Challenges and Strategies in Pediatric Critical Care: Insights From Low-Resource Settings.

Background. Pediatric critical care in low-resource settings faces challenges like inadequate infrastructure, limited personnel, financial constraints, and cultural considerations, leading to poor outcomes for critically ill children. Methods. This review synthesizes information from 2 articles on pediatric intensive care units (PICUs) in low- and middle-income countries (LMICs). It identifies challenges such as high care costs, cultural preferences, and resource allocation issues. Results. Challenges include the financial burden of care, limited resources, and the need for external funding. Family preferences impact healthcare decisions, leading to ethical dilemmas. Resource allocation issues affect patient outcomes, including delayed diagnoses and high mortality rates. Conclusion. Addressing these challenges requires a multifaceted approach involving governments, healthcare providers, and international stakeholders. Standardizing care, investing in infrastructure and training, and promoting collaboration are essential to improving pediatric critical care and ensuring equitable access.

Implementing the Early Start Denver Model in Senegal: Outcomes and Insights from a Low-Resource Context.

BACKGROUND: Autism Spectrum Disorders (ASD) are characterized by significant challenges in social interaction and communication, accompanied by repetitive behaviors. Effective early interventions, such as the Early Start Denver Model (ESDM) are crucial but primarily studied in well-resourced Western countries. This study explores the adaptation and effectiveness of ESDM in Senegal, a low-resource setting, to adress gaps in autism care and intervention accessibility in Africa. SUBJECTS AND METHODS: An observational study was conducted at Diamniadio Children's Hospital, Dakar, Senegal, from January 2019 to July 2021, focusing on children under 10 years suspected of having ASD. Diagnostic assessments were performed using the DSM-5 criteria with tools like the Autism Diagnostic Interview-Revised (ADI-R) and Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). Interventions based on ESDM were adapted to local resources and involved regular family and patient engagement. RESULTS: Of the 114 children referred for ASD suspicion, 80 were diagnosed with ASD. Post-diagnosis, 30 children received follow-up care at the day hospital, and another 30 were managed via outpatient care. 20 children did not receive any follow-up care at Diamniadio Children's Hospital. Significant socio-economic disparities were noted, influencing access to and engagement with intervention programs. No significant differences were found in clinical characteristics between groups, but socio-economic factors significantly affected intervention access. CONCLUSION: The adapted ESDM interventions show promise for implementation in resource-limited settings like Senegal, although challenges related to socio-economic disparities and service accessibility persist. Future research should focus on the integration of ASD services into broader health policies to enhance efficacy and accessibility.

A competency framework for simulation facilitation in low-resource settings: a modified Delphi study.

BACKGROUND: Skilled facilitators are essential to drive effective simulation training in healthcare. Competency-based frameworks support the development of facilitation skills but, to our knowledge, there are no frameworks that specifically address context-sensitive priorities developed with practitioners working in low-resource settings. METHODS: We aimed to develop a core competency framework for healthcare simulation facilitation in low-resource settings using a modified Delphi process. We drew on the domain expertise of members of the Vital Anaesthesia Simulation Training Community of Practice, with the study guided by a four-member steering group experienced in the conduct of simulation in low-resource settings. In survey round 1, participants (n = 54) were presented with an initial competency set derived from a previous qualitative study and co-created a set of 57 competencies for effective simulation facilitation in low-resource settings. In survey round 2, participants (n = 52) ranked competencies by relevance into three performance categories: techniques; artistry; and values. In survey round 3, participants (n = 50) ranked competencies on their importance. The steering group collated results and presented a draft core competency framework. In survey round 4, participants (n = 50) voted with 98% agreement that this framework represented the most relevant and important competencies for effective facilitation of simulation sessions in low-resource settings. RESULTS: The final 32-item framework encompasses core competencies found in existing standards and includes important new concepts such as demonstration of cultural sensitivity; humility; ability to recognise and respond to potential language barriers; facilitation team collaboration; awareness of logistics; and contingency planning. DISCUSSION: This competency-based framework highlights specific practices required for effective simulation facilitation in low-resource settings. Further work is required to refine and validate this tool to train simulation facilitators to deliver effective training to improve patient safety.

Investigating the Challenges, Successes, and Strategies of Implementing Advanced Neonatal Care Interventions in Low-Resource Settings: A Clinical Study.

Background: Neonatal care interventions are crucial for reducing infant mortality rates, particularly in low-resource settings where access to advanced medical facilities is limited. Implementing these interventions poses significant challenges due to resource constraints and infrastructural limitations. Materials and Methods: This clinical study investigated the challenges, successes, and strategies involved in implementing advanced neonatal care interventions in a low-resource setting. A retrospective analysis was conducted on the data collected from a neonatal care unit in a resource-limited area over a period of two years. The study assessed the availability of medical equipment, healthcare personnel training, and the efficacy of interventions in improving neonatal health outcomes. Results: The analysis revealed that despite resource constraints, significant strides were made in implementing advanced neonatal care interventions. Availability of essential medical equipment increased by 30%, and healthcare personnel received targeted training programs resulting in a 25% improvement in neonatal survival rates. Strategies such as task-shifting and community outreach programs played a pivotal role in overcoming infrastructural limitations. Conclusion: Implementing advanced neonatal care interventions in low-resource settings is challenging but feasible with targeted strategies. While resource constraints remain a barrier, innovative approaches such as task-shifting and community involvement can significantly improve neonatal health outcomes. Continued investment in infrastructure, training, and community engagement is essential for sustainable progress in reducing neonatal mortality rates in resource-limited areas.

Biomarker relationships with small bowel histopathology among malnourished children with environmental enteric dysfunction in a multicountry cohort study.

BACKGROUND: Validated biomarkers could catalyze environmental enteric dysfunction (EED) research. OBJECTIVES: Leveraging an EED histology scoring system, this multicountry analysis examined biomarker associations with duodenal histology features among children with EED. We also examined differences in 2-h compared with 1-h urine collections in the lactulose rhamnose (LR) dual sugar test. METHODS: Three cohorts of undernourished children unresponsive to nutrition intervention underwent esophagogastroduodenoscopy and duodenal biopsies. Histopathology scores were compared to fecal calprotectin (CAL), myeloperoxidase (MPO), neopterin (NEO), and urinary LR ratio and lactulose percentage recovery. Log-transformed biomarkers were used in linear regressions adjusted for age, center, and sample collection-biopsy time interval in multivariable models. RESULTS: Data on >1 biomarker were available for 120 Bangladeshi (CAL, MPO, NEO, and LR), 63 Pakistani (MPO, NEO, and LR), and 63 Zambian children (CAL). Median age at endoscopy was similar (19 mo) across centers. Median sample collection prior to endoscopy was consistent with each center's study design: 2 wk in Bangladesh (urine and stool) and Zambia (stool), and 6 (urine) and 11 (stool) mo in Pakistan. In multivariable models, intraepithelial lymphocytes were associated with CAL (exponentiated [exp.] coefficient: 1.19; 95% confidence interval [CI]: 1, 1.41), intramucosal Brunner's glands with MPO (exp. coefficient: 1.33; 95% CI: 1.05, 1.69) and NEO (exp. coefficient: 1.37; 95% CI: 1.1, 1.7), and chronic inflammation with NEO (exp. coefficient: 1.61; 95% CI: 1.17, 2.17). Intraepithelial lymphocytes were associated with lactulose % recovery (exp. coefficient: 1.22; 95% CI: 1.05, 1.41). LR recovery was substantially lower in 1-h collections than in 2-h collections. CONCLUSIONS: Four commonly used markers of enteric dysfunction were associated with specific histologic features. One-hour urine collection may be insufficient to reflect small bowel permeability in LR testing. While acknowledging the challenges with obtaining relevant tissue, these findings form the basis for further EED biomarker validation research.

The creation of a pediatric surgical checklist for adult providers.

PURPOSE: To address the need for a pediatric surgical checklist for adult providers. BACKGROUND: Pediatric surgery is unique due to the specific needs and many tasks that are employed in the care of adults require accommodations for children. There are some resources for adult surgeons to perform safe pediatric surgery and to assist such surgeons in pediatric emergencies, we created a straightforward checklist based on current literature. We propose a surgical checklist as the value of surgical checklists has been validated through research in a variety of applications. METHODS: Literature review on PubMed to gather information on current resources for pediatric surgery, all papers on surgical checklists describing their outcomes as of October 2023 were included to prevent a biased overview of the existing literature. Interviews with multiple pediatric surgeons were conducted for the creation of a checklist that is relevant to the field and has limited bias. RESULTS: Forty-two papers with 8,529,061 total participants were included. The positive impact of checklists was highlighted throughout the literature in terms of outcomes, financial cost and team relationship. Certain care checkpoints emerged as vital checklist items: antibiotic administration, anesthetic considerations, intraoperative hemodynamics and postoperative resuscitation. The result was the creation of a checklist that is not substitutive for existing WHO surgery checklists but additive for adult surgeons who must operate on children in emergencies. CONCLUSION: The outcomes measured throughout the literature are varied and thus provide both a nuanced view of a variety of factors that must be taken into account and are limited in the amount of evidence for each outcome. We hope to implement the checklist developed to create a standard of care for pediatric surgery performed in low resource settings by adult surgeons and further evaluate its impact on emergency pediatric surgery outcomes. FUNDING: Fulbright Fogarty Fellowship, GHES NIH FIC D43 TW010540.

Optical detection and enumeration of Escherichia coli and Salmonella enterica using a low-magnification light microscope.

A rapid and cost-effective method for detecting bacterial cells from surfaces is critical to food safety, clinical hygiene, and pharmacy quality. Herein, we established an optical detection method based on a gold chip coating with 3-mercaptophenylboronic acid (3-MPBA) to capture bacterial cells, which allows for the detection and quantification of bacterial cells with a standard light microscope under low-magnification (10×) objective lens. Then, integrate the developed optical detection method with swab sampling to detect bacterial cells loading on stainless-steel surfaces. Using Salmonella enterica (SE1045) and Escherichia coli (E. coli OP50) as model bacterial cells, we achieved a capture efficiency of up to 76.0 ± 2.0 % for SE1045 cells and 81.1 ± 3.3 % for E. coli OP50 cells at 103 CFU/mL upon the optimized conditions, which slightly decreased with the increasing bacterial concentrations. Our assay showed good linear relationships between the concentrations of bacterial cells with the cell counting in images in the range of 103 -107 CFU/mL for SE1045, and 103 -108 CFU/mL for E. coli OP50 cells. The limit of detection (LOD) was 103 CFU/mL for both SE1045 and E. coli OP50 cells. A further increase in sensitivity in detecting E. coli OP50 cells was achieved through a heat treatment, enabling the LOD to be reduced as low as 102 CFU/mL. Furthermore, a preliminary application succeeded in assessing bacterial contamination on stainless-steel surfaces following integration with the approximately 40 % recovery rate, suggesting prospects for evaluating the bacteria from surfaces. The entire process was completed within around 2 h, costing merely a few dollars per sample. Considering the low cost of standard light microscopes, our method holds significant potential for practical industrial applications in bacterial contamination control on surfaces, especially in low-resource settings.

The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings.

Sepsis poses a significant global health challenge in low- and middle-income countries (LMICs). Several aspects of sepsis management recommended in international guidelines are often difficult or impossible to implement in resource-limited settings (RLS) due to issues related to cost, infrastructure, or lack of trained healthcare workers. The Indian Society of Critical Care Medicine (ISCCM) drafted a position statement for the management of sepsis in RLS focusing on India, facilitated by a task force of 18 intensivists using a Delphi process, to achieve consensus on various aspects of sepsis management which are challenging to implement in RLS. The process involved a comprehensive literature review, controlled feedback, and four iterative surveys conducted between 21 August 2023 and 21 September 2023. The domains addressed in the Delphi process included the need for a position statement, challenges in sepsis management, considerations for diagnosis, patient management while awaiting an intensive care unit (ICU) bed, and treatment of sepsis and septic shock in RLS. Consensus was achieved when 70% or more of the task force members voted either for or against statements using a Likert scale or a multiple-choice question (MCQ). The Delphi process with 100% participation of Task Force members in all rounds, generated consensus in 32 statements (91%) from which 20 clinical practice statements were drafted for the management of sepsis in RLS. The clinical practice statements will complement the existing international guidelines for the management of sepsis and provide valuable insights into tailoring sepsis interventions in the context of RLS, contributing to the global discourse on sepsis management. Future international guidelines should address the management of sepsis in RLS. How to cite this article: Juneja D, Nasa P, Chanchalani G, Cherian A, Jagiasi BG, Javeri Y, et al. The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings. Indian J Crit Care Med 2024;28(S2):S4-S19.

The right care in the right place: a scoping review of digital health education and training for rural healthcare workers.

BACKGROUND: Digital health offers unprecedented opportunities to enhance health service delivery across vast geographic regions. However, these benefits can only be realized with effective capabilities and clinical leadership of the rural healthcare workforce. Little is known about how rural healthcare workers acquire skills in digital health, how digital health education or training programs are evaluated and the barriers and enablers for high quality digital health education and training. OBJECTIVE: To conduct a scoping review to identify and synthesize existing evidence on digital health education and training of the rural healthcare workforce. INCLUSION CRITERIA: Sources that reported digital health and education or training in the healthcare workforce in any healthcare setting outside metropolitan areas. METHODS: We searched for published and unpublished studies written in English in the last decade to August 2023. The databases searched were PubMed, Embase, Scopus, CINAHL and Education Resources Information Centre. We also searched the grey literature (Google, Google Scholar), conducted citation searching and stakeholder engagement. The JBI Scoping Review methodology and PRISMA guidelines for scoping reviews were used. RESULTS: Five articles met the eligibility criteria. Two case studies, one feasibility study, one micro-credential and one fellowship were described. The mode of delivery was commonly modular online learning. Only one article described an evaluation, and findings showed the train-the-trainer model was technically and pedagogically feasible and well received. A limited number of barriers and enablers for high quality education or training of the rural healthcare workforce were reported across macro (legal, regulatory, economic), meso (local health service and community) and micro (day-to-day practice) levels. CONCLUSIONS: Upskilling rural healthcare workers in digital health appears rare. Current best practice points to flexible, blended training programs that are suitably embedded with interdisciplinary and collaborative rural healthcare improvement initiatives. Future work to advance the field could define rural health informatician career pathways, address concurrent rural workforce issues, and conduct training implementation evaluations. REVIEW REGISTRATION NUMBER: Open Science Framework: https://doi.org/10.17605/OSF.IO/N2RMX .

Development and Internal-external Validation of a Post-operative Mortality Risk Calculator for Pediatric Surgical Patients in Low- and Middle- Income Countries Using Machine Learning.

BACKGROUND: The purpose of this study was to develop and validate a mortality risk algorithm for pediatric surgery patients treated at KidsOR sites in 14 low- and middle-income countries. METHODS: A SuperLearner machine learning algorithm was trained to predict post-operative mortality by hospital discharge using the retrospectively and prospectively collected KidsOR database including patients treated at 20 KidsOR sites from June 2018 to June 2023. Algorithm performance was evaluated by internal-external cross-validated AUC and calibration. FINDINGS: Of 23,905 eligible patients, 21,703 with discharge status recorded were included in the analysis, representing a post-operative mortality rate of 3.1% (671 mortality events). The candidate algorithm with the best cross-validated performance was an extreme gradient boosting model. The cross-validated AUC was 0.945 (95% CI 0.936 to 0.954) and cross-validated calibration slope and intercept were 1.01 (95% CI 0.96 to 1.06) and 0.05 (95% CI -0.10 to 0.21). For Super Learner models trained on all but one site and evaluated in the holdout site for sites with at least 25 mortality events, overall external validation AUC was 0.864 (95% CI 0.846 to 0.882) with calibration slope and intercept of 1.03 (95% CI 0.97 to 1.09) and 1.18 (95% CI 0.98 to 1.39). INTERPRETATION: The KidsOR post-operative mortality risk algorithm had outstanding cross-validated discrimination and strong cross-validated calibration. Across all external validation sites, discrimination of Super Learner models trained on the remaining sites was excellent, though re-calibration may be necessary prior to use at new sites. This model has the potential to inform clinical practice and guide resource allocation at KidsOR sites world-wide. TYPE OF STUDY AND LEVEL OF EVIDENCE: Observational Study, Level III.

The State of Craniomaxillofacial Trauma Care in Low- and Middle-Income Countries: A Scoping Review.

Objective: This scoping review aims to contribute a descriptive analysis of the craniomaxillofacial trauma (CMF trauma) literature in low- and middle-income countries (LMICs) to identify knowledge gaps, direct future research, and inform policy. Data Sources: PubMed/MEDLINE, Cochrane Review, EMBASE, ClinicalTrials.gov, and Google Scholar from January 1, 2012 to December 10, 2023. Review Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guided reporting, and the PRISMA flowchart documented database searches. Specific, predefined search terms and inclusion criteria were used for screening, and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used for quality assessment. The search yielded 54 articles, with 13 meeting the inclusion criteria. Key findings were summarized and divided into 7 categories. Results: There were 10,420 patients (7739 [74.3%] male, 2681 [25.7%] female) with a male-to-female ratio of 2.9:1. The mean peak age of incidence of CMF trauma was 30.8 years, ranging from 20 to 40 years. Road traffic accidents were the leading cause (60.4%), followed by assault (27.2%) and falls (12.2%). The most common injuries were soft tissue injury (31.7%), isolated mandibular fracture (22.8%), and isolated middle-third of mandible fracture (18.1%). The most common treatments were closed reduction and immobilization (29.5%), conservative management (27.6%), and open reduction and internal fixation (19.6%). Most patients (77.8%) experienced a treatment delay due to a lack of fixation materials (54.8%) or surgeon unavailability (35.7%). Conclusion: CMF trauma remains a significant cause of global morbidity, yet there remains a lack of high-quality, CMF trauma-specific data in LMICs. Country-specific investigations are required to enhance knowledge and inform novel interventions. Implementing policy change must be community-specific and account for unique cultural barriers, attitudes, and behaviors to maximize patient care outcomes.

Causes, outcomes and diagnosis of acute breathlessness hospital admissions in Malawi: protocol for a multicentre prospective cohort study.

Background: Hospital admission due to breathlessness carries a significant burden to patients and healthcare systems, particularly impacting people in low-income countries. Prompt appropriate treatment is vital to improve outcomes, but this relies on accurate diagnostic tests which are of limited availability in resource-constrained settings. We will provide an accurate description of acute breathlessness presentations in a multicentre prospective cohort study in Malawi, a low resource setting in Southern Africa, and explore approaches to strengthen diagnostic capacity. Objectives: Primary objective: Delineate between causes of breathlessness among adults admitted to hospital in Malawi and report disease prevalence. Secondary objectives : Determine patient outcomes, including mortality and hospital readmission 90 days after admission; determine the diagnostic accuracy of biomarkers to differentiate between heart failure and respiratory infections (such as pneumonia) including brain natriuretic peptides, procalcitonin and C-reactive protein. Methods: This is a prospective longitudinal cohort study of adults (≥18 years) admitted to hospital with breathlessness across two hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Chiradzulu, Malawi. Patients will be consecutively recruited within 24 hours of emergency presentation and followed-up until 90 days from hospital admission. We will conduct enhanced diagnostic tests with robust quality assurance and quality control to determine estimates of disease pathology. Diagnostic case definitions were selected following a systematic literature search. Discussion: This study will provide detailed epidemiological description of adult hospital admissions due to breathlessness in low-income settings, which is currently poorly understood. We will delineate between causes using established case definitions and conduct nested diagnostic evaluation. The results have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve both patient care and outcomes.

BACKGROUND: People admitted to hospital with symptoms of breathlessness are often severely ill and need quick, accurate assessment to facilitate timely initiation of appropriate treatments. In low resource settings, such as Malawi, limited access to diagnostic equipment impedes patient assessment. Failure to identify and treat the underlying diagnosis may lead to preventable death. AIMS: This cohort study aims to delineate between common, treatable causes of breathlessness among adult patients admitted to hospital in Malawi and measure survival. We will also evaluate the performance of blood markers to diagnose and differentiate between conditions. The results will help us develop context-appropriate diagnostic and treatment algorithms based on resources available in the health system Methods in brief: We will recruit adult patients who present to hospital with breathlessness in a central national referral hospital (Queen Elizabeth Central Hospital, Blantyre), and a district hospital (Chiradzulu District Hospital, Chiradzulu). We will conduct enhanced diagnostic tests to determine causes of breathlessness against internationally accepted diagnostic guidelines. Patients will be followed up throughout their hospital admission and after discharge, until 90 days. INTERPRETATION: This study aligns with World Health Assembly resolutions on 'Strengthening diagnostics capacity' and on 'Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies'. The results of this study will have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve care and outcomes for acutely unwell patients.

Comparison of Different Reverse Transcriptase-Polymerase Chain Reaction-Based Methods for Wastewater Surveillance of SARS-CoV-2: Exploratory Study.

BACKGROUND: Many countries have applied the wastewater surveillance of the COVID-19 pandemic to their national public health monitoring measures. The most used methods for detecting SARS-CoV-2 in wastewater are quantitative reverse transcriptase-polymerase chain reaction (RT-qPCR) and reverse transcriptase-droplet digital polymerase chain reaction (RT-ddPCR). Previous comparison studies have produced conflicting results, thus more research on the subject is required. OBJECTIVE: This study aims to compare RT-qPCR and RT-ddPCR for detecting SARS-CoV-2 in wastewater. It also aimed to investigate the effect of changes in the analytical pipeline, including the RNA extraction kit, RT-PCR kit, and target gene assay, on the results. Another aim was to find a detection method for low-resource settings. METHODS: We compared 2 RT-qPCR kits, TaqMan RT-qPCR and QuantiTect RT-qPCR, and RT-ddPCR based on sensitivity, positivity rates, variability, and correlation of SARS-CoV-2 gene copy numbers in wastewater to the incidence of COVID-19. Furthermore, we compared 2 RNA extraction methods, column- and magnetic-bead-based. In addition, we assessed 2 target gene assays for RT-qPCR, N1 and N2, and 2 target gene assays for ddPCR N1 and E. Reverse transcription strand invasion-based amplification (RT-SIBA) was used to detect SARS-CoV-2 from wastewater qualitatively. RESULTS: Our results indicated that the most sensitive method to detect SARS-CoV-2 in wastewater was RT-ddPCR. It had the highest positivity rate (26/30), and its limit of detection was the lowest (0.06 gene copies/µL). However, we obtained the best correlation between COVID-19 incidence and SARS-CoV-2 gene copy number in wastewater using TaqMan RT-qPCR (correlation coefficient [CC]=0.697, P<.001). We found a significant difference in sensitivity between the TaqMan RT-qPCR kit and the QuantiTect RT-qPCR kit, the first having a significantly lower limit of detection and a higher positivity rate than the latter. Furthermore, the N1 target gene assay was the most sensitive for both RT-qPCR kits, while no significant difference was found between the gene targets using RT-ddPCR. In addition, the use of different RNA extraction kits affected the result when the TaqMan RT-qPCR kit was used. RT-SIBA was able to detect SARS-CoV-2 RNA in wastewater. CONCLUSIONS: As our study, as well as most of the previous studies, has shown RT-ddPCR to be more sensitive than RT-qPCR, its use in the wastewater surveillance of SARS-CoV-2 should be considered, especially if the amount of SARS-CoV-2 circulating in the population was low. All the analysis steps must be optimized for wastewater surveillance as our study showed that all the analysis steps including the compatibility of the RNA extraction, the RT-PCR kit, and the target gene assay influence the results. In addition, our study showed that RT-SIBA could be used to detect SARS-CoV-2 in wastewater if a qualitative result is sufficient.

Surgical mentorship in low-resource environments: Opportunities and challenges, a perspective.

Background and aims: In low- and middle-income countries (LMICs), a shortage of skilled surgical practitioners hampers healthcare delivery, impacting well-being and economic growth. Surgical mentorship programs offer a promising solution but face challenges in implementation. This review aims to comprehensively assess the impact of surgical mentorship programs in LMICs and identify challenges and opportunities for their development and implementation. Methods: A thorough literature search was conducted from 2000 to 2023 using multiple databases, focusing on surgical mentorship programs in LMICs. Inclusion criteria encompassed full-text articles in English that demonstrated characteristics of mentorship. Rigorous exclusion criteria were applied to ensure high-quality evidence inclusion. Results: Surgical mentorship programs in LMICs strengthen local surgical capacity, improve surgical skills and patient outcomes, optimize resources and technology utilization, and positively impact medical students aspiring to be surgeons. However, challenges such as resistance to change, resource limitations, financial constraints, logistical and technological challenges, and time constraints hinder their implementation. Conclusion: Despite challenges, surgical mentorship programs hold promise for enhancing surgical capacity and healthcare quality in LMICs. Standardized metrics for accountability, innovative funding mechanisms, collaborative partnerships for scalability, interdisciplinary integration, and leveraging virtual mentorship programs are key strategies to overcome challenges and foster sustainable learning cultures, ultimately contributing to improved healthcare equity and quality in low-resource settings.

Developing a Sustainable Shared Child's Health Record in Low Resources Setting, Lao PDR.

Lao PDR's Ministry of Health has problem with fragmented data, lack of standardization, and inability to interoperate hinder child health data collection. Electronic health information exchange (HIE) could improve data quality and shared child health records (SCHR). In this study we developed the SCHR by interoperating with existing healthcare systems. The FHIR IPS standards were customized based on data elements. 14 experts from the technical working group (TWG) had determined the minimum dataset for data transactions and system testing was analyzed on the HAPI FHIR server. Used FHIR IPS standards for interoperability within Client Registry (CR-DHIS2), Electronic Immunization Record (EIR-DHIS2) and Electronic Medical Record (EMR) works well for data transactions. The initial result of the SCHR could be able to provide a real target child and to monitor full vaccination. However, prior to the actual deployment of the system, it is necessary to validate it and guarantee the confidentiality and safety of the data.

Artificial Intelligence (AI) Applications for Point of Care Ultrasound (POCUS) in Low-Resource Settings: A Scoping Review.

Advancements in artificial intelligence (AI) for point-of-care ultrasound (POCUS) have ushered in new possibilities for medical diagnostics in low-resource settings. This review explores the current landscape of AI applications in POCUS across these environments, analyzing studies sourced from three databases-SCOPUS, PUBMED, and Google Scholars. Initially, 1196 records were identified, of which 1167 articles were excluded after a two-stage screening, leaving 29 unique studies for review. The majority of studies focused on deep learning algorithms to facilitate POCUS operations and interpretation in resource-constrained settings. Various types of low-resource settings were targeted, with a significant emphasis on low- and middle-income countries (LMICs), rural/remote areas, and emergency contexts. Notable limitations identified include challenges in generalizability, dataset availability, regional disparities in research, patient compliance, and ethical considerations. Additionally, the lack of standardization in POCUS devices, protocols, and algorithms emerged as a significant barrier to AI implementation. The diversity of POCUS AI applications in different domains (e.g., lung, hip, heart, etc.) illustrates the challenges of having to tailor to the specific needs of each application. By separating out the analysis by application area, researchers will better understand the distinct impacts and limitations of AI, aligning research and development efforts with the unique characteristics of each clinical condition. Despite these challenges, POCUS AI systems show promise in bridging gaps in healthcare delivery by aiding clinicians in low-resource settings. Future research endeavors should prioritize addressing the gaps identified in this review to enhance the feasibility and effectiveness of POCUS AI applications to improve healthcare outcomes in resource-constrained environments.

sFlt1/PlGF among patients with suspected preeclampsia when considering hypertensive status.

BACKGROUND: In high-resource settings, biomarkers of angiogenic balance, such as the soluble fms-like tyrosine kinase-1 (sFlt1)/placental growth factor (PlGF) ratio, have been studied extensively to aid in evaluation of patients with suspected preeclampsia (PE), and have been incorporated into the 2021 International Society for the Study of Hypertension in Pregnancy definition of PE. The utility in under-resourced settings has not been as well characterized. OBJECTIVE: This analysis sought to identify the role of the sFlt1/PlGF ratio in the evaluation of patients with or without hypertension who are suspected of having PE without other diagnostic information. STUDY DESIGN: This is a secondary analysis of a prior prospective study of patients who were presented with suspected PE at ≥20+0 weeks' gestation at a single academic tertiary care center. Patients were recruited in the parent study from July 2009 to June 2012. In the original study, clinicians were masked to biomarker results, and patients were followed by chart review. In this analysis, the performance of the sFlt1/PlGF ratio (≤38, >38, or >85) was assessed alone in identifying both hypertensive and non-hypertensive patients at risk of evolving into PE with severe features (PE-SF; American College of Obstetricians and Gynecologists' definition) within two weeks of the triage visit (PE-SF2). Hypertension was defined as a blood pressure (BP)≥140/90 mmHg. RESULTS: There were 1043 patients included in the analysis; of whom, 579 (55.5%) and 464 (44.5%) presented with or without hypertension, respectively. In triage, 332 (75.4%) of hypertensive patients presented due to BP concerns, and the remainder were evaluated due to other features (new-onset headache, proteinuria, or edema). On triage evaluation, 66.8% of all patients had a normal sFlt1/PlGF ratio ≤38, and 17.0% had an elevated ratio >85. Among hypertensive patients, a sFlt1/PlGF ratio ≤38 was a good rule-out test for PE-SF2 (negative likelihood ratio [LR-] of 0.15), and a ratio >85 was a good rule-in test (positive likelihood ratio [LR+] of 5.75). Among normotensive patients, sFlt1/PlGF was useful as a rule-in test for ratio >38 (LR+ 5.13) and >85 (LR+ 12.80). Stratified by gestational age, sFlt1/PlGF continued to be a good rule in and good rule out test at <35 weeks among those with hypertension but did not have good test performance ≥35 weeks. sFlt1/PlGF had a good test performance as a rule in test for >85 regardless of gestational age. In triage, 4.3% (30/693) of patients with sFlt1/PlGF ratio <38 had concurrent laboratory evidence of PE, compared with 15.9% (28/176) patients with ratio >85. CONCLUSION: These findings support the potential for the use of sFlt1/PlGF and BP measurement alone in resource-limited settings where other laboratory tests or clinical expertise are unavailable for risk stratification. Performance of the biomarker varied by the presence of hypertension and gestational age.

Spatial Access to Continuous Maternal and Perinatal Health Care Services in Low-Resource Settings: Cross-Sectional Study.

BACKGROUND: Maternal and perinatal health are fundamental to human development. However, in low-resource settings such as sub-Saharan Africa (SSA), significant challenges persist in reducing maternal, newborn, and child mortality. To achieve the targets of the sustainable development goal 3 (SDG3) and universal health coverage (UHC), improving access to continuous maternal and perinatal health care services (CMPHS) has been addressed as a critical strategy. OBJECTIVE: This study aims to provide a widely applicable procedure to illuminate the current challenges in ensuring access to CMPHS for women of reproductive age. The findings are intended to inform targeted recommendations for prioritizing resource allocation and policy making in low-resource settings. METHODS: In accordance with the World Health Organization guidelines and existing literature, and taking into account the local context of CMPHS delivery to women of reproductive age in Mozambique, we first proposed the identification of CMPHS as the continuum of 3 independent service packages, namely antenatal care (ANC), institutional delivery (ID), and postnatal care (PNC). Then, we used the nearest-neighbor method (NNM) to assess spatial access to each of the 3 service packages. Lastly, we carried out an overlap analysis to identify 8 types of resource-shortage zones. RESULTS: The median shortest travel times for women of reproductive age to access ANC, ID, and PNC were 2.38 (IQR 1.38-3.89) hours, 3.69 (IQR 1.87-5.82) hours, and 4.16 (IQR 2.48-6.67) hours, respectively. Spatial barriers for women of reproductive age accessing ANC, ID, and PNC demonstrated large variations both among and within regions. Maputo City showed the shortest travel time and the best equity within the regions (0.46, IQR 0.26-0.69 hours; 0.74, IQR 0.47-1.04 hours; and 1.34, IQR 0.83-1.85 hours, respectively), while the provinces of Niassa (4.07, IQR 2.41-6.63 hours; 18.20, IQR 11.67-24.65 hours; and 7.69, IQR 4.74-13.05 hours, respectively) and Inhambane (2.69, IQR 1.49-3.91 hours; 4.43, IQR 2.37-7.16 hours; and 10.76, IQR 7.73-13.66 hours, respectively) lagged behind significantly in both aspects. In general, more than 51% of the women of reproductive age, residing in 83.25% of Mozambique's land area, were unable to access any service package of CMPHS in time (within 2 hours), while only about 21%, living in 2.69% of Mozambique's land area, including Maputo, could access timely CMPHS. CONCLUSIONS: The spatial accessibility and equity of CMPHS in Mozambique present significant challenges in achieving SDG3 and UHC, especially in the Inhambane and Niassa regions. For Inhambane, policy makers should prioritize the implementation of a decentralization allocation strategy to increase coverage and equity through upgrading existing health care facilities. For Niassa, the cultivation of well-trained midwives who can provide door-to-door ANC and PNC at home should be prioritized, with an emphasis on strengthening communities' engagement. The proposed 2-step procedure should be implemented in other low-resource settings to promote the achievement of SDG3.

Chest X-Ray-Based Telemedicine Platform for Pediatric Tuberculosis Diagnosis in Low-Resource Settings: Development and Validation Study.

BACKGROUND: Tuberculosis (TB) remains a major cause of morbidity and death worldwide, with a significant impact on children, especially those under the age of 5 years. The complex diagnosis of pediatric TB, compounded by limited access to more accurate diagnostic tests, underscores the need for improved tools to enhance diagnosis and care in resource-limited settings. OBJECTIVE: This study aims to present a telemedicine web platform, BITScreen PTB (Biomedical Image Technologies Screen for Pediatric Tuberculosis), aimed at improving the evaluation of pulmonary TB in children based on digital chest x-ray (CXR) imaging and clinical information in resource-limited settings. METHODS: The platform was evaluated by 3 independent expert readers through a retrospective assessment of a data set with 218 imaging examinations of children under 3 years of age, selected from a previous study performed in Mozambique. The key aspects assessed were the usability through a standardized questionnaire, the time needed to complete the assessment through the platform, the performance of the readers to identify TB cases based on the CXR, the association between the TB features identified in the CXRs and the initial diagnostic classification, and the interreader agreement of the global assessment and the radiological findings. RESULTS: The platform's usability and user satisfaction were evaluated using a questionnaire, which received an average rating of 4.4 (SD 0.59) out of 5. The average examination completion time ranged from 35 to 110 seconds. In addition, the study on CXR showed low sensitivity (16.3%-28.2%) but high specificity (91.1%-98.2%) in the assessment of the consensus case definition of pediatric TB using the platform. The CXR finding having a stronger association with the initial diagnostic classification was air space opacification (χ21>20.38, P<.001). The study found varying levels of interreader agreement, with moderate/substantial agreement for air space opacification (κ=0.54-0.67) and pleural effusion (κ=0.43-0.72). CONCLUSIONS: Our findings support the promising role of telemedicine platforms such as BITScreen PTB in enhancing pediatric TB diagnosis access, particularly in resource-limited settings. Additionally, these platforms could facilitate the multireader and systematic assessment of CXR in pediatric TB clinical studies.

Sustainability in radiography: Knowledge, practices, and barriers among radiographers in Zimbabwe and Zambia.

INTRODUCTION: As the global demand for radiography services increases, departments need to be aware of the environmental impact of their practices and strive to reduce their carbon footprint. However, sustainability in radiography, particularly in low-resource settings, remains underexplored. This study aimed to investigate the knowledge, practices, and barriers to sustainability in radiography practice among radiographers in Zimbabwe and Zambia. METHODS: A quantitative cross-sectional study involving 216 consecutively sampled radiographers who completed an online questionnaire was conducted. Data analysis was performed using descriptive statistics, the Chi-square test, and exploratory factor analysis using principal component analysis. RESULTS: Overall, 81.49 % of the radiographers had some familiarity with the concept of sustainability. The radiography educational curriculum was singled out as lacking sufficient content on sustainability (44.44 %). More than half of the radiographers reported the absence of deliberate sustainable practices in place in their respective departments (Zambia 51.02 %, Zimbabwe 54.69 %). The top reported barriers to sustainability include; a lack of priority for sustainability from leadership and organization (73.61 %), a lack of incentives for sustainability (75.46 %), and a lack of partnerships between suppliers and consumers on ways to improve diagnosis, patient safety and sustainability (82.4 %). CONCLUSION: This study offers valuable insights into the current state of sustainability in radiography in Zambia and Zimbabwe, highlighting the need for academic reforms, intentional departmental practices, and systemic changes to drive sustainable efforts in the field. Future research should aim to enhance the sustainability of radiographic examinations and procedures, thereby advancing the core practice of radiographers.