Care In Resource-limited Settings Research Articles

A simple and data-driven framework to foster multidisciplinary and timely care in resource-limited settings: A pilot program in Argentina.

e13517 Background: While numerous reports discuss various navigation methods and their effectiveness, implementing these programs in low- and middle-income countries (LMICs) is challenging. This study addresses this gap by assessing the feasibility of implementing a simple strategy using a small set of essential data gathered during routine patient care. The aim was to foster multidisciplinary case discussion and monitor key performance indicators (KPIs) to achieve timely access to treatment. Methods: As part of the BOLD initiative (Barriers or Limits Demolished Against Breast Cancer), we started a pilot program with the Breast Unit and the Medical Oncology Consult in the outpatient setting of a public hospital serving a vulnerable population in Buenos Aires City. Using a web-based spreadsheet accessible to both units, a simple framework collecting relevant consultation dates was implemented to assess the timeliness of specialist referrals and treatment initiation. We configured simple time-based alerts to highlight patients who exceeded prespecified timeframes, enabling healthcare providers to promptly reach out to patients, inquire about the reasons for access issues, and provide counseling to address them when possible. Results: The Breast Cancer Unit admitted 38 newly diagnosed patients from Sep/2023 to Nov/2023, of whom 22 (57.9%) had no health insurance. The main program KPIs are described in the Table. Surgery was the most frequent source of treatment delays (58.3%), mainly because of the scarce availability of operating rooms. Alerts from delayed initiation of systemic oncological treatments were present in 11 patients (28.9%). Navigation of those patients attributed the primary source of delays to administrative issues in the prior authorization process (45.5%, n=5), followed by patient-related factors such as social vulnerability and difficulty in coping with required procedures (n=4). Conclusions: A simple framework based on the prospective register of key consultation dates was feasible to implement in the routine care setting of a public hospital serving a vulnerable population. This model promotes quality and equity for breast cancer patients by providing an accessible way for LMICs to ensure a timely referral process, foster multidisciplinary case discussion, and offer patient support to overcome challenges arising primarily from delays within the health system. [Table: see text]

Factors associated with physical inactivity among Palestinians with type 2 diabetes mellitus treated in resource-limited settings

This study determined the prevalence and the associated factors with meeting the recommended amount of physical activity among type 2 diabetes mellitus (T2DM) patients receiving care in resource-limited settings of the West Bank of Palestine. Physical activity was assessed using the World Health Organization’s Global Physical Activity Questionnaire. Associations were examined using multivariate logistic regression. Of the 302 patients included, 117 (38.7%) met the recommended amount of physical activity. Being younger than 58 years [aOR = 2.1 (95% CI 1.0–4.3], were employed [aOR = 2.3 (95% CI 1.1–4.9)], had high income [aOR = 3.9 (95% CI 1.3–11.9)], had thought that physical activity was crucial for T2DM patients [aOR = 32.7 (95% CI 3.9–275.5)], did not have comorbidities [aOR = 2.2 (95% CI 1.1–4.4)], had normal weight [aOR = 2.8 (95% CI 1.3–6.0)], and those who were overweight [aOR = 2.6 (95% CI 1.1–6.0)] were more likely to meet the recommended amount of physical activity compared to the patients who were 58 years or older, had low income, did not think that physical activity was crucial for T2DM patients, had comorbidities, and were obese, respectively. There is a need to increase physical activity among T2DM patients in resource limited settings.

Characteristics and outcomes of patients admitted to intensive care units in Uganda: a descriptive nationwide multicentre prospective study

Intensive care unit (ICU) mortality rates have decreased over time. However, in low-and lower-middle income countries (LMICs), there remains an excess ICU mortality with limited understanding of patient characteristics, treatments, and outcomes from small single centre studies. We aimed therefore, to describe the characteristics, therapies and outcomes of patients admitted to all intensive care units in Uganda. A nationwide prospective observational study including all patients admitted Uganda’s ICUs with available daily charts was conducted from 8th January 2018 to 1st April 2018. Socio-demographics and clinical characteristics including worst vital signs in the first 24 h of admission were recorded with calculation of the National Early Warning Score (NEWS-2) and quick Sequential Organ Function Assessment (qSOFA) score. ICU interventions were recorded during the ICU stay and patients were followed up to 28 days in ICU. The primary outcome was 28 day ICU mortality. Three-hundred fifty-one patients were analysed with mean age 39 (24.1) years, 205 (58.4%) males with 197 (56%) surgical admissions. The commonest indication for ICU admission was postoperative care (42.9%), 214 (61%) had at least one comorbidity, with hypertension 104 (48.6%) most prevalent and 35 (10%) HIV positive. The 28 day ICU mortality was 90/351 (25.6%) with a median ICU stay of 3 (1–7) days. The highest probability of death occurred during the first 10 days with more non-survivors receiving mechanical ventilation (80% vs 34%; p < 0.001), sedation/paralysis (70% vs 50%; p < 0.001), inotropic/vasopressor support (56.7% vs 22.2%; p < 0.001) and renal replacement therapy (14.4% vs 4.2%; p < 0.001). Independent predictors of ICU mortality included mechanical ventilation (HR 3.34, 95% CI 1.48–7.52), sedation/paralysis (HR 2.68, 95% CI 1.39–5.16), inotropes/vasopressor (HR 3.17,95% CI 1.89–5.29) and an HIV positive status (HR 2.28, 95% CI 1.14–4.56). This study provides a comprehensive description of ICU patient characteristics, treatment patterns, and outcomes in Uganda. It not only adds to the global body of knowledge on ICU care in resource-limited settings but also serves as a foundation for future research and policy initiatives aimed at optimizing ICU care in Sub-Saharan Africa.

Cardiology across continents: an interactive, case-based learning series.

Heart University [https://www.heartuniversity.org/] is a free educational website providing structured training curricula with knowledge-based testing and access to webinars and conference recordings for practicing and in-training providers of paediatric and congenital cardiac care. To date, there are over 15,000 registered website users from over 140 countries on Heart University, with over 2,000 training modules and/or recorded educational videos. Heart University has developed an "asynchronous" educational lecture series entitled "Pediatric and Congenital Cardiac Care in Resource-Limited Settings." This recorded lecture series is specifically focused on topics relevant to practicing paediatric and/or congenital cardiac care in low-resource settings.A relatively new initiative, "Cardiology Across Continents," supplements the existing educational resources for providers of paediatric and/or congenital cardiac care in low-income countries and lower-middle-income countries by providing an additional live, interactive, case-based forum. Sessions occur every 1-2 months and focus on challenging cases from diagnostic or management perspective with a view to promote collaboration between partnered institutions. "Cardiology Across Continents" is an expanding initiative that facilitates learning and collaboration between clinicians across varied practice settings via interactive case discussions. We welcome trainees and providers of paediatric and congenital cardiac care to join the sessions and invite any insight that can enhance learning for clinicians around the world. This manuscript describes "Cardiology Across Continents" and discusses the development, history, current status, and future plans of Heart University.

Developing Systems of Emergency and Inpatient Neurologic Care in Resource-Limited Settings.

Neurologic diseases represent a significant global health challenge, leading to disability and mortality worldwide. Healthcare systems in low- and middle-income countries are disproportionally affected. In these resource-limited settings, numerous barriers hinder the effective delivery of emergency and inpatient neurologic care, including shortages of trained personnel, limited access to diagnostics and essential medications, inadequate facilities, and absence of rehabilitation services. Disparities in the neurology workforce, limited access to neuroimaging, and availability of acute interventions further exacerbate the problem. This article explores strategies to enhance global capacity for inpatient neurologic care, emphasizing the importance of workforce development, context-specific protocols, telehealth solutions, advocacy efforts, and collaborations.

Developing Systems of Care for Stroke in Resource-limited Settings.

Although stroke prevention and treatment strategies have significantly advanced in recent years, implementation of these care elements in resource-limited settings can be challenging, since the burden of stroke is higher and access to stroke care is lower. Barriers to stroke care in resource-limited settings include insufficient prevention, reduced awareness of stroke symptoms, limited prehospital care and lack of triage systems, limited access to comprehensive stroke centers, inadequate personnel education, lack of staff and resources, as well as limited access to neuroimaging, thrombolytics, mechanical thrombectomy, neurosurgical care, and rehabilitation. Here, we suggest strategies to improve stroke care in these settings, including public health campaigns, protocols for prehospital notification, organized flow to specialized stroke centers, development of dedicated stroke units, and utilization of telemedicine and telerehabilitation. We also highlight the role of international organizations and governments in reducing the global burden of stroke.

Abstract 6177: Machine learning enables prediction of ADC targets from whole slide H&amp;E images

Abstract Background: The efficacy of antibody-drug conjugates (ADCs) depends on the expression and specificity of the target antigen by tumor cells. Although H&amp;E-stained slides are routinely collected during cancer care, specialized IHC staining is typically required to ascertain antigen expression. Such stains are not always available or readily deployed. The need to perform separate IHC tests for each candidate ADC may burden clinical labs and can hinder access to care in resource-limited settings. Here we develop an ensemble of machine learning models to accurately predict the expression of 166 distinct ADC targets directly from H&amp;E images. Methods: For each ADC-targeted gene, patients with copy-number amplifications (CNAs) were identified from somatic whole exome sequencing. Genes differentially expressed in patients with CNAs were identified from bulk transcriptomics. For each gene, an expression signature was developed based on the expression levels of differentially upregulated genes. Next, whole-slide, H&amp;E-stained histopathology images were embedded into a lower-dimensional representation via a transformer model trained with self-supervised learning. Neural networks were developed to predict a patient’s probability of having a CNA in an ADC-targeted gene, as indicated by an expression signature exceeding the p90. All evaluation metrics were ascertained by 5-fold cross-validation, with training and evaluation on independent patients. Results: For each of the 166 ADC-targeted genes, a median of 154 patients were found to harbor a CNA, and the expression signature included a median of 180 genes. In all cases, patients with CNAs had significantly higher expression signatures than those without. For predicting likely CNA status directly from H&amp;E histopathology images, the mean AUROC was 0.888 (95% CI, 0.876-0.900) and the mean AUPRC was 0.571 (95% CI, 0.531-0.611). Among the 166 ADC-targeted genes, the AUROC exceeded 0.95 for 31.3%, 0.8 for 80.7%, and 0.725 for 100%. The best-predicted ADC target was SLC7A5 (AUROC: 0.995 [95% CI, 0.994-0.998]; AUPRC: 0.967 [95% CI, 0.963-0.976]). Conclusion: We have developed models that accurately predict the likely expression of ADC targets based solely on H&amp;E images. The ability to accurately discern the presence of ADC antigens from H&amp;E images has numerous potential applications, including cohort refinement, computer-aided diagnosis, and personalized treatment planning. Citation Format: Zachary Ryan McCaw, Anna Shcherbina, Yajas Shah, insitro Research Team, Philip Tagari, Daphne Koller, Christopher Probert. Machine learning enables prediction of ADC targets from whole slide H&amp;E images [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6177.

Peripartum mobility and maternal/child separation among women living with HIV in South Africa

ABSTRACT This prospective cohort study investigated the mobility patterns of 200 pregnant and postpartum women living with HIV in South Africa. Participants were enrolled during their third trimester from routine antenatal care near Cape Town, South Africa, and followed for six months postpartum. Quantitative data were collected at enrollment and follow-up. Mobility (self-reported) was common among the participants, despite the brief study period and the concurrent COVID-19 pandemic. While most reported stability in their current residence, 71% had a second main residence, primarily in the Eastern Cape (EC). Participants had a median of two lifetime moves, motivated by work, education, and family life. During the study period, 20% of participants met the study definition of travel (>7 days and >50 km), with trips predominantly to the EC, lasting a median duration of 30 days. Over one-third of participants with other living children reported that these children lived apart from them, with the mother’s family being primary caregivers. These findings emphasize the need for targeted interventions to support continuity of care for mobile populations, particularly peripartum women living with HIV. The study contributes valuable insights into mobility dynamics and highlights unique barriers faced by this population, contributing to improved HIV care in resource-limited settings.

Shaping the Future of General Surgery: A Minireview for A Fusion of Technological Advancements, Ethical Considerations, and Global Health Equity

This mini-review explores the transformative potential of technological advancements and innovation in shaping the future of general surgery. Artificial intelligence, robotics, bioprinting, gene editing, and nanotechnology hold immense promise for enhancing surgical precision, minimizing complications, and personalizing patient care. However, the review acknowledges the ongoing challenges of global surgery, particularly the need for solutions to bridge the gap in access to safe and effective surgical care for underserved populations. Telemedicine and mobile health platforms emerge as promising tools for delivering surgical consultations and follow-up care in resource-limited settings. Ethical considerations, including resource allocation, research conduct, and cultural competency, are recognized as crucial aspects of global surgery. Collaborative frameworks that prioritize equity and empower local communities are emphasized. The potential impact of climate change on surgical needs is also addressed, highlighting the importance of understanding this interplay to develop preparedness and mitigation strategies. Finally, the review explores unconventional topics with the potential to changing the shape of surgical practices, including the role of the gut microbiome, psychedelic substances, and personalized genetic approaches. The importance of further research in these areas is acknowledged. In conclusion, this article portrays a future of general surgery characterized by a fusion of cutting-edge technology, a commitment to global health equity, and a focus on ethical considerations and responsible innovation. This future holds immense promise for improved surgical outcomes, enhanced patient care, and a more equitable distribution of surgical resources across the globe.

Comparative Evaluation of the ETDRS Visual Acuity Chart and Arclight Cloth Chart (ARCchart) for Primary Eye Care in Resource-Limited Settings

This study compared the Arclight Cloth Chart (ARCchart) to the gold standard ETDRS chart for visual acuity (VA) measurement in 63 participants. Despite its potential limitations as a tool to measure subtle changes in VA over time, the ARCchart showed a limit of agreement between -0.23logMAR and 0.26logMAR with ETDRS values. It demonstrated 93% (95% Confidence Interval 86% to 100%) sensitivity and 90% (84% to 97%) specificity when used to screen for vision worse than 0.20logMAR. This low-cost, portable cloth VA chart is a valuable alternative for measuring VA and screening for low vision in resource poor settings.

Diagnostic Accuracy of the World Health Organization Pediatric Emergency Triage, Assessment and Treatment Tool Plus Among Patients Seeking Care in Nairobi, Kenya: A Cross-sectional Study.

The World Health Organization developed Emergency Triage Assessment and Treatment Plus (ETAT+) guidelines to facilitate pediatric care in resource-limited settings. ETAT+ triages patients as nonurgent, priority, or emergency cases, but there is limited research on the performance of ETAT+ regarding patient-oriented outcomes. This study assessed the diagnostic accuracy of ETAT+ in predicting the need for hospital admission in a pediatric emergency unit at Kenyatta National Hospital in Nairobi, Kenya. This was a secondary analysis of a cross-sectional study of pediatric emergency unit patients enrolled over a 4-week period using fixed random sampling. Diagnostic accuracy of ETAT+ was evaluated using receiver operating curves (ROCs) and respective 95% confidence intervals (CIs) with associated sensitivity and specificity (reference category: nonurgent). The ROC analysis was performed for the overall population and stratified by age group. A total of 323 patients were studied. The most common reasons for presentation were upper respiratory tract disease (32.8%), gastrointestinal disease (15.5%), and lower respiratory tract disease (12.4%). Two hundred twelve participants were triaged as nonurgent (65.6%), 60 as priority (18.6%), and 51 as emergency (15.8%). In the overall study population, the area under the ROC curve was 0.97 (95% CI, 0.95-0.99). The ETAT+ sensitivity was 93.8% (95% CI, 87.0%-99.0%), and the specificity was 82.0% (95% CI, 77.0%-87.0%) for admission of priority group patients. The sensitivity and specificity for the emergency patients were 66.0% (95% CI, 55.0%-77.0%) and 98.0% (95% CI, 97.0%-100.0%), respectively. ETAT+ demonstrated diagnostic accuracy for predicting patient need for hospital admission. This finding supports the utility of ETAT+ to inform emergency care practice. Further research on ETAT+ performance in larger populations and additional patient-oriented outcomes would enhance its generalizability and application in resource-limited settings.

The unique challenges of AYA cancer care in resource-limited settings

IntroductionAdolescents and young adults (AYAs) diagnosed with cancer represent a distinct group with exceptional and unique characteristics. The survival rates for this age group are worse than in children or adults. Cancer care for this population is a challenge, not only for low-income countries but also for the developed world. This review addresses the unique challenges adolescents and young adults (AYAs) diagnosed with cancer in low-income countries face.MethodsTwo individual authors conducted the literature review to present the global burden of AYAs in resource-limited settings. The articles selected focused on AYA care from Latin America, Asia, and Africa.ResultsAmong the challenges of managing AYAs with cancer are the absence of national and/or hospital cancer registries, and a lack of adequate infrastructure, AYA-dedicated programs, appropriate psycho-social support, fertility preservation, and genetic counseling services. Furthermore, education and training activities specifically dedicated to the care of AYAs diagnosed with cancer are scarce in those countries.ConclusionImplementing a dedicated AYA program in resource-limited settings will be critical in providing patient-centered care bolstered by age-appropriate infrastructure and comprehensive clinical, psycho-social, and allied health support. It will significantly reduce the treatment abandonment rate, diminish the duration of diagnosis delay, and alleviate emotional detachment and disarray.

What factors are associated with paediatric admissions and their outcomes in a rural hospital in northern Sierra Leone? Insights from a pilot observational study

IntroductionData on the pattern of admissions and causes of child death are crucial in informing priorities for improving child survival. In many health facilities in sub-Saharan Africa, understanding the pattern...

Barriers and Facilitators of Quality Family-Centered Communication in Pakistan.

Communication is a fundamental aspect of patient- and family-centered care. Unfortunately, there is a dearth of evidence regarding pediatric cancer communication in low- and middle-income countries, where over 90% of all children with childhood cancer live. The purpose of this study was to explore barriers and facilitators of quality communication within two pediatric cancer centers in Pakistan. Semistructured interviews were conducted with 20 multidisciplinary pediatric cancer clinicians and 18 caregivers of children with cancer at Children's Hospital of Lahore and Indus Hospital in Karachi, Pakistan. Interviews were conducted in English or Urdu, audio-recorded, transcribed, and translated to English. Two researchers coded each transcript using an inductively derived codebook. Thematic content analysis focused on barriers and facilitators of high-quality communication. Pakistani clinicians and caregivers identified factors that affected the quality of patient-centered cancer communication. These included structural factors including setting, available interpreters, documentation, patient volume, teamwork, and financial support. Clinician-level communication barriers and facilitators included communication training, clinician distress/boundaries, and the ability to have recurrent conversations. Patient or family characteristics affecting communication included education, income status, primary language, and geography; the child's specific disease type; and relational elements such as social support, empowerment, and split decision makers. Participants identified existing or potential interventions related to each factor. Multilevel factors serve as either barriers or facilitators for pediatric cancer communication in Pakistan. Identification of these elements of communication is an essential step toward interventions aimed at improving patient- and family-centered care in resource limited settings.

RART-LAMP: One-Step Extraction-Free Method for Genotyping within 40 min.

Loop-mediated isothermal amplification (LAMP) is a commonly used alternative to PCR for point-of-care detection of nucleic acids due to its rapidity, sensitivity, specificity, and simpler instrumentation. While dual-labeled TaqMan probes are widely used in PCR for single-nucleotide polymorphism (SNP) genotyping, real-time LAMP primarily relies on turbidimetry or intercalator fluorescence measurements, which can be non-specific and generate false-positive results. In this study, we propose a closed-tube, dual-labeled RNA-modified probes and RNase H II-assisted real-time LAMP (RART-LAMP) method for SNP genotyping. Our findings indicate that (1) fluorescence signals were predominantly derived from probe hydrolysis rather than hybridization, (2) temperature-controlled hybridization between the probe and template ensured the specificity of SNP analysis, and (3) RNase H II hydrolysis between the target containing SNP sites and probes did not exhibit sequence specificity. Our RART-LAMP approach demonstrated excellent performance in genotyping C677T clinical samples, including gDNA extracted from blood, saliva, and swabs. More importantly, saliva and swab samples could be directly analyzed without any pretreatment, indicating promising prospects for nucleic acid analysis at the point of care in resource-limited settings.

Improving palliative care outcomes in remote and rural areas of LMICs through family caregivers: lessons from Kazakhstan.

Approximately 60 million people require palliative care worldwide, and nearly 80% of them live in low- and middle-income countries (LMICs). Providing palliative care in remote and rural areas of LMICs requires special consideration to ensure equitable access to healthcare. This perspective aims to deliver pragmatic, context-oriented policy recommendations designed to improve palliative care outcomes in Kazakhstan by capitalizing on existing resources and considering its unique geopolitical and sociocultural context. With approximately half of the population in Kazakhstan residing in remote and rural regions, the provision of healthcare services - specifically palliative care - mandates particular attention to ensure equal access to high-quality care. To understand challenges of implementing palliative care in remote and rural regions of Kazakhstan and to propose tailored solutions, 29 key stakeholders, including family caregivers, health professionals, and palliative care administrators, were identified in five regions of Kazakhstan. The main challenges encountered by family caregivers include lack of palliative care skills, the need for home-based care from mobile services, and high out-of-pocket expenditures. The challenges highlighted by healthcare providers and administrators were the lack of formal education in palliative care, shortage of opioids, and limited societal awareness and state support. Based on challenges elaborated from stakeholders and existing literature in palliative care and family caregiving, this perspective advocates against replicating the strategies implemented in high-income countries. Family caregivers play a critical role in implementing affordable and efficient palliative care in resource-limited settings. Enhancing their competencies through digital training and increasing access to palliative care services through mobile teams are tailored and localized solutions that address specific challenges in Kazakhstan. It is postulated that these recommendations may find utility in other LMICs, potentially benefiting nearly 48 million individuals who require these services.

Remote Robotic Surgery and Virtual Education Platforms: How Advanced Surgical Technologies Can Increase Access to Surgical Care in Resource-Limited Settings.

Advanced surgical technologies consist of remote and virtual platforms that facilitate surgical care and education. It also includes the infrastructure necessary to utilize these platforms (e.g., internet access, robotic systems, and simulators). Given that 5 billion people lack access to safe and timely surgical care, the appeal of these technologies to the field of global surgery lies primarily in its ability to eliminate geographical barriers and address surgeon shortages. This article discusses the use of virtual and remote technologies in resource-limited settings, the potential applications of these technologies, the possible barriers to their integration, and the impact these technologies may have on access to surgical care and education. Specifically, it will explore how robotic surgery, telesurgery, virtual education platforms, and simulations have the potential to be instrumental in enhancing worldwide access to safe surgical care.

Two manual non-commercial preparation methods for platelet-rich plasma in donkeys (Equus asinus)

Platelet-rich plasma (PRP) is a biologic, whole blood (WB) derived, immunomodulatory therapeutic that has gained popularity in brood mares for its potential to mitigate post-breeding uterine inflammation/infection and enhance fertility rates. In jennies, increased susceptibility to post-breeding endometritis and poor fertility rates have been associated with insemination using frozen-thawed jack semen. Because many donkey breeds are threatened with extinction, frozen semen technology offers a viable chance at recovery. Thus, PRP has potential in similarly benefitting donkey breeding programs. However, the majority of PRP protocols previously described in donkeys have not undergone critical assessment. Commercial and noncommercial PRP production methods exist, but the latter confers advantages (e.g., field applicability and decreased cost) for a species more likely to receive veterinary care in resource-limited settings. The objective of this study was to evaluate two manual noncommercial methods of producing PRP (double centrifugation [DC] and single centrifugation [SC]) in six healthy adult donkeys (n=3 jennies; n=3 johns; ages 4-8 years old) undergoing three blood collections two weeks apart. For DC-PRP, WB collected into a 150 mL blood transfusion bag containing citrate-phosphate-dextrose solution with adenine was split into 50 mL tubes, centrifuged at 400 × g/15 min, then plasma transferred into 15 mL conical tubes and centrifuged at 1000 × g/10 min. Afterwards, the bottom 2.5 mL of plasma per tube waspreserved as DC-PRP with the above supernatant as DC platelet-poor plasma (PPP). For SC-PRP, WB was collected into 2.7 mL sodium citrate vacutainer tubes, then centrifuged at 120 × g/10 min. Post-centrifugation, the top third layer of plasma was deemed SC-PPP with the remaining portion as SC-PRP. Concentrations of platelets, leukocytes (WBC), and erythrocytes (RBC), and platelet-derived growth factor-BB (PDGF-BB) were assessed in the WB, and extracted PRP and PPP. Data was analyzed by Friedman and Dunn's as a post hoc test with significance as P<0.05. Both protocols concentrated platelets 1.7–5.2-fold, reduced WBC 1.1–50.4-fold, and decreased RBC at least 829-fold compared to WB (P<0.0001). Activity of PDGF-BB in DC-PRP and SC-PRP increased by 1.2–7.0-fold in comparison to WB (P=0.0003). Platelet concentration and PDGF-BB activity rose 3-fold (P<0.0001) and 5.8-fold (P=0.0007), respectively, in DC-PRP than SC-PRP. Leukocyte concentration was wider in DC-PRP than SC-PRP (P<0.0001), but did not differ between WB and DC-PRP (P=0.61). Reduction in WBC and RBC was 42-fold and 22-fold greater, respectively, in SC-PRP than DC-PRP (P<0.0001). These results indicate that noncommercial methods of PRP preparation described in horses are applicable in donkeys. Double centrifugation yielded higher platelet concentration and PDGF-BB activity despite greater WBC and RBC contamination than PRP processing via SC. Future studies are needed to determine in vivo efficacy of PRP in donkeys.

The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health

BackgroundHealthcare systems in low-resource settings need simple, low-cost interventions to improve services and address gaps in care. Though routine data provide opportunities to guide these efforts, frontline providers are rarely engaged in analyzing them for facility-level decision making. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages providers in use of facility-level data to promote systems-level thinking and quality improvement (QI) efforts within multi-step care cascades. SAIA was originally developed to address HIV care in resource-limited settings but has since been adapted to a variety of clinical care systems including cervical cancer screening, mental health treatment, and hypertension management, among others; and across a variety of settings in sub-Saharan Africa and the USA. We aimed to extend the growing body of SAIA research by defining the core elements of SAIA using established specification approaches and thus improve reproducibility, guide future adaptations, and lay the groundwork to define its mechanisms of action.MethodsSpecification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA-researchers, implementing agents and stakeholders using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor’s recommendations for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects.ResultsBased on this review and clarification of the operational definitions of the components of the SAIA, the four components of SAIA were mapped to 13 ERIC strategies. SAIA strategy meetings encompassed external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to three ERIC strategies: facilitating relay of clinical data to providers, use of audit and feedback of routine data with healthcare teams, and modeling and simulation of change. Process mapping matched to local needs assessment, local consensus discussions and assessment of readiness and identification of barriers and facilitators. Finally, continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change, and purposefully re-examining the implementation process.ConclusionsSpecifying the components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings.

Optimizing Haemophilia Care in Resource-Limited Countries: Current Challenges and Future Prospects.

About 75% of persons with hemophilia live in the developing world and do not have access to routine care due to many barriers. There are a lot of challenges associated with hemophilia care in resource-limited settings, ranging from financial to organisational and government commitments. This review discusses some of these challenges and future prospects, while highlighting the important role of the World Federation of Hemophilia in hemophilia patient care. A participative approach involving all stakeholders is key to optimizing care in resource-limited settings.