Care In Low-income And Middle-income Countries Research Articles

Enhancing colon cancer care in restricted-resource settings.

Colon cancer ranks third among the most frequently diagnosed cancers worldwide and was projected to claim more than 900 000 lives in 2020, according to the International Agency for Research on Cancer's GLOBOCAN data. 1 Sung H Ferlay J Siegel RL et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021; 71: 209-249 Crossref PubMed Scopus (30514) Google Scholar The overall survival rate for colon cancer varies on the basis of clinical and pathological factors, such as staging, performance status, and geographical location. Despite the lower incidence, survival of colon cancer in low-income and middle-income countries (LMICs) is considerably reduced compared with high-income and very-high-income countries, which is probably attributable to disparities in diagnostic and treatment access. Considering expected increases in colon cancer incidence due to demographic and dietary changes, there is an urgent and unmet need to enhance cancer care in LMICs through better resource allocation and cost-effective interventions to achieve optimal value for money and reduce health inequalities. 2 Khan SZ Lengyel CG Challenges in the management of colorectal cancer in low- and middle-income countries. Cancer Treat Res Commun. 2023; (published online April 6.)https://doi.org/10.1016/j.ctarc.2023.100705 Crossref Scopus (0) Google Scholar Global application of National Comprehensive Cancer Network resource-stratified guidelines for systemic treatment of colon cancer: a population-based, customisable model for cost, demand, and procurementWe have developed a customisable model that can be applied at global, national, and subnational levels to estimate systemic treatment needs, forecast drug procurement, and calculate expected drug costs on the basis of local data. This tool can be used to plan resource allocation for colon cancer globally. Full-Text PDF

Recommendations for developing effective and safe paediatric and congenital heart disease services in low-income and middle-income countries: a public health framework

The global burden of paediatric and congenital heart disease (PCHD) is substantial. We propose a novel public health framework with recommendations for developing effective and safe PCHD services in low-income...

Prevalence and prognostic implications of reduced left ventricular ejection fraction among patients with STEMI in India.

To describe clinical characteristics and outcomes for those with STEMI and reduced left ventricular ejection fraction (LVEF) in low-income and middle-income countries (LMICs). Adults presenting with STEMI to two government-owned tertiary care centres in Delhi, India were prospectively enrolled in the North India ST-elevation myocardial infarction (NORIN-STEMI) registry. LVEF was evaluated at presentation and clinical characteristics were compared across LVEF categories. Overall, 3597 patients were included, of whom 468 (13%) had LVEF >50%, 1482 (41%) had mildly reduced LVEF (40-49%), 1357 (38%) had moderately reduced LVEF (30-39%), and 290 (8%) had severely reduced LVEF (<30%). Presentation delay >24h, prior MI, and hyperlipidaemia were associated with decreasing LVEF category. Although most patients with reduced LVEF were discharged on appropriate guideline-directed therapies, adherence at 1year was low (ACE inhibitor/ARB 91% to 41%, beta blocker 98% to 78%, aldosterone receptor antagonist 69% to 6%). After multivariable adjustment, a Cox regression model showed moderately reduced LVEF (HR 1.77, 95% CI 1.20, 2.60) and severely reduced LVEF (HR 3.63, 95% CI 2.41, 5.48) were associated with increased risk of all-cause mortality compared with LVEF ≥50%. On presentation for STEMI, almost 90% of NORIN-STEMI participants had at least mildly reduced LVEF and almost half had LVEF <40%. Patients with LVEF <40% had significantly higher risk of mortality at 1year, and adherence to guideline-directed therapies at 1year was poor. Systematic initiatives to improve access to timely revascularization and guideline-directed therapies are essential in advancing STEMI care in LMICs.

Geospatial analysis of pediatric surgical need and geographical access to care in Somaliland: a cross-sectional study

BackgroundThe global burden of disease in children is large and disproportionally affects low-income and middle-income countries (LMICs). Geospatial analysis offers powerful tools to quantify and visualise disparities in surgical care...

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

SummaryBackgroundCongenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.MethodsWe did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.FindingsWe included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality.InterpretationUnacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.FundingWellcome Trust.

Low-cost oral metronomic chemotherapy versus intravenous cisplatin in patients with recurrent, metastatic, inoperable head and neck carcinoma: an open-label, parallel-group, non-inferiority, randomised, phase 3 trial

Regimens for palliation in patients with head and neck cancer recommended by the US National Comprehensive Cancer Network (NCCN) have low applicability (less than 1-3%) in low-income and middle-income countries (LMICs) because of their cost. In a previous phase 2 study, patients with head and neck cancer who received metronomic chemotherapy had better outcomes when compared with those who received intravenous cisplatin, which is commonly used as the standard of care in LMICs. We aimed to do a phase 3 study to substantiate these findings. We did an open-label, parallel-group, non-inferiority, randomised, phase 3 trial at the Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India. We enrolled adult patients (aged 18-70 years) who planned to receive palliative systemic treatment for relapsed, recurrent, or newly diagnosed squamous cell carcinoma of the head and neck, and who had an Eastern Cooperative Oncology Group performance status score of 0-1 and measurable disease, as defined by the Response Evaluation Criteria In Solid Tumors. We randomly assigned (1:1) participants to receive either oral metronomic chemotherapy, consisting of 15 mg/m2 methotrexate once per week plus 200 mg celecoxib twice per day until disease progression or until the development of intolerable side-effects, or 75 mg/m2 intravenous cisplatin once every 3 weeks for six cycles. Randomisation was done by use of a computer-generated randomisation sequence, with a block size of four, and patients were stratified by primary tumour site and previous cancer-directed treatment. The primary endpoint was median overall survival. Assuming that 6-month overall survival in the intravenous cisplatin group would be 40%, a non-inferiority margin of 13% was defined. Both intention-to-treat and per-protocol analyses were done. All patients who completed at least one cycle of the assigned treatment were included in the safety analysis. This trial is registered with the Clinical Trials Registry-India, CTRI/2015/11/006388, and is completed. Between May 16, 2016, and Jan 17, 2020, 422 patients were randomly assigned: 213 to the oral metronomic chemotherapy group and 209 to the intravenous cisplatin group. All 422 patients were included in the intention-to-treat analysis, and 418 patients (211 in the oral metronomic chemotherapy group and 207 in the intravenous cisplatin group) were included in the per-protocol analysis. At a median follow-up of 15·73 months, median overall survival in the intention-to-treat analysis population was 7·5 months (IQR 4·6-12·6) in the oral metronomic chemotherapy group compared with 6·1 months (3·2-9·6) in the intravenous cisplatin group (unadjusted HR for death 0·773 [95% CI 0·615-0·97, p=0·026]). In the per-protocol analysis population, median overall survival was 7·5 months (4·7-12·8) in the oral metronomic chemotherapy group and 6·1 months (3·4-9·6) in the intravenous cisplatin group (unadjusted HR for death 0·775 [95% CI 0·616-0·974, p=0·029]). Grade 3 or higher adverse events were observed in 37 (19%) of 196 patients in the oral metronomic chemotherapy group versus 61 (30%) of 202 patients in the intravenous cisplatin group (p=0·01). Oral metronomic chemotherapy is non-inferior to intravenous cisplatin with respect to overall survival in head and neck cancer in the palliative setting, and is associated with fewer adverse events. It therefore represents a new alternative standard of care if current NCCN-approved options for palliative therapy are not feasible. Tata Memorial Center Research Administration Council. For the Hindi, Marathi, Gujarati, Kannada, Malayalam, Telugu, Oriya, Bengali, and Punjabi translations of the abstract see Supplementary Materials section.

Global Nursing in Low-Resource and Middle-Resource Countries: Challenges and Opportunities in Perioperative Practice.

There are marked disparities in supply and demand for specialty-trained health care providers in low-income and middle-income countries (LMIC). Nurses are at the forefront in volunteering to provide humanitarian health support in local, national, and international disasters. Responding to the call to provide expert medical and surgical education and care in LMIC aligns with the passion and purpose of nursing. This article shares a real-world experience of perioperative nurses in partnership with the surgical team to provide cleft lip/palate repair for children in LMIC. It is all in the smile left behind.

Caring for the surgical patient with limited ICU resources.

The current review aims to discuss the management of surgical patients in an ICU in countries where resources are limited. ICU beds in low-income and middle-income countries (LMICs) are limited and also have limited human and structural resources. The working force has been described to be the costliest factor. Nevertheless, costs for intensive care in LMICs are one third from the cost reported from high-income countries. Alternative options have been described, so intensive care can be delivered outside ICU. Examples are Rapid-Response Systems and Medical Emergency Teams. The care of the surgical patients in an intensive care setting in countries with resource limitations should be optimized, protocols for standardized care implemented and Better research and resource allocation, as well as investment in healthcare training are essential for the development of intensive care in LMICs is necessary.

Cost and cost-effectiveness of point-of-care testing and treatment for sexually transmitted and genital infections in pregnancy in low-income and middle-income countries: a systematic review protocol

IntroductionThe economic and health burden of sexually transmitted and genital infections (henceforth, STIs) in low-income and middle-income countries (LMICs) is substantial. Left untreated, STIs during pregnancy may result in several...

The contribution of pediatric surgery to poverty trajectories in Somaliland.

BackgroundThe provision of health care in low-income and middle-income countries (LMICs) is recognized as a significant contributor to economic growth and also impacts individual families at a microeconomic level. The primary goal of our study was to examine the relationship between surgical conditions in children and the poverty trajectories of either falling into or coming out of poverty of families across Somaliland.MethodsThis work used the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool, a validated household, cross-sectional survey designed to determine the burden of surgical conditions within a community. We collected information on household demographic characteristics, including financial information, and surgical condition history on children younger than 16 years of age. To assess poverty trajectories over time, we measured household assets using the Stages of Progress framework.ResultsWe found there were substantial fluxes in poverty across Somaliland over the study period. We confirmed our study hypothesis and found that the presence of a surgical condition in a child itself, regardless of whether surgical care was provided, either reduced the chances of moving out of poverty or increased the chances of moving towards poverty.ConclusionOur study shows that the presence of a surgical condition in a child is a strong singular predictor of poverty descent rather than upward mobility, suggesting that this stressor can limit the capacity of a family to improve its economic status. Our findings further support many existing macroeconomic and microeconomic analyses that surgical care in LMICs offers financial risk protection against impoverishment.

Is Global Pediatric Surgery a Good Investment?

Investing in surgery has been highlighted as integral to strengthening overall health systems and increasing economic prosperity in low-income and middle-income countries (LMICs). The provision of surgical care in LMICs not only affects economies on a macro-level, but also impacts individual families within communities at a microeconomic level. Given that children represent 50% of the population in LMICs and the burden of unmet surgical needs in these areas is high, investing pediatric-specific components of surgical and anesthesia care is needed. Implementation efforts for pediatric surgical care include incorporating surgery-specific priorities into the global child health initiatives, improving global health financing for scale-up activities for children, increasing financial risk protection mechanisms for families of children with surgical needs, and including comprehensive pediatric surgical models of care into country-level plans.

Acquired heart disease in low-income and middle-income countries

The burden of illness associated with acquired cardiac disease in children in low-income and middle-income countries (LMIC) is significant and may be equivalent to that of congenital heart disease. Rheumatic...

Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: recommendations of the Simnovate Global Health Domain Group

BackgroundQuality of medical care in low income and middle income countries (LMICs) is variable, resulting in significant medical errors and adverse patient outcomes. Integration of simulation-based training and assessment may be considered to enhance quality of patient care in LMICs. The aim of this study was to consider the role of simulation in LMICs, to directly impact health professions education, measurement and assessment.MethodsThe Simnovate Global Health Domain Group undertook three teleconferences and a direct face-to-face meeting. A scoping review of published studies using simulation in LMICs was performed and, in addition, a detailed survey was sent to the World Directory of Medical Schools and selected known simulation centres in LMICs.ResultsStudies in LMICs employed low-tech manikins, standardised patients and procedural simulation methods. Low-technology manikins were the majority simulation method used in medical education (42%), and focused on knowledge and skills outcomes. Compared to HICs, the majority of studies evaluated baseline adherence to guidelines rather than focusing on improving medical knowledge through educational intervention. There were 46 respondents from the survey, representing 21 countries and 28 simulation centres. Within the 28 simulation centres, teachers and trainees were from across all healthcare professions.DiscussionBroad use of simulation is low in LMICs, and the full potential of simulation-based interventions for improved quality of care has yet to be realised. The use of simulation in LMICs could be a potentially untapped area that, if increased and/or improved, could positively impact patient safety and the quality of care.

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, affordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multi- disciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on thedomains of health-care delivery and management; work-force, training, and education; economics and finance; and information management. Our Commission has five key messages, a set of indicators and recommendations to improve access to safe, affordable surgical and anaesthesia care in LMICs, and a template for a national surgical plan.

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, affordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multi- disciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on thedomains of health-care delivery and management; work-force, training, and education; economics and finance; and information management. Our Commission has five key messages, a set of indicators and recommendations to improve access to safe, affordable surgical and anaesthesia care in LMICs, and a template for a national surgical plan.

Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti

BackgroundWomen with breast cancer in low-income and middle-income countries (LMICs) account for 51% of cases globally and often present with advanced disease. Fear of costs contributes to delay in seeking care, as health expenditures are financially catastrophic for families worldwide. Despite efforts to improve affordability of health care in LMICs, the financial burden of indirect costs (eg, transportation and lost wages) is often overlooked. We aimed to identify and quantify the expenditures of patients seeking breast cancer care in a LMIC. MethodsPatients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were interviewed to quantify their costs and assess the effect of these costs on patients and families. These costs included expenses for food, lodging, transportation, childcare, medical costs at other institutions, and lost wages. 61 patients were interviewed during diagnostic, chemotherapy, and surgical visits between March 1, and May 12, 2014. Institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante. FindingsThe median non-medical out-of-pockent expenses incurred by breast cancer patients at HUM were US$233 (95% CI 170–304) for diagnostic visits, US$259 (95% CI 200–533) for chemotherapy, and US$38 (95% CI 23–140) for surgery. The median total out-of-pockent expense (including medical costs) was US$717 (95% CI 619–1171). These costs forced 52% of participants into debt and 20% to sell possessions. The median percentage of potential individual income spent on out-of-pocket costs was 60%. The median sum of out-of-pocket costs and lost wages was US$2996 (95% CI 1676–5179). InterpretationIn Haiti, 74% of people earn less than US$2 per day. Even when breast cancer treatment is provided for free, out-of-pocket expenses could account for more than 91% of annual earnings at this income level. This financial burden is an overwhelming obstacle for Haiti's poorest citizens, and probably for many patients in LMICs. High-powered, multisite studies are needed to further characterise this burden worldwide. Funders and health-care providers should reduce indirect costs to achieve equitable access to oncology care. FundingBoston Children's Hospital and Partners in Health.

Care of surgical infections by Médecins Sans Frontières Operations Centre Brussels in 2008–14

BackgroundSurgical infections represent a substantial yet undefined burden of disease in low-income and middle-income countries (LMICs). Médecins Sans Frontières (MSF) provides surgical care in LMICs and collects data useful to describe the operative epidemiology of surgical need that would otherwise be unmet by national health services. We aimed to describe the experience of MSF Operations Centre Brussels surgery for infections during crisis; aid effective resource allocation; prepare humanitarian surgical staff; and further characterise unmet surgical needs in LMICs. MethodsWe reviewed all procedures undertaken in operating theatres at facilities run by the MSF Operations Centre Brussels between July, 2008, and June, 2014. Projects providing only specialty care were excluded. Procedures for infections were quantified, related to demographics and reason for humanitarian response was described. Findings96 239 operations were undertaken at 27 MSF Operations Centre Brussels sites in 15 countries. Of 61 177 general operations, 7762 (13%) were for infections. Operations for skin and soft tissue infections were the most common (64%), followed by intra-abdominal (26%), orthopaedic (6%), and tropical infections (3%). The proportion of operations for skin and soft tissue infections was highest during natural disaster missions, intra-abdominal infections during hospital support missions, and orthopaedic infections during conflict missions. Most procedures for skin and soft tissue infections were minor (76%), whereas most operations for intra-abdominal infections were major (98%). InterpretationSurgical infections are among the most common causes for operation in LMICs. Although many procedures were minor, they represent substantial use of perioperative resources. Growing evidence shows the need for improved perioperative capacity to aptly care for the volume and variety of conditions comprising the global burden of surgical disease. FundingMédecins Sans Frontières.

Financial contribution to global surgery: an analysis of 160 international charitable organisations

BackgroundThe non-profit and volunteer sector provides substantial contributions to global health. Within the field of surgery, this sector has made notable service contributions in low-income and middle-income countries (LMICs) where access to surgical care is poor. Little is known about financing and funding flows to surgical care in LMICs from both domestic and international sources. Because an estimated 55% of surgical care delivered in LMICs is via charitable organisations, understanding the financial contributions of this sector could provide valuable insight into estimating funding flows and understanding financing priorities in global surgery. MethodsBetween June, and September, 2014, we searched public online databases of registered charitable organisations in five high-income nations (the USA, the UK, Canada, Australia, and New Zealand) to identify organisations committed exclusively to surgical needs. Based on availability, the most current 5 years (2007–13) of financial data per organisation were collected. For each charitable organisation, we identified the type of surgical services provided. We examined revenues and expenditures for each organisation. Findings160 organisations representing 15 different surgical specialties were included in the analysis. Total aggregated revenue over the years 2008–2013 was US$3·3 billion. Total aggregated expenses for all 160 organisations amounted to US$3·0 billion. 28 ophthalmology organisations accounted for 45% of revenue and 49% of expenses. 15 cleft lip and palate organisations totalled 26% of both revenue and expenses. 19 organisations providing a mix of diverse surgical specialty services amounted to 14% of revenue and 16% of expenses. The remaining 15% of funds represented 12 specialties and 98 organisations. The US accounted for 77·7% of revenue and 80·8% of expenses. The UK accounted for 11·0% of revenue and 11·91% of expenses. Canada accounted for 1·85% of revenue and 2·01% of expenses. Australia and New Zealand accounted for 4·94% of revenue and 5·29% of expenses. InterpretationCharitable organisations addressing surgical conditions primarily focus on elective surgical care and cover a broad range of subspecialties. The largest funding flows from charitable organisations are directed at ophthalmology, followed by cleft lip and palate surgery. However, there is a clear need for improved, transparent tracking of funds to global surgery via charitable organisations. FundingNone.

An international survey of nutritional practices in low- and middle-income countries: a report from the International Society of Pediatric Oncology (SIOP) PODC Nutrition Working Group.

Optimal nutritional status is important in children with cancer, as it can influence clinical outcomes. To improve the nutritional health of children and adolescents receiving treatment for cancer residing in low income and middle-income countries (LMIC), we investigated nutrition practices among these nations' institutions providing treatment for childhood cancer. A cross-sectional survey of nutrition practice was administered to staff members at institutions providing treatment for children with cancer between 2011 and 2012. Countries classified as low income and middle income were divided by geographical region. Final analysis was performed with 96 surveys, which included 27 institutions from Asia, 27 institutions from Latin America and Caribbean, 27 institutions from Africa and 15 institutions from Europe. The study found that 55% of institutions had a dietician available on their service. Access to dieticians, lack of nutrition resources and lack of nutrition education of staff were the main barriers to providing nutrition care in LMIC. Half of the institutions performed nutritional assessment at diagnosis, and the methods used varied widely. Twenty-nine percent of all institutions used complementary and alternate therapies within their clinical practice, and 35% of institutions reported that nutrition education was provided to patients and families. Priority areas for improving the nutritional management in LMIC include the following: (1) improved nutrition education and assessment tools for doctors and nurses; (2) increased availability of nutrition education resources for families and patients; and (3) identification of the role of complementary and alternative therapies in closing gaps in symptom management in these institutions.

AUTHOR'S REPLY

<h3>Introduction</h3> The economic and health burden of sexually transmitted and genital infections (henceforth, STIs) in low-income and middle-income countries (LMICs) is substantial. Left untreated, STIs during pregnancy may result in several adverse pregnancy and birth outcomes. Timely diagnosis and treatment at point-of-care (POC) can potentially improve these outcomes. Despite the availability and promotion of POC diagnostics for STIs as a key component of antenatal care in LMICs, their widespread use has been limited, owing to the high economic costs faced by individuals and health systems. To date, there have been no systematic reviews which explore the cost or cost-effectiveness of POC testing and treatment of STIs in pregnancy in LMICs. The objective of this protocol is to outline the methods that will compare, synthesise and appraise the existing literature in this domain. <h3>Methods and analysis</h3> We will conduct literature searches in MEDLINE, Embase and Web of Science. To find additional literature, we will search Google Scholar and hand search reference lists of included papers. Two reviewers will independently search databases, screen titles, abstracts and full texts; when necessary a third reviewer will resolve disputes. Only cost and cost-effectiveness studies of POC testing and treatment of STIs, including syphilis, chlamydia, trichomonas, gonorrhoea and bacterial vaginosis, in pregnancy in LMICs will be included. Published checklists will be used to assess quality of reporting practices and methodological approaches. We will also assess risk of publication bias. Interstudy heterogeneity will be assessed and depending on variation between studies, a meta-analysis or narrative synthesis will be conducted. <h3>Ethics and dissemination</h3> Ethical approval is not required as the review will use published literature. The results will be published in a peer-reviewed open source journal and presented at an international conference. <h3>PROSPERO registration number</h3> CRD42018109072.