Access Barriers Research Articles

Improving patient outcomes in acute and subacute stroke using a wearable device-assisted rehabilitation system: a randomized controlled trial.

Multidisciplinary rehabilitation facilitates post-stroke functional recovery, but is associated with resource and accessibility barriers. This study evaluated the combination of a wearable device-assisted system (WEAR) and conventional therapy for post-stroke rehabilitation. This randomized, controlled, parallel group, clinical trial was conducted at two rehabilitation centers. A WEAR system was developed featuring sensors and application program-embedded smartphones. Stroke patients within 12 weeks of onset and modified Rankin Scale (mRS) scores of 2 to 4 were randomized into a wearable group (WG, WEAR + conventional rehabilitation) or control group (CG, conventional rehabilitation) for 90 days. The primary outcome was mRS score changes within 90 days. Among 127 stroke patients enrolled (76 men [59.8%]; mean age: 57.5 years), 63 and 64 patients were randomized to WG and CG, respectively. Both groups showed significant improvements in mRS scores. Between-group repeated measures analysis adjusted for sex, age and number of rehabilitation sessions showed greater improvement in mRS scores within 90 days in the WG than in the CG (estimate: 0.73). This combined WEAR and conventional rehabilitation approach may improve post-stroke functional recovery compared with conventional rehabilitation alone. The WEAR system permits remote monitoring and recording of rehabilitation in various settings.This clinical trial was retrospectively registered at www.clinicaltrials.gov with the Unique Identifier NCT04997408.

Assessing capacity for hereditary cancer risk assessment in metro Chicago.

307 Background: Since 2005, the United States Preventive Services Task Force (USPSTF) recommends that primary care (PC) clinicians identify and refer adults with a high-risk cancer family history to cancer genetic services (CGS), yet hereditary cancer risk assessment (HCRA) continues to be underutilized in PC. A population-based approach to HCRA in PC settings can expand access to cancer prevention and early detection to vulnerable populations and reduce disparities in cancer outcomes. The Chicago Cancer Screening and Testing Access Coalition (CCSTAC) is developing strategies to integrate HCRA in PC settings. We conducted an environmental scan to assess current capacity to deliver 1) HRCA in Federally Qualified Health Centers (FQHCs) and 2) follow-up CGS for high risk patients. Methods: In 2023, we administered two surveys to assess HCRA practices in Metro Chicago. We invited 22 FQHCs to complete a 21-item survey of current practices, readiness to implement, and barriers to HCRA. We also invited 21 CGS sites to complete a 25-item survey to understand staffing, utilization, referral patterns, and barriers to access. Surveys were administered electronically via Qualtrics. We conducted a descriptive analysis of survey data. Results: Twenty FQHCs (91%) completed the survey on HCRA in PC; 85% reported familiarity with USPSTF guidelines for HCRA. The majority (75%) reported no plans to implement HCRA. Clinic workflow, paucity of follow-up resources, cost, lack of provider knowledge, and absence of HCRA as a mandatory performance measure were cited as the most significant barriers to implementation. Genetic counselors (GCs) from 19 CGS hospital-based sites (90%) completed the survey on availability of genetic services. CGS were most often located in a cancer center (47%); no CGS were located in PC. Most referrals originated from oncology, surgery, or gastroenterology, with the lowest rate of referrals from community-based PC. Nearly half of CGS clinics (47%) reported capacity for at least a small increase in patient volume. Wait-time at the majority of CGS clinics was less than a month. GCs cited patient logistics (e.g. transportation, time off work), lack of referral information from providers, and systemic racism as significant barriers in patient access to CGS. Conclusions: After almost 20 years of evidence-based guidelines, use of HCRA is still very limited in the community-based PC setting. Our findings point to a need to bridge the gap between hospital-based CGS and FQHCs to ensure patients in vulnerable communities have access to guideline-concordant cancer prevention and screening strategies. Based on these findings, CCSTAC is designing strategies to integrate HCRA in primary care at FQHCs focused on provider education, well-designed clinic workflows, connections with existing CGS, and advocacy to align UDS and HEDIS measures with USPSTF guidelines.

Challenges and opportunities when studying movement ecology in science and practical conservation

Movement is a key mechanism influencing biodiversity patterns and ecosystem processes. Movement ecology science aims to understand the causal relationships between environmental conditions, animal movements, interactions and coexistence of species, as well as effects of movement patterns on ecosystem processes. In contrast, practical conservation primarily aims to understand organisms' movements to improve species management, protection, legal monitoring or risk assessment, and species-habitat interactions. Despite the many studies of movement ecology in basic and applied sciences as well as in practical conservation in terrestrial ecosystems, knowledge gain and transfer between disciplines are limited. Better integration and linking of both disciplines would result in diverse science-practice synergies, but these are currently constrained by numerous challenges that need to be overcome. From a scientific perspective, knowledge gain from practice is limited by multitude of case studies with limited spatial and temporal resolution. This can be overcome by improving access and combining the diversity of data for a research area that often deals with small sample sizes. From a practical perspective, the movement ecology framework which is often dedicated to basic research, and access and language barriers of scientific publications limit the application of scientific results in practice. Here movement ecologists should be encouraged to consider conservation issues more frequently in addition to basic research. The transfer of scientific results could be improved by scientists providing sufficient details for practitioners to extract relevant information and publish at least an open-access abstract in local language with clear management recommendations. Further, the use of open-access repositories allows both, scientists and practitioners an overview of the multitude of studies and helps to share data in order to derive general conclusions. Challenges impacting science and practice can be conceptual, organisational and technical in nature. Such constrains can be overcome, for example, by providing verified trapping protocols, using recent technological developments and analytical methods combined with trainings on these state-of-the-art tracking and analysing tools. In particular, collaborative project planning between scientists and practitioners can help to improve the sampling design of applied studies and broaden the data base for science in order to significantly advance the movement ecology framework and gain comprehensive knowledge for practical conservation.

“We just need to create as many avenues for access as we possibly can”: Clinician and administrator attitudes toward telehealth medication abortion in the U.S. South

ObjectivesThere is currently a gap in literature on the perspectives of sexual and reproductive health clinicians and administrators in the South toward telehealth abortion services. This research seeks to explore these perspectives to understand clinician and administrator attitudes toward importance and priority of telehealth abortion to contribute to the development of a richer understanding of telehealth abortion in the South. Study DesignThis study conducts a secondary analysis of data from the Provider Readiness for Virtual Implementation and Delivery of Medication Abortion Services (PROVIDA) study. We collected qualitative data regarding perspectives of 13 clinicians and 7 administrators toward importance and priority of telehealth abortion during a series of in-depth interviews that took place from June 2021-2022 and analyzed data using MAXQDA. ResultsWe identified four main themes: telehealth abortion is important for patient benefit in mitigating physical, administrative, financial, and privacy-related barriers; telehealth abortion is important for clinic benefit in improving clinic flow and sustainability; the political climate affects personal prioritization of telehealth abortion; and staff hesitance affects clinic prioritization of telehealth abortion. ConclusionsOur analysis revealed telehealth abortion to be particularly important in mitigating physical access barriers for patients and for clinic sustainability. We found the political climate to be the most notable factor influencing personal prioritization of telehealth abortion, with most participants noting it made telehealth abortion less of a priority. Additionally, our analysis found participant perception of staff hesitation to implement telehealth abortion to be the most notable factor affecting clinic prioritization. Future research should utilize these findings to inform studies examining the implementation climate of telehealth abortion in the South.

Impact of a remote second opinion program on changes in recommended treatment plans for patients with cancer across the U.S.

386 Background: Second opinion consultations are a promising strategy to identify errors in diagnosis and recommend the optimal course of treatment for the patient. Yet, there are several barriers to patients accessing second opinions, including geographic barriers. By bringing high-level care to patients where they live, remote second opinion programs might benefit populations without access to subspecialty cancer centers, including those from underserved communities. While meaningful changes from in-person second opinions have been observed at several institutions, little is known about how often remote second opinions lead to similar improvements in treatment plans. Thus, our objective was to examine the extent to which the Memorial Sloan Kettering Cancer Center (MSK) remote second opinion program led to changes in treatment plans for cancer patients residing across the U.S. Methods: MSK is a high-volume cancer center based in NYC. MSK’s remote second opinion program was developed and rolled out as part of a national cancer benefits solution in 2016. Each second opinion review process is conducted by an MSK subspecialist and enabled by a customized digital platform. The process is asynchronous. To capture subspecialists’ perceptions of the importance of any changes to diagnosis or treatment recommended, we designed and administered a questionnaire starting in December 2023 that subspecialists completed after each case. Here, we report summary findings from the first 100 second opinion cases with complete information from this questionnaire. Results: These 100 case reviews were completed between December 2023 and April 2024. Spanning cancer types, the cases were reviewed by 49 unique subspecialists. There were 17 patients with breast cancer, 9 with colon cancer, 9 with lymphoma, 9 with prostate cancer, 7 with endometrial cancer, 7 with squamous cell carcinoma, 6 with myeloma, 5 with ovarian cancer, and 31 with one of 18 other cancer types. Patients had a mean age of 57 years (median 58) and 61% were female. Patients were from 27 different U.S. states. Of the 100 cases reviewed, subspecialists made a “meaningful change” (expected to affect patient outcomes) in recommended treatment, in 39 cases (39%). These meaningful changes included better prognosis / survival (n=26, 67%), reduced short-term morbidity / quality of life / toxicity (n=17, 44%), or improved long-term morbidity / quality of life / toxicity (n=29, 74%). There was a higher percent of recommended changes for liquid tumor cases compared to solid tumor cases (11/17, 65% for liquid; 28/83, 34% for solid). Conclusions: Findings are crucial for understanding potential opportunities to grow remote second opinion programs to benefit patients. This information is also essential for identifying the most effective strategies to reach underserved communities with geographic access barriers to high-quality subspecialty cancer care.

Hospice Administrators' and Providers' Perspectives on Providing Upstream Palliative Care: Facilitators, Barriers, and Policy Prescriptions.

Background: Among patients with serious illness, palliative care before hospice enrollment is associated with improved quality of life, reduced symptom burden, and earlier transitions to hospice. However, fewer than half of eligible patients receive specialty palliative care referrals. As most hospice clinicians and administrators have experience in specialty palliative care, several emerging programs propose engaging hospice clinicians to provide early palliative care. Objective: We sought to identify barriers and facilitators to upstream palliative care. Design: We conducted a key informant qualitative study among hospice administrators and clinicians. Setting/Subjects: We conducted semi-structured interviews with 23 hospice administrators and clinicians in eight states from March to August 2022. We identified participants using snowball and purposive sampling using states that participate in Medicare Advantage's value-based insurance design Model. Results: Respondents indicated that barriers to early palliative care included inadequate staffing and reimbursement. Hospice clinicians providing community-based palliative care can address access barriers and improve transitions to hospice. Respondents expressed desire for payer guidance in identifying eligible patients but were cautious about payers acting as direct palliative care providers. However, payers could facilitate uptake by broadening and specifying coverage of services to include goals of care conversations and symptom management. Routine referrals initiated by objective measures could potentially increase access. Conclusions: Utilizing hospice providers to provide upstream palliative care can increase access, improve outcomes, and ease the transition to hospice.

Access to health and rights of children in street situations and working children: a scoping review

BackgroundStreet and working children (SWC) and young people (YP) are highly vulnerable to violence, exploitation, hazardous environments and human rights violations. While the UN Committee on the Rights of the...

Indigenous, Black, and Latine Adolescents Disproportionately Experience Barriers to Pediatric Gender-Affirming Care

Although prior studies have explored the barriers that transgender and nonbinary (TNB) adolescents experience in receiving gender-affirming medical care (GAMC), few have sought to understand how these barriers may differ among racial and ethnic minority groups. Accordingly, this study used data from a survey of TNB young adults (ages 18–20 years) to explore how barriers to GAMC during adolescence varied by race and ethnicity. Differences in the impact of 11 potential barriers when comparing the members of each racial and ethnic group with those who did not identify with that racial or ethnic group were evaluated usingttests. The results showed that Indigenous respondents indicated that parental unwillingness to consent for GAMC and attend a clinic visit and not being able to find a clinic contributed significantly more compared with those who did not identify as Indigenous. Black respondents indicated that not knowing it was possible to receive GAMC during adolescence and previous negative experiences in healthcare related to race or ethnicity contributed significantly more to their inability to receive GAMC during adolescence compared with those who did not identify as Black. Latine respondents indicated that parental unwillingness to consent for GAMC and attend a clinic visit, worries about cost, and previous negative experiences in healthcare due to race or ethnicity contributed significantly more compared with those who did not identify as Latine. Overall, the results suggest disproportionate barriers in access to GAMC during adolescence among Indigenous, Black, and Latine TNB individuals and illustrate a need for additional resources and interventions to promote more equitable access.

University students’ access and use of sexual and reproductive health services in Australia

University attendance can lead to changes in sexual behaviour that place people at increased risk of negative sexual and reproductive health (SRH) experiences; however, relatively few studies have explored access to and use of SRH services by university students in Australia. A convenience sample of students (N = 4291) from five universities completed an online survey to examine barriers and facilitators to accessing SRH services. Descriptive statistics were used to analyse variations by gender, sexuality, and enrolment status. Content analyses were conducted on responses to two open-ended questions. Over half (59%, 2934) had never spoken to a health professional about SRH issues. Of the 41% (1357) who had, female, non-binary/gender diverse, and Australian-born students were significantly more likely to have done so than students identifying as male, heterosexual, or as an international student. Frequently reported barriers to use of SRH services were ‘feeling embarrassed’, ‘being judged’ and ‘not knowing where to go’. LGBTQIA+ students along with international and overseas-born domestic students faced specific access barriers. Recommendations targeting student-identified barriers to access are offered, calling for universities to support student wellbeing by providing supportive, non-judgemental, and inclusive SRH promotion and health services that cater to needs of diverse student cohorts.

Accessibility Barriers for Blind Students in Teaching-learning Systems

The use of digital technology by educators has received increasingly higher focus in the recent years. In spite of this, students with disabilities still face many accessibility obstacles while using digital technologies. In this context, this paper has the main goal of identifying the accessibility barriers faced by the community of blind students and highlighting the main factors that hinder this community from accessing learning objects. For this purpose, initially, a Systematic Literature Review (SLR) was conducted, with which it was possible to collect the main accessibility problems identified by the scientific community. In order to complement and detail the information obtained in the SLR, a questionnaire was submitted to blind students, in which it was possible to discover new difficulties from a practical point of view. Finally, the accessibility barriers found in the SLR and in the questionnaire responses were analyzed and the results obtained were related to the Web Content Accessibility Guidelines (WCAG), the main document that explains how to make web content accessible for people with disabilities. This work seeks to explain the main factors that hinder or prevent access to learning objects in teaching-learning systems, promote a discussion on alternatives for improving these resources, identify gaps and guide more detailed studies on the subject.

I trust doctors and midwives: exploring breast cancer literacy among women referring to the health centers in Iran

BackgroundBreast cancer (BC) is the most common cancer in women worldwide. Early diagnosis of BC could considerably improve outcomes. Since health literacy could influence preventive behaviors and women’s ability to make decisions about breast care, therefore, this study aimed to explore breast cancer literacy in women.MethodsThis qualitative study was conducted in Iran using the directed content analysis. Data were collected through face-to-face interviews with a purposeful sample of women from April 2021 to June 2022 and continued until saturation was reached. Interviews were analyzed using the initial matrix developed based on the European health literacy framework.ResultsIn all twelve women were interviewed. During data analysis, 612 primary codes grouped into four dimension of health literacy (access, understanding, appraise, and apply) of three health domain (health care, disease prevention, and health promotion). Many believed that it was difficult to access accurate information about BC. They used various sources to obtain information. The participants addressed some facilitators and barriers in understanding the information and for information appraisal they mentioned seeking help from health professionals. Through the acquired cognitive skills, the participants took some steps to apply BC information. Also, having information about BC and the involvement of relatives with cancer were indicated as triggers for decision-making on breast care, while poor financial conditions, not having enough information, fear, shame, and embarrassment, were pointed out as inhibiting factors.ConclusionsThe findings suggest that barriers in access, and understanding of information on breast cancer exist among women. The findings also suggest that women’s decision-making and preventive behaviors on breast care are much dependent on social and cultural factors.

Mobile health clinics for distribution of vaccinations to underserved communities during health emergencies: A COVID-19 case study

ObjectivesMobile health clinics (MHCs) effectively provide healthcare to underserved communities. However, their application during health emergencies is understudied. We described the implementation of an MHC program delivering vaccinations during the COVID-19 pandemic, examined the program's reach to medically underserved communities, and investigated characteristics of vaccination uptake in order to inform the utility of MHCs during health emergencies. Study designThe study observed COVID-19 MHC vaccination rates and factors associated with uptake between February 20th, 2021, and February 17th, 2022. MethodsPrisma Health deployed six MHCs to underserved communities. We described the characteristics of individuals who utilized the MHCs and evaluated census tract-level community factors associated with use of the MHCs through generalized linear mixed effects models. ResultsThe MHCs conducted 260 visits at 149 unique sites in South Carolina, providing 12,102 vaccine doses to 8545 individuals: 2890 received a partial dose, 4355 received a primary series, and 1300 received a booster dose. Among individuals utilizing the MHC, the median age was 42 years (IQR: 22–58), 44.0 % were Black, 49.2 % were male, and 44.2 % were uninsured. Black, Hispanic, and uninsured individuals were significantly more likely to utilize MHC services for COVID-19 vaccination. During periods when vaccines were limited, MHC utilization was significantly greater in communities facing access barriers to healthcare. ConclusionsThe high COVID-19 vaccination uptake at MHCs demonstrated that the MHC framework is an effective and acceptable intervention among medically underserved populations during health emergencies, especially when resources are scarce. The identified factors associated with vaccination uptake demonstrated that the MHCs had the greatest impact in higher-risk communities and can be used to inform allocation of such field-level interventions in future health emergencies.

Providers’ perspectives of barriers and facilitators to scale-up of mental health care in the public health delivery system of Mozambique: a qualitative inquiry

BackgroundA central challenge to closing the mental health treatment gap in low- and middle-income countries (LMICs) is determining the most effective pathway for delivering evidence-based mental health services. We are conducting a cluster-randomized, Type 2 hybrid implementation-effectiveness trial across 20 districts of Mozambique called the Partnerships in Research to Implement and Disseminate Sustainable and Scalable EBPs (PRIDE) program. Following training of nonspecialized providers in facilitation of evidence-based treatments for mental health and informed by the Consolidated Framework for Implementation Research (CFIR), we identified how PRIDE compares to care as usual and the perceived barriers and facilitators of implementation and modifications needed for widescale service delivery and scale-up.MethodsWe conducted rapid ethnographic assessment using freelisting among 34 providers, followed by four focus group discussions (n = 29 participants) with a subsample of psychiatric technicians and primary care providers from 14 districts in Nampula Province. We used Thematic Analysis to inductively apply open codes to transcripts and then deductively applied the CFIR domains and constructs to organize open codes.ResultsThe main Outer Setting constructs relevant to implementation were recognition that patient mental health needs were significant. Additionally, numerous community-level characteristics were identified as barriers, including distance between clinics; shortage of providers; and low awareness of mental health problems, stigma, and discrimination among community members towards those with mental health struggles. The PRIDE program was perceived to offer a relative advantage over usual care because of its use of task-sharing and treating mental illness in the community. PRIDE addressed Inner Setting barriers of having available resources and training and provider low self-efficacy and limited knowledge of mental illness. Providers recommended leadership engagement to give support for supervision of other task-shared professionals delivering mental healthcare.ConclusionsPrimary care providers and psychiatric technicians in Mozambique perceived the relative advantage of the PRIDE program to address mental health treatment access barriers and offered recommendations for successful sustainment and scale up of integrated mental health care.

Joint Human and Animal Health Campaigns in Chad

Abstract Providing basic health services to nomadic populations is challenging mainly because of their mobility affecting geographical access to essential services but also due to their particular cultural habits and beliefs, influencing health intervention acceptance. The strategy of joint human and animal health campaigns applied in Chad for over 30 years has helped to improve coverage of childhood and livestock vaccination and increased access to disease prevention. The campaigns are organized by the Chadian ministries for public health and livestock, supported by the Swiss Tropical and Public Health Institute (Swiss TPH) and its local partners. The use of synergies across sectors intends to reduce costs compared to independent sectoral interventions. The gain lies not only in shared logistics but also in better trust in essential services by pastoralists. Planning of joint interventions should start with a careful assessment of the context through a transdisciplinary approach identifying possible access barriers. This allows multidisciplinary development of mitigation measures such as a locally adapted awareness strategy. The multi-disciplinary approach also provides information on the seasonal movements of the different pastoral groups, which is crucial for the timing and location of interventions. Administrative and technical preparation of the field visits needs concerted efforts by all ministries and partners involved to maximize the benefits. To facilitate the uptake and sustainability of joint campaigns in Chad, the involved partners together developed an implementation guide based on their long-standing experience. This case report draws on this guiding document and showcases it for other actors interested in implementing similar One Health strategies. Information © The Authors 2024

Understanding inter-farm inequalities in extreme weather event impacts: Insights from the Dutch agricultural sector

As a result of global climate change, extreme weather events are becoming more frequent and intense. Susceptibility to extreme weather events (EWEs) is high in the agricultural sector, as these extremes can cause a decline in yields and revenue for farmers. To provide insight into ways to reduce the impacts of EWEs, this study assessed which factors explain the differences in the impacts of past weather extremes between Dutch arable farms. A survey was conducted among potato and onion farmers in the Netherlands to collect information on the past impacts of EWEs between 2018 and 2022 and the vulnerability of farmers (N = 81). The survey results showed that EWEs have already had a strong effect on farm revenues, but the extent of the impacts varied among farms. By coupling the survey data to meteorological data on EWEs, it was found that dry summers, wet fields during harvest and plowing, and warm winters were the extremes that best explained the more detrimental impacts of extreme weather amongst respondents. Additionally, differences in the physical and social vulnerability of farmers played a significant role in the observed inter-farm inequalities in impacts. Farm practices that reduce physical vulnerability are frequently inaccessible to smaller-scale or younger farmers. Further research is needed to understand the access barriers faced by these farmers. Further, future research and policies targeting the Dutch agricultural sector should no longer ignore social vulnerability factors to avoid exacerbating inter-farm inequalities, as the impacts of EWEs increase due to climate change.

Enhancing seniors' dental care access: Analyzing the impact of government insurance in Canada.

A crucial policy question for the government is whether publicly funded insurance programs effectively improve access to care. Using 2015 and 2018 Canadian Community Health Survey (CCHS) data, we first estimated the effect of government dental insurance for seniors on promoting regular care access and lowering cost barrier. When controlling for individual heterogeneity, we found that having government coverage is associated with significantly lower probability of reporting avoidance of dental care due to cost compared to having no coverage. This effect is comparable with other types of insurance. However, the impact of the government program on regular access to dental care is modest. Secondly, using a portion of data collected in Alberta, we found that the government plan does not increase the overall coverage rate. Moreover, switching from an employer-based plan to government-provided coverage for seniors reduces the probability of regular access to care and increases the probability of experiencing cost barrier. This finding indicates that without expansion of overall coverage rate, the current government dental program may not be generous enough to offset the negative impact of leaving the employer-based plan.

A machine learning-based prediction of tau load and distribution in Alzheimer's disease using plasma, MRI and clinical variables.

Tau positron emission tomography (PET) is a reliable neuroimaging technique for assessing regional load of tau pathology in the brain, commonly used in Alzheimer's disease (AD) research and clinical trials. However, its routine clinical use is limited by cost and accessibility barriers. Here we explore using machine learning (ML) models to predict clinically useful tau-PET composites from low-cost and non-invasive features, e.g., basic clinical variables, plasma biomarkers, and structural magnetic resonance imaging (MRI). Results demonstrated that models including plasma biomarkers yielded the most accurate predictions of tau-PET burden (best model: R-squared=0.66-0.68), with especially high contribution from plasma P-tau217. In contrast, MRI variables stood out as best predictors (best model: R-squared=0.28-0.42) of asymmetric tau load between the two hemispheres (an example of clinically relevant spatial information). The models showed high generalizability to external test cohorts with data collected at multiple sites. Based on these results, we also propose a proof-of-concept two-step classification workflow, demonstrating how the ML models can be translated to a clinical setting. This study uncovers current potential in predicting tau-PET information from scalable cost-effective variables, which could improve diagnosis and prognosis of AD.

Pattern of care and treatment outcomes of metastatic non-clear cell kidney cancer: a single centre experience from India.

Non-clear-cell renal cell carcinoma (nccRCC) refers to a rare diverse heterogeneous group of tumours; usually treated with immune check point inhibitors and or tyrosine kinase inhibitors (TKIs). Prospective large-scale data from Asian countries is limited. This is a retrospective study of patients with metastatic nccRCC treated at Tata Medical Centre, Kolkata, India, from 2012 to 2022. Demographic profiles, histologic subtypes, treatment details, response to therapy (by response evaluation criteria in solid tumours (RECIST v1.1)) and survival status were captured from electronic medical records (EMRs) of hospitals up till May 2023. Kaplan Meier methods were estimated to assess progression-free survival (PFS) and overall survival (OS). A total of 89 consecutive patients were screened for this study, 24 were excluded due to inadequate data in EMR. 65 patients were included in the final analysis, with a median age at diagnosis of 59 years (range 20-84) of which 81% were male. Histologic subtypes comprised of 43% papillary, 31% clear cell with mixed histology, 3% sarcomatoid and 23% others including chromophobe, mucinous-tubular, spindle cell, oncocytic, medullary, poorly differentiated and rhabdoid). The most common site of metastasis was the lung 62% (n = 40) followed by non-regional nodes 32%, bone 26% and liver 14%. 15% patients presented with haematuria and 62% underwent nephrectomy prior to systemic therapy. The majority received pazopanib 46% (n = 30), chemotherapy 20% (n = 13) including bevacizumab plus erlotinib, sunitinib 15% (n = 10) or cabozantinib 14% (n = 9). Only 3(5%) patients received nivolumab plus cabozantinib combination. Response to treatment showed complete response in 1.5%, partial response in 20%, stable disease in 51% and progressive disease in 23% as per RECIST v1.1. 17 patients required dose reduction and interruption due to adverse effects and 33% (n = 22) received second-line therapy with nivolumab 18% (n = 4), axitinib and everolimus among others. After a median follow up of 44 months, the median PFS was 13 months (95%CI 7.2-18.9) and the median OS was 17 months (95%CI 12.1-22.1) for the entire cohort. The overall response and survival for metastatic nccRCC was relatively better in comparison with published data, despite the limited number of patients treated with ICIs due to cost and access barriers.

SME collaboration models for accelerating clean energy innovations: Insights from emerging market economies

This paper explores the critical role of collaboration between small and medium-sized enterprises (SMEs) and startups in accelerating clean energy innovation in emerging markets. It reviews various collaboration models, including strategic partnerships, incubation and acceleration programs, supply chain integration, and joint research and development (R&D), highlighting their impact on technology development and commercialization. The paper also examines the specific challenges SMEs and startups face, such as funding limitations, intellectual property (IP) concerns, and market access barriers, and analyzes the opportunities presented by new trends like digital platforms, impact investment, and public-private partnerships. The findings emphasize that collaborative efforts are essential for fostering sustainable growth and enabling the successful deployment of clean energy technologies in emerging markets. The paper concludes by discussing future directions and the importance of continued cooperation, supported by favorable policies and regulatory frameworks, in driving the clean energy transition. Keywords: Clean Energy Innovation, SME-Startup Collaboration, Emerging Markets, Sustainable Growth, Commercialization.

Feasibility, Acceptability, and Appropriate Use of Novel and Lesser-Used Medicines for Prevention and Treatment of Postpartum Hemorrhage: Evidence from Implementation Research

Maternal mortality remains one of the primary global health challenges of the 21st century, despite major medical advances in the field. Although solutions are available, inequities determine where mothers die, with the majority of maternal deaths occurring in low- and middle-income countries (LMICs). More than one-third of maternal deaths are related to obstetric hemorrhage and most commonly postpartum hemorrhage (PPH). Effective, quality-assured uterotonics significantly reduce PPH-related morbidity and mortality. Updated World Health Organization (WHO) recommendations on uterotonics used for PPH prevention include the addition of heat-stable carbetocin (HSC) to the suite of prophylactic uterotonic agents as well as the use of tranexamic acid (TXA) for PPH treatment. Both medicines are promising interventions in obstetric care. However, the introduction of these medicines faces numerous challenges to end-user access, such as decentralized procurement, time-consuming policy updates, market access barriers, lack of demand for quality-assured products, and inadequate systematic training and information provision, impeding access in many LMICs. Assessing the feasibility and acceptability of implementing these medicines in different resource settings can help bridge the gap between research and development to policy and practice, in an effort to reduce the significant health inequities facing women accessing the public health sector for quality care during labor and delivery. In this Special Collection, we explore the findings from mixed-methods implementation research studies in nine LMICs which support the acceptability and feasibility of HSC and TXA administration by healthcare providers, generating evidence to help inform the introduction and scale-up of these new and lesser-utilized PPH medicines.