Rapid Diagnostic Test Value and Implementation in Antimicrobial Stewardship Across Low-to-Middle and High-Income Countries: A Mixed-Methods Review.

Despite technological advancements in infectious disease rapid diagnostic tests (RDTs) and use to direct therapy at the per-patient level, RDT utilisation in antimicrobial stewardship programmes (ASPs) is variable across low-to-middle income and high-income countries. Key insights from a panel of seven infectious disease experts from Colombia, Japan, Nigeria, Thailand, the UK, and the USA, combined with evidence from a literature review, were used to assess the value of RDTs in ASPs. From this, a value framework is proposed which aims to define the benefits of RDT use in ASPs, separate from per-patient benefits. Expert insights highlight that, to realise the value of RDTs within ASPs, effective implementation is key; actionable advice for choosing an RDT is proposed. Experts advocate the inclusion of RDTs in the World Health Organization Model List of essential in vitro diagnostics and in iterative development of national action plans.

Current status and barriers in pulmonary hypertension care delivery in India: A qualitative analysis.

Although pulmonary hypertension (PH) is widely prevalent in India, care delivery for this condition has unique challenges in a lower middle-income country (LMIC). To describe care delivery for patients with PH and associated barriers in India. We interviewed physicians across eight healthcare systems in India about PH clinical care using semi-structured enquiries to understand care delivery and associated challenges in their specific practice as well as the associated health system. Qualitative analysis was performed using content analysis methodology. Physicians reported that common causes for PH in their practice were rheumatic mitral valve disease, coronary artery disease, and congenital heart disease (CHD). No center had a dedicated PH program. Only one center had a specific protocol for PH management. Diagnostic evaluations were limited, and right heart catheterizations were recommended for patients with CHD. Pulmonary vasodilator therapy was used for severe symptoms or markers of severe disease. Agents used to treat PH were widely variable across physicians and prostacyclins are unavailable in India. Barriers included limited training in PH for physicians, lack of consensus guidelines for PH specific to LMIC, and lack of financial incentives for health care systems to organize dedicated PH programs. Other barriers included poor patient health literacy and socioeconomic barriers that limit ability to test and treat PH. PH care delivery in India is variable with widely differing clinical practices. Dedicated training in PH management and establishing guidelines specific to LMIC like India can form the first step forward.

Pneumococcal Immunization Strategies for High-Risk Pediatric Populations Worldwide: One Size Does Not Fit All.

Despite the significant reduction in pneumococcal disease due to pneumococcal vaccines, protection of vulnerable high-risk individuals, especially pediatric populations, remains a great challenge. In an effort to maximize the protection of high-risk children against pneumococcal disease, a combined schedule that includes both conjugate and polysaccharide vaccines is recommended by several countries in the developed world. On the other hand, middle- and low-income countries do not have in place established policies for pneumococcal immunization of children at risk. Pneumococcal conjugate vaccines, despite their benefits, have several limitations, mainly associated with serotype replacement and the wide range of serotype coverage worldwide. In addition, PPV23-impaired immunogenicity and the hyporesponsiveness effect among populations at risk have been well-documented. Therefore, the added value of continuing to include PPV23 in vaccination schedules for high-risk individuals in the years to come remains to be determined by monitoring whether the replacing/remaining serotypes causing IPD are covered by PPV23 to determine whether its benefits outweigh its limitations. In this review, we aim to describe serotype distribution and vaccine efficacy data on pneumococcal disease in the pre- and post-PCV implementation era among high-risk children in both developed and developing countries, assessing the optimization of current recommendations for their vaccination against pneumococcal disease.

Challenges and Special Aspects of Pulmonary Hypertension in Middle- to Low-Income Regions: JACC State-of-the-Art Review.

Challenges and special aspects related to the management and prognosis of pulmonary hypertension (PH) in middle- to low-income regions (MLIRs) range from late presentation to comorbidities, lack of resources and expertise, cost, and rare options of lung transplantation. Expert consensus recommendations addressing the specific challenges for prevention and therapy of PH in MLIRs with limited resources have been lacking. To date, 6 MLIR-PH registries containing mostly adult patients with PH exist. Importantly, the global prevalence of PH is much higher in MLIRs compared with high-income regions: group 2 PH (left heart disease), pulmonary arterial hypertension associated with unrepaired congenital heart disease, human immunodeficiency virus, or schistosomiasis are highly prevalent. This consensus statement provides selective, tailored modifications to the current PH guidelines to address the specific challenges faced in MLIRs, resulting in the first pragmatic and cost-effective consensus recommendations for PH care providers, patients, and their families.

[The management of quality and safety of medical activities as world trend in health care: the review].

Since the publication of the reports of the Institute of medicine "To Err is to Human" and "Crossing the Quality Chasm" considerable attention in medical organizations all over the world is paid to improving quality medical care and safety of patients. The improvement of quality can consolidate health care delivery systems, improve efficiency of health sector and accelerate achievement of health-related goals. Therefore, quality improvement nowadays occupies meaningful position in health care policy programs in countries with different income levels.

Cuidado Paliativo em Crianças e Adolescentes com Câncer em Países de Alta/Média/Baixa Renda: Uma Revisão Integrativa / Palliative Care in Childrens and Adolescens with Cancer in High/Middle/Low Income Countries: an integrative review / Cuidado Paliativo en Niños y Adolescentes con Cáncer en Países de Alta / Media / Baja Renta: Una Revisión Integrativa

Introdução: O câncer em crianças e adolescentes com até 19 anos é a primeira causa de morte por doença em países desenvolvidos e a segunda em países em desenvolvimento. O Cuidado Paliativo (CP), como serviço de saúde com foco na qualidade de vida é essencial no cuidado desses pacientes. Objetivo: Avaliar o perfil do cuidado paliativo na oncologia pediátrica em países de alta, média e baixa renda e discutir as principais diferenças encontradas nas práticas adotadas entre estes países. Metodologia: revisão bibliográfica integrativa entre 2013 e 2018 em cinco bases de dados eletrônicas. Os artigos foram analisados pelo título e resumo. Os que foram selecionados foram lidos e estratificados de acordo com os temas CP ou Cuidado de Fim de Vida e assuntos envolvidos nesta temática. Resultados: Foram encontrados 1772 artigos, dos quais 89 foram selecionados e lidos. Destes, 78 artigos foram publicados por países de alta renda e 11 por países de média renda (de acordo com classificação do Banco Mundial). Os artigos foram divididos em dois temas: Cuidado Paliativo e Cuidado de Fim de Vida. Dentro de cada tema, os grupos de assuntos mais discutidos foram Qualidade de Vida e Experiência dos Cuidadores, que abrangem questões como: manejo de sintomas, controle da dor, tratamento no CP, Ensaios clínicos, entre outros. Conclusão: Houve maior contribuição de artigos de países de alta renda nos temas CP e Cuidado de Fim de Vida em comparação aos artigos de países de média renda. O que sugere maior domínio dos países de alta renda sobre os temas avaliados.

Introduction: Cancer in children and adolescents with age until 19 years old is the first cause of death by illness in developed countries and the second in developing countries. The Palliative Care (PC), as a health service with focus on quality of life is essential to the care of this patients. Objective: Evaluate the profile of Palliative Care in Childhood Cancer in High, Middle and Low Income Countries and discuss the major difference found on the medical practices between them. Metodology: integrative bibliographic review between 2013 and 2018 in five electronic databases. The articles were analyzed by title and abstract. Those that were selected were read and stratified according to the themes PC or End of Life Care and subjects involved in this theme. Results: 1772 articles were found, of which 89 were selected and read. Of these, 78 articles were published by high-income countries and 11 by middle-income countries (according to World Bank classification). The articles were divided into two themes: Palliative Care and End of Life Care. Within each theme, the most discussed groups of subjects were Quality of Life and Caregiver Experience, which cover issues such as: symptom management, pain management, CP treatment, clinical trials, among others. Conclusion: There was a greater contribution of articles from high-income countries in the areas of PC and End-of-Life Care compared to articles from middle-income countries. It suggests a higher dominance of the high income countries on the subjects evaluated.

Introducción: El cáncer en niños y adolescentes con hasta 19 años es la primera causa de muerte por enfermedad en países desarrollados y la segunda en países en desarrollo. El cuidado paliativo (CP), como servicio de salud con foco en la calidad de vida es esencial en el cuidado de esos pacientes. Objetivo: Evaluar el perfil del cuidado paliativo en la oncología pediátrica en países de alta, media y baja renta y discutir las principales diferencias encontradas en las prácticas adoptadas entre estos países. Metodología: revisión bibliográfica integrativa entre 2013 y 2018 en cinco bases de datos electrónicas. Los artículos fueron analizados por el título y el resumen. Los que fueron seleccionados fueron leídos y estratificados de acuerdo con los temas CP o Cuidado de Fin de Vida y asuntos involucrados en esta temática. Resultados: Se han encontrado 1772 artículos, de los cuales 89 han sido seleccionados y leídos. De ellos, 78 artículos fueron publicados por países de alta renta y 11 por países de media renta (de acuerdo con la clasificación del Banco Mundial). Los artículos se dividieron en dos temas: Cuidado Paliativo y Cuidado de fin de vida. En cada tema, los grupos de asuntos más discutidos fueron Calidad de Vida y Experiencia de los Cuidadores, que abarcan cuestiones como: manejo de síntomas, control del dolor, tratamiento en el CP, Ensayos clínicos, entre otros. Conclusión: Hubo mayor contribución de artículos de países de alta renta en los temas CP y Cuidado de Fin de Vida en comparación a los artículos de países de media renta. Lo que sugiere mayor dominio de los países de alta renta sobre los temas evaluados.

A survey of tobacco dependence treatment guidelines content in 61 countries.

AIMS: To assess tobacco dependence treatment guidelines content in accordance with Article 14 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) and its guidelines, and association between content and country income level. DESIGN: Cross-sectional study. SETTING: On-line survey from March to July 2016. PARTICIPANTS: Contacts in 77 countries, including 68 FCTC Parties, six Signatories and three non-Parties which had indicated having guidelines in previous surveys, or had not been surveyed before. MEASUREMENTS: A nine-item questionnaire on guidelines content, key recommendations, writing and dissemination. FINDINGS: We received responses from contacts in 63 countries (82%); 61 had guidelines. The majority are for doctors (93%), primary care (92%) and nurses (75%). All recommend brief advice, 82% recording tobacco use in medical notes, 98% nicotine replacement therapy (NRT), 61% quitlines, 31% text messaging and 87% intensive specialist support, and 54% stress the importance of health-care workers not using tobacco. Only 57% have a dissemination strategy, and 62% have not been updated for 5 or more years. Compared with high-income countries, quitlines are less likely to be recommended in upper middle-income countries guidelines [odds ratio (OR) = 0.15, 95% confidence interval (CI) = 0.04-0.61] and intensive specialist support in lower middle-income countries guidelines (OR = 0.01, 95% CI = 0.00-0.20). Guidelines updating is associated positively with country income level (P = 0.027). CONCLUSIONS: Although most tobacco dependence treatment guidelines in the 61 countries assessed in 2016 follow the World Health Organization's Framework Convention on Tobacco Control Article 14 recommendations and do not differ significantly by income level, improvements are needed in keeping guidelines up-to-date, applying good writing practices and developing a dissemination strategy.

A model for humanitarian outreach in today's world.

The traditional model for humanitarian work for surgeons has been a few long-term people and a larger number of volunteers on short-term missions to needy places for one or two weeks with limited opportunity for follow-up. While a great deal of good has resulted from these efforts, in the long term not much has changed. Recent studies like the U.N. Millennium Development Goals and the Lancet Commission Report, Surgery 2030, have pointed out that the burden of surgical disease is the major public health issue in the world, such that an estimated five billion people worldwide do not have access to safe surgery and anesthesia, with the largest number being in Africa where almost half of the population is less than age 18years. These and other reports related to essential surgery conclude that the key element in this problem is an extreme shortage of a capable, well-trained physician workforce, without which none of the Millennium Goals can be accomplished. For these reasons, we have directed our efforts to the development of a humanitarian model that meets the modern day need to expand the surgeon and anesthesia workforces using a Western university model adapted to locoregional African needs. The goal is to train the trainers in order to magnify the physician output rapidly over wide geographical areas and to train teams of surgeons and anesthesiologists who will work together. Although we have worked primarily in East Africa, particularly in Kenya, we feel that this model is widely applicable. While this effort is in its early stages, resident trainees from the home program in Kenya are now in Uganda, Rwanda, Ethiopia, Sierra Leone, Cameroon, and Madagascar, and they are in the process of developing their own residency training programs. It is our vision that with the expansion of the surgeon-anesthesiologist workforce, more people will have access to safe surgery and anesthesia, including obstetrical care, a humanitarian model in today's context.

Progress in implementation of WHO FCTC Article 14 and its guidelines: a survey of tobacco dependence treatment provision in 142 countries.

AIMS: To (1) estimate the number of Parties to the Framework Convention on Tobacco Control (FCTC) providing tobacco dependence treatment in accordance with the recommendations of Article 14 and its guidelines; (2) assess association between provision and countries' income level; and (3) assess progress over time. DESIGN: Cross-sectional study. SETTING: Online survey from December 2014 to July 2015. PARTICIPANTS: Contacts in 172 countries were surveyed, representing 169 of the 180 FCTC Parties at the time of the survey. MEASUREMENTS: A 26-item questionnaire based on the Article 14 recommendations including tobacco treatment infrastructure and cessation support systems. Progress over time was assessed for those countries that also participated in our 2012 survey and did not change country income level classification. FINDINGS: We received responses from contacts in 142 countries, an 83% response rate. Overall, 54% of respondents reported that their country had an officially identified person responsible for tobacco dependence treatment, 32% an official national treatment strategy, 40% official national treatment guidelines, 25% a clearly identified budget for treatment, 17% text messaging, 23% free national quitlines and 26% specialized treatment services. Most measures were associated positively and significantly with countries' income level (P < 0.001). Measures not associated significantly with income level included mandatory recording of tobacco use (30% of countries), offering help to health-care workers (HCW) to stop using tobacco (44%), brief advice integrated into existing services (44%), and training HCW to give brief advice (81%). Reporting having an officially identified person responsible for tobacco cessation was the only measure with a statistically significant improvement over time (P = 0.0351). CONCLUSION: Fewer than half of countries that are Parties to the Framework Convention on Tobacco Control have implemented the recommendations of Article 14 and its guidelines, and for most measures, provision was greater the higher the country's income. There was little improvement in treatment provision between 2012 and 2015 in all countries.