Low- To Middle-income Countries Research Articles

Wastewater surveillance of severe acute respiratory syndrome coronavirus-2 in open drains of two Indian megacities captures evolutionary lineage transitions: a zonation approach.

Wastewater-based environmental surveillance (WBES) has been proven as proxy tool for monitoring nucleic acids of pathogens shed by infected population before clinical outcomes. The poor sewershed network of low to middle-income countries (LMICs) leads to most of the wastewater flow through open drains. We studied the effectiveness of WBES using open drain samples to monitor the emergence of the SARS-CoV-2 variants in 2 megacities of India having dense population through zonation approach. Samples from 28 locations spanned into 5 zones of Pune region, Maharashtra, India, were collected on a weekly basis during October 2021 to July 2022. Out of 1115 total processed samples, 303 (~ 27%) tested positive for SARS-CoV-2. The periodical rise and fall in the percentage positivity of the samples was found to be in sync with the abundance of SARS-CoV-2 RNA and the reported COVID-19 active cases for Pune city. Sequencing of the RNA obtained from wastewater samples confirmed the presence of SARS-CoV-2. Of 337 sequences, lineage identification for 242 samples revealed 265 distinct SARS-CoV-2 variants including 10 highly transmissible ones. Importantly, transition from Delta to Omicron variant could be detected in wastewater samples 2weeks prior to any clinically reported Omicron cases in India. Thus, this study demonstrates the usefulness of open drain samples for real-time monitoring of a viral pathogen's evolutionary dynamics and could be implemented in LMICs.

Surgical care bundles for surgical site infection prevention in high-income and low-to-middle-income countries: A comparative review

Surgical site infections (SSIs) are infections of the incision site or organ space following a surgical procedure. The ramifications of an SSI extend beyond individual patient morbidity; SSIs lead to a substantial strain on healthcare systems, irrespective of the economic standing of the country. The utilization of a “care bundle” is a recommended approach for reducing the incidence of SSIs. These bundles typically involve the integration of evidence-based interventions, spanning preoperative, intraoperative, and postoperative phases of care, which aim to standardize healthcare delivery and infection prevention practices. While there is evidence supporting the efficacy of various care bundles, comparisons between specific bundles implemented in high-income countries (HICs) and low- to middle-income countries (LMICs) remain largely unreported. Understanding variations in implemented care bundles in these settings is central to optimize approaches for SSI risk reduction on a global scale.

Modified Pneumatic Reduction Protocol for Intussusception: A Retrospective Cohort Study in an Ultrahigh Volume Center

BackgroundThis study aims to assess the long-term outcomes of a modified pneumatic reduction protocol for intussusception at the Vietnam National Hospital of Pediatrics, an institution with a significant patient load in a lower-middle-income country. Patients and methodsA single center, retrospective cohort observational study was conducted to examine patients who underwent modified fluoroscopic-guided air-enema reduction (FGAR) for intussusception from January 2016 to December 2017. Data on patient demographics, complication rates, and the incidence of long-term recurrence was collected. ResultsBetween January 2016 and December 2017, a total of 3562 patients underwent modified FGAR at our institution, including 2313 males (64.9%) and 1249 females (35.1%). The median age was 19 months (range: 1–170), and the median FGAR procedure duration was 4 min (range: 2–24). The median hospital stay was 1 day (range: 1–31). Successful reduction was achieved in 98.7% of cases, with 43 unsuccessful cases and 4 cases of perforated bowel requiring surgery. Twenty patients, presenting with severe symptoms due to delayed treatment seeking, were admitted to the pediatric intensive care unit (ICU) post-FGAR. No mortality or severe morbidity was reported. Over a median 6-year follow-up, intussusception recurred in 198 patients, accounting for 5.6% of the cohort, with 97% of recurrences occurring within the first year post-reduction. Infants and children under 12 months of age had the highest complication rates, including failed FGAR, complicated intussusception, ICU admission, or recurrence, compared to other age groups, and this difference was statistically significant (p < 0.05). ConclusionThe modified FGAR protocol has been demonstrated to be safe and feasible, with a very high success rate, low complication rate, and low recurrence rate. Although further comparative studies are needed to confirm its reproducibility, it should be considered a promising approach for children in low-to middle-income countries. Level of EvidenceLevel III.

A scoping review on occupational therapy services with forcibly displaced individuals in low to middle income countries

This study underscores the distinctive role of occupational therapy in advancing the health and wellbeing of forcibly displaced individuals (FDIs), who often encounter contextual and systemic barriers and medical complications that prevent them from engaging in daily tasks. These injustices can be mitigated through health promotion and prevention strategies that aim to enhance participation in daily life activities. There has been limited research in low- to middle-income countries (LMICs) in relation to occupational therapy services for FDIs despite most FDIs originating from LMICs. To address this gap, this study adopted Arksey and O’Malley’s framework for a scoping review to consolidate existing knowledge on the occupational therapy health promotion and prevention of disease and disability services for FDIs in LMICs. Searches were conducted on six online databases. Six studies aligned with the inclusion criteria. Findings revealed that most occupational therapy services are directed towards refugees in Jordan, which contains one of the largest refugee camps. FDIs from Africa and internally displaced people receive the least number of interventions. The occupational therapy services outlined in the six sources primarily consist of health education talks, early childhood interventions, and health promotion activities centred around various occupations such as work and sports groups. Recommendations for policy guidelines include incorporating occupational therapy services within the stipulated FDI services. Our approach aims to situate the contribution of occupational therapy health promotion and prevention of disease and disability services within the broader context of FDIs’ overall health and wellbeing.

Mitigating machine learning bias between high income and low–middle income countries for enhanced model fairness and generalizability

Collaborative efforts in artificial intelligence (AI) are increasingly common between high-income countries (HICs) and low- to middle-income countries (LMICs). Given the resource limitations often encountered by LMICs, collaboration becomes crucial for pooling resources, expertise, and knowledge. Despite the apparent advantages, ensuring the fairness and equity of these collaborative models is essential, especially considering the distinct differences between LMIC and HIC hospitals. In this study, we show that collaborative AI approaches can lead to divergent performance outcomes across HIC and LMIC settings, particularly in the presence of data imbalances. Through a real-world COVID-19 screening case study, we demonstrate that implementing algorithmic-level bias mitigation methods significantly improves outcome fairness between HIC and LMIC sites while maintaining high diagnostic sensitivity. We compare our results against previous benchmarks, utilizing datasets from four independent United Kingdom Hospitals and one Vietnamese hospital, representing HIC and LMIC settings, respectively.

Milrinone in persistent pulmonary hypertension of newborn: a scoping review.

Persistent pulmonary hypertension of the newborn (PPHN) is a common neonatal condition in newborns admitted to the neonatal intensive care units (NICUs). PPHN has still a high mortality and morbidity. Inhaled nitric oxide (iNO) is the first line vasodilator therapy for PPHN in high income countries. In low-to-middle income countries (LMICs), availability of iNO remains scarce and expensive. The purpose of this scoping review was to evaluate the current existing literature for milrinone therapy in PPHN and to identify the knowledge gaps in milrinone use in infants with PPHN. The available evidence for milrinone remains limited both as monotherapy and as an adjuvant to iNO. The studies were heterogeneous, conducted in different settings, with different populations and more importantly the endpoints of these trials were short-term outcomes such as changes in oxygenation and blood pressure. Large prospective studies investigating long-term outcomes, mortality, and the need for Extracorporeal membrane oxygenation (ECMO) are warranted. Randomized controlled trials with milrinone as monotherapy are needed in LMICs where iNO availability remains limited. IMPACT: Milrinone has a potential role in the management of PPHN both as an adjuvant to iNO as well as a monotherapy. This scoping review identified the problems existing in the published literature on milrinone and the barriers to generalization of these results. Multi-centre randomized controlled trials on milrinone, especially involving centers from low- and middle-income countries are needed, where it can be evaluated as first-line pulmonary vasodilator therapy.

Bioprinting in cardiovascular medicine: Possibilities, challenges, and future perspectives for low and middle-income countries.

Cardiovascular diseases (CVD) stemming from various factors significantly impact the quality of life (QoL) and are prevalent with high mortality rates in both developed and developing countries. In cases where pharmacotherapy proves insufficient and end-stage disease ensues, a heart transplant/surgical repair becomes the only feasible treatment option. However, challenges such as a limited supply of heart donors, complications associated with rejection, and issues related to medication compliance introduce an additional burden to healthcare services and adversely affect patient outcomes. The emergence of bioprinting has facilitated advancements in creating structures, including ventricles, valves, and blood vessels. Notably, the development of myocardial/cardiac patches through bioprinting has offered a promising avenue for revascularizing, strengthening, and regenerating ventricles. Employment loss in developing countries as a circumstance of disability or death can severely impact a family's well-being and means for sustainable living. Innovations by means of life sustaining treatment options can provide hope for the impoverished and help reduce disability burden on the economy of low- to middle-income countries (LMICs). Such developments can have a significant impact that can last for generations, especially in developing countries. In this review, the authors delve into various types of bioprinting techniques, exploring their possibilities, challenges, and potential future applications in treating various end-stage cardiovascular conditions in LMICs.

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence

Background The epidemiology of traumatic brain injury (TBI) is unclear – it is estimated to affect 27–69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment. Objective The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research. Design Multi-centre, international, registry-based, prospective cohort study. Subjects Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence. Methods All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol. Data Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.

Significance of colonization by antibiotic-resistant organisms prior to congenital heart disease surgery in children from low- to middle-income countries sent by non-governmental organizations to Switzerland.

Children with congenital heart disease (CHD) from low- to middle-income countries (LMIC) are suspected to have a high prevalence of antibiotic-resistant microorganisms (ARMOs) carriage, but data are currently lacking. Carriage of ARMOs could impact the post-operative course in pediatric intensive care unit (PICU). The aim of the study was to assess the prevalence of ARMOs carriage in children with CHD from LMIC and its impact on post-operative outcomes. This was a retrospective monocentric study from 01/2019 to 12/2022. Included patients were children (0-18 years) from a LMIC admitted after CHD surgery and with AMRO screening performed the week before. Infections and post-operative evolution were compared based on ARMOs carriage status. Among 224 surgeries (median age 38.5 months (IQR 22-85.5)), ARMOs carriage was evidenced in 95 cases (42.4%). Main organisms isolated were Extended Spectrum Beta-Lactamase (ESBL) producing E. coli (75/224) 33.5%)) and ESBL-K. pneumoniae (30/224) 13.4%)). Median mechanical ventilation duration was 1 day (IQR 0-1), PICU stay 3 days (IQR 2-4) and hospital stay 6.5 days (IQR 5-10). A total of 17 infectious episodes occurred in 15 patients, mostly consisting in hospital-acquired pneumonia (HAP) (12/17). Only two infections were caused by a colonizing ARMO. Occurrence of infections and patients' outcome were similar between ARMO carriers and non-carriers. Higher use of carbapenems (6 (6.3%) vs 1 (0.8%), p = 0.04) and a trend to a higher use of vancomycin (14 (13.7%) vs 9 (6.9%), p = 0.04) in case of ARMOs carriage. Applying current guidelines, negative swab screening could have led to sparing most of empirical vancomycin therapy (11/12) for HAP based on current guidelines. Prevalence of AMROs carriage is high in children from LMIC and has a limited impact on patients' outcome. However, ARMOs carriage leads to higher consumption of antibiotics. Screening may help saving use of broad-spectrum antibiotic in non-carrier patients.

Policy brief: Optimising antimicrobial usage in paediatric inpatient hospital settings.

Antimicrobial resistance (AMR) poses a global threat, partly fueled by antimicrobial overuse. Paediatric inpatients are particularly vulnerable to infections, leading to high antimicrobial consumption. In low-to-middle income countries (LMICs) like South Africa, research on antimicrobial usage for neonatal and paediatric healthcare-associated infections (HAI) is limited. This cross-sectional study evaluated antimicrobial usage in three academic public sector hospitals in South Africa to improve appropriateness. 22.9% of hospitalised children received at least one prescribed antimicrobial, with neonates, infants, and adolescents having higher prescription rates for HAIs. Common antimicrobials prescribed included beta-lactamase sensitive penicillin, aminoglycosides, and carbapenems. Antimicrobial selection aligned with the WHO AWaRe classification system. HIV infection did not emerge as a risk factor for HAIs or excessive antimicrobial usage. The policy brief recommends several strategies, summarized by the acronym 'PRACTICE,' to optimize antimicrobial prescribing practices. These include implementing standardized policies for empiric antimicrobial use, routine review of antimicrobial therapy, age-specific antimicrobial stewardship programs, and continued collaborative efforts and research. Individualized treatment plans, improved infection prevention and control measures, ongoing surveillance, and exploring electronic technology for antimicrobial stewardship are also crucial. Addressing antimicrobial usage is imperative to combat the growing threat of AMR and improve patient outcomes in LMICs like South Africa.

Fracture Risk Assessment Tool-Based Screening for Osteoporosis in Older Adults in Resource-Limited Settings

Purpose: Osteoporosis is a pressing public health concern among older adults, contributing to substantial mortality and morbidity rates. Low- to middle-income countries (LMICs) often grapple with limited access to dual-energy X-ray absorptiometry (DXA), the gold standard for early osteoporosis detection. This study aims to assess the performance of the FRAX® score as a population-wide screening tool for predicting osteoporosis risk, rather than fracture, in individuals aged 50 and above within an LMIC context.Methods: This retrospective cohort study (n=864) assessed the performance of the FRAX® score for predicting osteoporosis risk using comparative c-statistics from Receiver Operating Characteristic (ROC) curves. Hazard ratios (HR) and 95 % confidence intervals (CI) were calculated, with p-values <0.05 indicating statistically significant.Results: The 10-year FRAX® probability for hip fracture, calculated without bone mass density (BMD), exhibited significantly superior performance compared to the 10-year FRAX® probability for major fracture in predicting osteoporosis risk (AUROC: 0.71 versus 0.67, p<0.001). Within 2 to 10 years of follow-up, the 10-year FRAX® probability for hip fracture showed both greater predictive performance and net benefit in the decision curve compared to the FRAX® 10-year probability for major fracture. A newly established cutoff of 1.9 % yielded a negative predictive value of 92.9 % (95 %CI: 90.4-94.8 %) for the 10-year FRAX® probability for hip fracture.Conclusion: The 10-year FRAX® probability for hip fracture estimated without BMD emerges as an effective 10-year screening tool for identifying osteoporosis risk in aged 50 and older, especially when confronted with limited access to DXA scans in LMICs.Mini abstract: The Fracture Risk Assessment Tool score performance as an osteoporosis screening tool was assessed in areas with limited dual-energy X-ray access. The hip fracture probability showed better performance than major fracture probability within 2 to 10 years. The tool emerges as effective for screening osteoporosis risk in individuals over 50.

Dry and liquid formulations of IBT-V02, a novel multi-component toxoid vaccine, are effective against Staphylococcus aureus isolates from low-to-middle income countries.

Staphylococcus aureus is the leading cause of skin and soft tissue infections (SSTIs) in the U.S. as well as more serious invasive diseases, including bacteremia, sepsis, endocarditis, surgical site infections, osteomyelitis, and pneumonia. These infections are exacerbated by the emergence of antibiotic-resistant clinical isolates such as methicillin-resistant S. aureus (MRSA), highlighting the need for alternatives to antibiotics to treat bacterial infections. We have previously developed a multi-component toxoid vaccine (IBT-V02) in a liquid formulation with efficacy against multiple strains of Staphylococcus aureus prevalent in the industrialized world. However, liquid vaccine formulations are not compatible with the paucity of cold chain storage infrastructure in many low-to-middle income countries (LMICs). Furthermore, whether our IBT-V02 vaccine formulations are protective against S. aureus isolates from LMICs is unknown. To overcome these limitations, we developed lyophilized and spray freeze-dried formulations of IBT-V02 vaccine and demonstrated that both formulations had comparable biophysical attributes as the liquid formulation, including similar levels of toxin neutralizing antibodies and protective efficacy against MRSA infections in murine and rabbit models. To enhance the relevancy of our findings, we then performed a multi-dimensional screen of 83 S. aureus clinical isolates from LMICs (e.g., Democratic Republic of Congo, Palestine, and Cambodia) to rationally down-select strains to test in our in vivo models based on broad expression of IBT-V02 targets (i.e., pore-forming toxins and superantigens). IBT-V02 polyclonal antisera effectively neutralized toxins produced by the S. aureus clinical isolates from LMICs. Notably, the lyophilized IBT-V02 formulation exhibited significant in vivo efficacy in various preclinical infection models against the S. aureus clinical isolates from LMICs, which was comparable to our liquid formulation. Collectively, our findings suggested that lyophilization is an effective alternative to liquid vaccine formulations of our IBT-V02 vaccine against S. aureus infections, which has important implications for protection from S. aureus isolates from LMICs.

Building Equitable Neuroscience Research Collaborations in Resource-limited Settings.

The burden of noncommunicable neurological disorders, such as stroke, dementia, and headache disorders, are on the rise in low- to middle-income countries (LMICs), while neuroinfectious diseases remain a major concern. The development of neuroscience research aimed at defining the burden of neurological diseases across the lifespan, as well as optimizing diagnosis and treatment strategies, is fundamental to improving neurological health in resource-limited settings. One of the key factors to advancing neuroscience research in LMICs is the establishment of effective collaborations based on responsible and trustworthy partnerships between local scientists in LMICs and international collaborators. LMIC researchers face many logistical, institutional, and individual level challenges as they embark on their neuroscience research journey. Despite these challenges, there are opportunities for improving LMIC investigator-led research that should focus on human and institutional infrastructure development. With regard to human capacity building, potential areas for offering support include enhancing research methodology training, offering instruction in manuscript and grant-writing, institutionalizing mentorship programs, and providing opportunities to conduct funded, mentored research to disseminate in high-impact journals. The foundational elements required for implementing and optimizing neuroscience research within an institution include an institutional review board, mentorship programs, data management, research administration, and laboratory facilities. This institutional capacity varies significantly across and within countries, and many rely on collaborations with better-resourced institutions to initiate research. Successful equitable collaborations ensure the engagement of all local and international stakeholders, as well as implementation of a self-sustaining long-term program. Building research capacity in LMICs is an essential endeavor that requires ongoing commitment to training independent scientists. As research capacity increases, LMIC institutions and governments should consider developing competitive research grant programs to support innovative studies led by local researchers, foster regional collaborations, and hence create a sustainable and independent neuroscience research environment.

Implementation of an adapted perioperative ventriculoperitoneal shunting protocol in a tertiary center located in a low-to-middle-income country.

Preventative protocols have efficaciously reduced shunt infection in developed countries. However, the generalizability of these protocols in low-to-middle-income countries (LMICs) remains unclear. Previously, shunt insertion in the authors' center was routinely performed under institutional preventative precautions, which was updated via merging with the Hydrocephalus Clinical Research Network (HCRN) protocol. This study aimed to investigate the ventriculoperitoneal shunt (VPS) infection rates in pediatric patients following the implementation of the adapted protocol. The adapted protocol was implemented in all first-time VPS implantations between 2011 and 2021. The primary outcome was a 6-month shunt infection. The Pearson chi-square test was used for categorical variables and the Mann-Whitney U-test for numeric variables to evaluate the correlation with shunt infection. A total of 352 first-time VPS procedures were performed adhering to the adapted protocol. The median age was 5months, and 189 (53.7%) were male. Overall, 37 patients (10.5%) experienced shunt infection, with 30 (8.5%) occurring within the first 6months, which was lower than 13.3% infection rate of the previous series of the same center. The infection rate was slightly higher than the 5.7% and 6.0% rates reported by HCRN studies. Patients with shunt infection were significantly younger (7.5 versus 17.5months, P < 0.001). This study validates the efficacy of an adapted perioperative protocol in mitigating shunt infection in a high-volume center in a LMIC. Adhering to a step-by-step protocol, modified to suit the healthcare resources and financial constraints of LMICs, could maintain low shunt infection rates that are roughly comparable to those of centers in high-income countries.

Willingness-To-Pay for Health Insurance: Protocol for a Comparative Study Between Formal and Informal Health-Workers

INTRODUCTION People in low- to middle-income countries (LMICs), such as Bangladesh, have less access to healthcare than those in wealthier nations with less than 1% of the population having access to social health protection, which is mostly limited to those who work in the formal sector (14.9% of all jobs). This comparative study aims to use the contingent valuation method (CVM) to determine the factors affection and compare the mean willingness-to-pay (WTP) for community-based health insurance (CBHI) between formal and informal health workers. METHODS AND ANALYSIS This comparative study will be conducted among 250 doctors who will be selected by a convenience sampling technique from various formal and informal workstations in Dhaka City. Of the 250 participants, 125 will be from each group. To collect data, a semi-structured questionnaire will be used via face-to-face interviews. Data will be processed and analyzed using R (v4.3.0) and RStudio (v2023.03.1). WTP for CBHI will be estimated using the “DCchoice” package. The primary outcome is to estimate the proportion and mean WTP across the groups and compare it using double bound dichotomous choice (DBDC) method. Secondary outcomes include identifying the socio-demographic, job-related and healthcare seeking-related factors that influence the WTP. ETHICS AND DISSEMINATION Ethics approval has been obtained from Institutional Review Board (IRB) of the National Institute of Preventive and Social Medicine (NIPSOM). Informed consent will be taken from each participant before data collection. The results of the study will be published in scientific, peer-reviewed journals. STRENGTHS AND LIMITATIONS OF THIS STUDY – The contingent valuation method is a well-established method of eliciting WTP for health insurance. – The current study will be among the first of its nature as it will focus on formal and informal healthcare workers. – Starting point bias may affect the result as this type of bias comes with the Double bounded dichotomous choice (DBDC) method used in this study.

Transfusion safety: Is there a difference between reported reactions in low-to-middle income and high-income countries?

Background and objectivesTransfusion safety may be becoming dependent on the financial resources made available for transfusion structures and may vary between high-income countries (HIC) and low-to-middle-income countries (LMIC). To assess whether there is a difference in the reported TR between these two groups of countries, we examined TR reported in Tunis the capital of Tunisia, a LMIC, and compared their frequency with reported TR in HIC. Materials and methodsData of TR were collected from transfusion incident report (TIR) forms declared by healthcare facilities in Tunis between 2015 and 2019. They were analysed and compared to reported TR in France (ANSM) and UK (SHOT). ResultsThe incidence of TR was 70.6/100 000 blood components (BP) issued. A third of TR (36.8%) occurred at night. Febrile non-hemolytic transfusion reactions (43.7%) and allergic reactions (35%) were the most reported TR respectively 22.4/100 000 BP and 17.9/100 000 BP. The rate of ABO incompatibilities was 1.96/100 000 red blood cell units (RBC): they were all caused by human error. The rates of TRALI, TACO and bacterial contaminations were respectively 1.26/100 000 BP, 1.4/100 000 RBC and 0.7/100 000 BP. ConclusionWhile advanced technologies applied to transfusion have improved transfusion safety, this study shows that their impact has been relatively minor, as reported TR in LMIC are still comparable to those in HIC. ABO-incompatibilities are still higher in LMIC: this should be addressed by reinforcing the training of all healthcare personnel involved in transfusion medicine.

Catalysing global surgery: a meta-research study on factors affecting surgical research collaborations with Africa.

In December 2019, the COVID-19 pandemic highlighted the urgent need for rapid collaboration, research, and interventions. International research collaborations foster more significant responses to rapid global changes by enabling international, multicentre research, decreasing biases, and increasing study validity while reducing overall research time and costs. However, there has been low uptake of collaborative research by African institutions and individuals. To systematically review facilitating factors and challenges to collaborative surgical research studies conducted in Africa. A meta-research review using PubMed®/MEDLINE and Embase on surgical collaboration in Africa from 1st of January 2011 to 31st of September 2021 in accordance to PRISMA guidelines. Surgical studies by collaborative groups involving African authors and sites were included (55 papers). Data on the study period, geographical regions, and research scope, facilitating factors, and challenges were extracted from the studies retrieved from the search. Most of the collaborations in Africa occurred with European institutions (76%). Of the 54 African countries, 63% (34/54) participated in surgical collaborations. The highest collaboration frequency occurred in South Africa (11%) and Nigeria (8%). However, most publications originated from Eastern Africa (43%). Leveraging synergies between high- and low- to middle-income countries (LMICs), well-defined structures, and secure data platforms facilitated collaboration. However, the underrepresentation of collaborators from LMICs was a significant challenge. Available literature provides critical insights into the facilitating factors and challenges of research collaboration with Africa. However, there is a need for a detailed prospective study to explore the themes highlighted further. PROSPERO 2022 CRD42022352115 .

Mortality and associated factors among children admitted to an intensive care unit in muhimbili national hospital, from the time of admission to three months after discharge: a prospective cohort study

BackgroundMortality of children admitted to Intensive Care Units (ICU) is higher in low-to-middle-income countries (LMICs) as compared to high-income countries (HICs). There is paucity of information on outcomes following discharge from ICU, especially from sub-Saharan Africa region. This study was conducted to determine mortality and its associated factors among children admitted to Pediatric ICU (PICU) at Muhimbili National Hospital, from admission to three months after discharge.MethodologyThis was a hospital-based prospective cohort study conducted between July 2021 and May 2022, among children admitted to PICU who were followed up for 3-month after discharge. Structured questionnaires were used to collect data from their medical charts. Telephone interviews were made after discharge. Medical records and verbal autopsy were used to determine the cause of death after discharge. Cox regression analysis was performed to assess the association between variables. A p-value of < 0.05 was considered statistically significant. Survival after PICU discharge was estimated by Kaplan - Meier curve.ResultsOf 323 children recruited, 177(54.8%) were male, with a median age of 17 months (1-168). The leading cause of PICU admission was severe sepsis 90/323(27.9%). A total of 161/323 children died, yielding an overall mortality of 49.8%. Of 173 children discharged from PICU, 33(19.1%) died. The leading cause of death among children who died in the general ward or as readmission into PICU was sepsis 4/17(23.5%). Respiratory diseases 4/16(25.0%) were the commonest cause of death among those who died after hospital discharge. Independent predictors of overall mortality included single organ dysfunction with hazard ratio(HR):5.97, 95% confidence interval (CI)(3.05–12.26)] and multiple organ dysfunction [HR:2.77,95%CI(1.03–2.21)]. Chronic illness[HR:8.13,95%CI(2.45–27.02)], thrombocytosis [HR:3.39,95%CI(1.32–8.73)], single[HR:3.57,95%CI(1.42–9.03)] and multiple organ dysfunction[HR:3.11,95%CI(1.01–9.61)] independently predicted post-PICU discharge mortality.ConclusionOverall mortality and post- PICU discharge mortality were high and more likely to affect children with organ dysfunction, chronic illness, and thrombocytosis. The leading causes of mortality post- PICU discharge were sepsis and respiratory diseases. There is a need for a focused follow up plan of children post- PICU discharge, further research on the long term survival and strategies to improve it.

Multidisciplinary perceptions and considerations for spiritual care and biblical framework counseling in mental health

Background: Religious/Spiritual (R/S) care is often desired by mental health clients for culturally sensitive, patient-focused treatment that can promote positive health behaviors and outcomes. Yet providers may be hesitant or overlook this need and treatment guidelines are limited. This mixed-method study aimed to gain insights on existing R/S care, as well as perspectives on what support would be considered for patients choosing Biblical Framework Counseling (BFC) for schizophrenia. This is part of a project aimed to collaboratively extend population-based, mental health care access in resource–constrained communities of both the US, a High-Income Country (HIC), and Low-to-Middle Income Countries (LMICs) in Africa. The project was led by an Africa- Diaspora Citizen Engagement Collaborative (CEC) and is entitled Multi-level Engagement eCoCM (expanded Collaborative Care Model) for Mental Health Integration in Primary and Specialty Care of Resource-Constrained Communities. Methods: A mixed methods approach, comprising of 1) qualitative literature synthesis of 40 journal articles and medical education guidelines for spiritual care, 2) semi-structured survey of 54 multidisciplinary respondents, 3) case report of a patient with schizophrenia treated with Biblical Framework Counseling (BFC), and thematic analysis. Results: The literature review identified multidisciplinary health professional provision of R/S, medical, and/or psychological interventions as monotherapy, concurrent, or integrated strategies. There was a paucity of medical education guidelines. Qualitative themes encompassing literature review, multidisciplinary survey, and BFC case were developed from the extraction of coding categories of disciplines, treatment, and values. Overall themes included 1) there is some multidisciplinary willingness to provide or coordinate R/S care for mental health clients, with varying attitudes about BFC efficacy or implementing biblically based interventions; 2) the ways or extent of care to be provided involves a balance of patient preferences, provider practice considerations and scope; and 3) R/S care implementation can be facilitated via interprofessional education and research that inform on professional and patient-centered values and skills. Survey respondents supported interventions for confirmatory mental health diagnosis and history, scheduled patient follow-ups, ethical hand-offs or referrals, spiritual growth and maintenance, medication management and adherence, and individual psychotherapy depending on professional-patient spirituality congruence, comfort-level with biblical based interventions, and perceived relapse potential. Recognizing both healthcare and spiritual care treatment perspectives and ethical considerations could assist the selection of R/S care approach. Graduate Medical Education (GME) and other health professional programs and guidelines may incorporate these considerations, new and existing R/S interventions, and multidisciplinary provider scope of practice as options for clinician training, mobilization, and design of R/S care practice models. Future research steps should comprise anecdotal case reports, evidence-based case series, and implementation science studies across a broader range of mental disorders.

Mechanical valve replacement for patients with rheumatic heart disease: the reality of INR control in Africa and beyond.

The majority of patients requiring heart valve replacement in low- to middle-income countries (LMICs) need it for rheumatic heart disease (RHD). While the young age of such patients largely prescribes replacement with mechanical prostheses, reliable anticoagulation management is often unattainable under the prevailing socioeconomic circumstances. Cases of patients with clotted valves presenting for emergency surgery as a consequence of poor adherence to anticoagulation control are frequent. The operative mortality rates of reoperations for thrombosed mechanical valves are several times higher than those for tissue valves, and long-term results are also disappointing. Under-anticoagulation prevails in these regions that has clearly been linked to poor international normalised ratio (INR) monitoring. In industrialised countries, safe anticoagulation is defined as >60%-70% of the time in the therapeutic range (TTR). In LMICs, the TTR has been found to be in the range of twenty to forty percent. In this study, we analysed >20,000 INR test results of 552 consecutive patients receiving a mechanical valve for RHD. Only 27% of these test results were in the therapeutic range, with the vast majority (61%) being sub-therapeutic. Interestingly, the post-operative frequency of INR tests of one every 3-4 weeks in year 1 had dropped to less than 1 per year by year 7. LMICs need to use clinical judgement and assess the probability of insufficient INR monitoring prior to uncritically applying Western guidelines predominantly based on chronological age. The process of identification of high-risk subgroups in terms of non-adherence to anticoagulation control should take into account both the adherence history of >50% of patients with RHD who were in chronic atrial fibrillation prior to surgery as well as geographic and socioeconomic circumstances.