Low- To Middle-income Countries Research Articles

An Overview of Medical, Surgical, and Rehabilitation Outcome Measures Used in Randomized Controlled Trials of Moderate to Severe Traumatic Brain Injury

Abstract Optimal reporting of outcomes is critical for the interpretation of research findings. This review aimed to examine the utilization of outcome measures (OMs) in randomized controlled trials (RCTs) of moderate to severe TBI (MSTBI). Systematic searches were conducted up to December 2022 in MEDLINE, PubMed, Scopus, CINAHL, EMBASE and PsycINFO, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs were included if the population studied had ≥18 years and ≥ 50% had MSTBI. 662 met inclusion criteria. There was a total of 839 unique OMs across all included RCTs. Of these, only 195 (23.2%) were used in ≥4 RCTs. On average, RCTs included 1.26 OMs (range 1 to 23). A total of 495 (59%) of OMs were classified in the recovery and rehabilitation category, and 344 (41%) in the medical and surgical measures category. There was a more equal representation of OMs in high income countries (HICs) compared to low to middle income countries (LMICs), with the latter using fewer recovery and rehabilitation OMs. OMs used in RCTs of MSTBI have significant heterogeneity and variable clinical relevance, which limits the impact and generalizability of research in MSTBI, and the ability to compare across studies.

A Systematic Review of Upper Extremity Outcome Measures Assessed in Randomized Controlled Trials of Post-Stroke Upper Extremity Rehabilitation in Low-to-Middle-Income and High-Income Countries.

To systematically review Randomized Controlled Trials (RCTs) of post-stroke upper extremity (UE) motor rehabilitation interventions to identify the outcome measures used in studies in low-to-middle-income countries (LMICs) and high-income countries (HICs) and describe the differences in the context of the International Classification of Functioning Disability and Health (ICF). Five databases "Embase, PubMed, CINAHL, Scopus and Web of Science" were searched from 1960 to April 1, 2021. Studies were included if they were: 1) RCTs or RCT crossovers in English; 2) with ≥50% participants affected by ischemic/hemorrhagic stroke; 3) participants ≥18 years old, 4) used an intervention for the hemiparetic UE as the primary objective of the study. Title and abstract screening and full-text studies were reviewed, and data for included studies were extracted by two independent investigators. The study quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Data analyses were performed using SPSS (V29.0). Of 5,408 records, 1,276 RCTs were eligible, 298 RCTs were conducted in LMICs and 978 in HICs. A higher percentage of RCTs in LMICs employed body structure and function outcome measures for central nervous system (e.g. Fugl Meyer Assessment) and tone and range of motion (e. g. modified Ashworth Scale) as well as activity outcome measures for general activities of daily living (e.g. Barthel Index). In HICs, a higher percentage of RCTs utilized body structure and function outcome measures assessing strength (e.g. Motricity index), activity outcome measures examining motor specific activity (e. g. Action Research Arm Test, Wolf Motor Function Test) and dexterity (e.g. Box and Block Test), as well as participation outcome measures (e. g. Stroke Impact Scale). There were significant differences in the outcome measures chosen for assessing post stroke UE rehabilitation interventions by researchers in LMICs and HICs. This suggests that there might be potential resource and expertise as well as timing constraints that influences the choice of outcome measures in RCTs between HICs and LMICs and highlights the need for investigating the availability of resources, infrastructure, and expertise and their impact on the feasibility and practicality of employing different outcome measures in different countries.

Unlocking the potential for microbiome-based therapeutics to address the sustainable development goal of good health and wellbeing.

Recent years have witnessed major advances and an ever-growing list of healthcare applications for microbiome-based therapeutics. However, these advances have disproportionately targeted diseases common in high-income countries (HICs). Within low- to middle-income countries (LMIC), opportunities for microbiome-based therapeutics include sexual health epidemics, maternal health, early life mortality, malnutrition, vaccine response and infectious diseases. In this review we detail the advances that have been achieved in microbiome-based therapeutics for these areas of healthcare and identify where further work is required. Current efforts to characterise microbiomes from LMICs will aid in targeting and optimisation of therapeutics and preventative strategies specifically suited to the unmet needs within these populations. Once achieved, opportunities from disease treatment and improved treatment efficacy through to disease prevention and vector control can be effectively addressed using probiotics and live biotherapeutics. Together these strategies have the potential to increase individual health, overcome logistical challenges and reduce overall medical, individual, societal and economic costs.

FOLFOXIRI for First-Line Treatment of Unresectable Colorectal Cancer with Liver Metastases in a Resource-Limited Setting.

FOLFOXIRI is a standard treatment for unresectable colorectal cancer (CRC) liver metastases. However, limited data exists on its safety and effectiveness in low-to-middle-income countries (LMICs). This prospective study addresses this gap in a Vietnamese LMIC setting. We enrolled 92 patients with unresectable CRC liver metastases between 2022 and 2023. All patients received FOLFOXIRI every 2 weeks, with routine G-CSF prophylaxis to prevent neutropenia. A multidisciplinary team (MDT) assessed diagnoses and treatment responses. Outcomes were R0/R1 resection rate, progression-free survival (PFS), overall survival (OS), objective response rate (ORR), disease control rate (DCR), adverse events (AEs), and recurrence-free survival (RFS) for surgical patients. The median patient age was 56 years, with a male predominance (70.7%). The primary tumors were located in the left colon (42.4%), rectum (37%), and right colon (20.7%). Thirty-two patients (34.8%) experienced severe (grade 3 or higher) AEs, with thrombocytopenia (13.1%) and anemia (9.8%) being the most frequent. Most patients (72/87, 82.9%) achieved a partial response. The ORR and DCR were 85.1% and 95.4%, respectively. Fifty-seven patients (62%) achieved resectability, and 54 (58.7%) underwent radical surgery. The R0/R1 resection rate was 88.9%. The median PFS and OS for all patients were 13 and 22 months, respectively. The median RFS of surgical patients was 14 months. FOLFOXIRI improves the response rates, R0/R1 resection rates, and survivals for patients with CRC liver metastases. Future research is necessary to improve the prognosis of patients while minimizing toxicities. NCT05362825 dated 5 May 2022.

Experience of Continuous Ambulatory Peritoneal Dialysis In Remote Area of Southeast Bangladesh

Background: Chronic kidney disease (CKD) is a major public health problem that continues to increase in prevalence globally. The prevalence of chronic kidney disease is increasing day by day in low to middle income countries (LMICs). People living in LMICs have the highest need for renal replacement therapy (RRT) despite they have lowest access to various modalities of treatment. As continuous ambulatory peritoneal dialysis (CAPD) does not require advanced technologies, very much infrastructure, dialysis staff support, it should be an ideal form of RRT in LMICs, particularly for those living in remote areas. To authors knowledge there was scarcity of data regarding CAPD performance in remote area of Bangladesh. This study was aimed to report the characteristics and outcomes of CAPD in ESRD patients lived in least developed area of Bangladesh. Methods: This prospective study was conducted in Cox’sbazar Medical College Hospital, Cox’sbazar and Parkview hospital Ltd, Chattogram, Bangladesh. Data were collected by questionnaire from the patients of any age with end-stage renal disease (ESRD) who underwent CAPD in 2018–2021. The baseline characteristics, PD-related complication as well as patient and technique survivals were analyzed. Results: Out of 31 patients who underwent CAPD, 18 (58%) were male on the age range of 15–79 years. The mean follow-up duration was 18 months. Mortality was inversely related with the EF of echocardiography. The peritonitis rate was 0.48 episodes per patient per year. The 1, 3 and 4-year patient survival rates were 64.34% (95% CI = 52.5–81.5), 23.79% (95% CI = 17.9 – 57.4) and 3.22% (95% CI = 31.2–77.5) respectively. Conclusions: In this study, CAPD performance was poorer than usual reference. Cardiac compromised patient and inappropriate dwell might be the main contributing factors behind this scenario. The peritonitis rate was nearly similar to that of developed countries. CAPD was cost effective than HD in remote area. Some accessible measures may be taken to make CAPD a more acceptable RRT modality with improved outcomes in poor socioeconomic backgrounds area. J Dhaka Med Coll. 2023; 32(1) : 24-31

'I Do Not Want to Share My Pain With Anyone'-Coping With the Invisible Burden. A Qualitative Description of the Lived Experiences of Individuals With Rotator Cuff Related Shoulder Pain in an Indian Setting.

Rotator cuff related shoulder pain (RCRSP) significantly impacts the physical, and psychosocial well-being of an individual. While studies of lived experiences with shoulder pain were conducted in Western (developed countries) contexts, understanding such experiences in low-to middle-income countries such as India remains limited. This study explores and describes the lived experiences of individuals with RCRSP in Indian settings. A phenomenological approach explored the lived experience of individuals with RCRSP in South India. Ten participants with RCRSP (7 men and 3 women) with mean duration of symptoms ranging between 3 and 24months were interviewed individually using a semi-structured guide with inductive thematic analysis. Participants also completed the Disabilities of the Shoulder Arm and Hand (DASH) questionnaire for upper limb function. Interviews were audio recorded and transcribed verbatim. Three themes that emerged from the interviews were 'The multidimensional burden of RCRSP', 'Navigating the treatment journey between trust and uncertainties', and 'Pathway of healing: Coping with the invisible burden'. Shoulder pain significantly impacted activities, family, and volunteering roles. The majority of the suffering and expression of pain were hidden and influenced by cultural and societal norms. There was a strong belief in the body's ability to heal and acceptance of Eastern and Western treatment approaches. The findings highlight the need for a holistic management strategy that effectively addresses physical impairments, psychosocial support, and cultural beliefs to manage RCRSP in such settings.

Navigating the path: regulatory readiness and stakeholder insights in Indonesia's citywide inclusive sanitation landscape

Inadequate sanitation has catastrophic consequences for public health, standard of living, and productivity, as well as gender equality and social inclusion. Urban sanitation programmes yield suboptimal outcomes regarding long-term impact, effectiveness, sustainability, and fairness. To ensure that all urban dwellers in Low- to Middle-Income Countries (LMICs) have access to sanitation facilities that are properly maintained and safe, it is crucial to bring about a fundamental change in the urban sanitation sector through the implementation of Citywide Inclusive Sanitation (CWIS). This research analyses the sanitation regulatory framework and stakeholders' perspectives in Bandung City, Indonesia. The goal is to determine the possible obstacles and advantages of implementing a comprehensive CWIS (Citywide Inclusive Sanitation) system in Indonesia. The CWIS idea has been recognised at the national level in Indonesia. While existing legislation and policies partially govern and deal with CWIS components, there is no official programme establishment yet and limited implementation at the local level. Some challenges that have been identified include conflicting priorities in serving marginalised populations, a lack of political commitment and capacity to provide comprehensive services for all types of domestic wastewater (including grey water) and throughout the entire sanitation service chain (from containment to treatment and/or reuse and recovery), inadequate knowledge management and data transparency, a lack of incentives and penalties for local governments to meet sanitation standards, and limited motivation for meaningful and institutionalised private sector involvement. This study also delineates four crucial domains for efficiently fostering the deployment of CWIS in Indonesia.

A Scoping Review on the Utilization of Augmented Reality Platforms for Global Surgery in Low-to Middle-Income Countries

A Scoping Review on the Utilization of Augmented Reality Platforms for Global Surgery in Low-to Middle-Income Countries

The need for state-of-the-art orthopedic surgical technology in low- to middle income countries : The case of distraction epiphyseolysis for limb lengthening in children with fibular hemimelia in Uzbekistan.

Amongst low- to middle income countries (LMIC), outdated and poorly documented orthopedic interventions may pose patients at risk for complications, serious adverse events (SAE) and unsatisfactory results, contradicting the World Health Organization's (WHO) Safe Surgery mandates. Use cases of conditions managed inadequately in LMIC environments are necessary to increase awareness of stakeholders and overcome deficiencies in collaboration with high-income countries (HIC). Methodological and clinical experts from the BG Kliniken and the Charité, Berlin, Germany, were invited to investigate established processes for musculoskeletal disorders and injuries in Tashkent, Uzbekistan. Congenital lower leg discrepancy due to fibular hemimelia was recognized as an illustrative example to prove the effectiveness of local treatment guidelines, still relying on distraction epiphyseolysis (chondrodiatasis) via an Ilizarov frame. Routine data from hospital records, images and outpatient follow-up examinations were compared to estimates from a review of studies of limb-lengthening by other techniques. Data from 16 of 49 immature patients (10 males, 6 females, mean age at surgery, 4.2 ± 2.3 years) undergoing chondrodiatasis between 2017 and 2021 showed a mean limb elongation of 2.4 (95% confidence interval [CI], 1.9 to 2.9) cm after a median follow-up of 29 (range, 24 to 36) months. While no complications or SAE were noted, findings are compatible with a risk of 21% under an upper 97.5% confidence limit for null events. No reproducible classification of hemimelia, surgical or general complications, assessment of functional outcomes or health-related quality of life were available. The pooled average length gain from 21 studies on different other interventions with osteotomy enrolling 458 limbs was 5.1 (95% CI, 5.0 to 5.3) cm. Limb lengthening for hereditary fibular hemimelia in Uzbekistan revealed rather obsolete surgical algorithms, inadequate documentation, and unreliable outcome assessment. Resource limitations notwithstanding, knowledge transfer, implementation of current procedures and hardware, and international collaboration is vital to improve quality of care in this scenario and for the benefit of LMIC in general.

B - 102 Neurocognitive Functioning of Patients Diagnosed with Sickle Cell Disease in Low-to-Middle Income Countries

Abstract Objective Sickle Cell Disease (SCD) is a monogenic blood disorder affecting the production of hemoglobin, a protein that carries oxygen to all vital organs in the body. As a result, insufficient oxygen delivery and cerebrovascular complications often occur which can affect neurocognitive performance. In low-to-middle-income countries (LMIC) where health care and treatment of the disease are harder to access, there is minimal neurocognitive surveillance. Our research aim was to evaluate the neurocognitive impact of SCD in children living in LMIC and establish which neurocognitive assessment measures are commonly used in SCD samples worldwide. Data Selection To analyze this, a librarian created search terms in studies from Embase, PubMed, Web of Science, Global Health CABI, ERIC, CINAHL, and PsycINFO. Studies that focused on participants with SCD of any genotype with a measure for cognitive/academic outcomes were included while commentaries and editorials were excluded. Two research assistants screened 1831 abstracts in Covidence, 52 abstracts were chosen for full-text review, and 18 articles were ultimately included for data extraction. Data Synthesis A systematic review was used to analyze these studies. Most of the studies were conducted in African and Middle Eastern countries and Brazil. Common measures included the Wechsler Intelligence Scale for Children or Adults. Information regarding cultural or language adaptations of neurocognitive measures was rarely reported. Several of the studies demonstrated that individuals with SCD have lower neurocognitive functioning compared to a non-SCD control group. Conclusion Further research is needed regarding the validity of neurocognitive measures used in LMIC among patients diagnosed with SCD.

Artificial Intelligence and Cardiology Practice in Nigeria: Are We Ready?

Cardiovascular diseases are the leading cause of death globally. As cardiovascular risk factors continuously rise to pandemic levels, there is intense pressure worldwide to improve cardiac care in preventive cardiology, cardio-diagnostics, therapeutics, and interventional cardiology. Artificial intelligence (AI), an advanced branch of computer science has ushered in the fourth industrial revolution with myriad opportunities in healthcare including cardiology. The developed world has embraced the technology, and the pressure not to be left behind is intense for both policymakers and practicing physicians/cardiologists in low to middle-income countries (LMICs) like Nigeria. This is especially daunting for LMICs who are already plagued with a high burden of infectious disease, unemployment, physician burnt, brain drain, and a developing cardiac practice. Should the focus of cardiovascular care be on men or machines? Is the technology sustainable in a low-resource setting? What lessons did we learn from the COVID-19 pandemic? We attempt to zero in on the dilemmas of AI in the Nigerian setting including AI acceptance, the bottlenecks of cardiology practice in Nigeria, the role of AI, and the type of AI that may be adapted to strengthen cardiovascular care of Nigerians.

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.

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.

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.

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.