Low-resource Settings Research Articles

Improving capacity for advanced training in obstetric surgery: evaluation of a blended learning approach

BackgroundSignificant differences in outcomes for mothers and babies following obstetric surgical interventions between low- and middle-income countries and high-income settings have demonstrated a need for improvements in quality of care and training of obstetric surgical and anaesthetic providers. To address this, a five-day face-to-face training intervention was developed. When roll-out was disrupted by the COVID-19 pandemic, the course was redesigned for delivery by blended learning.MethodsThis 3-part blended-learning course (part-1: 15 h self-directed online learning, part-2: 13 h facilitated contemporaneous virtual workshops and part-3: 10 h face-to-face delivery), was conducted in Kenya. We assessed the completion rate of part-1 (21 assignments), participation rate in parts 2 and 3, participant satisfaction and change in knowledge and skills. Additionally, we compared the cost of the blended delivery to the 5-day face-to-face delivery, in GB pounds.ResultsSixty-five doctors participated in part 1, with 53 completing at least 90% of the assignments. Sixty doctors participated in part 2, and 53 participated in part 3. All participants who completed an evaluation reported (n = 53) that the training was relevant, useful and would lead to changes in their clinical practice. Mean (SD) knowledge score improved from 64% (7%) to 80% (8%) and practical skills from 44% (14%) to 87% (7%). The blended course achieved a cost-saving of £204 per participant compared to the 5-day face-to-face delivery approach.ConclusionWe have demonstrated that a blended learning approach to clinical training in a low-resource setting is feasible, acceptable and cost effective. More studies are required to investigate the effectiveness of this approach on health outcomes.

Childhood cancer and parental mental health: role of disease severity, socioeconomic status, and social dynamics

BackgroundThe impact of childhood cancer extends beyond the affected child, significantly influencing the mental health of their families. Since research in psycho-oncology has been carried out almost exclusively in high-income countries, little is known about the impact of childhood cancer on the family level in low- and middle income countries (LMICs). This is a notable gap in the evidence-base, as many LMICs are collectivist cultures, where social and family networks are crucial elements of health care.MethodsThis prospective, cross-sectional study examined the mental health of 307 Kurdish parents of children undergoing cancer treatment in the Kurdistan Region of Iraq (KRI). Data were collected through structured interviews at two major oncology hospitals in the KRI, utilizing standardized instruments to assess mental health symptoms, socioeconomic status, and social constraints. The study focused on understanding the effects of socioeconomic challenges, disease severity, and social support limitations on parental mental health.ResultsSignificant mental health challenges were observed among parents, with mothers experiencing higher symptom levels than fathers. Lower socioeconomic status was linked to poorer parental mental health. Additionally, parents of children with more severe cancer and those reporting their child’s reduced engagement in daily activities experienced heightened mental health symptoms. Social constraints on expressing feelings about the child’s illness further intensified parental stress, underscoring the cumulative impact of economic strain, disease severity, and limited social support on parental mental health.ConclusionsThe study highlights the intricate relationship between socioeconomic factors, the disease severity of the child, and social dynamics in shaping parental mental health in the context of pediatric cancer. Psychosocial interventions that target these specific stressors may aid in better supporting families, particularly those in low-resource settings.

Development of a Perioperative Risk Mortality Calculator for Humanitarian Surgical Care.

Risk models to predict perioperative mortality rates (POMR) are critical to surgical quality improvement yet are not widely adapted for use in humanitarian and low-resource settings (LRS). We developed a POMR and corresponding nomogram and calculator for use in humanitarian surgical care. Electronic health record data from a high-income academic medical center from 2015 to 2019 were retrospectively extracted, selecting variables and operations specific to LRS. This development dataset was used to create a logistic regression POMR model, which was then prospectively validated using data from 2022 to 2023 from the same institution. EHR from a total of 49,277 patients were used. The model fitted eight variables feasibly obtainable in LRS: age >65years (OR=4.05 and 95% CI: 3.71-4.43), male sex (OR=1.32 and 95% CI: 1.25-1.40), GCS < 13 (OR=5.20 and 95% CI: 4.73-5.73), glucose > 200mg/dL (OR=2.19 and 95% CI: 2.01-2.38), Hgb ≤ 11g/dL (OR=2.65 and 95% CI: 2.43-2.89), HR>120 bpm (OR=2.49 and 95% CI: 2.35-2.64), T>38 degrees Celsius (OR=1.32 and 95% CI: 1.19-1.45), and SBP > 180mmHg (OR=1.18 and 95% CI: 1.02-1.37). The model demonstrated a high area under the curve (0.847, 0.867, and 0.925), sensitivity (0.739, 0.886, and 0.844), specificity (0.807, 0.780, and 0.864), and negative predictive value (0.750, 0.997, and 0.999) on training, holdout, and prospective validation sets. We validated a POMR model for use in LRS using eight variables that are readily available in the target environment. This model's predictors and accompanying clinical tools of an Excel calculator and nomogram make it simultaneously comprehensive and accessible in LRS.

Utility of a novel point-of-care test for albuminuria in communities at high risk for chronic kidney disease in Thailand

IntroductionChronic kidney disease (CKD) is a major public health concern, and early detection is crucial to prevent adverse outcomes. Albuminuria is an early marker and key prognostic marker in CKD,...

Resource availability for CNS tumor diagnostics in the Asian Oceanian region: A survey by the Asian Oceanian Society of Neuropathology committee for Adapting Diagnostic Approaches for Practical Taxonomy in Resource-Restrained Regions (AOSNP-ADAPTR).

The shift toward a histo-molecular approach in World Health Organization classification of central nervous system tumors (WHO CNS5) emphasizes the critical role of molecular testing, such as next-generation sequencing (NGS) and DNA methylation profiling, for accurate diagnosis. However, implementing these advanced techniques is particularly challenging in resource-constrained countries. To address this, the Asian Oceanian Society of Neuropathology committee for Adapting Diagnostic Approaches for Practical Taxonomy in Resource-Restrained Regions (AOSNP-ADAPTR) was initiated to help pathologists in resource-limited regions to implement WHO CNS5 diagnoses using simpler diagnostic tools, mainly immunohistochemistry. An online survey by this group assessed the in-house/local availability of diagnostic resources and outsourcing capabilities across the Asian Oceanian region, covering 19 countries. Of 318 responding centers, the availability of molecular techniques in-house/locally was limited in lower middle-income countries (LMICs), with 29% having fluorescence in situ hybridization, 10.7% Sanger sequencing, and only 9.4% NGS. DNA methylation was largely unavailable in-house/locally in of LMICs, while in the whole region, its availability stood at a meager 4.4%. Though outsourcing for all diagnostic tests was an easily accessible alternative, outsourcing for NGS and DNA methylation was uncommon because of the financial burden on patients being a significant obstacle. The survey categorized centers into five resource levels (RLs) based on the in-house/local access to diagnostic techniques, which highlighted the variability and disparity in diagnostic capabilities across the region. High-income countries had 80% of centers with advanced RL IV, V resources, in contrast to LMICs, where 70.5% of centers fell into RL I-III. This comprehensive evaluation emphasizes the need for tailored resource level guidelines, with the aim of improving diagnostic accuracy and treatment as well as advocating better healthcare infrastructure in resource-constrained areas. However, the survey's reliance on responses from better-resourced centers may underestimate challenges in lower-resource settings, stressing the need for broader outreach and support.

Assessing the financial burden of multimorbidity among patients aged 30 and above in India

BackgroundMultimorbidity is associated with significant out-of-pocket expenditures (OOPE) and catastrophic health expenditure (CHE), especially in low- and middle-income countries like India. Despite this, there is limited research on the financial burden of multimorbidity in outpatient and inpatient care, and cross-state comparisons of CHE are underexplored.MethodsWe conducted a cross-sectional analysis using nationally representative data from the National Sample Survey 75th Round ‘Social Consumption in India: Health (2017–18)’, focusing on patients aged 30 and above in outpatient and inpatient care in India. We assessed multimorbidity prevalence, OOPE, CHE incidence, and CHE intensity. Statistical models, including linear, log-linear, and logistic regressions, were used to examine the financial risk, with a focus on non-communicable diseases (NCDs), healthcare facility choice, and socioeconomic status and Epidemiological Transition Levels (ETLs).ResultsMultimorbidity prevalence in outpatient care (6.1%) was six times higher than in inpatient care (1.1%). It was most prevalent among older adults, higher MPCE quintiles, urban patients, and those with NCDs. Multimorbidity was associated with higher OOPE, particularly in the rich quintile, patients seeking care from private providers, low ETL states, and rural areas. CHE incidence was highest in low ETL states, private healthcare users, poorest quintile, males, and patients aged 70 + years. CHE intensity, measured by mean positive overshoot, was greatest among the poorest quintile, low ETL states, rural, and male patients. Log-linear and logistic regressions indicated that multimorbidity patients with NCDs, those seeking private care, and those in low ETL states had higher OOPE and CHE risk. The poorest rural multimorbidity patients had the greatest likelihood of experiencing CHE. Furthermore, CHE intensity was significantly elevated among multimorbidity patients with NCDs (95% CI: 19.29–45.79), patients seeking care in private, poorest, and from low ETL states (95% CI: 7.36–35.79).ConclusionsThe high financial burden of OOPE and CHE among multimorbidity patients, particularly those with NCDs, highlight the urgent need for comprehensive health policies that address financial risk at the primary care level. To alleviate the financial burden among multimorbidity patients, especially in low-resource settings, it is crucial to expand public healthcare coverage, incorporate outpatient care into financial protection schemes, advocate for integrated care models and preventive strategies, establish standardized treatment protocols for reducing unnecessary medications linked to polypharmacy, and leverage the support of digital health technologies.

Immediate skin-to-skin contact and postpartum hemorrhagic morbidity.

To examine rates of postpartum hemorrhagic (PPH) morbidity among patients who did and did not have immediate skin-to-skin contact (SSC). This study was a retrospective cohort of all non-anomalous, term singleton vaginal births at a Level IV center over 2 years. Exclusion criteria included COVID-19. Immediate SSC was defined as at least 60 min of direct contact initiated between parturient and neonate within 10 min of birth. The primary outcome was a composite of maternal morbidity related to PPH compared among those with and without immediate SSC. We used multivariable Poisson regression adjusted for possible confounders with robust error variance to determine the strength of the association. Of 8623 deliveries during the study period, 3520 (40.8%) deliveries were included; of which 2428 (55.5%) had immediate SSC and 1028 (31.0%) did not. Immediate SSC reduced the overall rate of composite morbidity (adjusted relative risk 0.78, 95% confidence interval 0.65-0.92), and rate of blood loss 1000 mL or greater, use of additional uterotonics, and use of mechanical tamponade. Blood loss and third stage of labor duration were significantly less for immediate SSC. Transfusion rate and hematocrit change after delivery, did not differ. Immediate SSC among term vaginal deliveries was associated with a significant reduction in PPH. Emphasis on early contact for maternal benefit may increase uptake of SSC and provide an accessible intervention for PPH in high- and low-resource settings.

Breast fine-needle aspiration cytology in the era of core-needle biopsy: what is its role?

Fine-needle aspiration cytology (FNAC) has long been recognized as a minimally invasive, cost-effective, and reliable diagnostic tool for breast lesions. However, with the advent of core-needle biopsy (CNB), the role of FNAC has diminished in some clinical settings. This review aims to re-evaluate the diagnostic value of FNAC in the current era, focusing on its complementary use alongside CNB, the adoption of new approaches such as the International Academy of Cytology Yokohama System, and the implementation of rapid on-site evaluation to reduce inadequate sample rates. Advances in liquid-based cytology, receptor expression testing, molecular diagnostics, and artificial intelligence are discussed, highlighting their potential to enhance the diagnostic accuracy of FNAC. Despite challenges, FNAC remains a valuable diagnostic method, particularly in low-resource settings and specific clinical scenarios, and its role continues to evolve with technology.

Fever Prevention and Neurological Recovery in In-Hospital Cardiac Arrest Survivors at a Limited-Resource Setting.

Temperature management plays a critical role in the neurological recovery of cardiac arrest survivors. While advanced device-based temperature control systems are prevalent in high-resource settings, their implementation in low-resource environments remains a challenge. This study aimed to examine the impact of fever prevention on neurological outcomes in cardiac arrest survivors managed without device-based temperature control. We conducted a retrospective study of adult in-hospital cardiac arrest survivors at an academic institution from 2013 to 2020. Patients were included if they were ≥18 years old, survived for at least 72 hours post-return of spontaneous circulation (ROSC), and experienced cardiac arrest in inpatient wards, intensive care units, or the emergency department. Fever was defined as a rectal temperature ≥37.5°C, and neurological outcomes were assessed using the Cerebral Performance Category (CPC) scale at 1 month post-ROSC. A good neurological outcome was defined as CPC 1 or 2. Statistical analyses included chi-square tests and logistic regression to identify predictors of outcomes. Of the 427 patients included, 58.8% experienced fever, and 12.8% achieved a good neurological outcome. Patients with fever were significantly less likely to have favorable outcomes (p < 0.01). Logistic regression revealed that each 1°C increase in body temperature beyond 37.5°C was associated with a 31% reduction in the likelihood of a good outcome (p < 0.01). Other predictors of poor outcomes included prolonged low-flow states and higher pre-arrest frailty scores. Fever is strongly associated with poor neurological outcomes in cardiac arrest survivors, particularly in low-resource settings without device-based temperature management. Effective fever prevention strategies, such as intravenous antipyretics and physical cooling methods, should be prioritized to improve outcomes.

Evaluating Methods for Aflatoxin B1 Monitoring in Selected Food Crops Within Decentralized Agricultural Systems

Aflatoxin B1 (AFB1) contamination of food crops pose severe public health risks, particularly in decentralized agricultural systems common in low-resource settings. Effective monitoring tools are critical for mitigating exposure, but their adoption is limited by barriers such as cost, infrastructure, and technical expertise. The objectives of this study were: (1) to evaluate common AFB1 detection methods, including enzyme-linked immunosorbent assays (ELISA) and lateral-flow assays (LFA), validated via high-performance liquid chromatography (HPLC), focusing on their suitability for possible applications in decentralized, low-resource settings; and (2) to conduct a barriers-to-use assessment for commonly available AFB1 detection methods and their applicability in low-resource settings. Among four ELISA kits, the AgraQuant Aflatoxin B1 2/50 ELISA Kit demonstrated the highest accuracy and precision, reliably quantifying AFB1 in maize and tortillas across 5–150 ppb with minimal cross-reactivity. For LFA, a smartphone-based algorithm achieved a high presence/absence accuracy rate of 84% but struggled with concentration prediction. The barriers-to-use analysis highlighted the practicality of low-cost tools like moisture readers for field screening but underscored their qualitative limitations. Advanced methods like HPLC and LC-MS offer greater precision but remain impractical due to their high costs and infrastructure requirements, suggesting a potential role for adapted ELISA or LFA methods as confirmatory approaches. These findings support the development of multi-tiered frameworks integrating affordable field tools with regional or centralized confirmatory testing. Addressing systemic barriers through capacity building, partnerships, and improved logistics will enhance AFB1 monitoring in decentralized systems, protecting public health in vulnerable communities.

Head-mounted camera as a debriefing tool for surgical simulation-based training: a randomized controlled study in Senegal

IntroductionVideo feedback, particularly with a head-mounted camera, has previously been described as a useful debriefing tool in well-funded health systems but has never been performed in a low-resource environment. The purpose of this randomized, intervention-controlled study is to evaluate the feasibility of using video feedback with a head-mounted camera during intestinal anastomosis simulation training in a low-resource setting.MethodologyThis study recruited 14 first-year surgery residents in Senegal, who were randomized into control and camera groups. Both groups received reading materials and video lectures before performing a manual end-to-end intestinal anastomosis using a synthetic model. The control group received oral feedback, while the camera group’s first attempt was recorded, reviewed, and discussed before the second attempt. The primary outcomes were OSATS scores and completion time.ResultsThere were no significant demographic differences between the groups. Both groups showed significant improvement in OSATS scores from the first to the second attempt (control group: p = 0.002; camera group: p = 0.0021). The camera group demonstrated a significant reduction in completion time on the second attempt (p = 0.0038), unlike the control group (p = 0.17). Both groups reported increased confidence in performing the task (control group: p = 0.003; camera group: p = 0.0029) and had positive perceptions of the workshop’s effectiveness.ConclusionThis pilot study suggests that video feedback with a head-mounted camera is feasible and effective for debriefing during intestinal anastomosis simulation training in a low-resource setting, offering a low-cost, effective way to enhance technical skills. Further research with larger sample sizes is recommended to validate these findings and explore long-term impacts on surgical proficiency.

Pre-operative Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios as Predictors of Morbidity and Mortality in Diabetic Foot Infection Amputation Patients

Background: Diabetic foot infection is a complication of uncontrolled diabetes. Some cases require amputation to avoid the spread of infection; however, this can also lead to poor outcomes. Inflammatory markers, such as neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR), have been explored as predictors of outcomes following amputation; however, only a few published studies are available. Objective: The study aimed to determine the diagnostic value of pre-operative neutrophil-lymphocyte and platelet-lymphocyte ratios in predicting in-hospital morbidity and mortality among diabetic foot infection patients who underwent amputation in a tertiary government hospital. Methodology: This retrospective cohort study included a total of 535 diabetic foot ulcer patients who underwent amputation at a tertiary government hospital. Data was collected via medical chart review. Complete blood count (CBC) parameters closest to the time of amputation were obtained to calculate the neutrophil-lymphocyte and platelet-lymphocyte ratios. Stata software was used for data processing and analysis. Results: Only 10.28% of patients experienced in-hospital morbidity and/or mortality. Based on Youden’s index, the optimal cutoff points of neutrophil-lymphocyte and platelet-lymphocyte ratios were 7.27 and 32.40, respectively. Both markers showed 98% sensitivity in predicting the outcome. Specificity was 99% for the neutrophil-lymphocyte ratio and 93% for the platelet-lymphocyte ratio. Accuracy parameters remained high when morbidity and mortality were analyzed separately, and subgroup analyses by major and minor amputations were performed. Conclusion: Neutrophil-lymphocyte and platelet-lymphocyte ratios accurately predict in-hospital morbidity and mortality among diabetic foot infection patients who underwent amputation. The low cost and wide availability of a CBC make NLR and PLR valuable options in low-resource settings. Future studies should explore these markers' utility in predicting long-term outcomes after amputation.

Clinical entity-aware domain adaptation in low resource setting for inflammatory bowel disease

The digitization of healthcare records has revolutionized medical research and patient care, with electronic health records (EHRs) containing a wealth of structured and unstructured data. Extracting valuable information from unstructured clinical text presents a significant challenge, necessitating automated tools for efficient data mining. Natural language processing (NLP) methods have been pivotal in this endeavor, aiming to extract crucial clinical concepts embedded within free-form text. Our research addresses the imperative for robust biomedical entity extraction, focusing specifically on inflammatory bowel disease (IBD). Leveraging novel domain-specific pre-training and entity-aware masking strategies with contrastive learning, we fine-tune and adapt a general language model to be better adapted to IBD-related information extraction scenarios. Our named entity recognition (NER) tool streamlines the retrieval process, supporting annotation, correction, and visualization functionalities. In summary, we developed a comprehensive pipeline for clinical Dutch NER encompassing an efficient domain adaptation strategy with domain-aware masking and model fine-tuning enhancements, and an end-to-end entity extraction tool, significantly advancing medical record curation and clinical workflows.

Antibiotic Susceptibility Patterns in Gram-Positive and Gram-Negative Isolates from Post-Operative Wound Infections

Background: Post-operative wound infections (POWIs) are a leading cause of morbidity and increase in healthcare costs, especially in low resource settings. The rising prevalence of antibiotic resistance among pathogens also increases the complexity of treatment strategies, highlighting the importance of local surveillance of microbiological and resistance patterns. This study aims to find out the antibiotic susceptibility patterns of gram positive and gram negative isolates from the post-operative wound infections from women undergoing obstetric and gynecological surgeries. Methods: A cross-sectional study was conducted at Department of Obstetrics and Gynecology, Dhaka Medical College Hospital, Dhaka from October 2019 to September 2021. A total of 200 women with post-operative wound infections were purposively selected. Among them, 134 had culture-positive findings. Bacteriological analysis and antibiotic susceptibility testing were performed on isolates following standard microbiological methods. Results: Among the 134 culture-positive cases, 33.6% of isolates were gram-positive, with Staphylococcus aureus being predominant. Gram-negative bacteria accounted for 66.4% of isolates, with E. coli and Pseudomonas aeruginosa equally prevalent (20.9%). Gram-positive isolates showed high sensitivity to piperacillin-tazobactam (91.1%) and sulbactam (53.3%) but were resistant to ceftriaxone (48.9%) and cefixime (51.1%). Gram-negative bacteria exhibited sensitivity to amikacin and meropenem but demonstrated widespread resistance to ceftriaxone and doxycycline. Conclusion: This study describes the diverse microbiological profile and high prevalence of antibiotic resistance in POWIs. Novel antibiotic therapy and strict infection control measures are essential to curb the burden of these infections.

Smoking Cessation Interventions in the Lung Cancer Screening Setting

The optimal configuration of a smoking cessation intervention in a lung cancer screening (LCS) setting has not yet been established. To evaluate the efficacy of 3 tobacco treatment strategies of increasing integration and intensity in the LCS setting. In this randomized clinical trial, LCS-eligible current smokers were randomized into 3 treatments: quitline (QL), QL plus (QL+), or integrated care (IC). The study was conducted from July 2017 to June 2022 at a hospital-based tobacco treatment clinic in Houston, Texas. The QL intervention group had quitline referral and 12-week nicotine replacement therapy (NRT). The QL+ group had quitline referral plus 12-week NRT or pharmacotherapy prescribed by the LCS clinician. The IC group had 12-week NRT or prescription pharmacotherapy and counseling provided by tobacco treatment specialists within the LCS health care environment. The original primary outcome was biochemically verified 7-day point prevalence abstinence at 6 months; however, this was changed to self-reported abstinence during the conduct of the study due to COVID-19 pandemic restrictions. Of 630 participants, 320 (50.8%) were male, and the median (IQR) age was 59 (55-64) years. Participants smoked a median (IQR) of 20 (15-25) cigarettes per day. Each cohort (QL, QL+, and IC) was composed of 210 participants. The median (IQR) number of counseling sessions was 4 (2-5) sessions for both QL and QL+ and 8 (7-9) sessions for IC. At 3 months, 53 participants (25.2%) in QL, 57 (27.1%) in QL+, and 78 (37.1%) in IC reported abstinence. IC outperformed both QL (odds ratio [OR], 1.75 [95% CI, 1.15-2.66]; P = .01) and QL+ (OR, 1.58 [95% CI, 1.05-2.40]; P = .03). At 6 months, IC maintained the highest rate of abstinence with 68 individuals (32.4%), followed by QL+ at 58 (27.6%) and QL at 43 (20.5%). IC outperformed QL at this time point (OR, 1.86 [95% CI, 1.19-2.89]; P = .01). In the bayesian analysis, IC demonstrated a higher probability of positive absolute risk differences (ARDs) in abstinence at 3 months vs QL (ARD, 0.12) with 99% probability of positive ARD, and QL+ (ARD, 0.10) with 98% probability of positive ARD. This advantage was maintained at 6 months with ARDs of 0.12 for QL (probability of positive ARD, 99%) and 0.05 for QL+ (probability of positive ARD, 86%). In this randomized clinical trial, IC involving medication and intensive counseling provides the best opportunity for smoking cessation relative to QL counseling, with or without LCS clinician-managed medication. Although IC consistently outperformed QL and QL+, differences with QL+ were reduced at 6 months, suggesting QL+ could be considered in low-resource settings. ClinicalTrials.gov Identifier: NCT03059940.

Efficacy of Intermittent Peritoneal Dialysis in Pre Renal and Renal Acute Kidney Injury in Children

Background: Acute kidney injury (AKI) is a major health problem in children worldwide. Intermittent Peritoneal Dialysis (IPD) has been reported as the preferred modality for the management of AKI in low-resource setting countries like Bangladesh. Its efficacy in different varieties of AKI is less emphasized. This study aims to assess the efficacy of IPD in pre renal and renal causes of AKI in children. Methods: This prospective, interventional study was conducted at Department of Paediatric Nephrology, Bangladesh Shishu Hospital and Institute from January 2020 to December 2021. Total 56 children aged between 1 month to 12 years of either sex, diagnosed as AKI stage 2 or 3 due to pre renal and renal causes who required IPD were included. All patients got IPD for 72 hours. Clinical and laboratory parameters were measured daily and compared between pre renal and renal group on day 3 to assess efficacy. Results: In the pre renal group, 65.4% of patients were infants while in the renal group, 51.9% were aged 1-5 years. After 3 days of IPD, oedema improved in both groups but in renal group, more patients were still oedematous (p&lt;0.001). Serum creatinine, blood urea levels and urea reduction ratio improved significantly in both groups with greater changes in pre renal group (p&lt;0.001). In the renal group, 29.63% patients required hemodialysis and 7.4% required further IPD, whereas all pre renal patients improved with a single course of IPD without hemodialysis. Conclusion: Intermittent Peritoneal Dialysis is more effective in the treatment of pre renal AKI in children.

Using a Hand-Held Icterometer to Screen for Neonatal Jaundice: Validation, Feasibility, and Acceptability of the Bili-RulerTM in Kumasi, Ghana

Background: Neonatal jaundice (NNJ) remains a leading cause of newborn mortality in much of sub-Saharan Africa. We sought to examine the validity of using a hand-held icterometer as a screening tool to determine which newborns need further assessment. Additionally, we sought to assess the feasibility of its use among mothers. Methods: We recruited and trained healthcare workers at one large district hospital in Ghana to use a hand-held icterometer known as the Bili-RulerTM. We recruited mothers of 341 newborns aged 0 to 2 weeks at the same hospital. Mothers watched a standardized training video, after which they blanched the skin of the newborn’s nose and compared it with the yellow shades numbered one to six on the icterometer. Each newborn was also assessed with a transcutaneous bilirubin meter (TCB). Research assistants and health care workers screened the same newborns, recorded their scores separately, and were blinded to each other’s readings. In the second phase of this study, we recruited 100 new mothers to take the Bili-Ruler home with them, instructing them to check their newborns twice daily. We interviewed them 1–2 weeks later to determine the acceptability and feasibility of its use. Results: Out of 341 newborns screened, 20 had elevated TCB indicative of hyperbilirubinemia. Healthcare workers’ Bili-Ruler ratings had a strong and significant correlation with TCB scores, as did the ratings of researchers and mothers. When comparing Bili-Ruler scores against TCB, sensitivity across all three raters was 80% (95% CI 75.6–84.3), specificity ranged from 61.1% (healthcare providers) to 66.7% (researchers), positive predictive value ranged from 11.4% (healthcare providers) to 13.0% (researchers), and negative predictive value was 98.0% or higher across all raters. Area under the ROC curve ranged from 0.71 for healthcare providers to 0.73 for researchers. Mothers AUC was 0.72. In terms of acceptability and feasibility, the Bili-Ruler was widely accepted by the mothers and family. In total, 98% of mothers reported using it, and 90.8% used it 3 or more days in the first week after birth. Moreover, 89.8% used it more than twice per day. Conclusions: A hand-held, low-tech icterometer is an important potential mechanism for improving early jaundice identification in low-resource settings. Further studies using larger sample sizes with a higher prevalence of hyperbilirubinemia are warranted.

Rethinking chronic care: how blended patient-centered care delivery and innovative financing models can contribute to achieving universal health coverage – a case study of an integrated approach in Kenya

Abstract Universal Health Coverage (UHC) aims to ensure all individuals have access to essential health services without financial hardship. Chronic diseases, like hypertension and diabetes, play a critical role in achieving UHC due to their lifelong management needs. This paper examines the implementation of a digital and mobile-based, patient-centered care model aimed at improving care for hypertensive and diabetic patients in Kenya. Between 2018 and 2019, 1626 patients from 9 clinics in Nairobi, Kiambu, Nyeri and Vihiga counties were enrolled in an integrated non-communicable disease (NCD) care model including self-management devices for home monitoring, a digital health wallet (M-TIBA) for co-payment, and facility-based peer support groups. Follow-up data was collected November–December 2020. Results indicated significantly improved patient outcomes, with 50% of hypertensive and 74% of diabetic patients achieving disease control, compared to 42% and 52% at baseline. Additionally, peer group participation increased adherence to self-monitoring and lifestyle modifications, contributing to better health outcomes. Despite these successes, challenges such as accessing medications and technical issues with digital tools were identified. Financial sustainability and scalability remain critical concerns, particularly in under-resourced settings. The case study highlights the potential of digital health solutions to enhance chronic care and support UHC by improving accessibility and reducing costs. A multifaceted approach, combining digital tools with face-to-face support and addressing structural barriers in healthcare systems, is essential for long-term success. The findings contribute to the broader discourse on integrated care models for NCDs in low-resource settings, underscoring the importance of sustainable financing and innovative care delivery mechanisms.

Red cell distribution width as a cardiovascular risk predictor in adults with hypertension in sub-Saharan Africa.

Red cell distribution width (RDW) quantifies the degree of variation in erythrocyte size, is identified as a potential marker of adverse cardiovascular events, and may be a surrogate marker for assessing cardiovascular disease (CVD) risk in low-resource settings. We evaluated RDW as a predictor of CVD risk compared to the World Health Organization (WHO) CVD risk score among adults with hypertension attending primary healthcare centers (PHCs) in Ghana and Nigeria. Adults with hypertension attending selected PHCs in Ghana and Nigeria participated in a cross-sectional study. Each participant underwent blood pressure (BP) measurement and laboratory evaluation (RDW, total cholesterol, and fasting blood sugar) following standard methods. We recruited 319 adults aged 40-74 years from the study sites. The mean (standard deviation) RDW was 13.96 (1.1%). The median CVD risk score was 8.11% [interquartile range (IQR) 4.00 to 11.00]. For participants with hemoglobin (Hb) levels ≥ 12 g/dL, RDW showed positive correlations with age (r = 0.136; p = 0.042); systolic BP (r = 0.183; p = 0.006), diastolic BP (r = 0.206, p = 0.002) and WHO CVD risk scores (r = 0.166, p = 0.013). Multiple linear regression showed an independent association between RDW and WHO CVD risk scores with an upward gradient, and was most significant at 3rd quartiles. Using receiver operating characteristic curve, the C-statistic was 0.673 (95% confidence interval: 0.618 to 0.724), p = 0.031. With a cut-off of >14, the RDW demonstrated a sensitivity of 81.82% and specificity of 55.84%. This study shows that at Hb levels ≥ 12 g/dL, RDW modestly predicted CVD risk in adults with hypertension in sub-Saharan Africa.

Critical evaluation of Pap test adherence to routine screening in Amazonas State, Brazil.

This study critically evaluates adherence to Pap test screening practices in cytology-based cervical cancer screening in the state of Amazonas over a 10-year period. A retrospective analysis was conducted of the results of cytological screening examinations (Pap test) in Amazonas State from 2013 to 2023. For this purpose, Brazilian public databases Cervical Cancer Information System (SISCOLO) and Cancer Information System (SISCAN) (from The Department of Information and IT of the Unified Health System - DATASUS) were consulted. There was a decrease in the number of Pap tests performed during the period from 2019 to 2021, likely related to the COVID-19 pandemic. This was followed by a subsequent increase in the post-pandemic period. Notably, in municipalities with fewer than 10,000 annual Pap examinations there was a decrease in the average number of tests when comparing the years 2016-2018 to 2013-2015, and an even greater decrease during the pandemic. There is considerable variation in utilization of the cytological Pap test across different municipalities. This lack of uniformity throughout the State likely compromises the capacity to detect early stage cervical intraepithelial lesions. Cervical cancer screening, cervical cytology, cytology in low-resource settings, Primary screening, Public health.