston Metropolitan Area have been screened within the prior 3 years. This paper discusses the testing of theory-based messages to increase HPV screening uptake in a low-resource setting, using HPV self-test kits designed for this intervention. A total of 163 Jamaican women, aged 30–65 years, who had not had a pap test in at least 3 years, from two low socioeconomic status communities in Kingston, were enrolled and assigned to one of two versions of an HPV self-test kit, either with or without culturally targeted fear appeal messages. The uptake of screening was high across conditions; 95.6% of participants used the HPV self-test and returned their kits. However, surprising variations were observed in self-test acceptability, explained by differing attitudes toward the message conditions. Based on the results, we recommend four key components to increase HPV screening in low-resource settings: 1) focus on perceived threat in message design, 2) avoid written materials due to literacy concerns, 3) use culturally appropriate interpersonal or community-based channels, and 4) consider alternative solutions (such as a self-test) available at no or low cost to address structural barriers.

Hospital workers in Aruba have been facing an increased demand for healthcare in the unique setting of a Small Island Developing State (SIDS). This study assessed the impact of the first wave of the SARS-CoV-2 pandemic on the mental health of staff at the major hospital in Aruba, examining the differences between employee groups, with the goal of providing recommendations for targeted support and coping strategies in future crises in a small island setting. Patients and methods: In a mixed-method cohort design, Dr. Horacio E. Oduber Hospital staff were asked to complete a 25-item questionnaire about their concerns and worries, organization of work, and general wellbeing; 24% of the hospital staff filled in the questionnaire (mean age 41 ± 11 years, 79% female). Alongside the needs assessment questionnaire, six focus groups were established to explore staff feelings on specific measures taken by hospital management during the COVID-19 crisis. Results: Questionnaire analysis (n = 231) revealed employees' concerns about infecting their relatives and their financial stability. In particular, nurses were significantly more concerned than other staff groups. In the wellbeing section of the questionnaire, items regarding future security scored poorest, alongside increased levels of tiredness and nervousness. Focus groups discussions revealed frustrations of the hospital staff with the foreign staff brought in to help during the crisis and a need for better leadership and communication practices from hospital management. Conclusions: Comprehensive and holistic approaches should be implemented by the hospital management to prevent occupational burnout and demoralized work ethics and further emotional exhaustion. [ABSTRACT FROM AUTHOR]

Introduction: The past decade has seen key advances in early intervention for autistic children in high-income countries, with most evidence based on specialist delivery of interventions. The care gap seen in low- and middle-income countries (LMIC) remains close to 100%. A key challenge in addressing this care gap concerns the paucity of specialists available to deliver services. Task-sharing provides an important potential solution; there is a need to identify interventions that are suitable for scaled-up delivery through task-sharing in low-resourced settings. We aimed to conduct a scoping review to identify studies which reported autism intervention delivered by non-specialists within LMIC and, using established frameworks, specify intervention components with evidence of successful non-specialist delivery. Methods: A scoping literature search, conducted within four databases, generated 2,535 articles. Duplicates were removed, followed by screening of titles and abstracts, with 10% double-rated for reliability. 50 full text articles were then screened independently by two raters. Articles were included if studies: (a) were conducted in LMIC; (b) included samples of autistic children (age < 10); (c) evaluated psycho-social interventions delivered by non-specialists; (d) reported child outcomes; and (e) were peer-reviewed full-texts in English. Two established frameworks - @Practicewise and NDBI-Fi framework - were then used to ascertain the commonly delivered components of these interventions. Results: Two studies met the inclusion criteria. Both studies evaluated parent-mediated interventions delivered by non-specialists in South Asia. Through the two frameworks, we identified elements and techniques that had been delivered successfully by nonspecialists. Conclusion: There is evidence from two acceptability and feasibility trials that non-specialists can be trained to deliver some intervention elements and techniques within parent-mediated interventions, with good fidelity and acceptability and evidence of effectiveness. The review points up the lack of a widespread evidence base in this area and need for further research in low resourced settings, including well-powered trials and mechanistic analyses to identify active ingredients. A focus on the pre-requisites for non-specialist delivery is critical to reduce inequity and provide universal health coverage within resource-constrained health systems. [ABSTRACT FROM AUTHOR]

Abstract Purpose To compare updated prospective 5-year survival outcomes of cervical cancer patients living with and without human immunodeficiency virus (HIV) infection who initiated curative chemoradiation therapy (CRT) in a resource-limited setting. Methods & Materials Women in Botswana with locally advanced cervical cancer were enrolled in a prospective, observational, cohort study from July 2013 through January 2015. Survival outcomes were analyzed after 5 years of follow-up. Results This cohort included 143 women initiating curative CRT. Sixty-seven percent (n = 96) of cohort were women living with HIV (WLWH), all of whom were receiving antiretroviral therapy (ART) at the time of treatment initiation and boasted a median CD4 count of 481 cells/μL (IQR, 351-579 μL). The 5-year overall survival (OS) rates were 56.8% (95% CI, 40.0–70.5%) for patients without HIV infection and 55.1% (95% CI, 44.2–64.7%) for WLWH (p = 0.732). Factors associated with superior 5-year OS on multivariate analyses included baseline hemoglobin > 10 g/dL (hazard ratio (HR) 0.90, 95% CI, 0.83–0.98, p = 0.015), lower stage at diagnosis (stage I and II vs. III and IV) (HR 1.39, 95% CI 1.09–1.76, p = 0.007), and higher EQD2 (HR 0.98, 95% CI 0.97–0.99, p = 0.001). Conclusions Five-year OS was not impacted by HIV status in this population of WLWH with well-managed infection who initiated curative treatment for cervical cancer in Botswana. Regardless of HIV status, hemoglobin levels and stage at diagnosis were associated with survival. These findings suggest that treatment for cervical cancer in WLWH with well-controlled infection need not be altered solely due to HIV status.

IntroductionThe past decade has seen key advances in early intervention for autistic children in high-income countries, with most evidence based on specialist delivery of interventions. The care gap seen in low- and middle-income countries (LMIC) remains close to 100%. A key challenge in addressing this care gap concerns the paucity of specialists available to deliver services. Task-sharing provides an important potential solution; there is a need to identify interventions that are suitable for scaled-up delivery through task-sharing in low-resourced settings. We aimed to conduct a scoping review to identify studies which reported autism intervention delivered by non-specialists within LMIC and, using established frameworks, specify intervention components with evidence of successful non-specialist delivery.MethodsA scoping literature search, conducted within four databases, generated 2,535 articles. Duplicates were removed, followed by screening of titles and abstracts, with 10% double-rated for reliability. 50 full text articles were then screened independently by two raters. Articles were included if studies: (a) were conducted in LMIC; (b) included samples of autistic children (age < 10); (c) evaluated psycho-social interventions delivered by non-specialists; (d) reported child outcomes; and (e) were peer-reviewed full-texts in English. Two established frameworks – @Practicewise and NDBI-Fi framework - were then used to ascertain the commonly delivered components of these interventions.ResultsTwo studies met the inclusion criteria. Both studies evaluated parent-mediated interventions delivered by non-specialists in South Asia. Through the two frameworks, we identified elements and techniques that had been delivered successfully by non-specialists.ConclusionThere is evidence from two acceptability and feasibility trials that non-specialists can be trained to deliver some intervention elements and techniques within parent-mediated interventions, with good fidelity and acceptability and evidence of effectiveness. The review points up the lack of a widespread evidence base in this area and need for further research in low resourced settings, including well-powered trials and mechanistic analyses to identify active ingredients. A focus on the pre-requisites for non-specialist delivery is critical to reduce inequity and provide universal health coverage within resource-constrained health systems.

Congenital long QT syndrome [LQTS] is a channelopathy characterized by QT prolongation and polymorphic VT. LQTS however need not be a purely electrical disease. Defects in ion channels may cause myocardial architectural disruption leading to ventricular non compaction [VNC]. It is defined as the presence of prominent ventricular trabeculations and deep intertrabecular recesses within the endomyocardium. We describe the in-utero management of a foetus who was later found to have LQTS with VNC. The detection of ventricular tachycardia and complete heart block in utero should arouse the suspicion of LQTS. It would be wise to avoid QT prolonging antiarrhythmics in this subset of patients.

Background: The South African Triage Scale (SATS) requires the calculation of the Triage Early Warning Score (TEWS), which takes time and is prone to error. Aim: to derive and validate triage scores from a clinical database collected in a low-resource hospital in sub-Saharan Africa over four years and compare them with the ability of TEWS to triage patients. Methods: A retrospective observational study carried out in Kitovu Hospital, Masaka, Uganda as part of an ongoing quality improvement project. Data collected on 4482 patients was divided into two equal cohorts: one for the derivation of scores by logistic regression and the other for their validation. Results: Two scores identified the largest number of patients with the lowest in-hospital mortality. A score based on oxygen saturation, mental status and mobility had a c statistic for discrimination of 0.83 (95% CI 0.079–0.87) in the derivation, and 0.81 (95% CI 0.77–0.86) in the validation cohort. Another score based on respiratory rate, mental status and mobility had a c statistic of 0.82 (95% CI 0.078–0.87) in the derivation, and 0.81 (95% CI 0.77–0.86) in the validation cohort. The oxygen saturation-based score of zero points identified 51% of patients in the derivation cohort who had in-hospital mortality rate of 0.5%, and 49% of patients in the validation cohort who had in-hospital mortality of 1.0%. A respiratory rate-based score of zero points identified 45% in the derivation cohort who had in-hospital mortality rate of 0.5%, and 44% of patients in the validation cohort who had in-hospital mortality of 0.8%. Both scores had comparable performance to TEWS. Conclusion: Two easy to calculate scores have comparable performance to TEWS and, therefore, could replace it to facilitate the adoption of SATS in low-resource settings.

Background: Men's depression, alcohol use, and family problems commonly co-occur to create of cluster of mental health problems. Yet, few treatments exist to address these problems, especially in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel task-shifted intervention to address this cluster of men's mental health problems with a focus on engaging and retaining men in treatment. Methods: The intervention, Learn, Engage, Act, Dedicate (LEAD), is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop LEAD, we engaged in a community-engaged multi-step, collaborative process with local Kenyan stakeholders. LEAD was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated given engagement of men was key for proof of concept. Semi-structured interviews were conducted with participants and analyzed using thematic content analysis. Results: The development process resulted in a weekly 5-session intervention rooted in behavioral activation, motivational interviewing, and masculinity discussion strategies. These approaches were combined and adapted to fit contextually salient constructs, such as the importance of the man as provider, and streamlined for lay providers. Feasibility and acceptability results were promising with high attendance, acceptability of delivery and intervention content, and perceived intervention helpfulness. Conclusion: Results describe an acceptable task-shifted treatment that may engage men in care and addresses a cluster of common mental health problems among men in ways that consider social determinants like masculinity. Findings set the stage for a larger trial. Trial registration ISRCTN, ISRCTN130380278. Registered 7 October 2019—Retrospectively registered, http://www.isrctn.com/ISRCTN13038027 [ABSTRACT FROM AUTHOR]

Abstract Background Access to health care facilities is a key requirement to enhance safety for mothers and newborns during labour and delivery. Haydom Lutheran Hospital (HLH) is a regional hospital in rural Tanzania with a catchment area of about two million inhabitants. Up to June 2013 ambulance transport and delivery at HLH were free of charge, while a user fee for both services was introduced from January 2014. We aimed to explore the impact of introducing user fees on the population of women giving birth at HLH in order to document potentially unwanted consequences in the period after introduction of fees. Methods Retrospective analysis of data from a prospective observational study. Data was compared between the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. Logistic regression modelling was used to construct risk-adjusted variable-life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes. Results A total of 28,601 births were observed. The monthly number of births was reduced by 17.3% during the post-introduction period. Spontaneous vaginal deliveries were registered less frequently with a decrease of about 17/1000 births in non-cephalic presentations. Labour complications and caesarean sections increased with about 80/1000 births. There was a reduction in newborns with birth weight less than 2500 g. The observed changes were stable over time. For most variables, a significant change could be detected after a few weeks. Conclusion After the introduction of ambulance and delivery fees, an increase in labour complications and caesarean sections and a decrease in newborns with low birthweight were observed. This might indicate that women delay the decision to seek skilled birth attendance or do not seek help at all, possibly due to financial reasons. Lower rates of births in a safe health care facility like HLH is of great concern, as access to skilled birth attendance is a key requirement in order to further reduce perinatal mortality. Therefore, free delivery care should be a high priority.

Injuries are a public health crisis. Neurotrauma, a specific type of injury, is a leading cause of death and disability globally, with the largest burden in low- and middle-income countries (LMICs). However, there is a lack of quality neurotrauma-specific data in LMICs, especially at the national level. Without standard criteria for what constitutes a national registry, and significant challenges frequently preventing this level of data collection, we argue that singleinstitution or regional databases can provide significant value for context-appropriate solutions. Although granular data for larger populations and a universal minimum dataset to enable comparison remain the gold standard, we must put progress over perfection. It is critical to engage local experts to explore available data and build effective information systems to inform solutions and serve as the foundation for quality and process improvement initiatives. Other items to consider include adequate resource allocation and leveraging of technology as we work to address the persistent but largely preventable injury pandemic. [ABSTRACT FROM AUTHOR]

Background: Significant improvements in under-five mortality in Malawi have been demonstrated over the past thirty years; however, Malawian healthcare remains with gaps in availability and access to quality pediatric critical care nursing training and education. To improve expertise of pediatric critical care nurses in Malawi, Kamuzu University of Health Sciences (KUHeS), Queen Elizabeth Central Hospital (QECH), and Mercy James Center (MJC) entered a partnership with Seed Global Health, a US non-governmental organization. A needs assessment was conducted to understand the training needs of nurses currently working in pediatric critical care and in preparation for the development of a specialized Master's in Child Health pathway in Pediatric Critical Care (PCC) Nursing at KUHeS. Methods: The needs assessment was completed using a survey questionnaire formatted using an ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) framework. The questionnaire had Likert scale and yes/no questions. Data was manually entered into excel and was analyzed using descriptive statistics. Results: One hundred and fifty-three nurses at QECH and MJC responded to the survey. Most nurses were between the ages of 25 and 35 years (N = 98, 64%), female (N = 105, 69%), and held either a Bachelors (N = 72, 47%) or diploma (N = 70, 46%) in nursing. Nurses had high rates of confidence in certain skills: airway management (N = 120, 99%), breathing assessment & management (N = 153, 100%). However, nurses demonstrated little to no confidence in areas such as: mechanical ventilation (N = 68, 44%), ECG evaluation (N = 74, 48%), and arterial blood gas collection & interpretation (N = 49, 32%). Conclusion: It is important to identify priority areas for training and skills development to address in the PCC master's within the child health pathway at KUHeS. Ideally this partnership will produce practice-ready PCC nurses and will establish a recognized PCC nursing workforce in Malawi. [ABSTRACT FROM AUTHOR]

High-quality essential newborn care (ENC) can improve newborn health and reduce preventable newborn mortality. The World Health Organization recommends specific ENC interventions. Video recordings have potential as a tool for assessment of clinical care also in low and middle-income countries. To use video observations of healthy newborns to describe ENC practices in a low-income setting and compare actual clinical practice with WHO recommendations. This is a cross-sectional observational study. Video records of neonatal interventions to 324 healthy newborns were assessed. They were obtained at baseline of a pre-post intervention study during a 10-week study period in Pemba, Tanzania. Data also included postnatal structured questionnaires. Eight ENC interventions and quality indicators were defined as per the WHO recommendations. Descriptive statistics were used to summarize ENC practices and maternal and neonatal characteristics. None of the newborns received all eight recommended ENC interventions. The median duration of separation from the mother was 25 minutes and 15 seconds (ranging from 22 seconds to 3 hours and 36 minutes), 51% of the newborns received proper thermal care during the separation. Twenty-one percent had sufficient umbilical cord care, 8% were stimulated for breathing, 69% were observed at least once by healthcare staff and 9% did undergo suctioning. None of the newborns received antibiotic ointments or vitamin K. Video recording of healthy newborns was feasible. The study identified omission of key ENC practices including proper thermal care, skin-to-skin contact and establishment of breastfeeding within the first hour of life, vitamin K administration as well as application of unnecessary practices such as excessive suctioning of breathing newborns. [ABSTRACT FROM AUTHOR]

Background: Preeclampsia [PE] and fetal growth restriction [FGR] is a major cause of perinatal morbidity in both developed and developing countries but the disease leaves a severe impact in developing countries, due to the late presentation of cases where prevention and treatment becomes impossible. Routine antenatal ultrasound and health checkups in periphery are usually done in first trimester for dating and viability scan, in midtrimester for anomaly scan and in third trimester for safe confinement. Underlying disorder of deep placentation which is unidentified can lead to increased maternal morbidity and fetal compromise between 26 to 34 weeks of gestation The complications present at an irreversible stage where there is no sufficient time even for referral to tertiary care center. Frequent antenatal visits as suggested by WHO would definitely bring down maternal mortality but this increased surveillance when offered to all might be a huge burden to health care providers in low resource settings. An acceptable screening test should help in triaging the high risk group in first trimester itself targeting about only one third of the population for prophylactic therapy and increased antenatal surveillance.The objective of this study is to evaluate the performance and feasibility of different screening protocols in low resource settings.Methodology: Screening for PE and FGR was done at the 11-14 weeks aneuploidy scan as per FMF guidelines. Group I included 6289 women whose risk prediction was done with maternal characteristics [MC], mean arterial pressure [MAP] and Uterine artery Doppler [UAD]. Group II included 2067 women whose risk was predicted with MC, MAP, UAD and PAPP-A. Group III included 576 women whose risk prediction included all parameters with PLGF.Results: Two thousand five hundred fifty-seven cases were screen positive in group I and 602 were screen positive in group II. In group III which included PLGF, 24 were positive for early onset PE and 36 for late onset PE. The number needed to treat [NNT] was 35.9, 29.1 and 10% in Group I, II and III respectively. The detection rate [DR] for PE and FGR was 60% in Group I and DR for FGR in Group II was 85%. In Group III, for early onset PE the DR was 98% and 68% for late onset PE.Conclusion: Screening for PE with available resources in the periphery needs to be implemented to avoid its grave complications. Traditional screening for PE by NICE guidelines can be adopted but may have a detection rate of only 30-40%. Though screening by ACOG criteria may have good detection rates but more than two thirds of the population would become screen positive which nullifies this approach as a good screening methodology in low resource settings. Multiparametric approach for screening in first trimester serves as a better screening tool to enable higher detection rate of disease with least false positive rates. Uterine artery Doppler when combined with maternal characteristics and mean arterial pressure could achieve a detection rate of about 60% and would still target only one third of the population for increased antenatal surveillance. This requires training healthcare professionals in the periphery for this approach and this should be our prime focus in the current scenario. Inclusion of serum biochemistry would still bring down the target population to 10% and increase the DR and can be considered as an additional test in economically feasible population. In low resource settings a better screening approach to PE would be a combination of maternal history, biophysical or biochemical parameters whichever is feasible considering the economy and availability of resources. [ABSTRACT FROM AUTHOR]

Background: In high-income countries, laparoscopic surgery is the preferred approach for many abdominal conditions. Conventional laparoscopy is a complex intervention that is challenging to adopt and implement in low resource settings. This systematic review and meta-analysis evaluate the clinical effectiveness of gasless laparoscopy compared to conventional laparoscopy with CO2 pneumoperitoneum and open surgery for general surgery and gynaecological procedures. Methods: A search of the MEDLINE, EMBASE, Global Health, AJOL databases and Cochrane Library was performed from inception to January 2021. All randomised (RCTs) and comparative cohort (non-RCTs) studies comparing gasless laparoscopy with open surgery or conventional laparoscopy were included. The primary outcomes were mortality, conversion rates and intraoperative complications. Secondary outcomes: operative times and length of stay. The inverse variance random-effects model was used to synthesise data. Results: 63 studies were included: 41 RCTs and 22 non-RCTs (3,620 patients). No procedure-related deaths were reported in the studies. For gasless vs conventional laparoscopy there was no difference in intraoperative complications for general RR 1.04 [CI 0.45–2.40] or gynaecological surgery RR 0.66 [0.14–3.13]. In the gasless laparoscopy group, the conversion rates for gynaecological surgery were high RR 11.72 [CI 2.26–60.87] when compared to conventional laparoscopy. For gasless vs open surgery, the operative times were longer for gasless surgery in general surgery RCT group MD (mean difference) 10 [CI 0.64, 19.36], but significantly shorter in the gynaecology RCT group MD − 18.74 [CI − 29.23, − 8.26]. For gasless laparoscopy vs open surgery non-RCT, the length of stay was shorter for gasless laparoscopy in general surgery MD − 3.94 [CI − 5.93, − 1.95] and gynaecology MD − 1.75 [CI − 2.64, − 0.86]. Overall GRADE assessment for RCTs and Non-RCTs was very low. Conclusion: Gasless laparoscopy has advantages for selective general and gynaecological procedures and may have a vital role to play in low resource settings. [ABSTRACT FROM AUTHOR]

Abstract Background An epidemiological transition is interesting Sub-Saharan Africa increasing the burden of non-communicable diseases most of which are of surgical interest. Local resources are far from meeting needs and, considering that 50% of the population is less than 14 years of age, Pediatric surgical coverage is specially affected. Efforts are made to improve standards of care and to increase the number of Pediatric surgeons through short-term specialist surgical Missions, facilities supported by humanitarian organization, academic Partnership, training abroad of local surgeons. This study is a half term report about three-years Partnership between the University of Chieti- Pescara, Italy and the University of Gezira, Sudan to upgrade standard of care at the Gezira National Centre for Pediatric Surgery (GNCPS) of Wad Medani. Four surgical Teams per year visited GNCPS. The Program was financed by the Italian Agency for Development Cooperation. Methods The state of local infrastructure, current standard of care, analysis of caseload, surgical activity and results are reported. Methods utilized to assess local needs and to develop Partnership activities are described. Results Main surgical task of the visiting Team were advancements in Colorectal procedures, Epispadias/Exstrophy Complex management and Hypospadias surgery (20% of major surgical procedures at the GNCPS). Intensive care facilities and staff to assist more complex cases (i.e. neonates) are still defective. Proctoring, training on the job of junior surgeons, anaesthetists and nurses, collaboration in educational programs, advisorship in hospital management, clinical governance, maintenance of infrastructure together with training opportunities in Italy were included by the Program. Despite on-going efforts, actions have not yet been followed by the expected results. More investments are needed on Healthcare infrastructures to increase health workers motivation and prevent brain drain. Conclusions The key role that an Academic Partnership can play, acting through expatriated Teams working in the same constrained contest with the local workforce, must be emphasized. Besides clinical objectives, these types of Global Health Initiatives address improvement in management and clinical governance. The main obstacles to upgrade standard of care and level of surgery met by the Visiting Team are scarce investments on health infrastructure and a weak staff retention policy, reflecting in poor motivation and low performance.