Low Middle-income Countries Research Articles

The impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries: a systematic review of the evidence

BackgroundLow- and middle-income countries have committed to achieving universal health coverage (UHC) as a means to enhance access to services and improve financial protection. One of the key health financing reforms to achieve UHC is the introduction or expansion of health insurance to enhance access to basic health services, including maternal and reproductive health care. However, there is a paucity of evidence of the extent to which these reforms have had impact on the main policy objectives of enhancing service utilization and financial protection. The aim of this systematic review is to assess the existing evidence on the causal impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries.MethodsThe review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search included six databases: Medline, Embase, Web of Science, Cochrane, CINAHL, and Scopus as of 23rd May 2023. The keywords included health insurance, impact, utilisation, financial protection, and maternal and reproductive health. The search was followed by independent title and abstract screening and full text review by two reviewers using the Covidence software. Studies published in English since 2010, which reported on the impact of health insurance on maternal and reproductive health utilisation and or financial protection were included in the review. The ROBINS-I tool was used to assess the quality of the included studies.ResultsA total of 17 studies fulfilled the inclusion criteria. The majority of the studies (82.4%, n = 14) were nationally representative. Most studies found that health insurance had a significant positive impact on having at least four antenatal care (ANC) visits, delivery at a health facility and having a delivery assisted by a skilled attendant with average treatment effects ranging from 0.02 to 0.11, 0.03 to 0.34 and 0.03 to 0.23 respectively. There was no evidence that health insurance had increased postnatal care, access to contraception and financial protection for maternal and reproductive health services. Various maternal and reproductive health indicators were reported in studies. ANC had the greatest number of reported indicators (n = 10), followed by financial protection (n = 6), postnatal care (n = 5), and delivery care (n = 4). The overall quality of the evidence was moderate based on the risk of bias assessment.ConclusionThe introduction or expansion of various types of health insurance can be a useful intervention to improve ANC (receiving at least four ANC visits) and delivery care (delivery at health facility and delivery assisted by skilled birth attendant) service utilization in low- and lower-middle-income countries. Implementation of health insurance could enable countries’ progress towards UHC and reduce maternal mortality. However, more research using rigorous impact evaluation methods is needed to investigate the causal impact of health insurance coverage on postnatal care utilization, contraceptive use and financial protection both in the general population and by socioeconomic status.Trial registrationThis study was registered with Prospero (CRD42021285776).

Abstract LB336: The African Cancer Atlas: Leveraging African data to diversify precision oncology

Abstract Africa has some of the highest age adjusted cancer mortality rates globally and cancer incidence in Africa is expected to double by 2040. Despite this disproportionate burden of disease, African cancer patients are woefully understudied along the cancer continuum. People of African descent are significantly underrepresented in cancer research, accounting for less than 3% of globally available genomic data and are often the least well served by advances in precision medicine.To address this gap, we have initiated the African Cancer Atlas project. This is an Africa-centred approach to overcoming cancer inequities - providing much needed biological and clinical data, but also seeking to identify and address the social determinants of inequities both within the continent and between high and low-middle income countries (LMIC). We have established an oncology partner network across 9 geographically dispersed African countries (Senegal, Côte d’Ivoire, Ghana, Nigeria, Kenya, Uganda, Zimbabwe, South Africa, and Tunisia). We have developed LMIC-specific standardised protocols and best practices for sample collection and processing across multiple sites and continue to build a well-annotated bank of tissue, plasma, bone marrow and PBMC from individuals with breast, prostate, gastrointestinal cancers, liver, urinogenital and pediatric cancers that will be unrivalled in its diversity. So far, 1800 cancer samples have been collected and banked. We have also built a unique cloud-based clinical data management platform to facilitate the collection of longitudinal clinical metadata into a unified clinico-demographic database. We have initiated extensive genomic and molecular profiling of African-specific cancers using whole exome/genome sequencing (WES/WGS) of paired germline and tumour samples as well as RNA- sequencing of tumors. We have so far completed the first 200 WES, representing the first cancer samples sequenced entirely on the African continent. Ongoing work is investigating how population-specific genetic variation contributes to cancer risk, identifying driver mutations, somatic copy number alterations (SCNAs) and mutational signatures that can point to disease-relevant environmental exposures or impaired core biological pathways. Comparative analysis with existing cancer genomics cohorts will determine the prevalence of known hotspot mutations, cancer drivers and or common SCNAs in African cancer genomes. By comparing with available data for African Americans and other diasporan Africans, we will provide better understanding of cancer aetiology related to African ancestry applicable to the broader African diasporic communities in other regions of the world. We are also collecting data to assess socio-economic and health system factors affecting access to cancer care and survival across all study sites. Socio-demographic data collection is integrated with tissue/biodata collection creating digital longitudinal hospital-based cohorts. We will develop systems that integrate genomics, molecular demographics and clinical data with machine learning and a publicly accessible portal for data access and analytics will be available for the broader scientific community. Ultimately, this project will contribute towards better understanding of cancer among people of African descent and make precision oncology more effective for diverse populations. Citation Format: Yaw Bediako, Joyce Ngoi, Ruth Kiome, Seth Agyemang, Stephen Darkoh, Audrey Lemacon, Aida Manu, Frank Onyambu, Kanny Diallo, Lily Paemka, David Hutchful, Emmanuella Amoako, Abdoulaye Diallo. The African Cancer Atlas: Leveraging African data to diversify precision oncology [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB336.

Pneumocystis pneumonia in HIV-positive and non-HIV patients: a retrospective comparative study from a lower-middle income country.

In this study, we compared the predisposing factors, key demographic and clinical characteristics, clinical outcomes, and factors associated with poor prognosis in pneumocystis pneumonia (PCP) infection among the human immunodeficiency virus (HIV)-positive and non-HIV patient populations. This retrospective analysis was conducted at the Aga Khan University Hospital, Karachi, via the collection and analysis of patient records with a diagnosis of "pneumocystosis" between January 2015 and October 2020. Additionally, the laboratory database was evaluated, and patients with a laboratory-confirmed diagnosis of PCP were included. During the study period, 52 laboratory-confirmed hospitalized PCP patients were identified. Of these, 23 and 29 patients were diagnosed using microscopy and polymerase chain reaction, respectively. 34.6% of our patients were HIV positive, with a median CD4 count of 20.5 cells/mm3 (range: 10.7-50.5). Other conditions identified were corticosteroid use, autoimmune diseases, malignancy, radiation, and chemotherapy. On chest imaging, consolidation was found in 30%, ground-glass opacities in 24%, and nodular infiltrates in 20% of the cases. HIV-positive patients had a lower hemoglobin level and a higher level of β-D-glucan at the time of admission, whereas non-HIV patients were found to have more co-morbid conditions than HIV patients. We observed no difference in clinical outcomes between the two populations. Factors associated with a poor prognosis among our patients included concomitant infections at the time of diagnosis, the need for invasive mechanical ventilation, and a longer duration of stay in the hospital as well as the intensive care unit.

Pediatric neurosurgical medulloblastoma outcomes in La Paz, Bolivia: How a Lower Middle-Income Country (LMIC) institution in South America compares to the United States.

How pediatric medulloblastoma patients fare in Lower Middle-Income Country (LMICs) in South America is not well understood. Correspondingly, the aim of this study was to summarize the pediatric neurosurgical experience of an institution in La Paz, and compare outcomes to that of a generalized High Income Country (HIC) United States (US) experience. A retrospective review of all pediatric neurosurgical medulloblastoma patients at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2014 and 2023 was conducted and compared to a generalized US experience abstracted from the US National Cancer Database (NCDB) and National Inpatient Sample (NIS) databases. Categorical, continuous and survival data were statistically summarized and compared. A total of 24 pediatric medulloblastoma patients underwent neurosurgical treatment at the Hospital del Niño. In this La Paz cohort, there were 15 (63%) males and 9 (38%) females, with a mean age of 5.6 years old at diagnosis. The majority of patients underwent subtotal resection (STR, 79%), while the remaining patients underwent biopsy only. Ten (42%) patients expired during their hospitalization, and mean length of stay overall was 39 days. Only 8 (33%) patients received adjuvant treatment after surgery. Median overall survival from diagnosis in the La Paz cohort was 1.9 months. Compared to the US databases, the La Paz cohort experienced significantly more emergency room admissions for surgery, less gross total resection, more STR, more return to operating room for ventriculoperitoneal shunting, more bacteremia, more tracheostomy procedures, more percutaneous gastrostomy placements, longer lengths of stay, less adjuvant chemotherapy, less radiation therapy, shorter follow-up, and ultimately, significantly shorter overall survival (all P < 0.050). Pediatric neurosurgical medulloblastoma outcomes at the Children's Hospital of La Paz, Bolivia are significantly inferior to that of a generalized US experience. Future research is required to identify institution- and country-specific initiatives to improve discrepancies between institutions in LMICs in South America compared to HICs.

Defunctioning ileostomy for typhoid ileal perforations: Out of the frying pan into the fire?

Typhoid ileal perforation (TIP) is a common surgical emergency in low-middle income countries (LMICs). Its high surgical morbidity and mortality is due to its often late presentation or diagnosis, the patient's malnutrition, severe peritoneal contamination and unavailability of intensive care in most peripheral hospitals. This prompted the philosophy of minimizing the crisis by avoiding any repair or anastomosis, limiting the surgery in these physiologically compromised patients and performing only a temporary defunctioning ileostomy (DI) which could then be closed 10-12 weeks later.

Cultural competency and ethical behavior for collaboration in limited-resource settings: Guidelines from the Society of University Surgeons Academic Global Surgery Committee and the Association for Academic Global Surgery

BackgroundThere are an increasing number of global surgery activities worldwide. With such tremendous growth, there is a potential risk for untoward interactions between high-income country members and low-middle income country members, leading to programmatic failure, poor results, and/or low impact. MethodsKey concepts for cultural competency and ethical behavior were generated by the Academic Global Surgery Committee of the Society for University Surgeons in collaboration with the Association for Academic Global Surgery. Both societies ensured active participation from high-income countries and low-middle income countries. ResultsThe guidelines provide a framework for cultural competency and ethical behavior for high-income country members when collaborating with low-middle income country partners by offering recommendations for: (1) preparation for work with low-middle income countries; (2) process standardization; (3) working with the local community; (4) limits of practice; (5) patient autonomy and consent; (6) trainees; (7) potential pitfalls; and (8) gray areas. ConclusionThe article provides an actionable framework to address potential cultural competency and ethical behavior issues in high-income country - low-middle income country global surgery collaborations.

Factors Contributing to Increased Workplace Violence Against Nurses During COVID-19 in the Healthcare Settings of a Lower Middle-income Country: A Qualitative Study

PurposeTo provide the perceptions of nurses, nursing supervisors, and nursing administrators about factors contributing to increased workplace violence against nurses within the healthcare settings in Pakistan during the first wave of COVID-19 pandemic. MethodsThis study employed a Descriptive Qualitative design, with a purposive sampling technique. From September to December 2021, In-depth Interviews (IDIs) of 45 to 60 minutes, using a semi-structured interview guide, we collected data from a private and a public healthcare setting in Pakistan. Given the travel restrictions during COVID-19, these interviews were conducted online, using Zoom audio features. Bedside nurses, nursing supervisors, and nursing administrators with at least six months of work experience participated in this study. ResultsThe qualitative data analysis steps suggested by Braun and Clarke (2013) were used for thematic analysis. The overarching theme emerging from the data was "Factors perceived by nurses that contributed to increased workplace violence in their work settings during the first wave of COVID-19, in a lower middle-income country" The sub-themes from the participants’ narrations were (a) Highly stressed patients, attendants, and healthcare workers; (b) the financial burden on patients and their families; (c) lack of resources and shortage of staff; (d) restricted visiting policy and a weak security system; (e) lack of awareness about the seriousness of COVID-19; (f) misconceptions about COVID-19 vaccines and nurses’ role in disseminating awareness. ConclusionThe current pandemic increased the intensity of WPV against nurses in healthcare settings in Pakistan. Despite any supposed reasons for WPV, exposure to violence should never be an acceptable part of nursing. The healthcare system in Pakistan needs to pay equal attention to funding, resource provision, and ensuring a safe working environment for healthcare workers.

Knowledge and attitude on childhood cancer survivorship among healthcare trainees: a multicentre study from India

BackgroundThe proportion of childhood cancer survivors (CCS) in low/middle-income countries (LMICs) is rising. CCS often develop several physical and psycho-social long-term adverse effects, with unique healthcare needs. Primary healthcare providers...

Early Incorporation to Palliative Care (EPC) in Patients With Advanced Non-Small Cell Lung Cancer: The PACO Randomized Clinical Trial.

Patients with non-small cell lung cancer (NSCLC) experience a considerable disease burden, evident in symptomatic and psychological spheres. Advanced cancer represents a complex scenario for patients and the healthcare team. Early palliative care (EPC) has been proven as a clinically meaningful strategy in this context by several randomized trials but not in a resource-limited setting. This study aimed to evaluate the effect of EPC compared with standard oncological care (SOC) in patients with metastatic NSCLC in Mexico. A prospective, randomized clinical trial was conducted at Instituto Nacional de Cancerologia in Mexico. All patients had histologically confirmed metastatic NSCLC without previous treatment. Patients were randomly assigned (1:1) to receive SOC or SOC + EPC. The EPC group was introduced to the palliative care team at baseline after randomization, which was integrated by psychologists, bachelor's in nutrition, specialized nurses, and physicians. Patients randomized to this arm had programmed visits to meet with the team at baseline and through the 2nd, 4th-, and 6th cycles thereafter. The primary endpoint was overall survival (OS); secondary outcomes included quality of life (QoL), anxiety and depression, and symptom intensity. They were assessed using the instruments EORTC QLQ-C30 questionnaire, Edmonton Symptom Assessment Scale (ESAS), and the Hospital Anxiety and Depression Scale (HADS) (clinicaltrials.gov [NCT01631565]). Questionnaires were completed at baseline, at 2nd, 4th, and 6th cycles of treatment. Between March 2012 and June 2015, 201 patients were assessed for eligibility and 146 were enrolled and allocated to receive EPC (73) or SOC (73). Median OS for patients in the EPC vs SOC arm was 18.1 months (95% CI, 7.9-28.4) and 10.5 months (95% CI, 4.7-16.2) (P = .029). Having a poor performance status (HR 1.7 [1.2-2.5]; P = .004) and allocation to the control group (HR 1.5 [1.03-2.3]; P = .034) were independently associated with a worse OS. Those patients with a global QoL > 70 at baseline had a better OS if they were In the EPC arm (38.7 months (95% CI, 9.9-67.6) vs SOC 21.4 months (95% CI, 12.4-30.3)). Mean QoL had a numerical improvement in patients allocated to EPC after 6 cycles of follow-up, nonetheless this difference was not statistically significant (55.1 ± 23.7 vs 56.9 ± 25.3; P = .753). There were no significant differences in anxiety and depression at all study points. EPC is associated with a significant improvement in OS, although, we observed that the greatest benefit of providing EPC was observed in those with a global QoL > 70 at baseline. This study did not identify significant changes in terms of QoL or symptom burden between the study groups after follow-up. Evidence robustly suggests that EPC should be considered part of the multidisciplinary treatment of metastatic NSCLC patients since diagnosis. According to our study, EPC can be implemented in low- or middle-income countries (LMIC).

Understanding the Impact of Climate Change on Oral Health in Lower Middle-Income Countries.

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An umbrella review of health co-benefits from actions to reduce greenhouse gas emissions

BackgroundThere have been many modelled studies of potential health co-benefits from actions to reduce greenhouse gas emissions, but so far there have been no large-scale attempts to compare the magnitude of health and climate effects across sectors, countries, and study designs. MethodsAs part of the Pathfinder Initiative project an umbrella review of studies was done, and 26 previous reviews were identified with 57 primary studies included. Studies included in the review were required to have quantified changes in greenhouse gas emissions and health effects (or risk factors) from defined actions to reduce climate effects. Study data were extracted and harmonised by standardising impact measures per 100 000 of the national population (or urban population for city-level actions), averaging effects over a 1-year period and aggregating actions into their respective sectors by use of a predefined framework. FindingsFrom 200 mitigation actions, the majority were in the agriculture, forestry, and land use sector (103 actions [52%]), followed by the transport sector (43 actions [22%]). The largest effects on greenhouse gas emissions were seen from actions in the energy sector, and these actions also had substantial health co-benefits in lower middle-income countries, although benefits were smaller in high-income settings. The greatest health benefits were seen from actions to change diets and introduce clean cookstoves. The major pathways to health were through reduced air pollution, healthier diets, and increased physical activity from switching to active travel modes. Effect sizes tended to be larger from national modelling studies and smaller from localised or implemented actions. InterpretationThe potential co-benefits to health from actions to reduce climate change are large, but most evidence still comes from modelling studies and from high-income and middle-income countries. There are also major context-dependent differences in the magnitude of effects found, so actions need to be tailored to the local context and careful attention needs to be paid to potential trade-offs and spillover effects. FundingThe Wellcome Trust and the Oak Foundation.

Revisiting the relationship between natural resources and environmental quality— can ICT break the “resource curse” in the environment?

Despite the prevalence of discussions on the “resource curse”, the impact of natural resources on environmental quality for better or for worse has not been clearly answered, this study aims to answer the question by introducing the role of Information and Communication Technologies (ICT). To that end, by using the Instrumental Variable Generalized Method of Moments (IV GMM) estimator and a sample of 102 developing and emerging economies from 2006 to 2016, this paper studies the impact of ICT on the relationship between natural resources and environmental quality. Specially, the Environmental Performance Index (EPI) captures the environmental quality. The results show that natural resources have a significant negative effect on EPI, specially, EPI decreases by one unit with a 1% increase in natural resource rents. ICT significantly mitigates this adverse effect, and marginal effects analysis further confirms its positive moderate effects. The results proved to be robust by Lewbel 2SLS and Driscoll-Kraay techniques or other robust tests. It is noteworthy that the adverse effect of natural resources on EPI is greater and the mitigating effect of ICT is more pronounced in low-income countries and lower-middle income countries. Overall, these results remind resource-based countries to vigorously develop ICT, and apply intelligent exploration, digital monitoring, or other digital technologies to realize the high-efficiency use of natural resources, reducing environmental pollution and ecological damage.

Expanding Global Radiotherapy Access via Telemedicine

AimsCancer is a leading cause of death globally. Over 70% of the 10 million cancer deaths worldwide in 2020 occurred in low- and middle-income countries. Radiotherapy is an important cancer treatment, used in half of cancer patients. Significant global disparities in radiotherapy access exist, with low access in low- and middle-income countries. The benefits of tele-radiotherapy in low- and middle-income countries for expanding global radiotherapy access are yet to be fully realized. In this paper, we highlight potential applications of tele-radiotherapy in expanding access to high-quality radiotherapy in developing countries. Materials and MethodsWe performed a literature search to retrieve studies involving telemedicine applications in radiotherapy to provide a comprehensive overview of the topic. PubMed database served as the main source for retrieving studies, using the following search terms: (“telemedicine”, “radiotherapy”, “telehealth”, “remote monitoring”, “oncology”, and “remote training”). Additional selected papers were obtained from Web of Science, and Google Scholar using the same search terms. ResultsTelemedicine in radiotherapy has many applications. Virtual training could upgrade radiotherapy skills in low- and middle-income countries, enabling safe adoption of new radiotherapy techniques and quality assurance. Tele-radiotherapy consultations and patient follow-up could improve the efficiency of clinics while tele-radiotherapy planning and peer-review could enable equitable global access to radiotherapy expertise. Telemedicine could also facilitate wider global access to radiotherapy trials. While telemedicine in radiotherapy holds significant promise in improving global radiotherapy access, several barriers to its adoption exist. These include a lack of infrastructure, data security concerns, regulatory challenges, resistance from providers and patients, financial constraints, miscommunication during remote consultations, and lack of training. ConclusionTele-radiotherapy applications hold promise in providing solutions to overcome global radiotherapy access inequity but the benefits of tele-radiotherapy in low- and middle-income countries are yet to be fully realized.

Behavioural risk-factors of hypertension and its knowledge in rural South India: a cross-sectional study

Background: India, a lower middle-income country with a population of more than 1 billion is undergoing a rapid epidemiological transition characterized by an increased prevalence of non-communicable diseases. It is estimated to account for 10.8% of all deaths and 4.6% of all disability-adjusted life years in India. Hence this study is carried out to assess the socio-demographic profile and risk factors associated with hypertension (HTN) in rural India. and to determine the association between risk factors and hypertensive status. Methods: This is a community-based cross-sectional study in Shivamogga taluk of Karnataka from May-September 2023. Based on 2011 census, Shivamogga taluk has 117601 households bearing population of 507324 and sex-ratio 987 per 1000 males, 36.4% of population lives in urban area and 63.6% in rural area. Ayanur and Matthur are rural field practice area of SIMS having population of 3605 and 3144 respectively. The multi-stage random sampling method is used to study 430 study participants. Results: The study comprised of 430 participants, 162 (37.67%) were among the age group of 50-65 years, 223 (51.86%) were hypertensives and 306 (71.16%) stated that HTN adversely effects health of an individual. 381 (88.6%) opined that reducing salt intake in the diet can significantly reduce the development of HTN in an individual. Conclusions: HTN is a behavioural disease that is increasing day by day and there is no much difference between people living in urban/rural areas. Hence, this needs to be addressed at a primitive level to decrease the prevalence of NCD’s by promoting health, adopting healthy lifestyles and adherence towards medications.

Outcome of vaccinated vs nonvaccinated COVID-19 patients in an intensive care unit of a tertiary care hospital in a low-middle income country

Outcome of vaccinated vs nonvaccinated COVID-19 patients in an intensive care unit of a tertiary care hospital in a low-middle income country

Access to Child Psychotherapy in High- and Low/Middle-income Nations: A Cross-national Perspective and Potential Approaches

Psychotherapy of different types is recognized across the globe as an essential component of child and adolescent mental health services. At the same time, there are barriers and challenges in obtaining access to this modality that are as widespread as its acceptance. This article reviews barriers to accessing child and adolescent psychotherapy in high-income countries (HIC) as well as low/middle-income countries (LMIC). It also briefly reviews approaches to improve access using different interventions and modalities. We also report on our experience using one particular intervention, case management within pediatric collaborative care, as a promising approach for improving access in underserved populations.

Managing Basilar Artery Occlusions with Endovascular Thrombectomy: A Single-Center Case Series

Acute ischemic infarctions are caused by occlusions to blood vessels supplying the brain. Rapid recognition and intervention affect the course of management to provide prompt recanalization to minimize tissue injury, for which endovascular thrombectomy (EVT) has become an emerging standard of care. Recent clinical trials for basilar artery occlusions done in 2022 concluded that mechanical thrombectomy performed on patients with a National Institutes of Health Stroke Scale of ≥6 within 24 hours offers a significantly lower risk of 90-day mortality, and a 90-day modified Rankin scale of 0-3 despite the higher incidence of intracranial hemorrhage. Three of four cases of basilar artery occlusion completed their mechanical thrombectomies in our institution; two of which were performed under the recommended time window. Among those, two cases had prolonged hospital stay due to complications, but had a 90-day mRS of 3. Although larger studies should be performed for better representation of clinical outcomes, there is difficulty in gathering cases in the Philippines as it belongs to a low-middle income country with a low annual thrombectomy rate. This study reports three cases of basilar artery occlusions managed through mechanical thrombectomy in a single institution with outcomes consistent with the conclusions of the recent clinical trials.

Acute myocardial infarction complicated by cardiogenic shock in Ukraine: multicentre registry analysis 2021-2022.

Data on the results and management strategies in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) in the Low and Lower-Middle Income Countries (LLMICs) are limited. This lack of understanding of the situation partially hinders the development of effective cardiogenic shock treatment programs in this part of the world. The Ukrainian Multicentre Cardiogenic Shock Registry was analyzed, covering patient data from 2021 to 2022 in 6 major Ukrainian reperfusion centres from different parts of the country. Analysis was focusing on outcomes, therapeutic modalities and mortality predictors in AMI-CS patients. We analyzed data from 221 consecutive patients with CS from 6 hospitals across Ukraine. The causes of CS were ST-elevated myocardial infarction (85.1%), non-ST-elevated myocardial infarction (5.9%), decompensated chronic heart failure (7.7%) and arrhythmia (1.3%), with a total in-hospital mortality rate for CS of 57.1%. The prevalence of CS was 6.3% of all AMI with reperfusion rate of 90.5% for AMI-CS. In 23.5% of cases, CS developed in the hospital after admission. Mechanical circulatory support (MCS) utilization was 19.9% using intra-aortic balloon pump alone. Left main stem occlusion, reperfusion deterioration, Charlson Comorbidity Index >4, and cardiac arrest were found to be independent predictors for hospital mortality in AMI-СS. Despite the wide adoption of primary percutaneous coronary intervention as the main reperfusion strategy for AMI, СS remains a significant problem in LLMICs, associated with high in-hospital mortality. There is an unmet need for the development and implementation of a nationwide protocol for CS management and the creation of reference CS centers based on the country-wide reperfusion network, equipped with modern technologies for MCS.

Prospect of waste-to-energy technologies in selected regions of lower and lower-middle-income countries of the world

Waste-to-energy (WTE) is one of the pathways to deal with the large amount of waste generated due to urbanization and population growth. As lower and lower-middle income countries are struggling to cope up with large electricity demands, this study focuses on the feasibility analysis of implementing three of the most popular WTE technologies (incineration, landfill gas recovery and anaerobic digestion) in the five selected regions of lower and lower-middle income countries of the world, i.e., Bangladesh, Egypt, Afghanistan, Ghana and Indonesia. The selected WTE methods were assessed in terms of electricity generation potential, economic viability and socio-environmental impacts. Except for the study areas of Bangladesh and Afghanistan, incineration has shown the highest electricity generation potential having 684.21 GWh/yr, 467.93 GWh/yr and 3341.23 GWh/yr in the selected regions of Egypt, Indonesia and Ghana, respectively. The economic analysis showed that except for the study area of Ghana, incineration has the lowest levelized cost of energy (LCOE) making this pathway the most economical one in the selected regions. The environmental analysis of the WTE pathways showed that although incineration emits the least greenhouse gases (GHG), it emits more acidic gases and organic pollutants compared to anaerobic digestion. Furthermore, the sensitivity analysis showed that the net present value (NPV) is highly sensitive to the inflation rate. An increase of 27% inflation rate will increase the NPV by 66.50% for landfill gas recovery process, which is the highest among the three techniques. The overall feasibility analysis suggests that incineration will be the best option for the selected regions (except for Ghana) for its satisfactory results. The proposed WTE pathways will open doorway to the unemployed by creating more jobs as observed from the analysis of the job creation potentials.

Comparative global analysis of stroke rehabilitation recommendations across income levels

ObjectiveSuccessful implementation of stroke rehabilitation guidelines demands high-quality practice standards tailored to targeted sociodemographic contexts. The primary objective is to determine the quality differences in post-stroke rehabilitation practice guidelines (PGs), when comparing high-income countries (HIC) and low or middle-income countries (LMIC). Study Design and SettingWe conducted a scoping review of PGs in English or Spanish, published between 2012 and 2021, and providing recommendations on post-stroke rehabilitation. We used Search engines, databases, guideline libraries, gray literature, and references from previous reviews on post-stroke rehabilitation as sources of evidence. Quality assessment of PGs was performed using 6P’s, ELSE, IOM, and AGREE II instruments. We evaluated each item using a scale between 0 to 3, based on the confidence of adherence to the standard. For AGREE II, we followed the instruction manual for scoring. At least two reviewers were independently involved in every step of the process. A cloud-based spreadsheet was used to chart data. We compared the results of PGs originating from HIC with those from LMIC. ResultsThe inclusion criteria were met by 35 documents, which were subjected to evaluation. The study included 21 documents from HIC and 14 from middle-income countries (MIC). No manuscripts from low-income countries were available for inclusion in the study. The quality of PGs from MIC was found to be lower, in terms of methodological rigor and adherence to international recommendations for guidelines development. PGs from both groups of countries failed to include all target audiences and stakeholders (according to the 6P’s criteria) and integration of ethical, legal, social, and economic considerations. ConclusionThere are gaps in the quality and availability of stroke rehabilitation guidelines worldwide, especially in LMIC. Designing and providing financial support for the implementation of high-quality guidelines will contribute to more effective implementation strategies in stroke rehabilitation programs and lead to improved patient outcomes.