Low- To Middle-income Countries Research Articles

Genomic selection strategies to increase genetic gain in tea breeding programs.

Tea [Camellia sinensis (L.) O. Kuntze] is mainly grown in low- to middle-income countries (LMIC) and is a global commodity. Breeding programs in these countries face the challenge of increasing genetic gain because the accuracy of selecting superior genotypes is low and resources are limited. Phenotypic selection (PS) is traditionally the primary method of developing improved tea varieties and can take over 16yr. Genomic selection (GS) can be used to improve the efficiency of tea breeding by increasing selection accuracy and shortening the generation interval and breeding cycle. Our main objective was to investigate the potential of implementing GS in tea-breeding programs to speed up genetic progress despite the low cost of PS in LMIC. We used stochastic simulations to compare three GS-breeding programs with a Pedigree and PS program. The PS program mimicked a practical commercial tea-breeding program over a 40-yr breeding period. All the GS programs achieved at least 1.65 times higher genetic gains than the PS program and 1.4 times compared with Seed-Ped program. Seed-GSc was the most cost-effective strategy of implementing GS in tea-breeding programs. It introduces GS at the seedlings stage to increase selection accuracy early in the program and reduced the generation interval to 2yr. The Seed-Ped program outperformed PS by 1.2 times and could be implemented where it is not possible to use GS. Our results indicate that GS could be used to improve genetic gain per unit time and cost even in cost-constrained tea-breedingprograms.

Systematic Review of mHealth Interventions for Adolescent and Young Adult HIV Prevention and the Adolescent HIV Continuum of Care in Low to Middle Income Countries

Adolescents and young adults (AYA) in low to middle income countries (LMIC) have poorer outcomes along each step in the HIV continuum of prevention and care compared to younger children or older adults. The use of mHealth technology provides a potentially promising implementation strategy for interventions to remedy these disparities. We therefore conducted a systematic review of the English literature and conference proceedings from January 1, 2000 to April 1, 2021 evaluating mHealth interventions targeting AYA along each step of the HIV continuum of care in LMIC. We identified 27 mHealth interventions across the HIV continuum, with no interventions addressing transition from pediatric to adult care. The majority of studies were single arm, uncontrolled or underpowered, with few randomized trials resulting in mixed and inconclusive outcomes. mHealth interventions have potential to remedy disparities along the HIV continuum of care for AYA in LMIC but larger, powered randomized trials are needed.

Innovations and adaptations in neonatal and pediatric respiratory care for resource constrained settings.

Respiratory disease is a leading cause of death in children under 5 years of age worldwide, and most of these deaths occur in low- to middle-income countries (LMICs) where advanced respiratory care technology is often limited. Much of the equipment required to provide advanced respiratory care is unavailable in these areas due to high costs, the need for specialty trained personnel, and myriad other resource constraints that limit uptake and sustainable use of these devices, including reliable access to electricity, sensitive equipment needing frequent maintenance, single-patient-use supplies, and lack of access to sterilization equipment. Compounding the problem, pediatrics is uniquely challenging in that one size does not fit all, or even most patients. Despite these substantial barriers, numerous innovations in respiratory care technology have been made in recent years that have brought increasing access to high quality respiratory care in some of the most remote areas of the world. In this article, we intend to review the global burden of respiratory diseases for children, highlight the prototypical innovations that have been made in bringing respiratory care to LMICs, spotlight some of the technologies being actively developed to improve respiratory care in resource-constrained settings, and conclude with a discussion highlighting areas where further innovation is still needed.

Experiences and Perceptions of Telephone-delivery of the Common Elements Treatment Approach for Mental Health Needs Among Young People in Zambia During the COVID-19 Pandemic.

BackgroundMental and behavioral health needs are immense in low-to-middle income countries (LMIC), particularly for adolescents and young adults (AYA). However, access to mental health services is limited in LMIC due to barriers such as distance to a health care site, low number of providers, and other structural and logistical challenges. During the COVID-19 pandemic, these barriers were significantly exacerbated and, thus, mental health services were severely disrupted. A potential solution to some of these barriers is remote delivery of such services via technology. Exploration of AYA experiences is needed to understand the benefits and challenges when shifting to remotely delivered services.MethodsParticipants included 16 AYA (15–29 years) residing in Lusaka, Zambia who met criteria for a mental or behavioral health concern and received telehealth delivery of the Common Elements Treatment Approach (CETA). AYA participated in semi-structured qualitative interviews to explore feasibility, acceptability, and barriers to telephone-delivered treatment in this context. Thematic coding analysis was conducted to identify key themes.FindingsThree major response themes emerged: 1) Advantages of telehealth delivery of CETA, Disadvantages or barriers to telehealth delivery of CETA, 3) AYA recommendations for optimizing telehealth (ways to improve telehealth delivery in Zambia. Results indicate that logistical and sociocultural barriers i.e., providing AYA with phones to use for sessions, facilitating one face-to-face meeting with providers) need to be addressed for success of remotely delivered services.ConclusionAYA in this sample reported telehealth delivery reduces some access barriers to engaging in mental health care provision in Zambia. Addressing logistical and sociocultural challenges identified in this study will optimize feasibility of telehealth delivery and will support the integration of virtual mental health services in the Zambian health system.

The notable global heterogeneity in the distribution of COVID-19 cases and the association with pre-existing parasitic diseases.

The coronavirus Disease 2019 (COVID-19) is a respiratory disease that has caused extensive ravages worldwide since being declared a pandemic by the World Health Organization (WHO). Unlike initially predicted by WHO, the incidence and severity of COVID-19 appeared milder in many Low-to-Middle-Income Countries (LMIC). To explain this noticeable disparity between countries, many hypotheses, including socio-demographic and geographic factors, have been put forward. This study aimed to estimate the possible association of parasitic diseases with COVID-19 as either protective agents or potential risk factors. A country-level ecological study using publicly available data of countries was conducted. We conceptualized the true number of COVID-19 infections based on a function of test positivity rate (TPR) and employed linear regression analysis to assess the association between the outcome and parasitic diseases. We considered demographic, socioeconomic, and geographic confounders previously suggested. A notable heterogeneity was observed across WHO regions. The countries in Africa (AFRO) showed the lowest rates of COVID-19 incidence, and the countries in the Americas (AMRO) presented the highest. The multivariable model results were computed using 165 countries, excluding missing values. In the models analyzed, lower COVID-19 incidence rates were consistently observed in malaria-endemic countries, even accounting for potential confounding variables, Gross Domestic Product (GDP) per capita, the population aged 65 and above, and differences in the duration of COVID-19. However, the other parasitic diseases were not significantly associated with the spread of the pandemic. This study suggests that malaria prevalence is an essential factor that explains variability in the observed incidence of COVID-19 cases at the national level. Potential associations of COVID-19 with schistosomiasis and soil-transmitted helminthiases (STHs) are worthy of further investigation but appeared unlikely, based on this analysis, to be critical factors of the variability in COVID-19 epidemic trends. The quality of publicly accessible data and its ecological design constrained our research, with fundamental disparities in monitoring and testing capabilities between countries. Research at the subnational or individual level should be conducted to explore hypotheses further.

Second Footprint of Reports from Low- and Low- to Middle-Income Countries in the Neurosurgical Data: A Study from 2018–2020 Compared with Data from 2015–2017

In 2019, we highlighted the disparities in scientific production between high-income countries (HICs) and low- to middle-income countries (LMICs) by emphasizing how scientific research was underrepresented in the latter. The present study aimed to investigate research productivity in neurosurgery of low-income countries (LICs) and LMICs for the years 2018-2020 and to compare it with the results of our previous study for 2015-2017. We performed a retrospective bibliometric analysis using PubMed and Scopus databases to record all the reports published in 2018-2020 by investigators affiliated with neurosurgical departments in LICs and LMICs. The attribution of the study to LMICs was based on the presence of either the first author or the majority of authors. Our systematic search identified 486 studies reported by LICs and LMICs for full text examination in 12 journals. These articles represent 4.9% of all published neurosurgical articles, compared with 4.5% in the 2015-2017 study. India remained the country with the highest contribution, with a 17.1% increase in reports. Other countries, such as Nigeria and Philippines, also show an increased percentage of reports (from 0.9% to 3.7% and from 0.6% to 2.1%, respectively). There is growing consensus in the neurosurgical scientific community that the dissemination and analysis of epidemiologic and clinical data from developing countries can provide guidelines and practical suggestions worldwide. However, our study shows that the number of neurosurgical articles published by low-income countries in 2018-2020 remained at approximately 5% of the total, resulting in a negative impact on the process of globalization.

WhatsApp supervision for a lay-led Islamic trauma-focused intervention in Somaliland: Qualitative content analysis.

Clinical supervision is critical for the uptake of psychotherapy but difficult to facilitate in countries with limited providers, resources, and internet infrastructure. Innovative supervision approaches are needed to increase access to mental health treatments in low-to-middle income countries (LMICs). This study examined the content and feasibility of remote WhatsApp text supervision conducted as part of an open clinical trial in Somaliland. Islamic Trauma Healing ITH) is a brief, group, lay-lead, trauma-focused, mosque-based intervention that has demonstrated initial efficacy in pilot studies in the United States and Somaliland. After a 2-day, in-person training, lay leaders led four groups of five to seven members focused on trauma-related psychopathology and community reconciliation. Somali lay leaders trained in ITH (n = 9) and the research team (n = 6) attended weekly WhatsApp supervision during the intervention. Content was logged and subjected to qualitative analysis by two coders. Comments related to intervention implementation indicated that lay leaders understood the treatment rationale, adhered to treatment procedures, and believed the intervention components to be helpful and culturally relevant. Themes related to engagement suggested perfect attendance across groups and high levels of participation. Lay leader psychoeducation and skill development; supervisor praise, support, and encouragement; and supervisee gratitude emerged as additional themes. Remote text supervision conducted via WhatsApp was technologically feasible and may have facilitated skill development and the effective implementation of this lay-led intervention. When tailored to the local context, remote supervision approaches hold promise for increasing access to services in LMICs with limited resources.

Midwifery continuity of care: A scoping review of where, how, by whom and for whom?

Systems of care that provide midwifery care and services through a continuity of care model have positive health outcomes for women and newborns. We conducted a scoping review to understand the global implementation of these models, asking the questions: where, how, by whom and for whom are midwifery continuity of care models implemented? Using a scoping review framework, we searched electronic and grey literature databases for reports in any language between January 2012 and January 2022, which described current and recent trials, implementation or scaling-up of midwifery continuity of care studies or initiatives in high-, middle- and low-income countries. After screening, 175 reports were included, the majority (157, 90%) from high-income countries (HICs) and fewer (18, 10%) from low- to middle-income countries (LMICs). There were 163 unique studies including eight (4.9%) randomised or quasi-randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research. Midwives led almost all continuity of care models. In HICs, the most dominant model was where small groups of midwives provided care for designated women, across the antenatal, childbirth and postnatal care continuum. This was mostly known as caseload midwifery or midwifery group practice. There was more diversity of models in low- to middle-income countries. Of the 175 initiatives described, 31 (18%) were implemented for women, newborns and families from priority or vulnerable communities. With the exception of New Zealand, no countries have managed to scale-up continuity of midwifery care at a national level. Further implementation studies are needed to support countries planning to transition to midwifery continuity of care models in all countries to determine optimal model types and strategies to achieve sustainable scale-up at a national level.

Shotgun metagenomics of fecal samples from children in Peru reveals frequent complex co-infections with multiple Campylobacter species.

Campylobacter spp. are a major cause of bacterial diarrhea worldwide and are associated with high rates of mortality and linear growth faltering in children living in low- to middle-income countries (LMICs). Campylobacter jejuni and Campylobacter coli are most often the causative agents of enteric disease among children in LMICs. However, previous work on a collection of stool samples from children under 2 years of age, living in a low resource community in Peru with either acute diarrheal disease or asymptomatic, were found to be qPCR positive for Campylobacter species but qPCR negative for C. jejuni and C. coli. The goal of this study was to determine if whole-genome shotgun metagenomic sequencing (WSMS) could identify the Campylobacter species within these samples. The Campylobacter species identified in these stool samples included C. jejuni, C. coli, C. upsaliensis, C. concisus, and the potential new species of Campylobacter, "Candidatus Campylobacter infans". Moreover, WSMS results demonstrate that over 65% of the samples represented co-infections with multiple Campylobacter species present in a single stool sample, a novel finding in human populations.

ABCL-264 Insights Into the Treatment of Nodal Non-Hodgkin Lymphomas in a Low- to Middle-Income Country: A Unicentric Experience

Non-Hodgkin lymphomas (NHL) are one of the most diagnosed forms of lymphoproliferative diseases, of which diffuse large B-cell lymphoma is the most common form. According to the literature, NHL with primary involvement of the lymph nodes occurs in 52%-70% of patients, being the most common primary localization in NHL. Treatment opportunities for NHL have become increasingly heterogeneous, but the penetrability of many of them, especially targeted treatments, is low in low- to middle-income countries (LMICs). The aim of this study was to evaluate the therapeutic implication of the use of the targeted approach in combination with conventional chemotherapy in the treatment of nodal-onset NHL. A retrospective study was performed, including 82 patients diagnosed with NHL and monitored at the Oncological Institute of the Republic of Moldova. Eighty-two patients participated in the study, 39 of whom were men and 43 were women. The mean age of the patients was 56.02±13.8 years. NHL had its onset in the peripheral lymph nodes in 84.14% of patients, the mediastinal lymph nodes in 8.53%, and the abdominals in 7.31%. The majority of patients were diagnosed in generalized stages: 18 (21.95%) in stage III and 43 (52.43%) in stage IV. Localized stages were found in 25.6% of cases, with 7 (8.53%) stage I and 14 (17.07%) stage II cases. Aggressive NHLs were diagnosed in 53 (64.63%) patients, whereas indolent NHLs were diagnosed in 29 (35.36%) cases. Sixty-two (75.6%) patients received, as first-line therapy, the combination of rituximab+chemotherapy (subgroup 1; Sg1), and 20 (24.39%) patients received just conventional chemotherapy (subgroup 2; Sg2). The overall response rate (ORR) in Sg1 was 87.09% and 65.0% in Sg2. Complete remissions (CR) were achieved in 64.51% of patients in Sg1 and 45.0% of cases in Sg2. Progression-free survival (PFS) had a median of 20 months in Sg1 and 12 months in Sg2 (P=0.001) Conclusions: The use of targeted treatment with rituximab increased the ORR rate (87.09% vs. 65.0%), the frequency of CR (64.51% vs. 45.0%), and PFS (20 months vs. 12 months [P<0.05]).

MM-252 A Retrospective Review of Relapsed Multiple Myeloma Post Autologous Stem Cell Transplant: Data From an Indian Tertiary Cancer Center

Multiple myeloma (MM) relapsing post autologous stem cell transplant (ASCT) continues to have overall poor outcomes in low- to middle-income countries (LMICs), and the efficacy data on available salvage regimens is limited. Here, we report the treatment outcomes of such patients treated at an Indian tertiary cancer center. The primary objective was to determine the PFS with salvage treatment. Secondary objectives included objective response rates (ORR) and ≥ partial response (PR). Single-center retrospective study of MM patients relapsing post ASCT between January 2015 and October 2020, treated with salvage regimen and followed until January 2022. North Indian tertiary cancer referral center. Records of 51 relapsed MM patients were screened for the study. All of them received up-front ASCT followed by maintenance treatment and later relapsed. Six (8.5%) patients with incomplete treatment details were excluded. Forty-six patients were included in the study. PFS. Median age was 51 years (range 45-68 years); 67.8% were men. Thirteen (28.2%) patients had high-risk cytogenetics. An extramedullary pattern of relapse was seen in 7 (15.2%) patients. Pomalidomide-based salvage therapy (VPd, PCd) was used in 18 (39.2%) patients and VRd in 14 (30.5%) patients. ORR was 47.8% (24/46). CR was observed in 28.3% (13/46) of patients. After a median follow-up of 8.1 months (IQR 3.1-26.7 months), 30 patients progressed and the median PFS was 6.75 months (95% CI 0.7-27.5 months). Median PFS did not differ by type of salvage treatment, such as pomalidomide versus non-pomalidomide (hazard ratio [HR] 0.93; 95% CI 0.38-2.27; P-value 0.87). Multivariate Cox proportion analysis, however, suggested that extramedullary relapse (HR 2.63; 95% CI 1.04-6.65; P-value <0.001), presence of high-risk cytogenetics (HR 6.6; 95% CI 1.82-24; P-value <0.001), and poor response to salvage regimens (<PR) (HR 7.48; 95% CI 2.27-24.7; P-value <0.001) predicted poor PFS. In MM patients relapsing post ASCT, we suggest that extramedullary relapse, presence of high-risk cytogenetics, and poor response to a salvage regimen, irrespective of salvage used, predict a poor PFS. However, these findings require validation by a randomized control trial.

Perspectives of health care professionals’ on delivering mHealth sexual and reproductive health services in rural settings in low-and-middle-income countries: a qualitative systematic review

BackgroundIn low to middle income countries (LMICs) with limited health care providers (HCPs) and health infrastructure, digital technologies are rapidly being adopted to help augment service delivery. In this sphere, sexual and reproductive health (SRH) services are increasingly leveraging mobile health (mHealth) technologies to improve service and information provision in rural areas. This systematic review aimed to identify HCPs perspectives on barriers to, and facilitators of, mobile phone based SRH services and information in rural areas of LMICs from current literature.MethodsSearches were conducted using the following databases: Medline, Scopus, PsychINFO, CINAHL and Cochrane Library. Based on the inclusion and exclusion criteria, twelve full text qualitative studies published in English between January 2000 and December 2020 were included. The methodological quality of papers was assessed by two authors using the critical skills appraisal programme and synthesized using the narrative thematic analysis approach.ResultsPositive HCPs experiences surrounding the provision of mHealth based SRH services in LMICs included saving consultation time, ability to shift tasks, reduction in travel costs, easy referrals and follow up on clients, convenience in communicating health information confidentially, and the ability to consult groups of clients remotely rather than face-to-face. Barriers to the provision of mHealth reported by HCPs included lack of technological infrastructure, unreliable networks, limited power, the cost of mobile airtime/data and mobile phones and limited technological literacy or skills.ConclusionsImplementing innovative mHealth based SRH services could bridge a service provision and access gap of SRH information and services in rural areas of LMICs. Despite the advantages of this technology, several challenges associated with delivering mHealth SRH services need to be urgently addressed to enable scale-up and integration of sexual and reproductive mHealth into rural health systems.

Barriers to neurotrauma care in low- to middle-income countries: an international survey of neurotrauma providers.

Delays along the neurosurgical care continuum are associated with poor outcomes and are significantly greater in low- to middle-income countries (LMICs), with timely access to neurotrauma care remaining one of the most significant unmet neurosurgical needs worldwide. Using Lancet Global Surgery metrics and the Three Delays framework, the authors of this study aimed to identify and characterize the most significant barriers to the delivery of neurotrauma care in LMICs from the perspective of local neurotrauma providers. The authors conducted a cross-sectional study through the dissemination of a web-based survey to neurotrauma providers across all World Health Organization geographic regions. Responses were analyzed with descriptive statistics and Kruskal-Wallis testing, using World Bank data to provide estimates of populations at risk. Eighty-two (36.9%) of 222 neurosurgeons representing 47 countries participated in the survey. It was estimated that 3.9 billion people lack access to neurotrauma care within 2 hours. Nearly 3.4 billion were estimated to be at risk for impoverishing expenditure and 2.9 billion were at risk of catastrophic expenditure as a result of paying for care for neurotrauma injuries. Delays in seeking care were rated as slightly common (p < 0.001), those in reaching care were very common (p < 0.001), and those in receiving care were slightly common (p < 0.05). The most significant causes for delays were associated with reaching care, including geographic distance from a facility, lack of ambulance service, and lack of finances for travel. All three delays were correlated to income classification and geographic region. While expanding the global neurosurgical workforce is of the utmost importance, the study data suggested that it may not be entirely sufficient in gaining access to care for the emergent neurosurgical patient. Significant income and region-specific variability exists with regard to barriers to accessing neurotrauma care. Highlighting these barriers and quantifying worldwide access to neurotrauma care using metrics from the Lancet Commission on Global Surgery provides essential insight for future initiatives aiming to strengthen global neurotrauma systems.

SARS-CoV-2 infections in infants in Haiti 2020-2021; evidence from a seroepidemiological cohort.

Few data are available on frequency of SARS-CoV-2 infection among very young children in low- to middle-income countries (LMIC), with the studies that are available biased towards higher income countries with low reported infection and seroconversion rates. Between February 2019 and March 2021, 388 dried blood spot (DBS) samples were obtained from 257 children less than 30 months of age as part of a prospective observational cohort study of pregnant women and their infants in Haiti; longitudinal samples were available for 107 children. In a subsequent retrospective analysis, DBS samples were tested by ELISA for antibody targeting the receptor binding domain of the SARS-CoV-2 S1 protein. Over the course of the study, 16·7% of the infants became seropositive. All seropositive samples were collected after March 19, 2020 (the date of the first reported COVID-19 case in Haiti) with the highest hazards measured in August 2020. Sampling date was the only covariate associated with the hazard of seroconversion. Our data provide an estimate of SARS-CoV-2 infection rates among very young children without prior SARS-CoV-2 exposure during the initial pandemic waves in Haiti, and demonstrate that these children mount a detectable serological response which is independent of patient age.

Experience from a hypofractionation curriculum pilot: Overcoming education as a barrier to implement hypofractionation

<h3>Background</h3> Hypofractionation has equivalent oncologic outcomes to conventional fractionation, with the advantage of shortening treatment time. This is beneficial for health systems in low-to-middle income countries (LMICs); however, little is known about how to promote its adoption globally. <h3>Methods</h3> The non-profit Rayos Contra Cancer developed a hypofractionation e-learning program to pilot in Colombia, free of charge, and shared through the Colombian Association of Radiation Oncology. Two electronic surveys were distributed, one before and one after the completion of the course. Physicians were asked questions regarding their attitudes to hypofractionation. Different sections focused on clinical scenarios related to breast, prostate, rectal, and CNS gliomas, asking current practices regarding conventional fractionation, hypofractionation (15-20 fractions), and ultra-hypofractionation (5 fractions). To measure the impact of the curriculum, we categorized physicians' use of hypofractionation with a numerical score from 0 to 12 (12 = More conventional, 0=more hypofractionation). <h3>Results</h3> Across 19 cities in Colombia, 149 participants enrolled: 61 radiation oncologists, 59 medical physicists, 7 radiation oncology residents, 18 physics residents, 1 technologist, and 1 dosimetrist. 33 physicians responded both surveys. More respondents chose hypofractionation after the curriculum for all scenarios (mean "pre-curriculum" score=5.9, vs. "post-curriculum" score = 4.15, p=0.03). For breast cancer, hypofractionation use after N0 lumpectomy increased by 24.2% for older patients (51% to 75%, p=0.766) and 18.2% for younger patients (42% to 60%, p=0.00), and for locally advanced postmastectomy increased by 12.1% (76% to 85%, p=0.435). For prostate cancer, use for unfavorable intermediate-risk patients increased by 15% (67% to 82%, p=0.176), for favorable intermediate-risk by 12.1% (76% to 85%, p=0.00), and for high-risk by 12.1% (42% to 54%, p=0.52). For rectal cancer, the increase in hypofractionation for T3N1 and T4N1 mid-rectal patients was 24.2% and 21.2%, respectively. In CNS high-grade gliomas respondents increased the use of hypofractionation in older patients with poor performance status (18.2%). At baseline, education was perceived as a barrier for the use of breast (ultra-hypo/hypo), prostate (ultra-hypo/hypo), rectal, and CNS hypofractionation in 69.7%, 45.5%, 78.8%, 63.6%, respectively. These percentages decreased by 24.2%, 9.1%, 18.2% and 12.1%. When asked if the course had increased their confidence and knowledge towards hypofractionation 100% of respondents said yes. <h3>Discussion</h3> Education is a perceived barrier for the use of ultra-hypofractionation schedules in a LMIC with a bundled payment system. An E-learning approach appears to be feasible and effective at reducing the educational barrier and increasing the use of hypofractionation.

Building PRM in sub-Saharan Africa.

It is estimated that about 50% of people in low- and middle- income countries who require rehabilitation do not get it. Multidisciplinary rehabilitation services led by Physical and Rehabilitation Medicine (PRM) physicians have been shown to improve functioning, independence and the quality of life of persons with reduced functioning or disability. However, there is a dearth of PRM physicians in low to middle income countries (LMICs), particularly in sub-Saharan Africa. One potential solution to this lack of specialists is the establishment of PRM training programs, which are currently lacking. The International Rehabilitation Forum (IRF) developed and implemented a fellowship program to train physicians in rehabilitation medicine and has been successful in Ghana, Ethiopia and Cameroon, all LMICs in sub-Saharan Africa. However, ongoing challenges include inadequate PRM trainers, availability of logistics and services for hands on experience, and funding. The fellowship program has a promising future and an ultimate goal of having locally trained fellows leading the program and expanding it to other LMICs. There has however been no publication of the process followed to achieve this or of a similar process undertaken anywhere in Africa. The process followed in this publication highlights the journey from engaging stakeholders to the admission of new and current fellows in training.

Effect of environment and season on acute decompensated heart failure: Data from low-to middle-income country

ObjectivesThe environmental effect in heart failure (HF) patients is well established. However, the data is limited from low-to middle-income countries like India. This study determined the impact of environment on acute decompensated HF (ADHF) admissions and mortality in India. MethodsRetrospectively, the data of all HF patients admitted between April 2017 and March 2019 was accessed through electronic hospital records. Simultaneously, the environmental-related data was collected from the central pollution control board. ResultsThe study included 4561 patients of ADHF. The peak of monthly ADHF events (admission and mortality) was observed during the chilly month (January) while the lowest rates were observed in summer months (May–June). The most significant factor correlating inversely with the monthly ADHF admission (r = −0.78, p = 0.003) and mortality (r = −0.65, p = 0.004) was the maximum air temperature, and it was found to be the independent predictor for both ADHF mortality [t = −2.78, β = −0.84; 95%CI(-6.0 to −0.6), p = 0.021] and admission [t = −4.83, β = −0.91; 95%CI(-19.8 to −6.9), p = 0.001]. The above correlation was better seen in the elderly subset and male gender. Humidity and the air pollution attributes did not have a significant correlation with ADHF admission or mortality. ConclusionIn conclusion, even in low-to middle-income country like India, a periodic effect of season was demonstrated for ADHF mortality and admission, with a peak in ADHF events noted during winter months especially in the regions having extremes of seasons. Air pollution could not affect the ADHF outcome for which further studies are needed.

The role of CFA/I in adherence and toxin delivery by ETEC expressing multiple colonization factors in the human enteroid model.

Enterotoxigenic Escherichia coli (ETEC) is a primary causative agent of diarrhea in travelers and young children in low-to-middle-income countries (LMICs). ETEC adhere to intestinal epithelia via colonization factors (CFs) and secrete heat-stable toxin (ST) and/or heat-labile toxin (LT), causing dysregulated cellular ion transport and water secretion. ETEC isolates often harbor genes encoding more than one CF that are targets as vaccine antigens. CFA/I is a major CF that is associated with ETEC that causes moderate-to-severe diarrhea and plays an important role in pathogenesis. The Global Enteric Multicenter Study finding that 78% of CFA/I-expressing ETEC also encode the minor CF CS21 prompted investigation of the combined role of these two CFs. Western blots and electron microscopy demonstrated growth media-dependent and strain-dependent differences in CFA/I and CS21 expression. The critical role of CFA/I in adherence by ETEC strains expressing CFA/I and CS21 was demonstrated using the human enteroid model and a series of CFA/I- and CS21-specific mutants. Furthermore, only anti-CFA/I antibodies inhibited adherence by global ETEC isolates expressing CFA/I and CS21. Delivery of ST and resulting cGMP secretion was measured in supernatants from infected enteroid monolayers, and strain-specific ST delivery and time-dependent cGMP production was observed. Interestingly, cGMP levels were similar across wildtype and CF-deficient strains, reflecting a limitation of this static aerobic infection model. Despite adherence by ETEC and delivery of ST, the enteroid monolayer integrity was not disrupted, as shown by the lack of decrease in transepithelial electrical resistance and the lack of IL-8 cytokines produced during infection. Taken together, these data demonstrate that targeting CFA/I in global clinical CFA/I-CS21 strains is sufficient for adherence inhibition, supporting a vaccine strategy that focuses on blocking major CFs. In addition, the human enteroid model has significant utility for the study of ETEC pathogenesis and evaluation of vaccine-induced functional antibody responses.

A Step towards Achieving Sustainable Otologic Surgery in Low-Resource Settings: A Cost Comparison between Shipping an Otologic versus Microscopic Surgical Setup.

Background: The advancement of otologic surgery in low-resource settings has been limited by the cost and transport of surgical equipment. This study compared the transportation costs of an otologic microscopic surgical setup (MSS) versus an endoscopic surgical setup (ESS) in low- and low to middle-income countries (LMICs) for surgical teaching. Methods: Dimensions of microscopes, endoscopes and associated surgical instruments were used to calculate shipping costs from Minneapolis, MN, USA to Kenya, Haiti and Sri Lanka. Results: The average cost of internationally shipping the ESS is less than the MSS in Kenya (ESS: USD 1344.03; MSS: USD 20,947.00; p = 0.370), Haiti (ESS: USD 549.11; MSS: USD 1679.00; p < 0.05) and Sri Lanka (ESS: USD 945.38; MSS: USD 8490.57; p = 0.377). Freight shipping was required for the MSS while the ESS can be packed into an international checked bag for USD 35.00 USD. Discussion: The ESS has fewer logistical barriers than the MSS, making the endoscope a feasible option for surgical teaching in LMICs.

Core outcomes in neonatal encephalopathy: a qualitative study with parents

ObjectiveTo identify the outcomes considered important to parents or caregivers of infants diagnosed with neonatal encephalopathy, hypoxic ischaemic encephalopathy or birth asphyxia in high-income and low- to middle-income countries (LMiCs),...