Low- And Middle-income Countries Hospitals Research Articles

129 LaparoscopiX: Expanding Minimally Invasive Surgery Training in Kenya

OBJECTIVES/GOALS: Open surgery prevails in low- and middle-income countries (LMICs) due to scarcity of laparoscopic equipment and poor access to training. LaparosopiX is a box trainer system designed for teaching hospitals in LMICs; it includes an open-source laser print design and an app to allow surgical trainees to receive feedback from laparoscopic experts. METHODS/STUDY POPULATION: This study aims to assess the usability of Laparoscopix for surgical trainees and mentors at five large teaching hospitals in Kenya. Surgical trainees and mentors who participate in this study will be observed while setting up and using the app to identify natural pain-points. A post-session survey will be conducted to assess immediate perceptions of the platform including ease of navigation and intuitive design. Over three months, aggregate data regarding platform usage at these hospital sites will be collected and analyzed to assess user retention rates, usage and traffic patterns, and skill progression over time. Surveys will be sent out to assess attitudes towards the platform and to elucidate any aspects of the system we can improve. RESULTS/ANTICIPATED RESULTS: We hope to find overall positive impressions towards the LaparoscopiX system during this study. We expect there to be some pain-points that arise during navigation of the app, but we expect no large changes to the application architecture required. We anticipate an immediate increase and eventual plateau of users recruited. We hope to see that surgical trainees are advancing through the app while gaining practice and confidence. We will gather insightful data on which aspects of the app were helpful for trainees, and which can be improved. We also hope to learn what factors may play into trainee and mentor retention in the system. DISCUSSION/SIGNIFICANCE: Through this study, we hope to elucidate ways in which we can improve the LaparoscopiX platform, identify which features to prioritize, and determine the direction of future app development. We believe and hope that LaparoscopiX can expand access to laparoscopic surgical mentorship to improve surgical outcomes and health equity worldwide.

Assessing frailty amongst older people admitted to hospital in a low-income setting: a multicentre study in northern Tanzania

BackgroundPopulations are ageing globally and Low- and Middle-Income Countries (LMICs) are experiencing the fastest rates of demographic change. Few studies have explored the burden of frailty amongst older people in hospital in LMICs, where healthcare services are having to rapidly adapt to align with the needs of older people. This study aimed to measure the prevalence of frailty amongst older people admitted to hospital in Tanzania and to explore their demographic and clinical characteristics.MethodsThis study had a prospective observational design. Over a six-month period, all adults ≥ 60 years old admitted to medical wards in four hospitals in northern Tanzania were invited to participate. They were screened for frailty using the Clinical Frailty Scale (CFS) and the Frailty Phenotype (FP). Demographic and clinical characteristics of interest were recorded in a structured questionnaire. These included the Barthel Index, the Identification of Elderly Africans Instrumental Activities of Daily Living (IADEA-IADL) and Cognitive (IDEA-Cog) screens, the EURO-D depression scale and Confusion Assessment Method.Results540 adults aged ≥ 60 were admitted, and 308 completed assessment. Frailty was present in 66.6% using the CFS and participants with frailty were significantly older, with lower levels of education and literacy, greater disability, greater comorbidity, poorer cognition and higher levels of delirium. Using the FP, 57.0% of participants were classed as frail though a majority of participants (n = 159, 51.6%) could not be classified due to a high proportion of missing data.ConclusionsThis study indicates that the prevalence of frailty on medical wards in northern Tanzania is high according to the CFS. However, the challenges in operationalising the FP in this setting highlight the need for future work to adapt frailty screening tools for an African context. Future investigations should also seek to correlate frailty status with long-term clinical outcomes after admission in this setting.

Practice patterns in pediatric infectious encephalopathy in four centers in Africa.

Infectious encephalopathy (IE), including meningitis, infectious encephalitis, and cerebral abscess, remains prevalent and carries high mortality and morbidity in children, especially in low and middle income countries (LMIC). This study aims to describe the usual care and outcomes of pediatric IE in four LMIC hospitals in sub-Saharan Africa to support evidence-based care guideline development. This is a secondary analysis of the Prevalence of Acute Critical Neurological disease in children: A Global Epidemiological Assessment-Developing Countries study, a 4-week, prospective, observational study in children (1 week to 17 years) with IE presenting to referral hospitals in Ethiopia, Kenya, Rwanda, and Ghana. Data collection included diagnostic testing, interventions, and patient outcomes [e.g., mortality, Pediatric Cerebral and Overall Performance Category Scores (PCPC and POPC)]. Seventy-two children with IE were enrolled. Most patients were diagnosed with undifferentiated IE (78%, n = 56). Specific etiologies included cerebral malaria (10%, n = 7), viral encephalitis (4%, n = 3), tuberculosis (4%, n = 3), bacterial meningitis (3%, n = 2), and cerebral abscess (1%, n = 1). Fourteen patients (20%) had a head computed tomography performed. Thirty two (44%) children had a lumbar puncture but only 9 samples (28%) were sent for culture. Median time from diagnosis to antimicrobial therapy was 3 h (IQR 1-12 h). Half (51%, n = 33) of inpatients received intracranial pressure (ICP)-directed treatment but none underwent ICP monitoring. Mortality was 13% (n = 9). The percentage of children with a favorable cognitive score decreased from 95% (n = 62) prior to admission to 80% (n = 52) and 77% (n = 50) at discharge for PCPC and POPC respectively. IE led to considerable morbidity and mortality in this cohort, and evaluation and management varied across the care continuum. Resource limitations and diagnostic constraints may have affected diagnosis-directed therapy and other aspects of management. Further studies are needed to describe the epidemiology and management of IE in LMICs to inform future treatment protocols, the role of technological and human capacity building to support both basic monitoring and interventions, as well as creative new solutions to emergency and critical care in these settings.

ACORN (A Clinically-Oriented Antimicrobial Resistance Surveillance Network) II: protocol for case based antimicrobial resistance surveillance.

Background: Antimicrobial resistance surveillance is essential for empiric antibiotic prescribing, infection prevention and control policies and to drive novel antibiotic discovery. However, most existing surveillance systems are isolate-based without supporting patient-based clinical data, and not widely implemented especially in low- and middle-income countries (LMICs). Methods: A Clinically-Oriented Antimicrobial Resistance Surveillance Network (ACORN) II is a large-scale multicentre protocol which builds on the WHO Global Antimicrobial Resistance and Use Surveillance System to estimate syndromic and pathogen outcomes along with associated health economic costs. ACORN-healthcare associated infection (ACORN-HAI) is an extension study which focuses on healthcare-associated bloodstream infections and ventilator-associated pneumonia. Our main aim is to implement an efficient clinically-oriented antimicrobial resistance surveillance system, which can be incorporated as part of routine workflow in hospitals in LMICs. These surveillance systems include hospitalised patients of any age with clinically compatible acute community-acquired or healthcare-associated bacterial infection syndromes, and who were prescribed parenteral antibiotics. Diagnostic stewardship activities will be implemented to optimise microbiology culture specimen collection practices. Basic patient characteristics, clinician diagnosis, empiric treatment, infection severity and risk factors for HAI are recorded on enrolment and during 28-day follow-up. An R Shiny application can be used offline and online for merging clinical and microbiology data, and generating collated reports to inform local antibiotic stewardship and infection control policies. Discussion: ACORN II is a comprehensive antimicrobial resistance surveillance activity which advocates pragmatic implementation and prioritises improving local diagnostic and antibiotic prescribing practices through patient-centred data collection. These data can be rapidly communicated to local physicians and infection prevention and control teams. Relative ease of data collection promotes sustainability and maximises participation and scalability. With ACORN-HAI as an example, ACORN II has the capacity to accommodate extensions to investigate further specific questions of interest.

Local and timely antimicrobial resistance data for local and national actions: the early implementation of an automated tool for data analysis at local hospital level in Thailand.

In low- and middle-income countries (LMICs), hospitals can rarely utilize their own antimicrobial resistance (AMR) data in a timely manner. To evaluate the utility of local AMR data generated by an automated tool in the real-world setting. From 16 December 2022 to 10 January 2023, on behalf of the Health Administration Division, Ministry of Public Health (MoPH) Thailand, we trained 26 public tertiary-care and secondary-care hospitals to utilize the AutoMated tool for Antimicrobial resistance Surveillance System (AMASS) with their own microbiology and hospital admission data files via two online meetings, one face-to-face meeting and online support. All meetings were recorded on video, and feedback was analysed. Twenty-five hospitals successfully generated and shared the AMR reports with the MoPH by 28 February 2023. In 2022, the median frequency of hospital-origin bloodstream infections (BSIs) caused by carbapenem-resistant Escherichia coli (CREC) was 129 (range 0-1204), by carbapenem-resistant Klebsiella pneumoniae (CRKP) was 1306 (range 0-5432) and by carbapenem-resistant Acinetobacter baumannii (CRAB) was 4472 (range 1460-11 968) per 100 000 patients tested for hospital-origin BSI. The median number of all-cause in-hospital deaths with hospital-origin AMR BSI caused by CREC was 1 (range 0-18), by CRKP was 10 (range 0-77) and by CRAB was 56 (range 7-148). Participating hospitals found that the data obtained could be used to support their antimicrobial stewardship and infection prevention control programmes. Local and timely AMR data are crucial for local and national actions. MoPH Thailand is inviting all 127 public tertiary-care and secondary-care hospitals to utilize the AMASS. Using any appropriate analytical software or tools, all hospitals in LMICs that have electronic data records should analyse and utilize their data for immediate actions.

ACORN (A Clinically-Oriented Antimicrobial Resistance Surveillance Network) II: protocol for case based antimicrobial resistance surveillance

Background: Antimicrobial resistance surveillance is essential for empiric antibiotic prescribing, infection prevention and control policies and to drive novel antibiotic discovery. However, most existing surveillance systems are isolate-based without supporting patient-based clinical data, and not widely implemented especially in low- and middle-income countries (LMICs). Methods: A Clinically-Oriented Antimicrobial Resistance Surveillance Network (ACORN) II is a large-scale multicentre protocol which builds on the WHO Global Antimicrobial Resistance and Use Surveillance System to estimate syndromic and pathogen outcomes along with associated health economic costs. ACORN-healthcare associated infection (ACORN-HAI) is an extension study which focuses on healthcare-associated bloodstream infections and ventilator-associated pneumonia. Our main aim is to implement an efficient clinically-oriented antimicrobial resistance surveillance system, which can be incorporated as part of routine workflow in hospitals in LMICs. These surveillance systems include hospitalised patients of any age with clinically compatible acute community-acquired or healthcare-associated bacterial infection syndromes, and who were prescribed parenteral antibiotics. Diagnostic stewardship activities will be implemented to optimise microbiology culture specimen collection practices. Basic patient characteristics, clinician diagnosis, empiric treatment, infection severity and risk factors for HAI are recorded on enrolment and during 28-day follow-up. An R Shiny application can be used offline and online for merging clinical and microbiology data, and generating collated reports to inform local antibiotic stewardship and infection control policies. Discussion: ACORN II is a comprehensive antimicrobial resistance surveillance activity which advocates pragmatic implementation and prioritises improving local diagnostic and antibiotic prescribing practices through patient-centred data collection. These data can be rapidly communicated to local physicians and infection prevention and control teams. Relative ease of data collection promotes sustainability and maximises participation and scalability. With ACORN-HAI as an example, ACORN II has the capacity to accommodate extensions to investigate further specific questions of interest.

Breaking New Ground: Space Agencies and Epidemiologists Partner Up on Particulates

Breaking New Ground: Space Agencies and Epidemiologists Partner Up on Particulates

A survey of barriers and facilitators to ultrasound use in low- and middle-income countries

Point-of-care ultrasound has the potential to help inform assessment, diagnosis, and management of illness in low- and middle-income countries (LMIC). To better understand current ultrasound use, barriers and facilitators to use, and perceptions and practices in LMIC, we conducted an anonymous online global survey targeting healthcare providers training and using ultrasound in LMIC. A total of 241 respondents representing 62 countries participated and most were physicians working in publicly-funded urban tertiary hospitals in LMIC. Most had received ultrasound training (78%), reported expertise (65%) and confidence (90%) in ultrasound use, and had access to ultrasound (88%), utilizing ultrasound most commonly for procedures and for evaluations of lungs, heart, and trauma. Access to an ultrasound machine was reported as both the top barrier (17%) and top facilitator (53%); other common barriers included access to education and training, cost, and competition for use and other common facilitators included access to a probe, gel, and electricity, and acceptance by healthcare providers, administrators, and patients. Most (80%) noted ultrasound access was important and 96% agreed that ultrasound improves quality of care and patient outcomes. Improving access to low-cost ultrasound equipment is critical to increasing ultrasound use among those who are trained.

Global Health Challenges: Why the Four S's Are Not Enough.

A well-known tenant of global health is the need for the four-S's to be successful in providing care in any context; Staff, Stuff, Space and Systems. Advanced thoracoscopy is slow to gain traction in low- and middle-income countries (LMICs). To our knowledge, no pediatric advanced thoracoscopy had been attempted previously in either LMIC. Therefore, we report the challenges associated with the adoption of the first advanced thoracoscopic procedures in two LMIC hospitals by a visiting surgeon. To further identify aspects of care in promoting the introduction of advanced thoracoscopy, we added a fifth S as an additional category-Socialization. A key to accomplishing goals for the patients as a visiting surgeon, particularly when introducing an advanced procedure, is acceptance into the culture of a hospital. Despite facing significant obstacles in caring for complex thoracic pathology with heavy reliance on disposable and reusable instrumentation provided through donation and limitations in staff such as access to neonatologists and pediatric surgeons, many obstacles have been overcome. In this perspective article, we show that a "fifth S" is also integral-having local surgeons and anesthesiologists eager to learn with acceptance of the visiting surgeon's expertise opens a path towards attempting advanced procedures in limited-resource settings.

Estimates of Treatable Deaths Within the First 20 Years of Life from Scaling Up Surgical Care at First-Level Hospitals in Low- and Middle-Income Countries

BackgroundSurgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life.MethodsEpidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries.ResultsAn estimated 314,609 (95% UI, 239,619–402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year.ConclusionsImproving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

Improvised bubble continuous positive airway pressure ventilation use in neonates in resource-limited settings: a systematic review and meta-analysis.

In the face of limited fiscal and technical resources, improvised methods have been used to provide effective and sustainable ventilatory support in low-resource settings to reduce neonatal mortality associated with respiratory complications. This study assessed the use of improvised bubble continuous positive airway pressure (ibCPAP) ventilation among neonates with respiratory complications and determined its effect on neonatal outcomes in low- and middle-income countries (LMICs). Hospital-based studies conducted between 2010 and 2020 in LMICs were reviewed. Rayyan® software forsystematic review was used for screening and article selection. We used Stata® Statacorp Texas USA software to estimate pooled prevalence, proportion estimates, weighted mean differences and 95% Confidence Interval (CI), using the random effects model. A total of 193 articles were generated and 125 were reviewed. Thirteen articles with 806 neonates on ibCPAP ventilation were included. The pooled prevalence of ibCPAP use was 7.0% (95% CI: 3.0%-13.0%). There was a significant difference in mean oxygen saturation before and after ibCPAP use (-1.34% [95% CI:-1.65% to-1.02%, p<0.01). The duration of oxygen requirement among neonates on ibCPAP was 6.5hours less than controls (0.27days [95%CI:-0.49 to-0.05, p<0.01). IbCPAP had no effect on the respiratory rate, duration of admission, mortality and survival. IbCPAP use in LMIC hospitals is low and its use improved oxygen saturation and duration on oxygen among the neonates, but had no impact on length of stay, respiratory rate, mortality or survival.

Applying LEAN Healthcare in Lean Settings: Launching Quality Improvement in Resource-Limited Regions

Lean methodology is frequently utilized in high income settings to maximize capacity and operational efficiency during process improvement (PI) initiatives. To date there has been little published on the application of these techniques in low- and-middle-income countries (LMIC) despite the potential benefits in resource limited settings. We describe a pilot project developed in 2018 to promote sustainable operating theater efficiency at two hospitals in Abuja, Nigeria. This study details the first known attempt to use Lean techniques to improve surgical care systems in LMIC. Perioperative committees were established at two Nigerian institutions to evaluate current processes, identify problems, and compile a list of priorities. A physician champion and a PI specialist in conjunction with local physician-partners held a workshop to teach practical applications of PI methodology as part of an ongoing collaboration. Pre and post-workshop surveys were administered, and theme coding was used to categorize free responses. Results were compared with a chi-square test. In total, 42 individuals attended the PI workshop. After the workshop, 37 respondents reported the workshop as valuable both personally and for the perioperative committee (P < 0.001), and all reported that PI methodology could benefit the institution overall. By identifying stakeholders, holding a workshop to teach tools of PI, and establishing a committee for ongoing improvement, it is possible to implement quality improvement techniques at LMIC hospitals, which may be of future benefit. Sustainability in this project will be facilitated by tele mentoring, and future efforts include expansion beyond the perioperative setting.

Effect of mass deworming with antihelminthics for soil-transmitted helminths during pregnancy.

Helminthiasis is an infestation of the human body with parasitic worms. It is estimated to affect 44 million pregnancies, globally, each year. Intestinal helminthiasis (hookworm infestation) is associated with blood loss and decreased supply of nutrients for erythropoiesis, resulting in iron-deficiency anaemia. Over 50% of the pregnant women in low- and middle-income countries (LMIC) suffer from iron-deficiency anaemia. Though iron-deficiency anaemia is multifactorial, hookworm infestation is a major contributory cause in women of reproductive age in endemic areas. Antihelminthics are highly efficacious, but evidence of their beneficial effect and safety when given during pregnancy has not been established. This is an update of a Cochrane Review last published in 2015. To determine the effects of mass deworming with antihelminthics for soil-transmitted helminths (STH) during the second or third trimester of pregnancy on maternal and pregnancy outcomes. For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) (8 March 2021) and reference lists of retrieved studies. We included all prospective randomised controlled trials evaluating the effect of administration of antihelminthics versus placebo or no treatment during the second or third trimester of pregnancy; both individual-randomised and cluster-randomised trials were eligible. We excluded quasi-randomised trials and studies that were only available as abstracts with insufficient information. Two review authors independently assessed trials for inclusion and risk of bias, extracted data, checked accuracy and assessed the certainty of the evidence using the GRADE approach. We included a total of six trials (24 reports) that randomised 7873 pregnant women. All of the included trials were conducted in antenatal clinics within hospitals in LMICs (Uganda, Nigeria, Peru, India, Sierra Leone and Tanzania). Among primary outcomes, five trials reported maternal anaemia, one trial reported preterm birth and three trials reported perinatal mortality. Among secondary outcomes, included trials reported maternal worm prevalence, low birthweight (LBW) and birthweight. None of the included studies reported maternal anthropometric measures or infant survival at six months. Overall, we judged the included trials to be generally at low risk of bias for most domains, while the certainty of evidence ranged from low to moderate. Analysis suggests that administration of a single dose of antihelminthics in the second trimester of pregnancy may reduce maternal anaemia by 15% (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.72 to 1.00; I²= 86%; 5 trials, 5745 participants; low-certainty evidence). We are uncertain of the effect of antihelminthics during pregnancy on preterm birth (RR 0.84, 95% CI 0.38 to 1.86; 1 trial, 1042 participants; low-certainty evidence) or perinatal mortality (RR 1.01, 95% CI 0.67 to 1.52; 3 trials, 3356 participants; low-certainty evidence). We are uncertain of the effect of antihelminthics during pregnancy on hookworm (average RR 0.31, 95% CI 0.05 to 1.93; Tau² = 1.76, I² = 99%; 2 trials, 2488 participants; low-certainty evidence). Among other secondary outcomes, findings suggest that administration of antihelminthics during pregnancy may reduce the prevalence of trichuris (average RR 0.68, 95% CI 0.48 to 0.98; I²=75%; 2 trials, 2488 participants; low-certainty evidence) and ascaris (RR 0.24, 95% CI 0.19 to 0.29; I²= 0%; 2 trials, 2488 participants; moderate-certainty evidence). Antihelminthics during pregnancy probably make little or no difference to LBW (RR 0.89, 95% CI 0.69 to 1.16; 3 trials, 2960 participants; moderate-certainty evidence) and birthweight (mean difference 0.00 kg, 95% CI -0.03 kg to 0.04 kg; 3 trials, 2960 participants; moderate-certainty evidence). The evidence suggests that administration of a single dose of antihelminthics in the second trimester of pregnancy may reduce maternal anaemia and worm prevalence when used in settings with high prevalence of maternal helminthiasis. Further data is needed to establish the benefit of antihelminthic treatment on other maternal and pregnancy outcomes. Future research should focus on evaluating the effect of these antihelminthics among various subgroups in order to assess whether the effect varies. Future studies could also assess the effectiveness of co-interventions and health education along with antihelminthics for maternal and pregnancy outcomes.

Anesthesiology and Critical Care Response to COVID-19 in Resource-Limited Settings: Experiences from Nepal.

It is difficult to predict the future course and length of the ongoing COVID-19 pandemic, which has devastated health care systems in low- and middle-income countries. Anesthesiology and critical care services are hard hit because many hospitals have stopped performing elective surgeries, staff and scarce hospital resources have been diverted to manage COVID-19 patients, and several makeshift COVID-19 units had to be set up. Intensive care units are overwhelmed with critically ill patients. In these difficult times, low- and middle-income countries need to improvise, perform indigenous research, adapt international guidelines to suit local needs, and target attainable clinical goals.

166. Barriers to implementing antimicrobial stewardship programs in low- or middle-income country settings: findings from a multi-site qualitative study

BackgroundAntimicrobial resistance has been named as one of the top ten threats to health in the world. The World Health Organization has endorsed the implementation of hosptial-based antimicrobial stewardship programs (ASPs) to reduce antimicrobial resistance. We conducted a qualitative study to determine perceived barriers to the development and implementation of ASPs in low- and middle-income countries (LMICs).MethodsWe conducted 46 interviews with medical doctors at tertiary care hospitals in Sri Lanka (22 doctors), Kenya (12), and Tanzania (12). Interviews assessed knowledge and receptiveness to ASPs and barriers to implementing ASP protocols. Interviews were conducted in English, audio recorded, and transcribed. The interviews discussed knowledge of antimicrobial resistance and ASPs, current antimicrobial prescribing practices, access to diagnostics, receptiveness to ASPs, and perceived barriers to implementing ASPs. Data analysis followed procedures of applied thematic analysis, and used NVivo software. A codebook included structural themes based on the interview questions and emerging inductive themes. Two independent reviewers coded the interviews, and the coding was combined and reviewed for consensus. Themes were synthesized, with comparisons made across the three sites.ResultsMedical doctors from all three sites discussed multiple barriers to improving antimicrobial prescribing: prohibitively expensive antimicrobials, limited antimicrobial availability, resistance to change current practices regarding antimicrobial prescribing, and limited diagnostic data. The most frequent of these barriers discussed in all three locations was limited drug availability, mentioned by 12/22 physicians in Sri Lanka, 5/12 in Tanzania and 8/12 in Kenya. Improved education was a suggested component of ASPs in all three sites: 7/22 in Sri Lanka, 6/12 in Tanzania, and 6/12 in Kenya.ConclusionThe study highlighted several important issues in determining the next steps for the implementation of ASPs in these LMIC hospitals. Improving drug availability and improving education to change physicians’ antimicrobial prescribing practices are important targets that could be addressed by ASPs in these facilities.Disclosures All Authors: No reported disclosures

An Analysis of Factors Associated with Burn Injury Outcomes in Low- and Middle-Income Countries

BackgroundBurn injuries are a major cause of morbidity and mortality within low- and middle-income countries (LMICs). The World Health Organization developed the Global Burn Registry to centralize data collection for the guidance of burn prevention programs. This study analyzed the epidemiologic and hospital-specific factors associated with burn injury outcomes in LMICs and high-income countries (HICs). MethodsA retrospective review was performed using the Global Burn Registry over 3 y. Patients were stratified by income region. Bivariate analyses and stepwise regressions were performed to evaluate patient and hospital demographics and variables associated with injury patterns and outcomes. Outcomes of interest included mortality and length of stay. ResultsOver the study period, data were collected on 1995 patients from 10 LMICs (20 hospitals) and four HICs (four hospitals). Significantly higher mortality was seen in LMICs compared with HICs (17% versus 9%; P < 0.001). There was no significant difference between income regions for injury patterns (P = 0.062) or total body surface area of the burn injury (P = 0.077). Of the LMIC hospitals in this data set, 11% did not have reliable access to an operating theater. ConclusionsHICs had a lower overall mortality even with higher rates of concurrent injuries, as well as longer length of stay. LMIC hospitals had fewer resources available, which could explain increased mortality, given similar total body surface area. This study highlights how investing in health care infrastructure could lead to improved outcomes for patients in low-resource settings.

Enteric Function as a Determinant of Nutritional and Clinical Recovery from Acute Illness Among Children in Kenya and Pakistan

Abstract Objectives In low- and middle-income countries (LMICs), acutely ill undernourished children remain at high risk of mortality for months following discharge from hospital. Community-based studies suggest that enteric dysfunction (ED), including permeability and impaired absorption, is associated with poor outcomes. We used the lactulose rhamnose ratio (L: R) test, which provides a functional assessment of gut integrity, to determine if ED influences clinical and nutritional recovery in the post-discharge period. Methods Children aged 2–24 months without diarrhea were recruited from Civil Hospital Karachi, Pakistan and Migori County Referral Hospital, Kenya. L: R tests were administered after children were clinically stable (oral feeds, not dehydrated, no oxygen needs) and pre-discharge. Similarly aged children were pseudo-randomly selected from homes near those of children being discharged and were also tested. Prior to administration of sugars, urine was collected to detect background levels, followed by a two-hour collection. Samples were analyzed by high-performance chromatography mass spectroscopy. Crude L: R distributions were compared using the Mann-Whitney test. A priori determined confounders (age, mid-upper arm circumference [MUAC], HIV status, site) were adjusted for in linear regression of log-transformed L: R. Results 156 hospitalized and 91 community children were recruited. Median age was nine months in each group. Hospitalized children had lower median MUAC (12.4 vs 13.5 cm) and higher HIV infection prevalence (5% vs 1%). Both sugars were largely undetectable in pre-dose samples. Urinary median L: R among children being discharged (0.36 (interquartile range [IQR] 0.20–0.87)) was significantly higher compared to community peers (0.30 (IQR: 0.17–0.48, P = 0.038)). This difference remained significant in the adjusted model (p: 0.008). Conclusions Children at discharge from hospital in LMICs appear to have worse enteric function than community peers, and this difference does not appear to be attributable to young age or nutritional or HIV status. This analysis will be expanded to include L: R association with mortality, morbidity and growth outcomes prior to the conference. Funding Sources Thrasher Research Foundation 14,466, the Bill &amp; Melinda Gates Foundation OPP 1,131,320.

Evaluation of a Hospital-Based Post-Prescription Review and Feedback Pilot in Kathmandu, Nepal.

Capacity building is needed in low- and middle-income countries (LMICs) to combat antimicrobial resistance (AMR). Stewardship programs such as post-prescription review and feedback (PPRF) are important components in addressing AMR. Little data are available regarding effectiveness of PPRF programs in LMIC settings. An adapted PPRF program was implemented in the medicine, surgery, and obstetrics/gynecology wards in a 125-bed hospital in Kathmandu. Seven "physician champions" were trained. Baseline and post-intervention patient chart data were analyzed for changes in days of therapy (DOT) and mean number of course days for intravenous and oral antibiotics, and for specific study antibiotics. Charts were independently reviewed to determine justification for prescribed antibiotics. Physician champions documented recommendations. Days of therapy per 1,000 patient-days for courses of aminoglycoside (P < 0.001) and cephalosporin (P < 0.001) decreased. In the medicine ward, data indicate increased justified use of antibiotics (P = 0.02), de-escalation (P < 0.001), rational use of antibiotics (P < 0.01), and conforming to guidelines in the first 72 hours (P = 0.02), and for definitive therapy (P < 0.001). Physician champions documented 437 patient chart reviews and made 138 recommendations; 78.3% of recommendations were followed by the attending physician. Post-prescription review and feedback can be successfully implemented in LMIC hospitals, which often lack infectious disease specialists. Future program adaptation and training will focus on identifying additional stewardship programming and support mechanisms to optimize antibiotic use in LMICs.

Risk Factors for Infection After Intramedullary Nailing of Open Tibial Shaft Fractures in Low- and Middle-Income Countries.

(1) To determine the infection rate after fixation of open tibial shaft fractures using the Surgical Implant Generation Network (SIGN) intramedullary nail in low- and middle-income countries (LMICs) and (2) to identify risk factors for infection. Prospective cohort study using an international online database. Multiple hospitals in LMICs worldwide. A total of 1061 open tibia fractures treated with the SIGN nail in LMICs between March 2000 and February 2013. Intravenous antibiotic administration, surgical debridement, and definitive intramedullary nailing within 14 days of injury. Deep or superficial infection at follow-up, implant breakage/loosening, angular deformity >10 degrees, repeat surgery, radiographic union, weight bearing, and ability to kneel. The overall infection rate was 11.9%. Infection rates by the Gustilo and Anderson classification were type 1: 5.1%, type II: 12.6%, type IIIa: 12.5%, type IIIb: 29.1%, and type IIIc: 16.7% (P = 0.001 between groups). Patients who developed infection had a longer mean time from injury to definitive surgery (4.7 vs. 3.9 days, P = 0.03) and from injury to wound closure (13.7 vs. 3.6 days, P < 0.001). Distal fractures had a higher infection rate than midshaft fractures (13.3% vs. 8.2%, P = 0.03). Infection rates were not associated with time from injury to initial debridement, time from injury to initial antibiotic administration, or total duration of antibiotics. Open tibia fractures can be managed effectively using the SIGN intramedullary nail in LMICs with an overall infection rate of 11.9%. Risk factors for infection identified include more severe soft-tissue injury, delayed nailing, delayed wound closure, and distal fracture location. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Feasibility of bubble continuous positive airway pressure in secondary facilities in low and middle income countries

Background: Newborn respiratory distress is a leading cause of neonatal morbidity and mortality in developing countries. While there have been considerable reductions in child mortality in low and middle income countries (LMIC) in recent years, reductions in neonatal mortality have not been as substantial. Bubble CPAP (bCPAP), mechanical CPAP, and mechanical ventilation are all used to treat respiratory distress syndrome and other pulmonary complications in newborns. Methods: This study reviews the evidence for the efficacy, safety, and feasibility of bCPAP in neonates with respiratory distress in secondary facilities in LMIC. A systematic search (January 2014–January 2018) was performed of MEDLINE (PubMed), Cochrane, Embase, CINAHL, and Google Scholar. Articles reporting on bCPAP for respiratory distress in infants <28 days of age in hospitals in LMIC were included in the qualitative synthesis. Results: Three studies reported on bCPAP in secondary hospitals. The majority of infants given bCPAP survived to discharge. The most commonly reported complication of bCPAP was nasal irritation. CPAP and bCPAP use is increasing in LMIC, but appears limited to urban tertiary care centers. There is a paucity of information in the medical literature regarding bCPAP use in secondary settings. Conclusion: There is evidence that bCPAP, when used in tertiary care settings in LMIC is feasible, safe, effective, reduces the need for mechanical ventilation and ventilator CPAP, and may improve survival. There is very limited evidence supporting the feasibility of bCPAP use in secondary facilities in LMIC. Key words: bubble CPAP, respiratory distress, tertiary setting, low and middle income countries