High-resource Settings Research Articles

An integrated isothermal nucleic acid amplification test to detect HPV16 and HPV18 DNA in resource-limited settings.

High-risk human papillomavirus (HPV) DNA testing is widely acknowledged as the most sensitive cervical cancer screening method but has limited availability in resource-limited settings, where the burden of cervical cancer is highest. Recently, HPV DNA tests have been developed for use in resource-limited settings, but they remain too costly for widespread use and require instruments that are often limited to centralized laboratories. To help meet the global need for low-cost cervical cancer screening, we developed a prototype, sample-to-answer, point-of-care test for HPV16 and HPV18 DNA. Our test relies on isothermal DNA amplification and lateral flow detection, two technologies that reduce the need for complex instrumentation. We integrated all test components into a low-cost, manufacturable platform, and performance of the integrated test was evaluated with synthetic samples, provider-collected clinical samples in a high-resource setting in the United States, and self-collected clinical samples in a low-resource setting in Mozambique. We demonstrated a clinically relevant limit of detection of 1000 HPV16 or HPV18 DNA copies per test. The test requires six user steps, yields results in 45 min, and can be performed using a benchtop instrument and minicentrifuge by minimally trained personnel. The projected per-test cost is <$5, and the projected instrumentation cost is <$1000. These results show the feasibility of a sample-to-answer, point-of-care HPV DNA test. With the inclusion of other HPV types, this test has the potential to fill a critical gap for decentralized and globally accessible cervical cancer screening.

Estimation of the burden of tsutsugamushi disease in central part of Nepal with high resource settings

Estimation of the burden of tsutsugamushi disease in central part of Nepal with high resource settings

Assessing needs-based supply of physicians: a criteria-led methodological review of international studies in high-resource settings

BackgroundMany health systems embrace the normative principle that the supply of health services ought to be based on the need for healthcare. However, a theoretically grounded framework to operationalize needs-based supply of healthcare remains elusive. The aim of this paper is to critically assess current methodologies that quantify needs-based supply of physicians and identify potential gaps in approaches for physician planning. To this end, we propose a set of criteria for consideration when estimating needs-based supply.MethodsWe conducted searches in three electronic bibliographic databases until March 2020 supplemented by targeted manual searches on national and international websites to identify studies in high-resource settings that quantify needs-based supply of physicians. Studies that exclusively focused on forecasting methods of physician supply, on inpatient care or on healthcare professionals other than physicians were excluded. Additionally, records that were not available in English or German were excluded to avoid translation errors. The results were synthesized using a framework of study characteristics in addition to the proposed criteria for estimating needs-based physician supply.Results18 quantitative studies estimating population need for physicians were assessed against our criteria. No study met all criteria. Only six studies sought to examine the conceptual dependency between need, utilization and supply. Apart from extrapolations, simulation models were applied most frequently to estimate needs-based supply. 12 studies referred to the translation of need for services with respect to a physician’s productivity, while the rest adapted existing population-provider-ratios. Prospective models for estimating future care needs were largely based on demographic predictions rather than estimated trends in morbidity and new forms of care delivery.ConclusionsThe methodological review shows distinct heterogeneity in the conceptual frameworks, validity of data basis and modeling approaches of current studies in high-resource settings on needs-based supply of physicians. To support future estimates of needs-based supply, this review provides a workable framework for policymakers in charge of health workforce capacity planning.

Quality of life after traumatic thoracolumbar spinal cord injury: a North Indian perspective.

Cross-sectional study. To determine the Quality of Life (QOL) in individuals with traumatic Spinal Cord Injury (SCI) of thoracolumbar region in Indian population, the factors affecting QOL and to compare this to other SCI populations. Tertiary level hospital in low-middle income country. 93 individuals with SCI of minimum 1 year duration since injury were included in the study. Baseline demographics, socioeconomic parameters, and incidence of complications were ascertained. World Health Organisation Quality of Life-BREF (WHOQOL-BREF) score was used for measurement of QOL and was then compared to healthy Indian population and other SCI studies. Subgroup analysis was done to find out impact of variables on different domains of WHOQOL-BREF. The median (IQR)age of the study participants was 35 (25, 45) with a male predominance. The median (IQR) duration since injury in the study population was 50 (26, 70) months. Lowest mean(SD)score was observed in the psychological domain -50.3 (12.1) and comparison to healthy Indian and high-income SCI populations revealed drastically decreased scoresacross all domains (p < 0.01). Employed individuals and housewives had significantly higher scores across all domains than unemployed individuals (p < 0.05). American Spinal Injury Association Impairment Scale (AIS) grade, socioeconomic status, pain and presence of complications all had significant impact on domain scores (p < 0.05). Multiple regression analysis revealed that mobilisation status and pain had the greatest effect on QOL. Individuals with SCI have low QOL scores as compared to general Indian population as well as SCI individuals from a high resource setting. Pain and dependent mobilisation were found to be most significant predictors of poor WHOQOL-BREF domain scores. Housewives were found to have domain scores comparable to employed individuals. Presence of complications negatively impacts QOL.

Breast/Chestfeeding and HIV: Shared Decision-Making and the Needs of Women [ID: 1372281

INTRODUCTION: Breast/chestfeeding is considered both the healthiest infant-feeding option for the general population and the standard of care for birthing parents living with human immunodeficiency virus (HIV) in resource-limited settings. Inadequate research on breastfeeding and HIV in high-resource settings has resulted in a lack of clinical guidance for providers to support informed decision-making among women living with HIV in these areas. METHODS: The Well Project, a nonprofit working to change the course of the HIV pandemic through a unique and comprehensive focus on women, conducted a survey in 2021 that included questions about breastfeeding experiences. Among 200 self-identified women living with HIV surveyed via Survey Monkey, 33 women reported experiences around breastfeeding. RESULTS: Forty-nine percent of women reported discussing breastfeeding with their provider—60% with ID providers and 57% with obstetrician–gynecologists. Half of respondents reported their provider initiated the discussion. Sixty-nine percent said their provider told them they could not breastfeed; 19% said they received incomplete/inaccurate breastfeeding information; and 13% reported their provider supported them in making the best decision for their families. CONCLUSION: These numbers, although small, supplement anecdotal evidence suggesting that most U.S. women living with HIV are not counseled according to the Perinatal HIV Guidelines, which recommend people living with HIV who are interested in breastfeeding receive patient-centered, evidence-based counseling on their options and those who choose to breastfeed be supported in order to minimize transmission risk. Education is greatly needed to ensure providers support their patients through this decision-making process.

Developing Sustainable Cancer and Aging Programs.

Geriatric assessment (GA) has been shown to decrease toxicity from systemic therapy, improve completion of chemotherapy, and reduce hospitalizations in older adults with cancer. Given the aging of the cancer population, this has the potential to have a positive impact on the care of a large swath of patients seen. Despite endorsement by several international societies, including the American Society of Clinical Oncology, uptake of GA has been low. Lack of knowledge, time, and resources has been cited as reasons for this. Although challenges to developing and implementing a cancer and aging program vary depending on the health care context, GA is adaptable to every health care context from low- to high-resource settings, as well as those in which geriatric oncology is a well-established or just emerging field. We provide an approach for clinicians and administrators to develop, implement, and sustain aging and cancer programs in a doable and sustainable way.

Clinical Factors Associated with Poor Outcomes in Patients with Central Nervous System Tuberculosis Treated in San Francisco, CA from 2011 to 2021 (S25.006)

<h3>Objective:</h3> To identify risk factors associated with mortality and poor functional outcomes in patients with central nervous system tuberculosis (CNS TB) cared for in San Francisco, CA. <h3>Background:</h3> CNS TB is one of the most severe forms of TB. Studies evaluating risk factors for mortality and disability due to CNS TB are lacking across low- and high-resource settings. <h3>Design/Methods:</h3> Search terms were used to identify medical records from patients with possible CNS TB at two medical centers in San Francisco, CA between January 1st, 2011, and November 1st, 2021. Data was extracted from a sample (n=75) of cases who met criteria for definite or suspected CNS TB warranting treatment with anti-tuberculous medications. Logistic regression models were performed to identify associations of demographic factors, comorbidities, and clinical signs/symptoms with mortality and functional outcomes. <h3>Results:</h3> Of 75 cases of CNS TB, most were men (60%), 18–64 years of age (67%), foreign-born (75%), and publicly insured (60%). Diabetes (28%) and hypertension (45%) were common comorbidities. The prevalence of HIV (9.8%) was 32 times higher than in the general California population. Many patients experienced long-term moderate to severe impairments in mobility (56%) and cognition (47%) and loss of independent function (50%). Increasing age (OR=1.04 per year, 95%CI:1.00–1.07), hypertension (OR=5.40, 95%CI:1.24–23.10), intubation (OR=9.14, 95%CI: 2.14–39.07), and altered mental status (OR=7.09, 95%CI: 1.61–31.30) were significantly associated with increased odds of mortality. Altered mental status at presentation (p&lt;0.001) and hydrocephalus (p=0.040) were associated with a greater likelihood of long-term cognitive impairment. <h3>Conclusions:</h3> Mortality and functional impairment were common in patients with CNS TB cared for over the past decade in San Francisco. Older patients and those with hypertension had worse outcomes, as did patients presenting with altered mental status and hydrocephalus. Earlier CNS TB diagnosis and more effective treatment, including for patients with select risk factors, are needed to improve outcomes. <b>Disclosure:</b> Mr. HERNANDEZ CASTILLO has nothing to disclose. Dr. Chow has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Medicolegal consulting. The institution of Dr. Chow has received research support from NIH. Dr. Louie has nothing to disclose. Ms. Romo has nothing to disclose.

Breastfeeding Among People With Human Immunodeficiency Virus in North America: A Multisite Study.

In North American countries, national guidelines have strongly recommended formula over breastmilk for people with human immunodeficiency virus (HIV) because of concern for HIV transmission. However, data from resource-limited settings suggest the risk is <1% among virally suppressed people. Information regarding breastfeeding experience in high-resource settings is lacking. A retrospective multisite study was performed for individuals with HIV who breastfed during 2014-2022 in the United States (8 sites) and Canada (3 sites). Descriptive statistics were used for data analysis. Among the 72 cases reported, most had been diagnosed with HIV and were on antiretroviral therapy prior to the index pregnancy and had undetectable viral loads at delivery. Most commonly reported reasons for choosing to breastfeed were health benefits, community expectations, and parent-child bonding. Median duration of breastfeeding was 24 weeks (range, 1 day to 72 weeks). Regimens for infant prophylaxis and protocols for testing of infants and birthing parents varied widely among institutions. No neonatal transmissions occurred among the 94% of infants for whom results were available ≥6 weeks after weaning. This study describes the largest cohort to date of people with HIV who breastfed in North America. Findings demonstrate high variability among institutions in policies, infant prophylaxis, and infant and parental testing practices. The study describes challenges in weighing the potential risks of transmission with personal and community factors. Finally, this study highlights the relatively small numbers of patients with HIV who chose to breastfeed at any 1 location, and the need for further multisite studies to identify best care practices.

Maternal and umbilical cord blood lactate for predicting perinatal death: a secondary analysis of data from a randomized controlled trial

BackgroundIn high resource settings, lactate and pH levels measured from fetal scalp and umbilical cord blood are widely used as predictors of perinatal mortality. However, the same is not true in low resource settings, where much of perinatal mortality occurs. The scalability of this practice has been hindered by difficulty in collecting fetal scalp and umbilical blood sample. Little is known about the use of alternatives such as maternal blood, which is easier and safer to obtain. Therefore, we aimed to compare maternal and umbilical cord blood lactate levels for predicting perinatal deaths.MethodsThis was secondary analysis of data from a randomized controlled trial assessing the effect of sodium bicarbonate on maternal and perinatal outcomes among women with obstructed labour at Mbale regional referral hospital in Eastern Uganda. Lactate concentration in maternal capillary, myometrial, umbilical venous and arterial blood was measured at the bedside using a lactate Pro 2 device (Akray, Japan Shiga) upon diagnosis of obstructed labour. We constructed Receiver Operating Characteristic curves to compare the predictive ability of maternal and umbilical cord lactate and the optimal cutoffs calculated basing on the maximal Youden and Liu indices.ResultsPerinatal mortality risk was: 102.2 deaths per 1,000 live births: 95% CI (78.1–130.6). The areas under the ROC curves were 0.86 for umbilical arterial lactate, 0.71 for umbilical venous lactate, and 0.65 for myometrial lactate, 0.59 for maternal lactate baseline, and 0.65 at1hr after administration of bicarbonate. The optimal cutoffs for predicting perinatal death were 15 0.85 mmol/L for umbilical arterial lactate, 10.15mmol/L for umbilical venous lactate, 8.75mmol/L for myometrial lactate, and 3.95mmol/L for maternal lactate at recruitment and 7.35mmol/L after 1 h.ConclusionMaternal lactate was a poor predictor of perinatal death, but umbilical artery lactate has a high predictive value. There is need for future studies on the utility of amniotic fluid in predicting intrapartum perinatal deaths.

A Matter of Time: Anticipation Work and Digital Temporalities in Refugee Humanitarian Assistance in Turkey

Scholarly work interrogating time and temporality in CSCW predominantly focuses on the temporal coordination of work in high-resource settings and is usually based in Global North. This paper aims to complicate and complement this scholarship by investigating the temporal entanglements of digital humanitarian work with refugees and asylum seekers in Turkey during COVID-19. We interviewed 22 humanitarian workers to understand their experiences and concerns as well as strategies they employed to support refugees and immigrants at a distance. The data reveal the complex temporal, informational, and infrastructural dimensions of technologically-mediated refugee support work, challenging the trope of "pivot to remote work", as popular in western countries. Our findings contribute to the CSCW research on the theory of anticipation work and its relationship with the concept of collaborative rhythms to explicate the relational and situated aspects of the temporal experiences of humanitarian workers in low-resource settings.

Gross motor function profile of children with cerebral palsy in a low-resource setting: A call for reflection on the model of care.

The current study aimed to explore Gross Motor Function Measure (GMFM) profiles among children with cerebral palsy (CP) at various Gross Motor Function Classification System (GMFCS) levels in a low-resource setting. Ambulatory capacity of children with CP was classified using GMFCS levels. Functional ability of all participants was measured using GMFM-88. Seventy-one ambulatory children with CP (61% males), were studied after signed informed consent was obtained from parents and assent from children older than 12 years. Children with CP in a low-resource setting had 12-44% lower GMFM scores in dimensions of standing, walking, running, and jumping with reference to children from high-resource settings with similar ambulatory capacity reported previously. The most affected components across various GMFCS levels were 'sitting on a large and small bench from floor,' 'arm-free squatting,' 'half-kneeling,' 'kneel-walking,' and 'single-limb hop'. Knowledge of GMFM profiles can guide clinicians and policymakers in low-resource settings for strategic rehabilitation planning and extend the focus of rehabilitation from restoration of body structure and function to the wider domain of social participation in leisure, sport, work, and the community at large. Additionally, providing tailored rehabilitation based on a profile of motor function can ensure an economically, environmentally, and socially sustainable future.

Culturally adapted family intervention for people with schizophrenia in Indonesia (FUSION): a development and feasibility study protocol

BackgroundMental illnesses comprise the single largest source of health-related economic burden globally, and low- and middle-income countries are disproportionately affected. The majority of people with schizophrenia who need treatment do not receive it and are often wholly reliant on family caregivers for daily care and support. Family interventions have an exceptionally robust evidence base for their efficacy in high-resource settings, but it is unknown whether they can produce equivalent effects in some low-resource settings where cultural beliefs, explanatory models of illness and contextual socio-economic issues differ.MethodsThis protocol describes the methods for a randomised controlled trial to determine the feasibility of testing culturally adapt and refine an evidence-based, family intervention for relatives and caregivers of people with schizophrenia in Indonesia. The feasibility and acceptability of implementing our adapted, co-produced intervention via task shifting in primary care settings will be evaluated using the Medical Research Council framework for complex interventions. We will recruit 60 carer-service-user dyads and randomise them in a 1:1 ratio either to receive our manualised intervention or continue to receive treatment as usual. Healthcare workers in primary care settings will be trained to deliver family interventions using our manualised intervention by a family intervention specialist. Participants will complete the ECI, IEQ, KAST and GHQ. Service-user symptom level and relapse status will be measured using the PANSS at baseline, post-intervention and 3 months later by trained researchers. Fidelity to the intervention model will be measured using the FIPAS. Qualitative evaluation will further assist with refining the intervention, evaluating trial processes and evaluating acceptability.DiscussionNational healthcare policy in Indonesia supports the delivery of mental health services in a complex network of primary care centres. This study will provide important information on the feasibility of delivering family interventions for people with schizophrenia via task shifting in primary care settings in Indonesia and allow further refinement of the intervention and trial processes.

Operative Trauma Courses: A Scoping Review to Inform the Development of a Trauma Surgery Course for Low-Resource Settings.

A multitude of operative trauma courses exist, most of which are designed for and conducted in high-resource settings. There are numerous barriers to adapting such courses to low- and low-middle-income countries (LMICs), including resource constraints and contextual variations in trauma care. Approaches to implementing operative trauma courses in LMICs have not been evaluated in a structured manner. We conducted a scoping review of the literature including databases (e.g., PubMed, Web of Science, EMBASE), grey literature repositories, and structured queries of publicly available course materials to identify records that described operative trauma courses offered since 2000. The search identified 3,518 non-duplicative records, of which 48 relevant reports were included in analysis. These reports represented 23 named and 11 unnamed operative trauma courses offered in 12 countries. Variability existed in course format and resource requirements, ranging from USD 40 to 3,000 per participant. Courses incorporated didactic and laboratory components, which utilized simulations, cadavers, or live animals. Course content overlapped significantly but was not standardized. Data were lacking on course implementation and promulgation, credentialing of instructors, and standardized evaluation metrics. While many operative trauma courses have been described, most are not directly relatable to LMICs. Barriers include cost-prohibitive fees, lack of resources, limited data collection, and contextual variability that renders certain surgical care inappropriate in LMICs. Gaps exist in standardization of course content as well as transparency of credentialing and course implementation strategies. These issues can be addressed through developing an open-access operative trauma course for low-resource settings.

A Review on Hypertension: Practice and Diagnosis

Among various reasons of raised hypertension, excessive blood pressure is the major one. Hypertension affects over a billion people worldwide, especially the elder people. The International Society of Hypertension (ISH) has extensively developed the practice guidelines to reduce the extent of hypertension caused by high blood pressure (BP) with evidence-based contents for adults, expecting wide range of accessibility and applicability by the physicians from low to high resource settings inclusively. Optimal care defines the evidence-based standard of care while the essential standard refers to the principles of care allowing specification for the deprived settings only. However, the specific portion of this study required to take experts’ opinion when there was a limitation to evidence for undertaking the assessments. This paper evaluates the ways in which we can diagnose hypertension in patients and evaluate the preventive measures and treatment options through lifestyle changes and pharmacological treatments.

Establishing the Ethiopian Obstetric Surveillance System for Monitoring Maternal Outcomes in Eastern Ethiopia: A Pilot Study.

Although the majority of maternal deaths and complications occur in low-resource settings, almost all existing strong registration and confidential enquiry systems are found in high-resource settings. We developed and piloted the Ethiopian Obstetric Surveillance System (EthOSS), based on the successful United Kingdom Obstetric Surveillance System (UKOSS) methodology, in 3 regions in Ethiopia to improve ongoing surveillance and tracking of maternal morbidities and deaths, as well as confidential enquiry, compared to the currently used maternal death surveillance and response program in Ethiopia. We launched the EthOSS monthly case notification system in 13 hospitals in eastern Ethiopia in April 2021. Study participants included women admitted to the hospitals from April to September 2021 with major adverse obstetric conditions during pregnancy, childbirth, or within 42 days of termination of pregnancy. Designated clinicians at the hospitals used a simple online system to report the number of cases and maternal deaths monthly to the EthOSS team. We present findings on the incidence and case fatality rates for adverse conditions included in the EthOSS. Over the 6-month pilot period, 904 women with at least 1 EthOSS condition were included in the study, of whom 10 died (case fatality rate, 1.1%). Almost half (46.6%, 421/904) sustained major obstetric hemorrhage, 38.7% (350/904) severe anemia, 29.5% (267/904) eclampsia, 8.8% (80/904) sepsis, and 2.2% (20/904) uterine rupture. To enable care improvement alongside surveillance, the local committee received training on confidential enquiry into maternal deaths from internal and external experts. In this facility-based project, data on severe adverse obstetric conditions were captured through voluntary reporting by clinicians. Further analysis is essential to assess the robustness of these data, and confidential enquiry into maternal deaths for specific cases is planned to investigate the appropriateness of care.

Validation of a modified South African triage scale in a high-resource setting: a retrospective cohort study

BackgroundTriage systems are widely used in emergency departments, but are not always validated. The South African Triage Scale (SATS) has mainly been studied in resource-limited settings. The aim of this study was to determine the validity of a modified version of the SATS for the general population of patients admitted to an ED at a tertiary hospital in a high-income country. The secondary objective was to study the triage performance according to age and patient categories.MethodsWe conducted a retrospective cohort study of patients presenting to the Emergency Department of Haukeland University Hospital in Norway during a four-year period. We used short-term mortality, ICU admission, and the need for immediate surgery and other interventions as the primary endpoints.ResultsA total of 162,034 emergency department visits were included in the analysis. The negative predictive value of a low triage level to exclude severe illness was 99.1% (95% confidence interval: 99.0–99.2%). The level of overtriage, defined as the proportion of patients assigned to a high triage level who were not admitted to the hospital, was 4.1% (3.9–4.2%). Receiver operating characteristic (ROC) curves showed an area under the ROC for the detection of severe illness of 0.874 (95% confidence interval: 0.870–0.879) for all patients and 0.856 (0.837–0.875), 0.884 (0.878–0.890) and 0.869 (0.862–0.876) for children, adults and elderly individuals respectively.ConclusionWe found that the modified SATS had a good sensitivity to identify short-term mortality, ICU admission, and the need for rapid surgery and other interventions. The sensitivity was higher in adults than in children and higher in medical patients than in surgical patients. The over- and undertriage rates were acceptable.

Effectiveness of antenatal dexamethasone in reducing respiratory distress syndrome and mortality in preterm neonates: a nested case control study

BackgroundRespiratory distress syndrome (RDS) is a significant cause of preterm neonatal morbidity and mortality globally. Measures like the use of antenatal corticosteroids (ACS) and immediate resuscitation of the newborn after birth are taken to abate preterm related complications. Most studies that evidenced the benefit of ACS were done in high resource settings. Therefore, this study was conducted to assess the effectiveness of ACS in reducing RDS and neonatal mortality in preterm neonates in resource-limited settings.MethodsA three months prospective nested case–control study (1:2 unmatched) was conducted at Muhimbili National Hospital and Amana regional referral hospital in Dar es salaam, Tanzania. Neonates delivered at 28 to 34 gestational weeks were enrolled and followed up until discharge. Data analysis was done using the statistical package of social sciences version 23. Logistic regression analysis was used to determine the effect of ACS on the RDS and mortality in the cohort, controlling for important maternal and neonatal variables. All tests were considered statistically significant at p < 0.05.ResultsOut of 330 preterm neonates enrolled, 110 were cases and 220 were controls. The median gestational age at delivery was 30 weeks and 6 days (IQR 4.68) among cases and 33 weeks (IQR 3) among controls. One-minute APGAR score of < 7 (AOR: 3.11; 95% CI 1.54–6.30), and neonatal birth weight (AOR: 0.998; 95% CI 0.997–0.999) were significantly associated with RDS. No significant association was observed between ACS exposure and RDS occurrence (AOR: 1.65; 95% CI 0.86 – 3.15). The overall mortality rate was 9 per 1000 neonates. Neonatal mortality occurred only among cases whereby, a unit increase in gestational age was associated with a 30% reduction in neonatal mortality (Adjusted hazard ratio, AHR: 0.70, 95% CI: 0.5–0.92, p = 0.011).ConclusionDecrease in gestational age, one minute APGAR score of < 7 and decreasing birth weight were associated with RDS among preterm neonates. ACS was not associated with reduced RDS occurrence and neonatal mortality rates. Moreover, increase in gestation age was the only factor found to be protective against preterm neonatal mortality.

Reviews in Medical Education: Advances in Simulation to Address New Challenges in Neurology

Simulation is an engaging modality of medical education that leverages adult learning theory. Since its inception, educators have used simulation to train clinicians in bedside procedures and neurologic emergencies, as well as in communication, teamwork, and leadership skills. Many applications of simulation in neurology are yet to be fully adopted or explored. However, challenges to traditional educational paradigms, such as the shift to competency-based assessments and the need for remote or hybrid platforms, have created an impetus for neurologists to embrace simulation. In this article, we explore how simulation might be adapted to meet these current challenges in neurologic education by reviewing the existing literature in simulation from the field of neurology and beyond. We discuss how simulation can engage neurology trainees who seek interactive, contextualized, on-demand education. We consider how educators can incorporate simulation for competency-based evaluations and procedural training. We foresee a growing role of simulation initiatives that assess bias and promote equity. We also provide tangible solutions that make simulation an educational tool that is within reach for any educator in both high-resource and low-resource settings.

Change in glycaemic control with structured diabetes self-management education in urban low-resource settings: multicentre randomised trial of effectiveness

BackgroundIn high-resource settings, structured diabetes self-management education is associated with improved outcomes but the evidence from low-resource settings is limited and inconclusive.AimTo compare, structured diabetes self-management education to usual care, in adults with type 2 diabetes, in low-resource settings.Research design and methods.DesignSingle-blind randomised parallel comparator controlled multi-centre trial.Adults (> 18 years) with type 2 diabetes from two hospitals in urban Ghana were randomised 1:1 to usual care only, or usual care plus a structured diabetes self-management education program. Randomisation codes were computer-generated, and allotment concealed in opaque numbered envelopes. The intervention effect was assessed with linear mixed models.Main outcome: Change in HbA1c after 3-month follow-up.Primary analysis involved all participants.Clinicaltrial.gov identifier:NCT04780425, retrospectively registered on 03/03/2021.ResultsRecruitment: 22nd until 29th January 2021.We randomised 206 participants (69% female, median age 58 years [IQR: 49–64], baseline HbA1c median 64 mmol/mol [IQR: 45–88 mmol/mol],7.9%[IQR: 6.4–10.2]). Primary outcome data was available for 79 and 80 participants in the intervention and control groups, respectively. Reasons for loss to follow-up were death (n = 1), stroke(n = 1) and unreachable or unavailable (n = 47). A reduction in HbA1c was found in both groups; -9 mmol/mol [95% CI: -13 to -5 mmol/mol], -0·9% [95% CI: -1·2% to -0·51%] in the intervention group and -3 mmol/mol [95% CI -6 to 1 mmol/mol], -0·3% [95% CI: -0·6% to 0.0%] in the control group. The intervention effect was 1 mmol/mol [95%CI:-5 TO 8 p = 0.726]; 0.1% [95% CI: -0.5, 0.7], p = 0·724], adjusted for site, age, and duration of diabetes.No significant harms were observed.ConclusionIn low-resource settings, diabetes self-management education might not be associated with glycaemic control. Clinician’s expectations from diabetes self-management education must therefore be guarded.

Successful implementation of new Swiss recommendations on breastfeeding of infants born to women living with HIV

IntroductionSwiss national recommendations advise, since end of 2018, supporting women with HIV who wish to breastfeed. Our objective is to describe the motivational factors and the outcome of these women and of their infants. Methodsmothers included in MoCHiV with a delivery between January 2019 and February 2021 who fulfilled the criteria of the “optimal scenario” (adherence to cART, regular clinical care, and suppressed HIV plasma viral load (pVL) of <50 RNA copies/ml) and who decided to breastfeed after a shared decision-making process, were approached to participate in this nested study and asked to fill-in a questionnaire exploring the main motivating factors for breastfeeding. ResultsBetween January 9, 2019 and February 7, 2021, 41 women gave birth, and 25 decided to breastfeed of which 20 accepted to participate in the nested study. The three main motivational factors of these women were bonding, neonatal and maternal health benefits. They breastfed for a median duration of 6.3 months (range 0.7–25.7, IQR 2.5–11.1). None of the breastfed neonates received HIV post-exposure prophylaxis. There was no HIV transmission: 24 infants tested negative for HIV at least 3 months after weaning; one mother was still breastfeeding when we analyzed the data. ConclusionsAs a result of a shared decision-making process, a high proportion of mothers expressed a desire to breastfeed. No breastfed infant acquired HIV. The surveillance of breastfeeding mother-infant pairs in high resource settings should be continued to help update guidelines and recommendations.