Patients In Low-resource Settings Research Articles

Delivering effective, comprehensive, multi-exercise component cardiac rehabilitation (CR) for chronic heart failure patients in low resource settings in sub-Saharan Africa: Queen Elizabeth Central Hospital-(QECH-CR) randomised CR study, Malawi.

The delivery of Cardiac Rehabilitation (CR) and attaining evidence-based treatment goals are challenging in developing countries, such as Malawi. The aims of this study were to (i) assess the effects of exercise training/ CR programme on cardiorespiratory and functional capacity of patients with chronic heart failure (CHF), and (ii) examine the effectiveness of a novel, hybrid CR delivery using integrated supervised hospital- and home-based caregiver approaches. A pre-registered (UMIN000045380), randomised controlled trial of CR exercise therapy in patients with CHF was conducted between September 2021 and May 2022. Sixty CHF participants were randomly assigned into a parallel design-exercise therapy (ET) (n = 30) or standard of care (n = 30) groups. Resting hemodynamics, oxygen saturation, distance walked in six-minutes (6MWD) and estimated peak oxygen consumption (VO2 peak) constituted the outcome measures. The exercise group received supervised, group, circuit-based ET once weekly within the hospital setting and prescribed home-based exercise twice weekly for 12 weeks. Participants in both arms received a group-based, health behaviour change targeted education (usual care) at baseline, 8-, 12- and 16-weeks. Most of the participants were female (57%) with a mean age of 51.9 ±15.7 years. Sixty-five percent (65%) were in New York Heart Association class III, mostly with preserved left ventricular ejection fraction (HFpEF) (mean Left Ventricular Ejection Fraction 52.9 ±10.6%). The 12-weeks ET led to significant reductions in resting haemodynamic measures (all P <0.05). The ET showed significantly higher improvements in the 6MWD (103.6 versus 13.9 m, p<0.001) and VO2 peak (3.0 versus 0.4 ml·kg-1·min-1, p <0.001). Significant improvements in 6MWD and VO2 peak (both p<0.001), in favour of ET, were also observed across all follow-up timepoints. This novel, randomised, hybrid ET-based CR, delivered to mainly HFpEF patients using an integrated hospital- and home-based approach effectively improved exercise tolerance, cardiorespiratory fitness capacities and reduced perceived exertion in a resource-limited setting.

Navigating Community-Based Psychiatry Care of Pediatric Patients in Low-Resource Settings: A Case Report

Navigating Community-Based Psychiatry Care of Pediatric Patients in Low-Resource Settings: A Case Report

Development and Validation of Hospital Mental Health Screen to Detect Psychiatric Morbidity in Medically Ill Patients in India

Background: Psychiatric morbidities often go unnoticed in medically ill patients. It is essential to screen patients with medical morbidity so that they can be referred to psychiatrists for early interventions in general hospitals in India. There is a potential lacuna in terms of the availability of a scale that can aptly identify psychiatric symptoms in medically ill patients beyond depression or anxiety, especially in low-resource settings like India. Aim: The aim was to detect psychiatric morbidity in medically ill patients in India. Methodology: Items were generated using deductive and inductive approaches. Item-Content Validity Index (I-CVI) and Scale-Content Validity Index/Universal Agreement (S-CVI/UA) were computed by involving eight subject matter specialists. The tool was circulated to 397 medically ill patients for computing The exploratory factor analysis (EFA). Domain-wise reliability using Cronbach’s alpha was calculated for six factors. The concurrent criterion validity of the Hospital Mental Health Screen (HMHS) tool was calculated by the receiver operating curve (ROC) against the gold standard of any psychiatric morbidity diagnosed by two psychiatrists in 397 medically ill patients. We used IBM SPSS version 23. Results: Initially, 34 items were generated. At the I-CVI threshold of 79%, seven items were discarded. The S-CVI/UA of the scale was 85.1%. The Kaiser–Meier–Olkin Measure of Sampling Adequacy (KMO MSA) was found to be 0.916. At a factor loading threshold of 0.4 and an eigenvalue above 1, a six-factor structure was extracted using principal component analysis and varimax rotation. Domain-wise reliability was computed, which was between 0.657 and 0.840. The final tool consisted of 27 Likert items (0 = never to 4 = always). Using the ROC curve at the 19.5 threshold, 91.4% of the positive outcomes were correctly classified and 9.5% of the adverse outcomes were expected to be incorrectly identified by the HMHS screening tool. Conclusion: HMHS is a valid and reliable tool with good screening properties, designed especially for the Indian setting. This scale can assist in identifying psychiatric morbidity in medically ill patients in low-resource settings. There is further scope for performing confirmatory factor analysis (CFA) to reinforce the factor structure of HMHS.

Is telehealth useful in the management of placenta accreta spectrum in low-resource settings? Results of an exploratory survey.

The optimal management of placenta accreta spectrum (PAS) requires the participation of multidisciplinary teams that are often not locally available in low-resource settings. Telehealth has been increasingly used to manage complex obstetric conditions. Few studies have explored the use of telehealth for PAS management, and we aimed evaluate the usage of telehealth in the management of PAS patients in low-resource settings. Between March and April 2023, an observational, survey-based study was conducted, and obstetricians-gynecologists with expertise in PAS management in low- and middle-income countries were contacted to share their opinion on the potential use of telehealth for the diagnosis and management of patients at high-risk of PAS at birth. Participants were identified based on their authorship of at least one published clinical study on PAS in the last 5 years and contacted by email. This is a secondary analysis of the results of that survey. From 158 authors contacted we obtained 65 responses from participants in 27 middle-income countries. A third of the participants reported the use of telehealth during the management obstetric emergencies (38.5%, n = 25) and PAS (36.9%, n = 24). Over 70% of those surveyed indicated that they had used "informal" telemedicine (phone call, email, or text message) during PAS management. Fifty-nine participants (90.8%) reported that recommendations given remotely by expert colleagues were useful for management of patients with PAS in their setting. Telehealth has been successfully used for the management of PAS in middle-income countries, and our survey indicates that it could support the development of specialist care in other low resource settings.

The Impact of Participating in Surgical Trips to Low Income, Low Resource Countries on Professional Development of Plastic Surgery Trainees

Title: The impact of participating in surgical trips to low income, low resource countries on professional development of plastic surgery trainees. Objective: Global health initiatives have increased in popularity in recent years, yet international surgical volunteerism remains controversial. Though many U.S. residencies incorporate global health initiatives, there is no standardization of the role that surgical volunteerism plays in resident education. Our goal was to evaluate the impact of surgical volunteerism on former plastic surgery trainees during and after residency. Methods: An electronic survey was distributed to 35 graduates of the plastic surgery residency program at the University of Minnesota between 1991 and 2019. The survey included 28 yes/no questions and free responses. The response rate was 100% (n = 35). Results: 34 of 35 former graduates (97.1%) participated in at least one international surgical trip during residency. All participants had exposure to cleft surgery, and 82.4% reported a predominance of cleft cases. 23.5% of graduates have continued to perform cleft surgery as part of their practice, and 47.1% have continued to embark on surgical trips post-residency. Participants reported that volunteering on international surgical trips have made them more adaptable in the operating room (91.2%), gave them a better understanding of the challenges of poverty (97.1%), and helped them to provide better care for marginalized patients in low resource settings (70.6%). One hundred percent of participants reported that international surgical trips were an important part of their residency training (n = 34). Conclusions: International surgical volunteer work can provide an invaluable experience during training, and they should be offered by plastic surgery residency programs. Supporting resident involvement in surgical trips can have long term ramifications in their careers and commitment to helping the underserved.

Wilms tumor treatment protocol compliance and the influence on outcomes for children in Tanzania.

Standardized Wilms tumor treatment protocols exist for low- and middle-income countries, but outcomes equivalent to high-income countries are not achieved outside of clinical trials. As Wilms tumor treatment protocols in Africa shift with increasing resource capacity, it is not known how treatment compliance to each stage of therapy affects outcomes and where the critical breakpoints are for protocol adherence in clinical practice. We describe both treatment outcomes and treatment protocol adherence in a retrospective single-center cohort study of pediatric Wilms tumor patients at a zonal cancer referral hospital in Tanzania from 2016 to 2019, treated per the International Society of Paediatric Oncology standard (2016-2017) or Tanzania adapted (2018-2019) therapy protocols. A total of 69 patients were evaluated. The two-year overall survival and event-free survival rates were 40% and 29%, respectively. Only 29% of patients completed recommended chemotherapy per protocol, and completion of preoperative and postoperative chemotherapy was predictive of two-year overall survival (odds ratio [OR] 14.4, p<.001). There were delays at almost every stage of treatment, especially time from preoperative chemotherapy to surgery (56days), from surgery to pathology report (30days), and from surgery to initiation of postoperative chemotherapy (38days). Nonadherence with recommended Wilms tumor treatment guidelines due to key health system delays correlated to reduced overall survival rates, with chemotherapy nonadherence due to abandonment, lack of surgery, and deaths on therapy as the strongest contributors. Future interventions targeting health system delays and reducing deaths during therapy are critical to improving protocol compliance and increasing overall survival for pediatric Wilms tumor patients in low-resource settings.

Development and Validation of a Three-Parameter Scoring System for Monitoring HIV/AIDS Patients in Low-Resource Settings Using Hematological Parameters.

This study aimed to test the validity of a composite score using complete blood count (CBC) for monitoring HIV patients receiving antiretroviral therapy (ART) in the absence of viral load and CD4 count. This retrospective cohort study analyzed the laboratory data of 82 HIV patients who had pre- and post-treatment viral load, CD4 count, and CBC data. Pre- and post-treatment data were pooled to analyze the correlation of CBC parameters with Polymerase Chain Reaction (PCR) ranks and their performance in indicating a CD4 count<200 cells/mm3 using the Operating Characteristics Curve (ROC), with the determination of cutoffs. A score combining the significant parameters was tested to predict a CD4 count of <200. Total lymphocyte count (TLC), percentage (TLP), and hemoglobin concentration (Hb) were the most significant parameters, showing negative correlations with PCR (Spearman's Rho = -0.357 to -0.242). The risk of acquired immunodeficiency syndrome (AIDS) was independently associated with TLC<1345 cells/mm3 (OR=2.92), TLP<29.07% (OR=3.53), and Hb<10.55 mg/dL (OR=3.60). A combined score of 2-3 indicated a CD4 count<200 with an odds ratio of 8.3-86.7. The proposed 3-parameter score combining the use of TLC, TLP, and Hb, is an affordable and practical approach that may have clinical utility in monitoring HIV patients receiving ART in low-resource settings.

Protocol: identifying policy, system, and environment change interventions to enhance availability of blood for transfusion in Kenya, a mixed-methods study

BackgroundSafe blood is essential for the care of patients with life-threatening anemia and hemorrhage. Low blood donation rates, inefficient testing procedures, and other supply chain disruptions in blood administration affect patients in low-resource settings across Sub-Saharan countries, including Kenya. Most efforts to improve access to transfusion have been unidimensional, usually focusing on only point along the blood system continuum, and have excluded community stakeholders from early stages of intervention development. Context-appropriate interventions to improve the availability of safe blood at the point of use in low-resource settings are of paramount importance. Thus, this protocol proposes a multifaceted approach to characterize the Kenyan blood supply chain through quantitative and qualitative analyses as well as an industrial engineering approach.MethodsThis study will use a mixed-methods approach in addition to engineering process mapping, modeling and simulation of blood availability in Kenya. It will be guided by a multidimensional three-by-three-by-three matrix: three socioeconomic settings, three components of the blood system continuum, and three levels of urgency of blood transfusion. Qualitative data collection includes one-on-one interviews and focus group discussions with stakeholders across the continuum to characterize ground-level deficits and potential policy, systems, and environment (PSE) interventions. Prospectively-collected quantitative data will be used to estimate blood collection and transfusion of blood. We will create a process map of the blood system continuum to model the response to PSE changes proposed by stakeholders. Lastly, we will identify those PSE changes that may have the greatest impact on blood transfusion availability, accounting for differences across socioeconomic settings and levels of urgency.DiscussionIdentifying and prioritizing community-driven interventions to improve blood supply in low-resource settings are of utmost importance. Varied constraints in blood collection, processing, delivery, and use make each socioeconomic setting unique. Using a multifaceted approach to understand the Kenyan blood supply and model the response to stakeholder-proposed PSE changes may lead to identification of contextually appropriate intervention targets to meet the transfusion needs of the population.

High mortality rates among COVID-19 intensive care patients in Iraq: insights from a retrospective cohort study at Médecins Sans Frontières supported hospital in Baghdad.

The Coronavirus Disease 2019 (COVID-19) pandemic has highlighted the challenges of the healthcare system in Iraq, which has limited intensive care unit beds, medical personnel, and equipment, contributing to high infection rates and mortality. The main purpose of the study was to describe the clinical characteristics, the length of Intensive Care Unit (ICU) stay, and the mortality outcomes of COVID-19 patients admitted to the ICU during the first wave and two subsequent surges, spanning from September 2020 to October 2021, in addition to identify potential risk factors for ICU mortality. This retrospective cohort study analyzed data from COVID-19 patients admitted to the COVID-19 ICU at Al-Kindi Ministry of Health hospital in Baghdad, Iraq, between September 2020 and October 2021. The study included 936 COVID-19 patients admitted to the ICU at Al-Kindi Hospital. Results showed a high mortality rate throughout all waves, with 60% of deaths due to respiratory failure. Older age, male gender, pre-existing medical conditions, ICU procedures, and complications were associated with increased odds of ICU mortality. The study also found a decrease in the number of complications and ICU procedures between the first and subsequent waves. There was no significant difference in the length of hospital stay between patients admitted during different waves. Despite improvements in critical care practices, the mortality rate did not significantly decrease during the second and third waves of the pandemic. The study highlights the challenges of high mortality rates among critical COVID-19 patients in low-resource settings and the importance of effective data collection to monitor clinical presentations and identify opportunities for improvement in ICU care.

Regional Implicit Racial Bias and Rates of Breast Reconstruction, Complications, and Cost Among US Patients With Breast Cancer

Racial disparities influencing breast reconstruction have been well-researched; however, the role of implicit racial bias remains unknown. An analysis of the disparities in care for patients with breast cancer may serve as a policy target to increase the access and quality of care for underserved populations. To identify whether variations in implicit racial bias by region are associated with the differences in rates of immediate breast reconstruction, complications, and cost for White patients and patients from minoritized racial and ethnic groups. This cohort study used data from the National Inpatient Sample (NIS) from 2009 to 2019. Adult female patients with a diagnosis of or genetic predisposition for breast cancer receiving immediate breast reconstruction at the time of mastectomy were included. Patients receiving both autologous free flap and implant-based reconstruction were included in this analysis. US Census Bureau data were extracted to compare rates of reconstruction proportionately. The Implicit Association Test (IAT) was used to classify whether implicit bias was associated with the primary outcome variables. Data were analyzed from April to November 2022. IAT score by US Census Bureau geographic region. Variables of interest included demographic data, rate of reconstruction, complications (reconstruction-specific and systemic), inpatient cost, and IAT score by region. Spearman correlation was used to determine associations between implicit racial bias and the reconstruction utilization rate for White patients and patients from minoritized racial and ethnic groups. Two-sample t tests were used to analyze differences in utilization, complications, and cost between the 2 groups. A total of 52 115 patients were included in our sample: 38 487 were identified as White (mean [SD] age, 52.0 [0.7] years) and 13 628 were identified as minoritized race and ethnicity (American Indian, Asian, Black, and Hispanic patients and patients with another race or ethnicity; mean [SD] age, 49.7 [10.5] years). Implicit bias was not associated with disparities in breast reconstruction rates, complications, or cost. Nonetheless, the White-to-minoritized race and ethnicity utilization ratio differed among the regions studied. Specifically, the reconstruction ratio for White patients to patients with minoritized race and ethnicity was highest for the East South Central Division, which includes Alabama, Kentucky, Mississippi, and Tennessee (2.17), and lowest for the West South Central Division, which includes Arkansas, Louisiana, Oklahoma, and Texas (0.75). In this cohort study of patients with breast cancer, regional variation of implicit bias was not associated with differences in breast reconstruction utilization, complications, or cost. Regional disparities in utilization among racial and ethnic groups suggest that collaboration from individual institutions and national organizations is needed to develop robust data collection systems. Such systems could provide surgeons with a comparative view of their care. Additionally, collaboration with high-volume breast centers may help patients in low-resource settings receive the desired reconstruction for their breast cancer care, helping improve the utilization rate and quality of care.

Evaluation of practice change following SAFE obstetric courses in Tanzania: a prospective cohort study.

Anaesthesia has been shown to contribute disproportionately to maternal mortality in low-resource settings. This figure exceeds 500 per 100,000 live births in Tanzania, where anaesthesia is mainly provided by non-physician anaesthetists, many of whom are working as independent practitioners in rural areas without any support or opportunity for continuous medical education. The three-day Safer Anaesthesia from Education (SAFE) course was developed to address this gap by providing in-service training in obstetric anaesthesia to improve patient safety. Two obstetric SAFE courses with refresher training were delivered to 75 non-physician anaesthetists in the Mbeya region of Tanzania between August 2019 and July 2020. To evaluate translation of knowledge into practice, we conducted direct observation of the SAFE obstetric participants at their workplace in five facilities using a binary checklist of expected behaviours, to assess the peri-operative management of patients undergoing caesarean deliveries. The observations were conducted over a 2-week period at pre, immediately post, 6-month and 12-month post-SAFE obstetric training. A total of 320 cases completed by 35 participants were observed. Significant improvements in behaviours, sustained at 12 months after training included: pre-operative assessment of patients (32% (pre-training) to 88% (12 months after training), p < 0.001); checking for functioning suction (73% to 85%, p = 0.003); using aseptic spinal technique (67% to 100%, p < 0.001); timely administration of prophylactic antibiotics (66% to 95%, p < 0.001); and checking spinal block adequacy (32% to 71%, p < 0.001). Our study has demonstrated positive sustained changes in the clinical practice amongst non-physician anaesthetists as a result of SAFE obstetric training. The findings can be used to guide development of a checklist specific for anaesthesia for caesarean section to improve the quality of care for patients in low-resource settings.

Development of dissolving microneedles for intradermal delivery of the long-acting antiretroviral drug bictegravir

Oral administration and intramuscular (IM) injection are commonly recommended options for human immunodeficiency virus (HIV) treatment. However, poor patient compliance due to daily oral dosing, pain at injection sites and the demand for trained healthcare staff for injections limit the success of these administration routes, especially in low-resource settings. To overcome these limitations, for the first time, we propose novel bilayer dissolving microneedles (MNs) for the intradermal delivery of long-acting nanosuspensions of the antiretroviral (ARV) drug bictegravir (BIC) for potential HIV treatment and prevention. The BIC nanosuspensions were prepared using a wet media milling technique on a laboratory scale with a particle size of 358.99 ± 18.53 nm. The drug loading of nanosuspension-loaded MNs and BIC powder-loaded MNs were 1.87 mg/0.5 cm2 and 2.16 mg/0.5 cm2, respectively. Both dissolving MNs exhibited favorable mechanical and insertion ability in the human skin simulant Parafilm® M and excised neonatal porcine skin. Importantly, the pharmacokinetic profiles of Sprague Dawley rats demonstrated that dissolving MNs were able to intradermally deliver 31% of drug loading from nanosuspension-loaded MNs in the form of drug depots. After a single application, both coarse BIC and BIC nanosuspensions achieved sustained release, maintaining plasma concentrations above human therapeutic levels (162 ng/mL) in rats for 4 weeks. These minimally invasive and potentially self-administered MNs could improve patient compliance, providing a promising platform for the delivery of nanoformulated ARVs and resulting in prolonged drug release, particularly for patients in low-resource settings.

Ehealth technology in cardiac exercise therapeutics for pediatric patients with congenital and acquired heart conditions: a summary of evidence and future directions.

Many children and adolescents with congenital and acquired heart disease (CHD) are physically inactive and participate in an insufficient amount of moderate-to-vigorous intensity exercise. Although physical activity (PA) and exercise interventions are effective at improving short- and long-term physiological and psychosocial outcomes in youth with CHD, several barriers including resource limitations, financial costs, and knowledge inhibit widespread implementation and dissemination of these beneficial programs. New and developing eHealth, mHealth, and remote monitoring technologies offer a potentially transformative and cost-effective solution to increase access to PA and exercise programs for youth with CHD, yet little has been written on this topic. In this review, a cardiac exercise therapeutics (CET) model is presented as a systematic approach to PA and exercise, with assessment and testing guiding three sequential PA and exercise intervention approaches of progressive intensity and resource requirements: (1) PA and exercise promotion within a clinical setting; (2) unsupervised exercise prescription; and (3) medically supervised fitness training intervention (i.e., cardiac rehabilitation). Using the CET model, the goal of this review is to summarize the current evidence describing the application of novel technologies within CET in populations of children and adolescents with CHD and introduce potential future applications of these technologies with an emphasis on improving equity and access to patients in low-resource settings and underserved communities.

Abstract 52: Implementation of a Hospital-Based Peer Support Intervention Model for Cancer Patients: Results From a Pilot Study in Vietnam

Abstract Purpose: Provision of mental health psychosocial support can reduce psychological distress experienced by cancer patients, which can in turn improve their treatment adherence and outcomes. In this study, we present the results from the pilot trial of Stronger Together, a culturally adapted peer-to-peer support program, conducted in Vietnam. Methods: We recruited eligible women from four hospitals in Vietnam (K3 National Cancer Hospital, Hue Central Hospital Oncology Center, Can Tho Oncology Hospital, and Hung Vong Women’s Hospital Oncology Unit). Participants were newly diagnosed with breast or gynecologic cancers, and self-selected into either the control (usual care) or intervention arm (mentees who were matched up with trained peer mentors). Validated questionnaires were administered at baseline (0), 2-, 4-, and 6-months. We conducted a difference-in-difference (DID) analysis for the primary outcomes (assessed by the Depression, Anxiety, and Stress Scale [DASS-21]), comparing the difference in scores from baseline to 6 months and between intervention arms (mentees vs. usual care). Results: The analytic sample included n=186 participants (mentees: 91; usual care: 95), with the majority having breast cancer (85.5%), followed by cervical cancer (7.5%) and ovarian cancer (7.0%). There were no statistically significant differences between study arms in demographic and cancer characteristics (cancer type and stage). DID analyses showed that compared to usual care participants, mentees (those who received peer support) showed greater reductions in depression, anxiety, and stress scores between baseline and 6 months. Adjusting for age, education, marital status, and cancer stage, statistically significant reductions in stress scores (β=-1.47; 95%CI: [-2.9,-0.02]; p=0.047) were observed. Among breast cancer patients only, adjusted models showed significant reductions in depression scores (β=-1.80; 95%CI: [-3.0,-0.48]; p=0.007) and stress scores (β=-1.9; 95%CI: [-3.3,-0.37; p=0.015). Conclusion: The Stronger Together pilot study study shows that utilizing peer cancer survivors is a promising strategy to address the psychosocial needs of newly diagnosed cancer patients in low-resource settings. Future research should test this intervention model in larger samples or other similar populations and settings. Citation Format: PhuongThao Le, Carolyn Taylor, Rachel Monahan, Mai Do, Linh Nguyen, Minh Tri Phan, Cong Wang, Huong Tran, Ophira Ginsburg. Implementation of a Hospital-Based Peer Support Intervention Model for Cancer Patients: Results From a Pilot Study in Vietnam [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 52.

Tracheostomy-related indications, early complications and their predictors among patients in low resource settings: a prospective cohort study in the pre-COVID-19 era

BackgroundTracheostomy is a life-saving procedure whose outcomes may vary between hospitals based on disparities in their existing expertise. We aimed at establishing the indications, early tracheostomy-related complications and their associated factors in Uganda.MethodsIn a prospective cohort study, we consecutively enrolled one-hundred patients, both adults and children 2 h post-tracheostomy procedure. At baseline, information on patients’ socio-demographics, tracheostomy indications, pre- and post-procedural characteristics was collected through researcher administered questionnaires and from medical records. Clinical examination was performed at baseline but also at either day 7 or whenever a tracheostomy-related complication was suspected during the 7 days follow-up. Comparison of patients’ baseline characteristics, tracheostomy indications and complications across two hospitals was done using Pearson’s chi-square. For predictors of early tracheostomy complications, bivariate and multivariate analysis models were fitted using binomial regression in STATA 13.0 software.ResultsAll patients underwent surgical tracheostomy. Majority were adults (84%) and males (70%). The commonest tracheostomy indications were; pulmonary toilet (58%) and anticipated prolonged intubation (42%). Overall, 53% (95% CI: 43.0 – 62.7) had early complications with the commonest being tube obstruction (52.6%). Independent predictors of early tracheostomy-related complications were; anticipated prolonged intubation as an indication (RR = 1.8, 95%CI: 1.19 – 2.76), Bjork flap tracheal incision (RR = 1.6, 95%CI: 1.09 – 2.43), vertical tracheal incision (RR = 1.53, 95%CI: 1.02 – 2.27), and age below 18 years (RR = 1.22, 95%CI: 1.00 – 1.47).ConclusionPulmonary toilet is the commonest tracheostomy indication at major hospitals in Uganda. The incidence of early tracheostomy complications is high and majorly related to post-procedure tracheostomy tube management. Having anticipated prolonged intubation as an indication for tracheostomy, a Bjork flap or vertical tracheal incisions and being a child were associated with increased risk of complications. Emphasis on multidisciplinary team care, standardization of tracheostomy care protocols, and continuous collection of patient data as well as paying attention to patient quality of life factors such as early return to oral feeding, ambulation and normal speech may have great potential for improved quality of tracheostomy care in low resource settings.

Medication availability and economic barriers to adherence in asthma and COPD patients in low-resource settings

Inhaled medication is essential to control asthma and COPD, but availability and proper adherence are challenges in low-middle income countries (LMIC). Data on medication availability and adherence in Central Asia are lacking. We aimed to investigate the availability of respiratory medication and the extent of financially driven non-adherence in patients with COPD and asthma in Kyrgyzstan. A cross-sectional study was conducted in two regions of Kyrgyzstan. Patients with a physician- and spirometry confirmed diagnosis of asthma and/or COPD were included. The main outcomes were (1) availability of respiratory medication in hospitals and pharmacies, assessed by a survey, and (2) medication adherence, assessed by the Test of Adherence to Inhalers (TAI). Logistic regression analyses were used to identify predictors for adherence. Of the 300 participants (COPD: 264; asthma: 36), 68.9% were buying respiratory medication out-of-pocket. Of all patients visiting the hospital, almost half reported medication not being available. In pharmacies, this was 8%. Poor adherence prevailed over intermediate and good adherence (80.7% vs. 12.0% and 7.3%, respectively). Deliberate and erratic non-adherence behavior patterns were the most frequent (89.7% and 88.0%), followed by an unconscious non-adherent behavioral pattern (31.3%). In total, 68.3% reported a financial reason as a barrier to proper adherence. Low BMI was the only factor significantly associated with good adherence. In this LMIC population, poor medication availability was common and 80% were poorly adherent. Erratic and deliberate non-adherent behaviors were the most common pattern and financial barriers play a role in over two-thirds of the population.

Triage in the time of COVID-19

Triage in the time of COVID-19

Abstract PO-051: Blending research paradigms and methods to compare 3 modes of cancer genetic counseling with diverse public hospital patients: Insights from case studies

Abstract Purpose: Genetic counseling (GC) and testing for hereditary breast/ovarian cancer (HBOC) is concentrated in elite medical centers and not offered in most public hospitals despite comparable risk across income levels. GC may be extended remotely by phone or video to patients in low resource settings, but the benefits and harms of these modes for these patients are unknown. Methods: We conducted a multicenter partially randomized preference noninferiority trial in 3 public hospitals to compare the effectiveness of 3 GC modes (in-person, phone, video) among 679 diverse patients at high-risk for HBOC. To answer some of our most important questions (e.g. How engaged are patients with counselors and how does that affect outcomes? What about the GC affects key message recall? How do patients' life/health contexts affect GC impact? How do these dynamics differ by GC mode?), we compiled 23 case studies (CS) for a multifaceted understanding of patient context, intended to reveal influences that may be subtle, complex, and not accessible from individual self-report. The main trial outcome was presented at AACR 2020; here we report the case studies methods and findings. CS participants had consented to audio-recording their GC sessions; agreed to be contacted for further research during the final trial survey; and had been offered genetic testing but did not have results at the time of the in-depth CS interview. An iterative analytic process integrated and summarized qualitative and quantitative data from surveys, interviews, genetic counselor reflections and audio recordings for each case including: patient demographics, health literacy rating, GC mode; GC session duration, key points, and engagement; genetic counselor reflections; interview highlights; general conclusions about that case; conclusions based on mode; patient quotes; and an integrated conclusion from all the data elements. Results: Our randomized trial produced equivalent outcomes across 3 GC modes. But our case studies revealed critical differences including higher quality engagement and trust-building via in-person and video counseling compared with phone, where distractions and brevity were common. While more patients opted for the convenience of phone, and for many it was their only option due to work and other demands, those counseled by phone were least likely to complete genetic testing when it was offered. Patients in all modes struggled with information recall. Conclusions: GC by phone is an important source of access for low-income patients but research should strive for higher quality. GC by video holds promise but availability is a concern. For both remote modes, easy access to testing is required. Strategies to improve information recall are needed in all modes. Research using quantitative cognitive ascertainment should include mixed methods for a more multifaceted in-depth exploration that yields rich real-world insights. Citation Format: Rena J. Pasick, Claudia Guerra, Selina R. Flores, Galen Joseph. Blending research paradigms and methods to compare 3 modes of cancer genetic counseling with diverse public hospital patients: Insights from case studies [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-051.

Pragmatic sedation strategies to prevent secondary brain injury in low-resource settings.

Traumatic brain injury is the alteration in brain function due to an external force. It is common and affects millions of people worldwide annually. The World Health Organization estimates that 90% of global deaths caused by injuries occur in low- and middle-income countries, with traumatic brain injury contributing up to half of these trauma-related deaths. Patients with traumatic brain injury in low- and middle-income countries have twice the odds of dying compared with their counterparts in high-income countries. Sedation is a key element of care in the management of traumatic brain injury, used for its neuroprotective effects and to prevent secondary brain injury. While sedatives have the potential to improve outcomes, they can be challenging to administer and have potentially dangerous complications. Sedation in low-resource settings should aim to be effective, safe, affordable and feasible. In this paper, we summarise the indications for sedation in traumatic brain injury, the choice of sedative drugs and the pragmatic management and monitoring of sedated traumatic brain injury patients in low-resource settings.

Early Institutional Experience of Dual Tracer and Single-Photon Emission Computed-Tomography/Computed-Tomography Mapping for Sentinel Node Biopsy: A Report of Two Early-Stage Breast Cancer

Intraoperative sentinel lymph node mapping (SLNM) with methylene blue dye (MBD) tracer has been the recommended method to detect SLN in early-stage breast cancer patients in low-resource settings. However, the use of MBD alone is hampered by the high false-negative rate; thus, it requires coupling with other mapping methods if the appropriate infrastructure and services are available. In this article, we present two prospective cases detailing our initial experience using the gold-standard dual tracer technique (DTT: MBD and 99mTc-nanocolloid radioisotope) in combination with hybrid single-photon emission computed-tomography/computed-tomography (SPECT/CT) preoperative mapping for image-guided SLN biopsy (SLNB). Overall, both studies were successful in identifying the SLNs, which aided in mapping the possible anatomical spread of the disease.