Management In Resource-limited Settings Research Articles

Developing conceptual framework and methodological considerations in community-supported chronic disease management

Developing conceptual framework and methodological considerations in community-supported chronic disease management

Wound Bed Preparation 2024: Delphi Consensus on Foot Ulcer Management in Resource-Limited Settings.

Wound Bed Preparation 2024: Delphi Consensus on Foot Ulcer Management in Resource-Limited Settings.

Wound bed preparation 2024: Delphi consensus on foot ulcer management in resource-limited settings

Wound bed preparation 2024: Delphi consensus on foot ulcer management in resource-limited settings

Wound Bed Preparation 2024: Delphi Consensus on Foot Ulcer Management in Resource-Limited Settings.

To review a practical and scientifically sound application of the wound bed preparation model for communities without ideal resources. This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care. After participating in this educational activity, the participant will:1. Summarize issues related to wound assessment.2. Identify a class of drugs for the treatment of type II diabetes mellitus that has been shown to improve glycemia, nephroprotection, and cardiovascular outcomes.3. Synthesize strategies for wound management, including treatment in resource-limited settings.4. Specify the target time for edge advancement in chronic, healable wounds.

Case report on "Spontaneous Remission in Paroxysmal Nocturnal Hemoglobinuria: A Rare Phenomenon

ABSTRACT Background: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disorder characterized by a deficiency of GPI-anchored proteins on blood cells. It is associated with hemolysis, thromboembolic events, and bone marrow failure. Management includes complement inhibitors, anticoagulation, and stem cell transplantation. Spontaneous remission of PNH is rarely reported. Case Presentation: A 28-year-old male initially diagnosed with aplastic anemia developed PVT and was subsequently diagnosed with PNH. Due to the unavailability of complement inhibitors, anticoagulation therapy and supportive care were employed. Splenectomy with splenorenal shunt was performed for chronic thrombosis and associated complications. The patient achieved spontaneous remission with normalized blood counts and diminished PNH clone. Conclusion: Managing PNH in resource-limited settings presents challenges due to the unavailability of complement inhibitors. Spontaneous remission of PNH is rarely reported and needs further research. Multidisciplinary approach, accessibility to diagnostic tests and advanced treatments will enhance PNH management in resource limited settings.

Improving the Treatment of Neonatal Sepsis in Resource-Limited Settings: Gaps and Recommendations.

Neonatal sepsis causes significant global morbidity and mortality, with the highest burden in resource-limited settings where 99% of neonatal deaths occur. There are multiple challenges to achieving successful treatment of neonates in this setting. Firstly, reliable and low-cost strategies for risk identification are urgently needed to facilitate treatment as early as possible. Improved laboratory capacity to allow identification of causative organisms would support antimicrobial stewardship. Antibiotic treatment is still hampered by availability, but also increasingly by antimicrobial resistance - making surveillance of organisms and judicious antibiotic use a priority. Finally, supportive care is key in the management of the neonate with sepsis and has been underrecognized as a priority in resource-limited settings. This includes fluid balance and nutritional support in the acute phase, and follow-up care in order to mitigate complications and optimise long-term outcomes. There is much more work to be done in identifying the holistic needs of neonates and their families to provide effective family-integrated interventions and complete the package of neonatal sepsis management in resource-limited settings.

Use of risk-based cervical screening programs in resource-limited settings

Cervical cancer screening and management in the U.S. has adopted a risk-based approach. However, the majority of cervical cancer cases and deaths occur in resource-limited settings, where screening and management are not widely available. We describe a conceptual model that optimizes cervical cancer screening and management in resource-limited settings by utilizing a risk-based approach. The principles of risk-based screening and management in resource limited settings include (1) ensure that the screening method effectively separates low-risk from high-risk patients; (2) directing resources to populations at the highest cancer risk; (3) screen using HPV testing via self-sampling; (4) utilize HPV genotyping to improve risk stratification and better determine who will benefit from treatment, and (5) automated visual evaluation with artificial intelligence may further improve risk stratification. Risk-based screening and management in resource limited settings can optimize prevention by focusing triage and treatment resources on the highest risk patients while minimizing interventions in lower risk patients.

Penetrating cardiac injury presentation and management in resource-limited settings: A case series from Ethiopia

Introduction and importancePenetrating cardiac injury is rare (0.1 % of trauma admissions) but fatal. Presentation is with features of cardiac tamponade or hemorrhagic shock. Urgent clinical evaluation, ultrasound, temporizing pericardiocentesis or surgical repair with cardiopulmonary bypass as back up consist of standard management. In this paper, experience of management of penetrating cardiac injury from a resource limited country is presented. Case presentationsThere were seven patients, five had a stab injury and two had gunshot wound. All were men with mean age of 31.1 years. Patients arrived within 30 min (3), 2 h (2), 4 h (1) and 18 h (1) after injury. Mean initial blood pressure and pulse rates were 83/51 mm Hg and 121, respectively. One patient had pericardiocentesis before referral. Exploration was via left anterolateral thoracotomy. Four (57.1 %) had right ventricle perforation, one had both right and left ventricle, and two (28.5 %) had left ventricle perforation. Suture repair (6) and pericardial patch (1) were done without bypass machine as back up. Mean duration of stay in the intensive care unit and in the surgical wards were 4.4 days (range: 2–15) and 10.8 days (range: 1–48), respectively. All were discharged improved. Clinical discussionPenetrating cardiac injury presents with low blood pressure and tachycardia after stab or gunshot wounds. Right ventricle is mostly affected. Pericardiocentesis can be done as temporary measure. While having bypass machine as back up is recommended, the absence of it should not preclude intervention. Suture repair can be done with left anterolateral thoracotomy. ConclusionPenetrating cardiac injury can be managed in resource limited settings without back up of cardiopulmonary bypass. Early identification and surgical intervention results in favorable outcome.

Urolithiasis Management in Resource-Limited Settings: A Multicentric Retrospective Study in the Democratic Republic of Congo

Introduction: Despite the increasing use of minimally invasive surgery techniques in the management of urolithiasis worldwide, resource-limited countries are still experiencing various challenges. This study aims to analyze different therapeutic modalities used in the treatment of urolithiasis in the Democratic Republic of Congo. Methods: After Institutional Review Board approval, records of 194 patients who presented with documented urolithiasis in 13 hospitals across 4 provinces from January 2010 through September 2019 were retrospectively analyzed. The different layers of stones were analyzed by infrared spectrophotometry. Results: Urolithiasis was symptomatic in 52.6% (n=194) of patients. Overall, 86.1% (i.e. 167 out of 194) of stones were removed by surgery, 9.8% spontaneously resolved; 3.1% were extracted after ureteroscopy and 1% of patients had undergone extracorporeal shock wave lithotripsy. Lumbotomy was the most used route (45.2% of cases) in conventional surgery. Conclusion: Most patients in this study were treated by conventional surgery. These results suggest the need to increase the use of minimally invasive surgery.

Pediatric brain tumors in low- and middle-income countries: available evidence on recent advancements in management, challenges, and recommendations – editorial

Pediatric brain tumors in low- and middle-income countries: available evidence on recent advancements in management, challenges, and recommendations – editorial

Leveraging Responsible, Explainable, and Local Artificial Intelligence Solutions for Clinical Public Health in the Global South.

In the present paper, we will explore how artificial intelligence (AI) and big data analytics (BDA) can help address clinical public and global health needs in the Global South, leveraging and capitalizing on our experience with the "Africa-Canada Artificial Intelligence and Data Innovation Consortium" (ACADIC) Project in the Global South, and focusing on the ethical and regulatory challenges we had to face. "Clinical public health" can be defined as an interdisciplinary field, at the intersection of clinical medicine and public health, whilst "clinical global health" is the practice of clinical public health with a special focus on health issue management in resource-limited settings and contexts, including the Global South. As such, clinical public and global health represent vital approaches, instrumental in (i) applying a community/population perspective to clinical practice as well as a clinical lens to community/population health, (ii) identifying health needs both at the individual and community/population levels, (iii) systematically addressing the determinants of health, including the social and structural ones, (iv) reaching the goals of population's health and well-being, especially of socially vulnerable, underserved communities, (v) better coordinating and integrating the delivery of healthcare provisions, (vi) strengthening health promotion, health protection, and health equity, and (vii) closing gender inequality and other (ethnic and socio-economic) disparities and gaps. Clinical public and global health are called to respond to the more pressing healthcare needs and challenges of our contemporary society, for which AI and BDA can help unlock new options and perspectives. In the aftermath of the still ongoing COVID-19 pandemic, the future trend of AI and BDA in the healthcare field will be devoted to building a more healthy, resilient society, able to face several challenges arising from globally networked hyper-risks, including ageing, multimorbidity, chronic disease accumulation, and climate change.

Case report on "Spontaneous Remission in Paroxysmal Nocturnal Hemoglobinuria: A Rare Phenomenon

Background: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disorder characterized by a deficiency of GPI-anchored proteins on blood cells. It is associated with hemolysis, thromboembolic events, and bone marrow failure. Management includes complement inhibitors, anticoagulation, and stem cell transplantation. Spontaneous remission of PNH is rarely reported. Case Presentation: A 28-year-old male initially diagnosed with aplastic anemia developed PVT and was subsequently diagnosed with PNH. Due to the unavailability of complement inhibitors, anticoagulation therapy and supportive care were employed. Splenectomy with splenorenal shunt was performed for chronic thrombosis and associated complications. The patient achieved spontaneous remission with normalized blood counts and diminished PNH clone. Conclusion: Managing PNH in resource-limited settings presents challenges due to the unavailability of complement inhibitors. Spontaneous remission of PNH is rarely reported and needs further research. Multidisciplinary approach, accessibility to diagnostic tests and advanced treatments will enhance PNH management in resource limited settings.

Admission Forced Vital Capacity Adds a Predictive Physiologic Tool to Triage Patients Suffering Rib Fractures: A Prospective Observation Trial.

Patients with rib fractures are at high risk for morbidity and mortality. This study prospectively examines bedside percent predicted forced vital capacity (% pFVC) in predicting complications for patients suffering multiple rib fractures. The authors hypothesize that increased % pFVC is associated with reduced pulmonary complications. Adult patients with =3 rib fractures admitted to a level I trauma center, without cervical spinal cord injury or severe traumatic brain injury, were consecutively enrolled. FVC was measured at admission and % pFVC values were calculated for each patient. Patient were grouped by % pFVC <30% (low), 30-49% (moderate), and =50% (high). A total of 79 patients were enrolled. Percent pFVC groups were similar except for pneumothorax being most frequent in the low group (47.8% vs. 13.9% and 20.0%, p = .028). Pulmonary complications were infrequent and did not differ between groups (8.7% vs. 5.6% vs. 0%, p = .198). Increased % pFVC was associated with reduced hospital and intensive care unit (ICU) length of stay (LOS) and increased time to discharge to home. Percent pFVC should be used in addition to other factors to risk stratify patients with multiple rib fractures. Bedside spirometry is a simple tool that can help guide management in resource-limited settings, especially in large-scale combat operations. This study prospectively demonstrates that % pFVC at admission represents an objective physiologic assessment that can be used to identify patients likely to require an increased level of hospital care.

High morbidity and mortality associated with primary bloodstream infections among pediatric patients with cancer at a Guatemalan tertiary referral hospital.

Infectious complications remain major contributors to adverse outcomes in patients treated for non-communicable disease, particularly in resource limited settings. We performed a 5-year retrospective study of primary bloodstream infections at a dedicated pediatric oncology center in Guatemala. Two hundred and twelve episodes occurring in 194 unique patients qualified for inclusion. Patients required intensive care unit admission in 55% of episodes and death occurred in 24% of episodes. Despite subspecialty support in infectious diseases, poor outcomes, including prolonged hospitalization and mortality, were frequent. Our findings suggest that investments in laboratory and clinical data collection are critical to understanding the contributors to poor outcomes and therefore to improving the quality of bloodstream infection management in resource limited settings.

A simple guide to ultrasound screening for placenta accreta spectrum for improving detection and optimizing management in resource limited settings.

Placenta accreta spectrum is a pregnancy complication associated with severe morbidity and maternal mortality especially when not suspected antenatally and appropriate management instigated. Women in resource-limited settings are more likely to face adverse outcomes due to logistic, technical, and resource inadequacies. Accurate prenatal imaging is an important step in ensuring good outcomes because it allows adequate preparation and an appropriate management approach. This article provides a simple three-step approach aimed at guiding clinicians and sonographers with minimal experience in placental accreta spectrum through risk stratification and basic prenatal screening for this condition both with and without Doppler ultrasound.

Economic burden of malaria in Burundian children: An evidence for disease management in resource limited settings

In Burundi, malaria is the leading cause of morbidity and mortality, especially in children under five. This results in high clinical burden of the disease; however, its economic burden remains unknown. The aim of this study was to estimate the economic burden associated with malaria in Burundi and explore the factors that can affect the costs. This study was a prospective incidence-based cost-of-illness study analysed from the societal perspective. The study included children aged under five years with malaria infection, who visited and received treatment at any of the two study health facilities in the period of November to December 2019. Data collection was done by reviewing medical and financial records and by interviewing caregivers of the patients. Micro-costing approach was used to estimate the economic costs of malaria per episode. The cost was presented in international dollars (Int$) for the year 2019. Stepwise multiple linear regression method was applied to examine the factors affecting the costs and to generate a cost model. Eighty-five children with the average age of 29 months were included in the study. Most of them (70.5%) were treated as in-patient. The out-patient visits costed Int$23.5, while the in-patient hospitalization costed Int$218.2. The types of medical services, health facilities, antimalarials used, and duration of fever before seeking appropriate medical care were found to affect the costs. The model indicates that up to Int$18.76 can be saved per malaria episode if treated early (in less than 2 days). This can save up to Int$24,257,748 per year at national level. This study demonstrated that malaria is associated with a considerable economic burden in Burundi. It will support decision makers in deciding an appropriate clinical management for malaria prevention like the community case management program.

Management of Refractory Status Epilepticus: An International Cohort Study (MORSE CODe) Analysis of Patients Managed in the ICU.

Status epilepticus that continues after the initial benzodiazepine and a second anticonvulsant medication is known as refractory status epilepticus (RSE). Management is highly variable because adequately powered clinical trials are missing. We aimed to determine whether propofol and midazolam were equally effective in controlling RSE in the intensive care unit, focusing on management in resource-limited settings. Patients with RSE treated with midazolam or propofol between January 2015 and December 2018 were retrospectively identified among 9 centers across 4 continents from upper-middle-income economies in Latin America and high-income economies in North America, Europe, and Asia. Demographics, Status Epilepticus Severity Score, etiology, treatment details, and discharge modified Rankin Scale (mRS) were collected. The primary outcome measure was good functional outcome defined as a mRS score of 0-2 at hospital discharge. Three hundred eighty-seven episodes of RSE (386 patients) were included, with 162 (42%) from upper-middle-income and 225 (58%) from high-income economies. Three hundred six (79%) had acute and 79 (21%) remote etiologies. Initial RSE management included midazolam in 266 (69%) and propofol in 121 episodes (31%). Seventy episodes (26%) that were initially treated with midazolam and 42 (35%) with propofol required the addition of a second anesthetic to treat RSE. Baseline characteristics and outcomes of patients treated with midazolam or propofol were similar. Breakthrough (odds ratio [OR] 1.6, 95% CI 1.3-2.0) and withdrawal seizures (OR 2.0, 95% CI 1.7-2.5) were associated with an increased number of days requiring continuous intravenous anticonvulsant medications (cIV-ACMs). Prolonged EEG monitoring was associated with fewer days of cIV-ACMs (1-24 hours OR 0.5, 95% CI 0.2-0.9, and &gt;24 hours OR 0.7, 95% CI 0.5-1.0; reference EEG &lt;1 hour). This association was seen in both, high-income and upper-middle-income economies, but was particularly prominent in high-income countries. One hundred ten patients (28%) were dead, and 80 (21%) had good functional outcomes at hospital discharge. Outcomes of patients with RSE managed in the intensive care unit with propofol or midazolam infusions are comparable. Prolonged EEG monitoring may allow physicians to decrease the duration of anesthetic infusions safely, but this will depend on the implementation of RSE management protocols. Goal-directed management approaches including EEG targets may hold promise for patients with RSE. This study provides Class III data that propofol and midazolam are equivalently efficacious for RSE.

Evaluating a novel, low-cost technique for cervical-spine immobilization for application in resource-limited LMICs: a non-inferiority trial.

Non-inferiority trial. Limited cervical spinal (c-spine) immobilization in resource-limited settings of LMICs suggests alternatives are necessary for patients with traumatic injuries. We propose a novel method of c-spine immobilization using folded towels. Washington University in St. Louis. Using non-inferiority trial design, thirty healthy patients (median age = 22) were enrolled to test the efficacy of folded towels in comparison with rigid cervical collars, foam neck braces, and no immobilization. We measured cervical range of motion (CROM) in six cardinal directions in seated and supine positions. A weighted composite score (CS) was generated to compare immobilization methods. A preserved fraction of 75% was determined for non-inferiority, corresponding to the difference between the median values for CROM between control (no immobilization) and c-collar states. C-collars reduce median CROM in six cardinal directions in seated and supine positions by an average of -36.83° seated (-17.75° supine) vs. no immobilization. Folded towels and foam neck braces reduced CROM by -27° seated (-16.75° supine) and -14.25° seated (-9.5° supine), respectively. Compared to a 25% non-inferiority margin (permitting an average 9.21° of cervical movement across six cardinal directions), the CS determined folded towels are non-inferior (CSseated = 0.89, CSsupine = 0.47). Foam neck braces are inferior (CSseated = 2.35, CSsupine = 2.10). CS > 1 surpassed the non-inferiority margin and were deemed inferior. Folded towels are a non-inferior means of immobilizing c-spine in extension and rotation, but not flexion, vs. c-collars. We propose folded towels could be trialed in combination with backboards to deliver affordable and effective prehospital TSCI management in resource-limited settings.

Bilateral chylothorax following neck dissection on a child—Diagnosis and management in resource-limited settings: a case report

Bilateral chylothorax is a rare complication following neck dissection, with fewer than thirty cases being reported over the last century. A serious life-threatening condition mostly encountered during thoracic procedures and dissections. In our case, conservative management resulted in complete resolution. We report a case of a 4-year-old child who underwent deep neck dissection due to recurrent hemangioma. She developed bilateral chylothorax and a conservative approach led to complete resolution.

Acute Myeloid Leukemia in Western Kenya: A Snapshot

Introduction: Steady advances in the treatment of acute myeloid leukemia (AML) have improved outcomes in high-resource settings, with a 5-year overall survival rate of 29% and rising in the United States. In contrast, a diagnosis of AML in many resource-limited settings automatically confers a less than 10% one-year survival rate. To better understand this significant disparity, as well as how to narrow it, it is important to gather data illustrating the current landscape of AML management in resource limited-settings, including patient characteristics, disease-related and treatment-related factors. Here we examine the population of patients with AML at a single large academic medical center in Western Kenya that serves a catchment area of more than 20 million people.Objectives: To describe characteristics of patients presenting with AML at Moi Teaching and Referral Hospital (MTRH) hematology and oncology clinic between 2014 and 2020, to help identify areas of need to inform future interventions.Methodology: Retrospective, cross-sectional chart review study of all newly diagnosed patients (age 15 years and older) with AML presenting to the MTRH adult hematology and oncology clinic from January 2014 to December 2020.Results: We reviewed the charts of 113 patients with AML. The median age at diagnosis was 40 years (range 15-86 years), with an average age of 42 years. Forty-nine percent (n=55) were female. Thirty-five patients did not have French American British (FAB) subtypes documented (this method remains the main form of AML disease classification in this resource-limited setting). M2 subtype was the most common (n= 24). Seven patients had acute promyelocytic leukemia (APML), of which 4 died due to bleeding complications and lack of access to ATRA. Three APML patients who had access to ATRA were alive more than 1 year after diagnosis. White blood count (WBC) at diagnosis ranged between 600/cm3 and 336,000/cm3 with neutrophil predominance. Mean hemoglobin at presentation was 7g/dl (range 2.6g/dl-16g/dl). Most patients had been transfused with red blood cells prior to presentation and continue to require more transfusion. Platelet counts ranged between 4,000/cm3 to 782,000/cm3 with 36% of patients (n=41) having a count of less than 50,000/cm3. Fifty patients with AML received low dose subcutaneous cytarabine (20mg subcutaneous twice a day for 10 days every 4 to 6 weeks) and 3 patients had etoposide added to their treatment (50mg/m2 intravenous once a day for 7 days). No patient was treated with standard intensive induction chemotherapy, (7+3), due to lack of adequate supportive care. Only 5 of 63 (7.9%) non-APML patients whose outcomes were established survived for more than 12 months. The median overall survival at after diagnosis was 45 days. Thirteen percent of patients were lost to follow up (n= 15) and 1 patient was referred to another facility for possible induction with 7+3.Conclusion: AML remains a disparately lethal disease in resource-limited settings, where it impacts a relatively healthy, young patient population. In well-resourced settings, many of these patients would have a reasonable chance at long term survival and potential cure, but in Western Kenya most patients die within a few months of diagnosis. Due to the lack of adequate supportive care resources, even the younger patients mostly did not receive standard-of-care intensive induction therapy. The outdated FAB classification system is still in use. Lack of access to improved diagnostics, appropriate supportive care (antimicrobials and transfusion products) and limited availability of newer, effective, and less toxic treatment regimens are the main impedance to care. More efforts are needed to improve the management of acute leukemia in under-resourced countries. DisclosuresLeBlanc: Pfizer: Consultancy, Other: Advisory Board; Otsuka: Consultancy, Honoraria, Other; Daiichi-Sankyo: Consultancy, Honoraria, Other: Advisory board; AbbVie: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; Flatiron: Consultancy, Other: Advisory board; Helsinn: Consultancy, Research Funding; Duke University: Research Funding; Agios: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; Amgen: Consultancy, Other: travel; BMS/Celgene: Consultancy, Honoraria, Other: Travel fees, Research Funding, Speakers Bureau; Jazz Pharmaceuticals: Research Funding; Astellas: Consultancy, Honoraria, Other: Advisory board; American Cancer Society: Research Funding; Heron: Consultancy, Honoraria, Other: advisory board; AstraZeneca: Consultancy, Honoraria, Other: Advisory board, Research Funding; Seattle Genetics: Consultancy, Other: Advisory board, Research Funding; CareVive: Consultancy, Other, Research Funding; NINR/NIH: Research Funding; UpToDate: Patents & Royalties.