Outcomes In Low- And Middle-income Countries Research Articles

An Analysis of Factors Associated with Burn Injury Outcomes in Low- and Middle-Income Countries

BackgroundBurn injuries are a major cause of morbidity and mortality within low- and middle-income countries (LMICs). The World Health Organization developed the Global Burn Registry to centralize data collection for the guidance of burn prevention programs. This study analyzed the epidemiologic and hospital-specific factors associated with burn injury outcomes in LMICs and high-income countries (HICs). MethodsA retrospective review was performed using the Global Burn Registry over 3 y. Patients were stratified by income region. Bivariate analyses and stepwise regressions were performed to evaluate patient and hospital demographics and variables associated with injury patterns and outcomes. Outcomes of interest included mortality and length of stay. ResultsOver the study period, data were collected on 1995 patients from 10 LMICs (20 hospitals) and four HICs (four hospitals). Significantly higher mortality was seen in LMICs compared with HICs (17% versus 9%; P < 0.001). There was no significant difference between income regions for injury patterns (P = 0.062) or total body surface area of the burn injury (P = 0.077). Of the LMIC hospitals in this data set, 11% did not have reliable access to an operating theater. ConclusionsHICs had a lower overall mortality even with higher rates of concurrent injuries, as well as longer length of stay. LMIC hospitals had fewer resources available, which could explain increased mortality, given similar total body surface area. This study highlights how investing in health care infrastructure could lead to improved outcomes for patients in low-resource settings.

Management of neuroblastoma in limited-resource settings.

BACKGROUNDNeuroblastoma (NB) is a heterogeneous disease with variable outcomes among countries. Little is known about NB in low- and middle-income countries (LMICs).AIMThe aim of this review was to evaluate regional management protocols and challenges in treating NB in paediatric oncology units in LMICs compared to high-income countries (HICs).METHODSPubMed, Global Health, Embase, SciELO, African Index Medicus and Google Scholar were searched for publications with keywords pertaining to NB, LMICs and outcomes. Only English language manuscripts and abstracts were included. A descriptive review was done, and tables illustrating the findings were constructed.RESULTSLimited information beyond single-institution experiences regarding NB outcomes in LMICs was available. The disease characteristics varied among countries for the following variables: sex, age at presentation, MYCN amplification, stage and outcome. LMICs were found to be burdened with a higher percentage of stage 4 and high-risk NB compared to HICs. Implementation of evidence-based treatment protocols was still a barrier to care. Many socioeconomic variables also influenced the diagnosis, management and follow-up of patients with NB.CONCLUSIONPatients presented at a later age with more advanced disease in LMICs. Management was limited by the lack of resources and genetic studies for improved NB classification. Further research is needed to develop modified diagnostic and treatment protocols for LMICs in the face of limited resources.

A Systematic Review of Household and Family Alcohol Use and Adolescent Behavioural Outcomes in Low- and Middle-Income Countries

Exposure to alcohol misuse is considered an adverse childhood experience impacting on neurodevelopmental and behavioural outcomes in adolescents including substance use, mental illness, problem behaviours, suicidality, and teenage pregnancy. Most research on this issue has focussed on higher income countries, whereas patterns of alcohol use and related factors may be different in low- and middle-income countries (LMICs). This systematic review therefore seeks to collate all published studies from 1990–2020 on the topic set in LMICs. 43 studies were included, totalling 70,609 participants from 18 LMICs. Outcomes assessed included: substance use; depression/anxiety; suicidal ideation; problem behaviour; emotional dysfunction; teenage pregnancy; and self-harm. Despite heterogeneity in the studies identified, this review documented some association between exposure to household alcohol misuse and adverse adolescent outcomes in LMICs, including mental health problems, problem behaviours, and suicidality. The mechanisms leading to these outcomes are likely varied, and further research in different socio-economic and cultural contexts, particularly in the form of longitudinal studies, is called for.

Screening and diagnostic imaging at centers performing congenital heart surgery in low- and middle-income countries.

Purpose: The International Quality Improvement Collaborative (IQIC) for CHD has aimed to improve the quality of care and surgical outcomes in low-and middle-income countries (LMICs). Little is known about prenatal and postnatal diagnostic imaging infrastructure gaps for CHD in LMICs. Methods: A survey was administered to all sites participating in IQIC using a REDCap database. This survey included assessment of imaging infrastructure and workforce. Responses were summarized as medians [25th, 75th percentiles] for continuous …

Outcomes associated with anaesthetic techniques for caesarean section in low- and middle-income countries: a secondary analysis of WHO surveys

Associations between anaesthetic techniques and pregnancy outcomes were assessed among 129,742 pregnancies delivered by caesarean section (CS) in low- and middle-income countries (LMICs) using two WHO databases. Anaesthesia was categorized as general anaesthesia (GA) and neuraxial anaesthesia (NA). Outcomes included maternal death (MD), maternal near miss (MNM), severe maternal outcome (SMO), intensive care unit (ICU) admission, early neonatal death (END), neonatal near miss (NNM), severe neonatal outcome (SNO), Apgar score <7 at 5 minutes, and neonatal ICU (NICU) admission. A two‐stage approach of individual participant data meta‐analysis was used to combine the results. Adjusted odds ratio (OR) with 95% confidence intervals (CIs) were presented. Compared to GA, NA were associated with decreased odds of MD (pooled OR 0.28; 95% CI 0.10, 0.78), MNM (pooled OR 0.25; 95% CI 0.21, 0.31), SMO (pooled OR 0.24; 95% CI 0.20,0.28), ICU admission (pooled OR 0.17; 95% CI 0.13, 0.22), NNM (pooled OR 0.63; 95% CI 0.55, 0.73), SNO (pooled OR 0.55; 95% CI 0.48, 0.63), Apgar score <7 at 5 minutes (pooled OR 0.35; 95% CI 0.29, 0.43), and NICU admission (pooled OR 0.53; 95% CI 0.45, 0.62). NA therefore was associated with decreased odds of adverse pregnancy outcomes in LMICs.

Maternal body mass index and risks of neonatal mortality and offspring overweight and obesity: Findings from 0.5 million samples in 61 low- and middle-income countries.

Evidence on associations of maternal overweight and obesity with risks of offspring mortality and obesity is limited in low- and middle-income countries (LMICs). We aimed to assess the associations of maternal overweight and obesity with neonatal mortality, and offspring overweight and obesity in LMICs. Data were from the Demographic and Health Surveys in 61 LMICs. A total of 507 203 pairs of mother and offspring were included in the analysis for neonatal mortality, and 455 534 pairs in the analysis for overweight and obesity in offspring aged 3 to 59 months. Survey logistic regression models were used to examine the associations of maternal overweight and obesity with neonatal mortality, and offspring overweight and obesity in consideration of complex survey design with adjustment for potential covariates. Compared with mothers having normal weight, neonatal mortality risks were increased in mothers having overweight, modest obesity and severe obesity, with ORs (95% CIs) of 1.32 (1.17-1.49), 1.50 (1.27-1.77) and 1.56 (1.22-1.98), respectively. In addition, offspring with mothers having overweight, modest obesity and severe obesity were at increased risks of overweight (with ORs [95% CIs] of 1.32 [1.24-1.40], 1.61 [1.48-1.74] and 1.69 [1.52-1.88], respectively) and obesity (with ORs [95% CIs] of 1.23 [1.13-1.34], 1.22 [1.10-1.35] and 1.42 [1.21-1.66], respectively). Our results suggest that maternal overweight and obesity increased the risks of neonatal mortality, and offspring overweight and obesity in LMICs. Maternal weight control should be considered as the highest priority goal for preventing offspring's adverse health outcomes in LMICs.

Household energy insecurity: dimensions and consequences for women, infants and children in low- and middle-income countries.

Energy insecurity, the lack of access to adequate, affordable, reliable, acceptable, and clean sources of energy for a healthy and sustainable livelihood, poses a challenge to several households. However, the conceptualization of its dimensions and role in the health outcomes of women, infants, and children in most sub-Saharan African countries have rarely been investigated systematically. We assessed the dimensions and adverse consequences of household energy insecurity (HEINS) in a sample of 347 Ghanaians and 420 Nigerians, with over 80% participation of women. The majority of respondents from Ghana (57%) and Nigeria (80%) had experienced of energy insecurity, at least once in the last four weeks. Following the energy insecurity framework, the experiences of participants were classified into physical, behavioral, and economic dimensions of energy insecurity. The consequences of energy insecurity grouped into psychosocial, nutritional, and disease domains. The development of a national as well as a cross-culturally validated scale that embodies these dimensions and domains will facilitate the assessment of the prevalence, causes, and consequences of HEINS. This will eventually enable the development of interventions and policies to mitigate energy insecurity and unearth modifiable factors that influence deleterious maternal, infant and child health outcomes in low-and middle-income countries.

Implementation Strategies and the Uptake of the World Health Organization Surgical Safety Checklist in Low and Middle Income Countries: A Systematic Review and Meta-analysis.

To identify the implementation strategies used in World Health Organization Surgical Safety Checklist (SSC) uptake in low- and middle-income countries (LMICs); examine any association of implementation strategies with implementation effectiveness; and to assess the clinical impact. The SSC is associated with improved surgical outcomes but effective implementation strategies are poorly understood. We searched the Cochrane library, MEDLINE, EMBASE and PsycINFO from June 2008 to February 2019 and included primary studies on SSC use in LMICs. Coprimary objectives were identification of implementation strategies used and evaluation of associations between strategies and implementation effectiveness. To assess the clinical impact of the SSC, we estimated overall pooled relative risks for mortality and morbidity. The study was registered on PROSPERO (CRD42018100034). We screened 1562 citations and included 47 papers. Median number of discrete implementation strategies used per study was 4 (IQR: 1-14, range 0-28). No strategies were identified in 12 studies. SSC implementation occurred with high penetration (81%, SD 20%) and fidelity (85%, SD 13%), but we did not detect an association between implementation strategies and implementation outcomes. SSC use was associated with a reduction in mortality (RR 0.77; 95% CI 0.67-0.89), all complications (RR 0.56; 95% CI 0.45-0.71) and infectious complications (RR 0.44; 95% CI 0.37-0.52). The SSC is used with high fidelity and penetration is associated with improved clinical outcomes in LMICs. Implementation appears well supported by a small number of tailored strategies. Further application of implementation science methodology is required among the global surgical community.

Determinants of clean birthing practices in low- and middle-income countries: a scoping review

BackgroundInfection is a leading cause of maternal and newborn mortality in low- and middle-income countries (LMIC). Clean birthing practices are fundamental to infection prevention efforts, but these are inadequate in LMIC. This scoping study reviews the literature on studies that describe determinants of clean birthing practices of healthcare workers or mothers during the perinatal period in LMIC.MethodsWe reviewed literature published between January 2000 and February 2018 providing information on behaviour change interventions, behaviours or behavioural determinants during the perinatal period in LMIC. Following a multi-stage screening process, we extracted key data manually from studies. We mapped identified determinants according to the COM-B behavioural framework, which posits that behaviour is shaped by three categories of determinants – capability, opportunity and motivation.ResultsSeventy-eight studies were included in the review: 47 observational studies and 31 studies evaluating an intervention. 51% had a household or community focus, 28% had a healthcare facility focus and 21% focused on both. We identified 31 determinants of clean birthing practices. Determinants related to clean birthing practices as a generalised set of behaviours featured in 50 studies; determinants related specifically to one or more of six predefined behaviours – commonly referred to as “the six cleans” – featured in 31 studies. Determinants of hand hygiene (n = 13) and clean cord care (n = 11) were most commonly reported. Reported determinants across all studies clustered around psychological capability (knowledge) and physical opportunity (access to resources). However, greater heterogeneity in reported behavioural determinants was found across studies investigating specific clean birthing practices compared to those studying clean birthing as a generalised set of behaviours.ConclusionsEfforts to combine clean birthing practices into a single suite of behaviours – such as the “six cleans”– may simplify policy and advocacy efforts. However, each clean practice has a unique set of determinants and understanding what drives or hinders the adoption of these individual practices is critical to designing more effective interventions to improve hygiene behaviours and neonatal and maternal health outcomes in LMIC. Current understanding in this regard remains limited. More theory-grounded formative research is required to understand motivators and social influences across different contexts.

The effects of diagnosis-related groups payment on hospital healthcare in China: a systematic review

BackgroundThere has been a growing interest in using diagnosis-related groups (DRGs) payment to reimburse inpatient care worldwide. But its effects on healthcare and health outcomes are controversial, and the evidence from low- and middle- income countries (LMICs) is especially scarce. The objective of this study is to evaluate the effects of DRGs payment on healthcare and health outcomes in China.MethodA systematic review was conducted. We searched literature databases of PubMed, Cochrane Library, EMBASE, Web of Science, Chinese National Knowledge Infrastructure and SinoMed for empirical studies examining the effects of DRGs payment on healthcare in mainland China. We performed a narrative synthesis of outcomes regarding expenditure, efficiency, quality and equity of healthcare, and assessed the quality of evidence.ResultsTwenty-three publications representing thirteen DRGs payment studies were included, including six controlled before after studies, two interrupted time series studies and five uncontrolled before-after studies. All studies compared DRGs payment to fee-for-service, with or without an overall budget, in settings of tertiary (7), secondary (7) and primary care (1). The involved participants varied from specific groups to all inpatients. DRGs payment mildly reduced the length of stay. Impairment of equity of healthcare was consistently reported, especially for patients exempted from DRGs payment, including: patient selection, cost-shifting and inferior quality of healthcare. However, findings on total expenditure, out of pocket payment (OOP) and quality of healthcare were inconsistent. The quality of the evidence was generally low or very low due to the study design and potential risk of bias of included studies.ConclusionDRGs payment may mildly improve the efficiency but impair the equity and quality of healthcare, especially for patients exempted from this payment scheme, and may cause up-coding of medical records. However, DRGs payment may or may not contain the total expenditure or OOP, depending on the components design of the payment. Policymakers should very carefully consider each component of DRGs payment design against policy goals. Well-designed randomised trials or comparative studies are warranted to consolidate the evidence of the effects of DRGs payment on healthcare and health outcomes in LMICs to inform policymaking.

A systematic literature review of school climate in low and middle income countries

Research on school climate has largely been conducted in high-income countries, with less focus on school climate in low-and middle-income countries (LMICs). As such, there is limited understanding of how school climate may be associated with students’ socio-emotional, behavioral, and academic outcomes in these contexts. Five reviewers completed a two-stage review process; 35 articles met inclusion criteria for review. Results indicated a lack of consensus in the research around what constitutes or how to measure school climate, but consistent associations with socio-emotional, behavioral, and academic outcomes were found. Although findings suggested that school climate is associated with positive student outcomes in LMICs, additional work is needed to increase the rigor of school climate research and its impact in these settings.

Impact of maternal mental health interventions on child-related outcomes in low- and middle-income countries: a systematic review and meta-analysis.

Observational studies have shown a relationship between maternal mental health (MMH) and child development, but few studies have evaluated whether MMH interventions improve child-related outcomes, particularly in low- and middle-income countries. The objective of this review is to synthesise findings on the effectiveness of MMH interventions to improve child-related outcomes in low- and middle-income countries (LMICs). We searched for randomised controlled trials conducted in LMICs evaluating interventions with a MMH component and reporting children's outcomes. Meta-analysis was performed on outcomes included in at least two trials. We identified 21 trials with 28 284 mother-child dyads. Most trials were conducted in middle-income countries, evaluating home visiting interventions delivered by general health workers, starting in the third trimester of pregnancy. Only ten trials described acceptable methods for blinding outcome assessors. Four trials showed high risk of bias in at least two of the seven domains assessed in this review. Narrative synthesis showed promising but inconclusive findings for child-related outcomes. Meta-analysis identified a sizeable impact of interventions on exclusive breastfeeding (risk ratio = 1.39, 95% confidence interval (CI): 1.13-1.71, ten trials, N = 4749 mother-child dyads, I2 = 61%) and a small effect on child height-for-age at 6-months (std. mean difference = 0.13, 95% CI: 0.02-0.24, three trials, N = 1388, I2 = 0%). Meta-analyses did not identify intervention benefits for child cognitive and other growth outcomes; however, few trials measured these outcomes. These findings support the importance of MMH to improve child-related outcomes in LMICs, particularly exclusive breastfeeding. Given, the small number of trials and methodological limitations, more rigorous trials should be conducted.

Harmonization of Biosafety and Biosecurity Standards for High-Containment Facilities in Low- and Middle-Income Countries: An Approach From the Perspective of Occupational Safety and Health.

Following the global-level Ebola virus disease (EVD) outbreak during 2014–2016, international collaboration with multiorganizational participation has rapidly increased. Given the greater priorities for research and development (R&D) outcomes despite the quantitative and qualitative lack of high-containment laboratory facilities in low- and middle-income countries (LMICs), where biological targets for investigation are located near their natural habitats, occupational readiness for health workers' safety has not been well-addressed, where limited global expert human resources are being deployed to high-containment laboratories including biosafety level 4 (BSL-4) facilities for case management and medical investigations. Pursuing scientific and managerial success to make laboratories efficient and productive, most laboratory safety policies have focused on the functionality of technical skills or performance, procedural methodologies, and supervision over the employees to collaborate in LMICs. The experts dispatched from advanced countries bring a long list of scientific tasks with high-tech devices, supplies, and training programs to introduce their collaboration with local partners in LMICs. However, the dispatched experts would subsequently realize their list becomes endless to establish their basic functions required in high-containment laboratories to ensure qualified scientific outcomes in LMICs. Under such circumstances where dual or multiple policies and standards accommodated pose dilemmas for operational procedures to ensure biosafety and biosecurity, all the frontline experts from both LMICs and advanced countries may be exposed to significant risks of life-threating infection of highly pathogenic agents like EVD, without any pragmatic measures or road maps to establish valued international collaboration, pursuing its sustainability. Given the fact mentioned above, we conducted a quick review of the key biosafety and biosecurity management documents, relevant policy analyses, and research to understand the current status and, if any, measures to dissolve critical dilemmas mentioned above. As a result, we found that occupational safety and health (OSH) aspects had not been sufficiently addressed, particularly in the context of international BSL-4 collaboration in LMICs. Moreover, consideration of OSH can be one of the key drivers to make such collaborative interventions more pragmatic, safer to reorient, harness disease-based vertical approaches, and harmonize policies of biosafety and biosecurity, particularly for collaborations organized in resource-limited settings.

Sleep problems and depression among 237 023 community-dwelling adults in 46 low- and middle-income countries

Sleep problems are considered a core symptom of depression. However, there is little information about the comorbidity of sleep problems and depression in low- and middle-income countries (LMICs), and whether sleep problems with depression confer additional risk for decrements in health compared to sleep problems alone. This study thus examined the association between sleep problems and depression and whether sleep problems with depression are associated with an increased risk for poorer health in 46 LMICs. Cross-sectional, community-based data from 237 023 adults aged ≥18 years from the World Health Survey (WHS) 2002–2004 were analyzed. Information on sleep problems (severe/extreme) and International Classification of Diseases 10th Revision depression/depression subtypes was collected. Multivariable logistic (binary and multinomial) and linear regression analyses were performed. Sleep problems were associated with subsyndromal depression (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.84–2.70), brief depressive episode (OR = 2.48, 95% CI = 2.09–2.95) and depressive episode (OR = 3.61, 95% CI = 3.24–4.03). Sleep problems with depression (vs. sleep problems alone) conferred additional risk for anxiety, perceived stress and decrements in health in the domains of mobility, self-care, pain, cognition, and interpersonal activities. Clinicians should be aware that the co-occurrence of sleep problems and depression is associated with a variety of adverse health outcomes in LMICs. Detecting this co-occurrence may be important for treatment planning.

Impact of mobile health (mHealth) interventions during the perinatal period for mothers in low- and middle-income countries: a systematic review.

The primary objective of this review was to determine the impact of mother-targeted mobile health (mHealth) educational interventions available during the perinatal period in low- and middle-income countries (LMICs) on maternal and neonatal outcomes. There has been significant growth of mHealth projects in LMICs. The use of mHealth interventions across the perinatal period offers the ability to share information with mothers about essential newborn care and to encourage mothers to attend perinatal clinics to obtain additional in-person support as needed. The impact of perinatal mHealth educational interventions on maternal behavior change and early neonatal mortality and morbidity outcomes in LMICs is unknown. This review considered studies that included mHealth educational interventions targeting mothers living in LMICs during the antenatal or postnatal period using mobile devices. The intervention must have been initiated during the antenatal period (conception through birth) through six weeks postnatally. All experimental study designs were included. Outcomes included maternal knowledge, maternal self-efficacy, antenatal/postnatal care attendance and newborn early morbidity and mortality. PubMed, Embase and CINAHL were searched on March 19, 2018 for studies published in English. The search was updated on June 7, 2018. Critical appraisal was undertaken by two independent reviewers using standardized critical appraisal instruments. Quantitative data were extracted from included studies independently by two reviewers using a standardized data extraction tool. All conflicts were resolved through consensus with a third reviewer. Quantitative data were, where possible, pooled in statistical meta-analysis. Where statistical pooling was not possible, the findings were reported narratively. A total of 1514 articles were screened, and 71 full-text papers were assessed for eligibility, with 23 articles critically appraised. Following appraisal, three articles were excluded due to poor quality. Of the 20 articles included, 16 were peer reviewed articles and four were gray literature reports. Eight papers targeted antenatal education, eight covered postnatal education and four covered both antenatal and postnatal education. Studies varied in terms of design, country, approach, frequency and content. Mothers who received an mHealth intervention attended a significantly greater number of antenatal care contacts (mean difference = 0.67, 95% confidence interval, 0.35 to 0.99, P = 0.0001) and were significantly more likely to have at least one postnatal care contact between six and eight weeks (odds ratio = 1.36, 95% confidence interval, 1.00 to 1.85, P = 0.05). Maternal knowledge, self-efficacy and neonatal mortality and morbidity were inconsistently reported across studies. mHealth education interventions are associated with increased maternal contact antenatally and postnatally in LMICs. Due to heterogeneity of studies among country of implementation, approach, frequency and content of the mHealth interventions, the impact on other maternal and neonatal outcomes is inconclusive. Future work using mHealth to target maternal education during the perinatal period should focus on standardization of content and outcome evaluations.

Self-management of non-communicable diseases in low- and middle-income countries: A scoping review.

BackgroundThe prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries (LMICs). Self-management, which enables patients to better manage their health, presents a potentially-scalable means of mitigating the growing burden of NCDs in LMICs. Though the effectiveness of self-management interventions in high-income countries is well-documented, the use of these strategies in LMICs has yet to be thoroughly summarized.ObjectiveThe purpose of this scoping review is to summarize the nature and effectiveness of past interventions that have enabled the self-management of NCDs in LMICs.MethodsUsing the scoping review methodology proposed by Arksey and O’Malley, PubMed was searched for relevant articles published between January 2007 and December 2018. The implemented search strategy comprised three major themes: self-management, NCDs and LMICs.ResultsThirty-six original research articles were selected for inclusion. The selected studies largely focused on the self-management of diabetes (N = 21), hypertension (N = 7) and heart failure (N = 5). Most interventions involved the use of short message service (SMS, N = 17) or phone calls (N = 12), while others incorporated educational sessions (N = 10) or the deployment of medical devices (N = 4). The interventions were generally effective and often led to improvements in physiologic indicators, patient self-care and/or patient quality of life. However, the studies emphasized results in small populations, with little indication of future scaling of the intervention. Furthermore, the results indicate a need for further research into the self-management of cardiovascular diseases, as well as for the co-management of diabetes and cardiovascular disease.ConclusionsSelf-management appears to be an effective means of improving health outcomes in LMICs. Future strategies should include patients and clinicians in all stages of design and development, allowing for a focus on long-term sustainability, scalability and interoperability of the intervention in the target setting.

A traumatic brain injury prognostic model to support in-hospital triage in a low-income country: a machine learning-based approach.

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide, with a disproportionate burden of this injury on low- and middle-income countries (LMICs). Limited access to diagnostic technologies and highly skilled providers combined with high patient volumes contributes to poor outcomes in LMICs. Prognostic modeling as a clinical decision support tool, in theory, could optimize the use of existing resources and support timely treatment decisions in LMICs. The objective of this study was to develop a machine learning-based prognostic model using data from Kilimanjaro Christian Medical Centre in Moshi, Tanzania. This study is a secondary analysis of a TBI data registry including 3138 patients. The authors tested nine different machine learning techniques to identify the prognostic model with the greatest area under the receiver operating characteristic curve (AUC). Input data included demographics, vital signs, injury type, and treatment received. The outcome variable was the discharge score on the Glasgow Outcome Scale-Extended. The AUC for the prognostic models varied from 66.2% (k-nearest neighbors) to 86.5% (Bayesian generalized linear model). An increasing Glasgow Coma Scale score, increasing pulse oximetry values, and undergoing TBI surgery were predictive of a good recovery, while injuries suffered from a motor vehicle crash and increasing age were predictive of a poor recovery. The authors developed a TBI prognostic model with a substantial level of accuracy in a low-resource setting. Further research is needed to externally validate the model and test the algorithm as a clinical decision support tool.

Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries.

Inadequate micronutrient intakes are relatively common in low‐ and middle‐income countries (LMICs), especially among pregnant women, who have increased micronutrient requirements. This can lead to an increase in adverse pregnancy and birth outcomes. This review presents the conclusions of a task force that set out to assess the prevalence of inadequate micronutrient intakes and adverse birth outcomes in LMICs; the data from trials comparing multiple micronutrient supplements (MMS) that contain iron and folic acid (IFA) with IFA supplements alone; the risks of reaching the upper intake levels with MMS; and the cost‐effectiveness of MMS compared with IFA. Recent meta‐analyses demonstrate that MMS can reduce the risks of preterm birth, low birth weight, and small for gestational age in comparison with IFA alone. An individual‐participant data meta‐analysis also revealed even greater benefits for anemic and underweight women and female infants. Importantly, there was no increased risk of harm for the pregnant women or their infants with MMS. These data suggest that countries with inadequate micronutrient intakes should consider supplementing pregnant women with MMS as a cost‐effective method to reduce the risk of adverse birth outcomes.

Audit of Early Mortality among Patients Admitted to the General Medical Ward at a District Hospital in Botswana.

Background:Mortality among adult general medical admissions has been reported to be high across sub-Saharan Africa, yet there is a paucity of literature on causes of general medical inpatient mortality and quality-related factors that may contribute to the high incidence of deaths. Based on a prior study at our hospital as well as our clinical experience, death early in the hospitalization is common among patients admitted to the adult medical wards.Objective:Quantify early inpatient mortality and identify factors contributing to early in-hospital mortality of medical patients in a resource-limited hospital setting in Botswana.Methods:Twenty-seven cases of patients who died within 48 hours of admission to the general medical wards at Scottish Livingstone Hospital in Molepolole, Botswana from December 1, 2015–April 25, 2016 were retrospectively reviewed through a modified root cause analysis.Findings:Early in-hospital mortality was most frequently attributed to septic shock, identified in 20 (74%) of 27 cases. The most common care management problems were delay in administration of antibiotics (15, 56%), inappropriate fluid management (15, 56%), and deficient coordination of care (15, 56%). The most common contributing factors were inadequate provider knowledge and skills in 25 cases (93%), high complexity of presenting condition in 20 (74%), and inadequate communication between team members in 18 (67%).Conclusions:Poor patient outcomes in low-and middle-income countries like Botswana are often attributed to resource limitations. Our findings suggest that while early in-hospital mortality in such settings is associated with severe presenting conditions like septic shock, primary contributors to lack of better outcomes may be healthcare-provider and system-factors rather than lack of diagnostic and therapeutic resources. Low-cost interventions to improve knowledge, skills and communication through a focus on provider education and process improvement may provide the key to reducing early in-hospital mortality and improving hospitalization outcomes in this setting.

Estratégias de Intervenção para Adesão ao Tratamento do Câncer Infantojuvenil: Relato de Caso

Introdução: O câncer infantil é considerado um problema de saúde pública em razão do seu impacto na mortalidade. O abandono de tratamento é apontado como uma das principais causas de insucesso da terapêutica; dessa forma, estratégias para evitar o abandono são fundamentais para a melhora dos resultados de tratamento em países de baixa e média rendas. Relato do caso: Paciente com 4 anos e 11 meses de idade, admitido na instituição com massa abdominal à direita de crescimento rápido. A biópsia da tumoração confirmou se tratar de neoplasia maligna. O plano de tratamento incluiu quimioterapia e radioterapia. O paciente teve acompanhamento irregular com múltiplas faltas às consultas, aos exames agendados e ao tratamento devido ao contexto socioeconômico em que estava inserido. A equipe multiprofissional orientou à família sobre a importância do tratamento, buscando salvaguardar a saúde da criança, assim como garantir a continuidade do tratamento. As estratégias implementadas foram: institucionais, articulação com a rede e suporte social. Conclusão: Após diversas intervenções da equipe multiprofissional do INCA , foi possível contribuir para aderência da criança ao tratamento proposto.