Crisis Settings Research Articles

A Novel and Simple Technique of Reconstructing the Central Arch Mandibular Defects-a Solution During the Resource-Constrained Setting of COVID Crisis.

The current COVID 19 pandemic has a major impact on healthcare delivery globally. Oral cancer involving anterior arch of mandible is difficult to reconstruct and ideally, requires free fibular osteomyocutaneous flap. During this time of resource constraint situation, these free flaps are not a great choice, as it increases exposure of both patient and surgical team to the deadly virus. We are describing a novel method of reconstruction after resection of oral cancer involving anterior arch of mandible. In this new technique, we have reconstructed central arch defect by hanging bipaddle pectoralis major myocutaneous flap with orbicularis oris muscle using ethylene terephthalate suture. Operative time, early postoperative complications and early cosmetic and functional outcome were assessed. We have used this novel technique in eight patients of T4a oral cancer involving anterior arch of mandible and skin over chin. Mean operative time was 180 min. One patient had minor flap loss with surgical site infection (Clavien-Dindo grade I). In all patients, we were able to discharge all patients on eighth postoperative day. Cosmetic outcome and functional outcomes were mostly satisfactory. All patients were able to oppose their lips without any oral incompetence and drooling. Tongue mobility was good. There was no incidence of ‘Andy Gump deformity’. This is a feasible option for reconstructing anterior arch defect in resource- and time-limited setting of COVID 19 pandemic. This technique can also be used in comorbid conditions where it is not advisable to do very long surgery.

A Resilience for Survival: Reimagine. Reconfigure. Restart

Governments, Industrialists and CEOs are agreeing that the COVID-19 crisis will impact us way more than the 2008 crisis (Gurnani, 2020). No one really knows how to solve the financial crisis set into motion by COVID-19. Amidst this, there is mounting pressure on sales teams in organisations to sell products and services without sufficient salespeople. To make any sale, or receive funding, organisations go through a process where they must develop a business proposal. Almost no business in the B2B (business to business) market is won without a formal business proposal. Business proposal management and writing has evolved over the years with best practices and certifications, just like project management, but the COVID-19 crisis has given it a jolt unlike any other. Salesteams, bid and proposal management teams. proposal writers and associated graphic specialists need to use this crisis as a catalyst for change. There is a resounding, echoing bell ring that asks us to reimagine, reconfigure and restart. And the bell does not ring just for teams but also for individuals. The future depends on interactive technologies and proposal teams must think about playing strategic roles if they want to stay relevant. For the investigation and writing of this paper, we have used both primary and secondary research techniques. They are listed as follows: Primary Research - Questionnaires and Interviews; Secondary Research - Journals, Harvard Business Review, Economic Times, Internationally acclaimed websites, Textbooks

Large-Scale, In-House Production of Viral Transport Media To Support SARS-CoV-2 PCR Testing in a Multihospital Health Care Network during the COVID-19 Pandemic.

The COVID-19 pandemic has severely disrupted worldwide supplies of viral transport media (VTM) due to widespread demand for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription-PCR (RT-PCR) testing. In response to this ongoing shortage, we began production of VTM in-house in support of diagnostic testing in our hospital network. As our diagnostic laboratory was not equipped for reagent production, we took advantage of space and personnel that became available due to closure of the research division of our medical center. We utilized a formulation of VTM described by the CDC that was simple to produce, did not require filtration for sterilization, and used reagents that were available from commercial suppliers. Performance of VTM was evaluated by several quality assurance measures. Based on cycle threshold (CT ) values of spiking experiments, we found that our VTM supported highly consistent amplification of the SARS-CoV-2 target (coefficient of variation = 2.95%) using the Abbott RealTime SARS-CoV-2 Emergency Use Authorization (EUA) assay on the Abbott m2000 platform. VTM was also found to be compatible with multiple swab types and, based on accelerated stability studies, able to maintain functionality for at least 4 months at room temperature. We further discuss how we met logistical challenges associated with large-scale VTM production in a crisis setting, including use of a staged assembly line for VTM transport tube production.

Sexual and reproductive health during disasters: A scoping review of the evidence

PurposeThe objective of this scoping review was to identify and describe the international scientific literature and published post-disaster needs assessments (PDNAs), on post-disaster provision of healthcare services for sexual and reproductive health. MethodologyA systematic search was conducted to identify potential source documents, which were screened for edibility and included documents were full-text reviewed. Thirteen published research papers and 55 PDNAs were reviewed. ResultsPDNAs did not address the sexual health needs of affected communities in a thorough manner and provided limited guidance on the actions required during the recovery stage. HIV was more likely to be considered in PDNAs than sexually transmitted infections (STI). Source documents showed STI prevalence increased in a community after a disaster, that people living with HIV are particularly vulnerable, and that service provision is influenced by humanitarian agencies’ ability to collaborate across sectors and governments. ConclusionIn this first scoping review on the topic, the evidence has shown that there is an enduring gap between the recommendations in published guidelines and the implementation of these during a disaster or crisis. More work is required, as well as critical analysis of post-disaster recovery operations, to identify ways to improve service provision during disaster and crisis settings. In contrast to international humanitarian communities during emergencies, unfortunately, affected governments’ recovery agencies and their donors need to ensure that STI and HIV issues can be systematically identified and addressed during recovery assessment and implementation.

Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm.

Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm.

Collecting and evaluating convalescent plasma for COVID-19 treatment: why and how?

Plasma provided by COVID-19 convalescent patients may provide therapeutic relief as the number of COVID-19 cases escalates steeply worldwide. Prior findings in various viral respiratory diseases including SARS-CoV-related pneumonia suggest that convalescent plasma can reduce mortality, although formal proof of efficacy is still lacking. By reducing viral spread early on, such an approach may possibly downplay subsequent immunopathology. Identifying, collecting, qualifying and preparing plasma from convalescent patients with adequate SARS-CoV-2-neutralizing Ab titres in an acute crisis setting may be challenging, although well within the remit of most blood establishments. Careful clinical evaluation should allow to quickly establish whether such passive immunotherapy, administered at early phases of the disease in patients at high risk of deleterious evolution, may reduce the frequency of patient deterioration, and thereby COVID-19 mortality.

A model for specific goals for in-patient treatment linked to resources and limitations in out-patient treatment.

The author reflects on the Norwegian inpatient service descriptions contained in Wilkinson's article, considering the challenges laid out in his piece from the perspective of a child and adolescent psychiatrist working in a hospital crisis setting, as well as within the context of child and adolescent mental healthcare staffing across the UK.

Contraceptive use among adolescent and young women in North and South Kivu, Democratic Republic of the Congo: Across-sectional population-based survey.

BackgroundAdolescent girls in humanitarian settings are especially vulnerable as their support systems are often disrupted. More than 20 years of violence in the Democratic Republic of the Congo (DRC) has weakened the health system, resulting in poor sexual and reproductive health (SRH) outcomes for women. Little evidence on adolescent contraceptive use in humanitarian settings is available. CARE, International Rescue Committee (IRC), and Save the Children, in collaboration with the Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative, Columbia University, have supported the Ministry of Health (MOH) since 2011 to provide good quality contraceptive services in public health facilities in conflict-affected North and South Kivu. In this study, we analyzed contraceptive use among sexually active young women aged 15–24 in the health zones served by the partners’ programs.Methods and findingsThe partners conducted cross-sectional population-based surveys in program areas of North and South Kivu using two-stage cluster sampling in six health zones in July–August 2016 and 2017. Twenty-five clusters were selected in each health zone, 22 households in each cluster, and one woman of reproductive age (15–49 years) was randomly selected in each household. This manuscript presents results from a secondary data analysis for 1,022 women aged 15–24 who reported ever having sex: 326 adolescents (15–19 years) and 696 young women (20–24 years), 31.7% (95% confidence interval [CI] 29.5–34.1), of whom were displaced at least once in the previous five years. Contraceptive knowledge was high, with over 90% of both groups able to name at least one modern contraceptive method. Despite this high knowledge, unmet need for contraception was also high: 31.7% (95%CI 27.9–35.7) among 15–19-year-olds and 40.1% (95% CI 37.1–43.1, p = 0.001) among 20–24-year-olds. Current modern contraceptive use (16.5%, 95% CI 14.7–18.4) was similar in both age groups, the majority of whom received their method from a supported health facility. Among current users, more than half of 15–19-year-olds were using a long-acting reversible contraceptive (LARC; 51.7%, 95% CI 41.1–61.9) compared to 36.5% of 20–24-year-olds (95% CI 29.6–43.9, p = 0.02). Age, younger age of sexual debut, having some secondary education, being unmarried, and having begun childbearing were associated with modern contraceptive use. The main limitations of our study are related to insecurity in three health zones that prevented access to some villages, reducing the representativeness of our data, and our defining sexually active women as those who have ever had sex.ConclusionsIn this study, to our knowledge one of the first to measure contraceptive prevalence among adolescents in a humanitarian setting, we observed that adolescent and young women will use modern contraception, including long-acting methods. Meaningful engagement of adolescent and young women would likely contribute to even better outcomes. Creating an enabling environment by addressing gender and social norms, however, is key to reducing stigma and meeting the demand for contraception of young women. As we continue to build such supportive environments, we can see that they will use effective contraception when contraceptive services, including short- and long-acting methods, are available, even in protracted crisis settings.

A financial incentive program to improve appointment attendance at a safety-net hospital-based primary care hepatitis C treatment program

IntroductionHepatitis C (HCV) infection is a significant health threat, with increasing incidence rates in the setting of the opioid crisis. Many patients miss appointments and cannot initiate treatment. We implemented financial incentives to improve appointment attendance in a primary care-based HCV treatment setting.MethodsWe conducted a systems-level financial incentives intervention at the Adult Primary Care HCV Treatment Program at Boston Medical Center which provides care to many patients with substance use disorders. From April 1 to June 30, 2017, we provided a $15 gift card to patients who attended appointments with an HCV treatment provider. We evaluated the effectiveness of the incentives by 1) conducting a monthly interrupted time series analysis to assess trends in attendance January 2016—September 2017; and 2) comparing the proportion of attended appointments during the intervention to a historical comparison group in the previous year, April 1 to June 30, 2016.Results327 visits were scheduled over the study period; 198 during the intervention and 129 during the control period. Of patient visits in the intervention group, 72.7% were attended relative to 61.2% of comparison group visits (p = 0.03). Appointments in the intervention group were more likely to be attended (adjusted odds ratio 1.94, 95% confidence interval 1.16–3.24). Interrupted time series analysis showed that the intervention was associated with an average increase of 15.4 attended visits per 100 appointments scheduled, compared to the period prior to the intervention (p = 0.01).ConclusionsImplementation of a financial incentive program was associated with improved appointment attendance at a safety-net hospital-based primary care HCV treatment program. A randomized trial to establish efficacy and broader implementation potential is warranted.

Community engagement for health system resilience: evidence from Liberia's Ebola epidemic.

The importance of community engagement (CE) for health system resilience is established in theoretical and empirical literature. The practical dimensions of how to operationalize theory and implement its principles have been less explored, especially within low-resource crisis settings. It is therefore unclear how CE is drawn upon and how, if at all, it facilitates health system resilience in times of health system crises. To address this critical gap, we adapt and apply existing theoretical CE frameworks to analyse qualitative data from 92 in-depth interviews and 16 focus group discussions collected with health system stakeholders in Liberia in the aftermath of the 2014-15 Ebola outbreak. Health system stakeholders indicated that CE was a crucial contributing factor in addressing the Ebola epidemic in Liberia. Multiple forms of CE were used during the outbreak; however, only some forms were perceived as meaningful, such as the formation of community-based surveillance teams. To achieve meaningful CE, participants recommended that communities be treated as active participants in-as opposed to passive recipients of-health response efforts and that communication platforms for CE be established ahead of a crisis. Participant responses highlight that meaningful CE led to improved communication with and increased trust in health authorities and programming. This facilitated health system response efforts, leading to a fortuitous cycle of increased trust, improved communication and continued meaningful CE-all necessary conditions for health system resilience. This study refines our understanding of CE and demonstrates the ways in which meaningful CE and trust work together in mutually reinforcing and beneficial ways. These findings provide empirical evidence on which to base policies and programmes aimed at improving health system resilience in low-resource settings to more effectively respond to health system crises.

Pandemics, Existential and non-Existential Risks to Humanity

Abstract The pandemic caused by the SARS-Cov-2 virus has initiated an era of structural economic stagnation. With it, we have crossed a threshold in which the planet’s so-called “ecosystemic services” have started becoming “ecosystemic disservices”. Covid-19 is one of those disservices. In itself, it certainly does not constitute an existential risk to humanity. But what will be discussed here is the existence of a clear dividing line between existential and non-existential risks. Frequently, an existential risk results from a set of crises that, separately, do not existentially threaten humanity. Nevertheless, combined and acting in synergy, those crises have the potential to do so. The current pandemic points at the chance for a great civilizational shift, probably the last chance before environmental imbalances escape societies’ control.

Expanding Access to Comprehensive Abortion Care in Humanitarian Contexts: Case Study from the Rohingya Refugee Camps in Bangladesh.

The need for comprehensive sexual and reproductive health (SRH) care can be especially acute during humanitarian crises, as women and girls are at increased vulnerability of experiencing sexual violence, unintended pregnancy and pregnancy-related complications. However, in such settings, the chaos of displacement and basic survival may supplant the importance of SRH care, and individuals may also have diminished access to safe services. Abortion and abortion-related care may be particularly limited in humanitarian contexts because of a number of barriers beyond the lack of infrastructure, supplies and trained staff: For example, abortion care practitioners in emergency settings may perceive or face legal complications or loss of funding due to their provision of abortion services, insititutions and governments may lack timely data on and underestimate the true volume of abortion demand among refugees, and providers may hold a perception that providing abortion care in crisis settings may be too difficult to attempt.

Ethical reflections on children’s participation in educational research during humanitarian crises

This paper aims to reflect upon ethical dilemmas arising from educational research in humanitarian contexts, particularly when involving children. In recognition of the paucity of knowledge on how to define ethics in humanitarian research, we review the existing body of literature that explores ethical responsibilities towards children involved in educational research at school and their communities. The paper argues that research ethics should be at the forefront of every study that is conducted in crisis contexts and more rigorous review and vetting processes are necessary to protect children, researchers and wider communities who live in crisis settings. We hope to promote an informed debate on research ethics in humanitarian contexts, while encouraging the development of rigorous guidelines, notes and minimum standards.

How Do Financial Analysts Respond to Precision and Tone in Management Revenue Forecast Arguments During Times of Heightened Uncertainty? – Some Evidence from Europe

Prior research concludes that supplementary statements improve management forecast credibility especially during heightened uncertainty. However, little attention has been paid to the legitimacy of the connection between the hard forecast and the supporting detail, and no attention to whether the legitimacy of this connection affects forecast accuracy and analyst reactions in these conditions. Focusing on revenue forecasts, this study shows that when the precision of the supporting detail agrees with the precision of the hard forecast in a crisis setting, the odds that the forecast meets its target multiply. In contrast, sign agreement between the supporting detail and the hard forecast in general is found to be unrelated to revenue forecast accuracy in this setting. Furthermore, analyst revisions are depressed by precision agreement. In these conditions, also sign agreement is negatively related to analyst revisions for growth forecasts, adding to prior studies which argue for the predictive ability of positive tone in more normal conditions. Overall, these findings expand Trueman’s (1986) signaling theory by suggesting that management do not signal their ability to predict performance only by releasing a forecast but also by releasing supporting data that are adequately precise to justify the forecast claim.

Self-Fulfilling Debt Crises, Revisited

We revisit self-fulfilling rollover crises by exploring the potential uncertainty introduced by a gap (however small) between an auction of new debt and the payment of maturing liabilities. It is well known (Cole and Kehoe 2000) that the lack of commitment at the time of auction to repayment of imminently maturing debt can generate a run on debt, leading to a failed auction and immediate default. We show the same lack of commitment leads to a rich set of possible self-fulfilling crises, including a government that issues \emph{more} debt because of the crisis, albeit at depressed prices. Another possible outcome is a ``sudden stop'' (or forced austerity) in which the government sharply curtails debt issuance. Both outcomes stem from the government's incentive to eliminate uncertainty about imminent payments at the time of auction by altering the level of debt issuance. In an otherwise standard quantitative version of the one-period debt model, including such crises increase the default probabilities by a factor of five and the spread volatility by a factor of twenty-five.

Multiple criteria decision analysis of public investment options: application to streetlighting renewal projects

The last global economic crisis set fiscal consolidation as one of the most relevant goals of economic policy. At the same time, efforts are necessary to increase economic growth rates, particularly by increasing quantity and quality of public investment. However, the lack of fiscal space and other impediments make these goals hard to attain. On the contrary, in many countries data show negative dynamics of quantity and quality of public investment. In terms of energy efficiency investment, trends are positive. However, the pace of investment significantly underperforms the goals set. We argue that one of the major reasons is the lack of financial innovation and project selection methodology. For this reason, projects have still been mainly financed under traditional procurement models. Surprisingly, most countries do not exploit the advantages of alternative models of financing which do not affect public debt level, significantly reduce fiscal deficits and reduce fiscal risks. This article argues that a multi-criteria approach used at the initial stages of project preparation increases the potential for project realisation and the overall quantity and quality. In order to provide empirical evidence, we use information on energy efficiency streetlighting projects and present a case of a traditional versus alternative financing models. Highlights a need for a systematic approach when selecting optimal financing model is a must; a lack of financial innovation is one of the most critical impediments to a higher level of investment in revenue-generating projects common for the energy efficiency sector; alternative models of financing enable public investment increase without harming the fiscal position; a new methodology for selecting the most preferable model is presented; a policy mix should take more comprehensive stance towards complexity of public investment projects.

Comparing the Productive Effects of Cash and Food Transfers in a Crisis Setting: Evidence from a Randomised Experiment in Yemen

The productive impacts of transfer programmes have been receiving increased attention. However, little is known about such effects in emergency and crisis settings. Even less is known about whether transfer type – a food basket or a cash grant – influences the productive potential of such transfers. Theory suggests that cash transfers can relieve liquidity constraints associated with investments, but subsidised food provision, by acting as a form of insurance, may prevent households from retreating to conservative income-generating strategies during volatile periods. This report contrasts the effects of transfer modality during a randomised field experiment in Yemen. The results demonstrate a modest productive impact of both modalities and suggest a role for liquidity and price risk channels. Cash transfer recipients invested relatively more in activities with higher liquidity requirements (livestock), while food recipients incorporated higher-return crops into their agricultural portfolios.

Lessons learned in the provision NCD primary care to Syrian refugee and host communities in Lebanon: the need to ‘act locally and think globally’

Prevention and control of non-communicable diseases (NCDs) remain inadequate in resource-scarce countries, particularly in conflict situations. This paper describes a multicomponent intervention for management of hypertension and diabetes among older adult Syrian refugees and the Lebanese host community and reflects on challenges for scaling up NCD integration into primary care in humanitarian situations. Using a mixed method approach, the study focused on monitoring and evaluation of the three components of the intervention: healthcare physical facilities and documentation processes, provider knowledge and guideline-concordant performance, and refugee and host community awareness. Findings revealed overall high compliance of healthcare workers with completing data collection forms. Their knowledge of basic aspects of hypertension/diabetes management was adequate, but diagnosis knowledge was low. Patients and healthcare providers voiced satisfaction with the program. Yet, interruptions in medicines' supplies and lapses in care were perceived by all study groups alike as the most problematic aspect of the program. Our intervention program was aligned with internationally agreed-upon practices, yet, our experiences in the field point to the need for more 'local testing' of modified interventions within such contexts. This can then inform 'thinking globally' on guidelines for the delivery of NCD care in crisis settings.

Enhanced recovery after surgery: A clinical review of implementation across multiple surgical subspecialties

Enhanced recovery after surgery (ERAS) is a multimodal protocol applied towards perioperative patient care. ERAS programs are implemented by a multidisciplinary team centered around the patient, incorporating outpatient clinical staff, preoperative nurses, anesthesiologists, operative nurses, postoperative recovery staff, floor inpatient nurses, dieticians, physical therapists, social workers, and surgeons. Initial studies on perioperative care measures focused on cardiac surgery. Subsequently, the development of the ERAS Study Group in 2001 focused on colorectal surgery and postoperative outcome measures. Today, ERAS protocols have been implemented across many surgical subspecialties including: bariatric, breast, plastic, cardiac, colorectal, esophageal, head and neck, hepatic, gynecologic, neurosurgical, orthopedic, pancreatic, thoracic, and urologic surgery. The goal of ERAS programs is to promote rapid recovery as quantified by decreasing the length of hospital stay, complications, and cost of specific surgical interventions. In the setting of the opioid crisis in America, there is also an increasing focus on minimizing perioperative narcotic use. The purpose of this review is to compare ERAS protocols across surgical subspecialties, focusing on quantified metrics of improvement, and to provide a clear and concise summary of the literature in regards to current ERAS practices and success rates.

MEDICAL MANAGEMENT OF PAIN IN GERIATRIC PATIENTS

Pain and pain management is a growing concern for older adult patients and their health care providers. Upwards of 50% of older adults report having bothersome pain and 75% of these individuals report having pain in more than one location. Persistent pain is associated with decreased physical function, depression, isolation, and a decreased quality of life. Managing chronic pain in the setting of an opioid crisis requires special knowledge about the aging body so that medications can be used safely and effectively; and adjuvant therapies such as PT or acupuncture can be maximized. This segment of the symposium will review common challenges faced by primary care providers when managing chronic pain in older adults: the natural physiologic changes that occur in the aging body, co-morbid chronic diseases which can complicate pain syndromes, and assessing pain in cognitively impaired patients.