Limited diagnostic facilities impeding the therapeutic approach of Mucopolysaccharidosis in Bangladesh: a case report

In resource-constrained settings, mucopolysaccharidosis (MPS) is a rare hereditary metabolic illness that frequently remains undiagnosed. We present a scenario that illustrates the challenges in diagnosing and managing MPS because of test inaccessibility, and we propose potential approaches to minimize the hurdles. We recommend that physicians anticipate a rare genetic disease, such as MPS, based on the clinical history findings from routine radiological investigations. Additionally, stakeholders should perform risk stratification and implement screening tests as soon as possible to ensure that patients are effectively enrolled in treatment programs.

The Prevalence of Interpersonal Violence (IPV) Against Women and its Associated Variables: An Exploratory Study in the Rongo Sub-County of Migori County, Kenya

Interpersonal violence (IPV) within intimate partner relationships and gender-based violence remain major public health problems worldwide; 44.8% of Kenyan women have reported experiencing IPV beginning after the age of 15 years (National Bureau of Statistics Nairobi, Kenya, 2015). Combatting IPV and its sequelae is integral to promoting gender equality, a key target of the Sustainable Development Goals. We quantify the lifetime prevalence of IPV among women in two rural Kenyan communities, as well as factors associated with IPV in this area, such as educational attainment and severe depression. We conducted a cross-sectional population-based survey of households in the North and East Kamagambo wards of Migori County, Kenya in May 2018. A questionnaire regarding IPV was given to female respondents. Group-wise comparisons and multiple logistic regression analyses were performed to describe community prevalence and factors associated with IPV against women. A total of 873 women completed questions about IPV, representing a population estimate of 11,252 women in the study area. Lifetime IPV prevalence in the study area was 60.3%. Variables associated with IPV included involvement in a polygamous marriage (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: [1.13, 2.88]; p = .013), attaining six or fewer years of education (aOR: 1.84; 95% CI: [1.27, 2.66]; p = .001), and IPV exposure in girlhood (aOR: 1.59; 95% CI: [1.12, 2.28]; p = .011). IPV was independently associated with experience of emotional abuse (OR: 11.22; 95% CI: [7.02, 17.95]; p < .001) and severe depression (OR: 3.51; 95% CI: [1.03, 11.97]; p = .045). Violence against women is a public health emergency in Migori County, Kenya. Low educational attainment, IPV exposure in girlhood, and polygamy were significantly associated with experience of IPV. Our results provide hyper-local data necessary for targeted interventions and generalizable data with sampling methods for use by other implementing organizations in sub-Saharan Africa.

Pattern and Outcome of Traumatic Brain Injury, Addis Ababa, Ethiopia: A Cross-sectional Hospital-based Study

Background

Traumatic brain injury (TBI) is the leading cause of death and disability in young adults in the world. This study assessed clinical characteristics and in-hospital outcomes among traumatic brain injury patients presenting to Addis Ababa Burn, Emergency, and Trauma hospital.

Methods

A cross-sectional hospital-based survey was conducted at AaBET hospital from January 01/2020 to April 30/2020. Data were collected using structured questionnaires from the trauma registry and patient chart. The collected data were analyzed using statistical software SPSS v 25.0.

Results

Among the 304 traumatic brain injury patients, 75% were males with a mean age of 30.4 + 15.7, and 59.2% came from the Oromia region. Road traffic injury was responsible for 45% of the cases, of which pedestrian struck accounts for 52.2% of the cases. Only 50 (16.4%) patients arrived below 02 hours. 201 (66.1%) patients had mild traumatic brain injury the rest had moderate to severe traumatic brain injury. Skullbone fracture (linear, DSF, & BSF) was the most common (n=157, 63.1%) followed by intracerebral lesions (DAI, brain contusion, & ICH) (n=140, 56.5%). Forty-three (14.1%) patients were intubated. 45(14.8%) cases had a neurosurgical intervention. The mortality rate of severe, moderate, & mild TBI were 25%, 8.0% & 2.0% respectively with an overall mortality of 5.6%.

Conclusion

This study showed road traffic injury was the commonest cause of traumatic brain injury which affected young age groups. There was a delayed presentation to AaBET hospital Emergency. The mortality rate was lower than other Ethiopian hospital studies.

Recovery of renal function after early versus late switching of tenofovir disoproxil fumarate in people living with HIV with renal insufficiency

BACKGROUND

Although many guidelines recommend switching tenofovir disoproxil fumarate (TDF) to other antiretroviral agents if there is a progressive decline in the estimated glomerular filtration rate (eGFR) not explained by other causes, a definite cut-point of the eGFR for TDF switching is not known.

METHODS

A cohort study was conducted among people living with HIV (PLHIV) who switched from TDF to other agents due to declined eGFR. Participants were categorized according to the eGFR at TDF switching: early-switch (eGFR ≥ 60 mL/min/1.73 m²) and late-switch (eGFR < 60 mL/min/1.73 m²) groups. Binary logistic regression was used to determine factors associated with complete recovery of renal function.

RESULTS

Of 141 participants, mean age was 54.2 ± 12.2 years and 74.5% were male. Median duration of TDF use was 5.2 years. Mean eGFR at the time of TDF switching was 72.4 ± 13.7 mL/min/1.73 m² in the early-switch group and 47.0 ± 14.8 mL/min/1.73 m² in the late-switch group. Six months after TDF switching, mean eGFR significantly increased to 84.2 ± 13.5 (p = .001) and 58.5 ± 13.2 mL/min/1.73 m² (p < .001) in early-switch and late-switch groups, respectively. At 12 months after TDF switching, 44.4% of participants in early-switch group and 2.3% of participants in late-switch group had eGFR recovery to ≥ 90 mL/min/1.73 m² (p < .001). Multivariate analysis showed that only early switching (vs late switching) of TDF was associated with complete recovery of renal function at 12 months after TDF switching [OR, 7.542; 95% CI, 2.441-11.119; p = .028].

CONCLUSIONS

In PLHIV with TDF-associated renal insufficiency, eGFR significantly recovers after switching TDF to other agents. Early TDF switching has a higher chance of complete recovery of renal function.

Portable, handheld, and affordable blood perfusion imager for screening of subsurface cancer in resource-limited settings

Existing procedures of screening subsurface cancers are either prohibitively resource-intensive and expensive or are unable to provide direct quantitative estimates of the relevant physiological parameters for accurate classification accommodating interpatient variabilities and overlapping clinical manifestations. Here, we introduce a handheld and inexpensive blood perfusion imager that provides a noninvasive in situ screening approach for distinguishing precancer, cancer, and normal scenarios by precise quantitative estimation of the localized blood circulation in the tissue over an unrestricted region of interest without any unwarranted noise in the data, augmented by machine learning–based classification. Clinical trials in minimally resourced settings have established the efficacy of the method in differentiating cancerous and precancerous stages of suspected oral abnormalities, as verified by gold-standard biopsy reports.

Precise information on localized variations in blood circulation holds the key for noninvasive diagnostics and therapeutic assessment of various forms of cancer. While thermal imaging by itself may provide significant insights on the combined implications of the relevant physiological parameters, viz. local blood perfusion and metabolic balance due to active tumors as well as the ambient conditions, knowledge of the tissue surface temperature alone may be somewhat inadequate in distinguishing between some ambiguous manifestations of precancer and cancerous lesions, resulting in compromise of the selectivity in detection. This, along with the lack of availability of a user-friendly and inexpensive portable device for thermal-image acquisition, blood perfusion mapping, and data integration acts as a deterrent against the emergence of an inexpensive, contact-free, and accurate in situ screening and diagnostic approach for cancer detection and management. Circumventing these constraints, here we report a portable noninvasive blood perfusion imager augmented with machine learning–based quantitative analytics for screening precancerous and cancerous traits in oral lesions, by probing the localized alterations in microcirculation. With a proven overall sensitivity >96.66% and specificity of 100% as compared to gold-standard biopsy-based tests, the method successfully classified oral cancer and precancer in a resource-limited clinical setting in a double-blinded patient trial and exhibited favorable predictive capabilities considering other complementary modes of medical image analysis as well. The method holds further potential to achieve contrast-free, accurate, and low-cost diagnosis of abnormal microvascular physiology and other clinically vulnerable conditions, when interpreted along with complementary clinically evidenced decision-making perspectives.

Submassive Pulmonary Embolism Treated With Catheter-Directed Thrombolysis in Resource-Limited Setting: A Case Report and Review of Literature

We describe a case of a young male who presented with acute onset progressively worsening shortness of breath for four days duration. He used to smoke cigarettes, and his profession required prolonged periods of standing. He underwent a two-dimensional echocardiogram showing right ventricular (RV) strain and computed tomography (CT) showing thrombus in the left major pulmonary artery. His pulmonary embolism severity index (PESI) score was high, predicting higher short-term mortality. Treatment options including risks and benefits were discussed with the patient, and he underwent catheter-directed thrombolysis (CDT) with rapid resolution of symptoms, oxygen saturation, and pulmonary artery pressures (PAP). He was discharged home safely after successful treatment of his condition.

Radiographic outcomes of femur fractures following SIGN Fin nailing in low- and middle-income countries

Objective:

To measure the effectiveness of the Surgical Implant Generation Network (SIGN) Fin nail for achieving satisfactory postoperative radiographic alignment following femoral shaft fractures.

Methods:

Femoral shaft fractures stabilized with the SIGN Fin nail were identified using the SIGN Online Surgical Database. A random number generator was used to identify 500 femur fractures fixed within 6 weeks of injury for which postoperative radiographs were available. Fractures were classified using OTA/AO and Winquist-Hansen classification systems. Deviation from anatomic alignment was measured on anterior-posterior and lateral radiographs using an on-screen protractor tool. Other clinical variables recorded in the SIGN Online Surgical Database were also analyzed. Simple logistic regression was used to assess for associations between subject and surgical characteristics and misalignment status. Intra- and inter-rater agreement was assessed with intraclass correlation coefficient (ICC).

Results:

The overall rate of malalignment >5° was 9.4%. Factors associated with increased incidence of malalignment include older age, increased time to surgery, distal diaphyseal location, closed (vs open) reduction, degree of comminution, and fracture classification. Intra-rater ICC was 0.70 (0.52, 0.82) in the coronal plane and 0.55 (0.32, 0.72) in the sagittal plane. Inter-rater ICC was 0.37 (0.08, 0.60) and 0.32 (0.05, 0.54), respectively.

Conclusion:

The SIGN Fin nail is an effective implant for fixation of femoral shaft fractures in resource-limited regions, achieving rates of satisfactory postoperative alignment comparable to that of the standard SIGN nail as well as femoral shaft fractures treated in North American Trauma Centers. Further research is required to investigate rotational alignment and long-term clinical outcomes for the SIGN Fin nail.

Level of evidence:

IV.

A ketamine package for use in emergency cesarean delivery when no anesthetist is available: An analysis of 401 consecutive operations

OBJECTIVE

To evaluate the safety and effectiveness of a ketamine-based anesthesia package to support emergency cesarean section when no anesthetist is available.

METHODS

A prospective case-series was conducted between December 11, 2013 and September 30, 2021 across nine sub-county hospitals in Kenya. Non-anesthetist healthcare providers undertook an evidence-based five-day training course. A structured instrument was used to collect preoperative, intraoperative, and postoperative data, and patients were contacted 6 months following the surgery to collect outcomes. The primary outcome measures were maternal and newborn survival and the ability of the ketamine package (ESM-Ketamine) to safely support cesarean deliveries.

RESULTS

A total of 401 emergency cesarean sections were performed using ketamine, administered by 54 non-anesthetist providers. All mothers survived to discharge. Brief oxygen desaturations were recorded among 33 (8.2%) mothers, and agitation and hallucinations occurred among 13 (3.2%). There were no maternal serious adverse events. At 6-month follow-up, 94.2% of mothers who could be reached reported no complaints. Additionally, 402 (92.4%) of the 435 operative births survived to discharge.

CONCLUSION

The ESM-Ketamine package can be used by trained non-anesthetist providers to support emergency cesarean sections when no anesthetist is available. Ketamine has significant potential to increase access to emergency cesarean deliveries in resource-limited settings.

Cardiac point of care ultrasound in resource limited settings to manage children with congenital and acquired heart disease

BACKGROUND

In resource limited settings, children with cardiac disease present late, have poor outcomes and access to paediatric cardiology programmes is limited. Cardiac point of care ultrasound was introduced at several Médecins Sans Frontières sites to facilitate cardiopulmonary assessment. We describe the spectrum of disease, case management and outcomes of cases reviewed over the Telemedicine platform.

METHODS

Previously ultrasound naïve, remotely placed clinical teams received ultrasound training on focussed image acquisition. The Médecins Sans Frontières Telemedicine platform was utilised for remote case and imaging review to diagnose congenital and acquired heart disease and guide management supported by a remotely situated paediatric cardiologist.

RESULTS

Two-hundred thirty-three cases were reviewed between 2016 and 2018. Of 191 who underwent focussed cardiac ultrasound, diagnoses included atrial and ventricular septal defects 11%, atrioventricular septal defects 7%, Tetralogy of Fallot 9%, cardiomyopathy/myocarditis 8%, rheumatic heart disease 8%, isolated pericardiac effusion 6%, complex congenital heart disease 4% and multiple other diagnoses in 15%. In 17%, there was no identifiable abnormality while 15% had inadequate imaging to make a diagnosis. Cardiologist involvement led to management changes in 75% of cases with a diagnosis. Mortality in the entire group was disproportionately higher among neonates (38%, 11/29) and infants (20%, 16/81). There was good agreement on independent review of selected cases between two independent paediatric cardiologists.

CONCLUSION

Cardiac point of care ultrasound performed by remote clinical teams facilitated diagnosis and influenced management in cases reviewed over a Telemedicine platform. This is a feasible method to support clinical care in resource limited settings.

Association between Adult Vaccine Hesitancy and Parental Acceptance of Childhood COVID-19 Vaccines: A Web-Based Survey in a Northwestern Region in China

China has initiated the COVID-19 vaccination for children aged 15-17 years since late July 2020. This study aimed to determine the association between adult vaccine hesitancy and parental acceptance of childhood COVID-19 vaccines in a multi-ethnicity area of northwestern China. A web-based investigation was performed with a convenience sampling strategy to recruit the parents aged 20-49 years. In a total of 13,451 valid respondents, 66.1% had received the COVID-19 vaccination, 26.6% were intent to receive, while 7.3% were not intent, with an increasing vaccine hesitancy (p < 0.001). Moreover, vaccination uptake of four common vaccines in their children remained low (29.0% for influenza vaccine, 17.9% for pneumonia vaccine, 10.9% for rotavirus vaccine, 8.0% for Enterovirus-71 vaccine), while overall parental acceptance of childhood COVID-19 vaccines was 50.0% (32.7% for those aged 0-5, 46.6% for 6-10, 73.3% for 11-18; p < 0.001). Vaccination uptake of these four vaccines and parental acceptance of childhood COVID-19 vaccine were negatively associated with adult vaccine hesitancy. In addition, respondents mostly preferred childhood COVID-19 vaccines with weak mild common adverse events (β = 1.993) and no severe adverse events (β = 1.731), demonstrating a positive association with adult vaccine hesitancy. Thus, it warrants specific countermeasures to reduce adult vaccine hesitancy and improve strategies for childhood vaccination.

A mixed methods evaluation of Advanced Life Support in Obstetrics (ALSO) and Basic Life Support in Obstetrics (BLSO) in a resource-limited setting on the Thailand-Myanmar border

Background: Short emergency obstetric care (EmOC) courses have demonstrated improved provider confidence, knowledge and skills but impact on indicators such as maternal mortality and stillbirth is less substantial. This manuscript evaluates Advanced Life Support in Obstetrics (ALSO) and Basic Life Support (BLSO) as an adult education tool, in a protracted, post-conflict and resource-limited setting. Methods: A mixed methods evaluation was used. Basic characteristics of ALSO and BLSO participants and their course results were summarized. Kirkpatrick's framework for assessment of education effectiveness included: qualitative data on participants' reactions to training (level 1); and quantitative health indicator data on change in the availability and quality of EmOC and in maternal and/or neonatal health outcomes (level 4), by evaluation of the post-partum haemorrhage (PPH) related maternal mortality ratio (MMR) and stillbirth rate in the eight years prior and following implementation of ALSO and BLSO. Results: 561 Thailand-Myanmar border health workers participated in ALSO (n=355) and BLSO (n=206) courses 2008-2020. Pass rates on skills exceeded 90% for both courses while 50% passed the written ALSO test. Perceived confidence significantly improved for all items assessed. In the eight-year block preceding the implementation of ALSO and BLSO (2000-07) the PPH related MMR per 100,000 live births was 57.0 (95%CI 30.06-108.3)(9/15797) compared to 25.4 (95%CI 11.6-55.4)(6/23620) eight years following (2009-16), p=0.109. After adjustment, PPH related maternal mortality was associated with birth before ALSO/BLSO implementation aOR 3.825 (95%CI 1.1233-11.870), migrant (not refugee) status aOR 3.814 (95%CI 1.241-11.718) and attending ≤four antenatal consultations aOR 3.648 (95%CI 1.189-11.191). Stillbirth rate per 1,000 total births was 18.2 (95%CI 16.2-20.4)(291/16016) before the courses, and 11.1 (95%CI 9.8-12.5)(264/23884) after, p=0.038. Birth before ALSO/ BLSO implementation was associated with stillbirth aoR 1.235 (95%CI 1.018-1.500). Conclusions: This evaluation suggests ALSO and BLSO are sustainable, beneficial, EmOC trainings for adult education in protracted, post-conflict, resource-limited settings.

A mixed methods evaluation of Advanced Life Support in Obstetrics (ALSO) and Basic Life Support in Obstetrics (BLSO) in a resource-limited setting on the Thailand-Myanmar border

Background: Short emergency obstetric care (EmOC) courses have demonstrated improved provider confidence, knowledge and skills but impact on indicators such as maternal mortality and stillbirth is less substantial. This manuscript evaluates Advanced Life Support in Obstetrics (ALSO) and Basic Life Support (BLSO) as an adult education tool, in a protracted, post-conflict and resource-limited setting. Methods: A mixed methods evaluation was used. Basic characteristics of ALSO and BLSO participants and their course results were summarized. Kirkpatrick's framework for assessment of education effectiveness included: qualitative data on participants' reactions to training (level 1); and quantitative health indicator data on change in the availability and quality of EmOC and in maternal and/or neonatal health outcomes (level 4), by evaluation of the post-partum haemorrhage (PPH) related maternal mortality ratio (MMR) and stillbirth rate in the eight years prior and following implementation of ALSO and BLSO. Results: 561 Thailand-Myanmar border health workers participated in ALSO (n=355) and BLSO (n=206) courses 2008-2020. Pass rates on skills exceeded 90% for both courses while 50% passed the written ALSO test. Perceived confidence significantly improved for all items assessed. In the eight-year block preceding the implementation of ALSO and BLSO (2000-07) the PPH related MMR per 100,000 live births was 57.0 (95%CI 30.06-108.3)(9/15797) compared to 25.4 (95%CI 11.6-55.4)(6/23620) eight years following (2009-16), p=0.109. After adjustment, PPH related maternal mortality was associated with birth before ALSO/BLSO implementation aOR 3.825 (95%CI 1.1233-11.870), migrant (not refugee) status aOR 3.814 (95%CI 1.241-11.718) and attending ≤four antenatal consultations aOR 3.648 (95%CI 1.189-11.191). Stillbirth rate per 1,000 total births was 18.2 (95%CI 16.2-20.4)(291/16016) before the courses, and 11.1 (95%CI 9.8-12.5)(264/23884) after, p=0.038. Birth before ALSO/ BLSO implementation was associated with stillbirth aoR 1.235 (95%CI 1.018-1.500). Conclusions: This evaluation suggests ALSO and BLSO are sustainable, beneficial, EmOC trainings for adult education in protracted, post-conflict, resource-limited settings.

Acute Kidney Injury in Hospitalized Children with COVID19

BACKGROUND

Acute kidney injury (AKI) has been recognized as a significant risk factor for mortality among adults with severe acute respiratory syndrome coronavirus infection.

AIM

The aim of this study is to assess the prevalence and risk factors for AKI and mortality in children with coronavirus disease 2019 (COVID19) from a resource-limited setting.

METHODS

Cross-sectional analysis of laboratory confirmed COVID19 children admitted from 1 March to 30 November 2020 in a tertiary care hospital in New Delhi, India was done. Clinical features and associated comorbidities of COVID19 were noted. Baseline serum creatinine (height-independent Hoste's equation) and peak serum creatinine were used for staging of AKI by the 2012 Kidney Disease Improving Global Outcomes serum creatinine criteria. Univariate analysis and Kaplan-Meier survival analysis were used to compare the overall outcome in the AKI vs. the non-AKI group.

RESULTS

A total of 64 810 children between 1 month and 18 years visited the hospital; 3412 were tested for suspected COVID19, 295 tested positive and 105 (54% boys) were hospitalized. Twenty-four hospitalized children (22.8%) developed AKI; 8 in Stage 1 (33.3%), 7 in Stage 2 (29.2%) and 9 in Stage 3 (37.5%) respectively. Overall, three patients received KRT. Highest reported mortality was (66.6%) in AKI Stage 3. Risk factors for AKI included associated sepsis (OR 95% CI, 1.22-9.43, p < 0.01), nephrotic syndrome (OR 95% CI, 1.13-115.5, p < 0.01), vasopressor support (OR 3.59, 95% CI, 1.37-9.40, p value< 0.007), shock at presentation (OR 2.98, 95% CI, 1.16-7.60, p value 0.01) and mechanical ventilation (OR 2.64, 95% CI, 1.04-6.71, p value< 0.03). Mortality (25.71%) was higher in the AKI group (OR 95% CI, 1.14-8.35, p < 0.023) with shock (OR 45.92; 95% CI, 3.44-612.0, p value <0.004) and ventilation (OR 46.24; 95% CI, 1.6-1333.0 p value< 0.02) as significant risk factors for mortality.

CONCLUSION

AKI is an important modifiable risk factor for mortality in children with COVID19 in a resource-limited setting. Our study supports the strengthening of kidney replacement therapy and its timely initiation to reduce the progression of AKI and thus mortality in children.

Breast cancer in Zimbabwe: patterns of care and correlates of adherence in a national referral hospital radiotherapy center cohort from 2014 to 2018

Background

Breast cancer is the second most common cancer among women in Zimbabwe. Patients face socioeconomic barriers to accessing oncology care, including radiotherapy. We sought to understand patterns of care and adherence for women with breast cancer in sub‐Saharan Africa (SSA) with radiotherapy access.

Methods

A retrospective cohort was created for women with breast cancer evaluated at the Parirenyatwa Hospital Radiotherapy and Oncology Center (RTC) from 2014 to 2018. Clinical data were collected to define patterns of care. Non‐adherence was modeled as a binary outcome with different criteria for patients with localized versus metastatic disease.

Results

In total, 351 women presented with breast cancer with median age 51 at diagnosis (IQR: 43–61). Receptor status was missing for 71% (248). 199 (57%) had non‐metastatic disease, and 152 (43%) had metastases. Of women with localized disease, 34% received post‐mastectomy radiation. Of women with metastatic disease, 9.7% received radiotherapy. Metastatic disease and missing HIV status were associated with increased odds of study‐defined non‐adherence (aOR: 1.85, 95% CI: 1.05, 3.28; aOR: 2.13, 95% CI: 1.11, 4.05), while availability of ER/PR status was associated with lower odds of non‐adherence (aOR: 0.18, 95% CI: 0.09, 0.36).

Conclusions

Radiotherapy is likely underutilized for women with breast cancer, even in a setting with public sector availability. Exploring patient‐level factors that influence adherence to care may provide clinicians with better tools to support adherence and improve survival. Greater investment is needed in multidisciplinary, multimodality care for breast cancer in SSA.

Diverse Human Immunodeficiency Virus-1 Drug Resistance Profiles at Screening for ACTG A5288: A Study of People Experiencing Virologic Failure on Second-line Antiretroviral Therapy in Resource-limited Settings

BACKGROUND

Human immunodeficiency virus (HIV) drug resistance profiles are needed to optimize individual patient management and to develop treatment guidelines. Resistance profiles are not well defined among individuals on failing second-line antiretroviral therapy (ART) in low- and middle-income countries (LMIC).

METHODS

Resistance genotypes were performed during screening for enrollment into a trial of third-line ART (AIDS Clinical Trials Group protocol 5288). Prior exposure to both nucleoside reverse transcriptase inhibitors (NRTIs) and non-NRTIs and confirmed virologic failure on a protease inhibitor-containing regimen were required. Associations of drug resistance with sex, age, treatment history, plasma HIV RNA, nadir CD4+T-cell count, HIV subtype, and country were investigated.

RESULTS

Plasma HIV genotypes were analyzed for 653 screened candidates; most had resistance (508 of 653; 78%) to 1 or more drugs. Genotypes from 133 (20%) showed resistance to at least 1 drug in a drug class, from 206 (32%) showed resistance to at least 1 drug in 2 drug classes, and from 169 (26%) showed resistance to at least 1 drug in all 3 commonly available drug classes. Susceptibility to at least 1 second-line regimen was preserved in 59%, as were susceptibility to etravirine (78%) and darunavir/ritonavir (97%). Susceptibility to a second-line regimen was significantly higher among women, younger individuals, those with higher nadir CD4+ T-cell counts, and those who had received lopinavir/ritonavir, but was lower among prior nevirapine recipients.

CONCLUSIONS

Highly divergent HIV drug resistance profiles were observed among candidates screened for third-line ART in LMIC, ranging from no resistance to resistance to 3 drug classes. These findings underscore the need for access to resistance testing and newer antiretrovirals for the optimal management of third-line ART in LMIC.

Universal COVID-19 screening of 4040 health care workers in a resource-limited setting: an Egyptian pilot model in a university with 12 public hospitals and medical centers

BACKGROUND

The scale of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among health care workers (HCWs), particularly in resource-limited settings, remains unclear. To address this concern, universal (non-symptom-based) screening of HCWs was piloted to determine the proportion of SARS-CoV-2 infection and the associated epidemiological and clinical risk factors at a large public health care facility in Egypt.

METHODS

Baseline voluntary screening of 4040 HCWs took place between 22 April and 14 May 2020 at 12 hospitals and medical centres in Cairo. Epidemiological and clinical data were collected using an online survey. All participants were tested for SARS-CoV-2 using reverse transcription polymerase chain reaction (RT-PCR) and rapid IgM and IgG serological tests.

RESULTS

Of the 4040 HCWs screened, 170 [4.2%; 95% confidence interval (CI): 3.6-4.9] tested positive for SARS-CoV-2 by either of the three tests (i.e. infected); 125/170 (73.5%) tested PCR-positive. Most infected HCWs were nurses (97/170, 57.5%). Median age of infected HCWs was 31.5 [interquartile range (IQR): 27.0-41.3] years. Of infected HCWs, 78 (45.9%) reported contact with a suspected case and 47 (27.6%) reported face-to-face contact within 2 m with a confirmed case. The proportion of infection among symptomatic HCWs (n = 54/616) was 8.8% (95% CI: 6.7-11.3); 6/54 (11.1%) had fever ≥38°C and 7/54 (13.0%) reported severe symptoms. Most infected HCWs were asymptomatic (116/170, 68.2%). The proportion of infection among asymptomatic HCWs (n = 116/3424) was 3.4% (95% CI: 2.8-4.0).

CONCLUSIONS

The high rate of asymptomatic infections among HCWs reinforces the need for expanding universal regular testing. The infection rate among symptomatic HCWs in this study is comparable with the national rate detected through symptom-based testing. This suggests that infections among HCWs may reflect community rather than nosocomial transmission during the early phase of the COVID-19 epidemic in Egypt.

Calcaneal Quantitative Ultrasonography and Urinary Retinol-Binding Protein in Antiretroviral-Treated Patients With Human Immunodeficiency Virus in Uganda: A Pilot Study

BACKGROUND

Data on bone health and renal impairment in people with human immunodeficiency virus (HIV) in resource-limited settings are limited. The primary aim of this study was to investigate the potential role of calcaneal quantitative ultrasonography (QUS) in predicting bone mineral density (BMD) reduction in a population of Ugandan HIV-infected  individuals receiving long-term antiretroviral therapy; the secondary end point was to assess the prevalence of proximal tubular dysfunction and the correlation between elevated urinary retinol-binding protein-urinary creatinine ratio (uRBP/uCr) and reduced BMD.

METHODS

We conducted a cross-sectional study at the Infectious Diseases Institute, Kampala, Uganda. We included 101 HIV-infected adults who had been receiving continuous antiretroviral therapy for ≥10 years and had undergone dual-energy x-ray absorptiometry (DXA) during the previous 12 months. All patients underwent calcaneal QUS evaluation and urine sample collection.

RESULTS

DXA BMD measurements were significantly associated (P < .01) with calcaneal speed of sound, broadband ultrasound attenuation, and QUS index. Forty-seven individuals (47%) had abnormal uRBP/uCr values. A significant inverse correlation was observed between uRBP/uCr and DXA T scores (lumbar [P = .03], femoral neck [P < .001], and total hip [P = .002]).

CONCLUSIONS

Calcaneal QUS results showed a moderate correlation with DXA outputs. The identified high prevalence of subclinical tubular impairment also highlights the importance of expanding access to tenofovir disoproxil fumarate-sparing regimens in resource-limited settings.

Needs Assessment and Identification of the Multifaceted COPD Care Bundle in the Emergency Department of a Tertiary Hospital in Nepal

Purpose

Acute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting.

Methods

We conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care.

Results

The AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43-4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11-3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362-6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation.

Conclusion

The current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.

qSOFA as a predictor of ICU outcomes in a resource-limited setting in KwaZulu-Natal Province, South Africa

Background

Sepsis is a major cause of morbidity and mortality, especially in critical care patients. Developing tools to identify patients who are at risk of poor outcomes and prolonged length of stay in intensive care units (ICUs) is critical, particularly in resource-limited settings.

Objectives

To determine whether the quick sequential organ failure assessment (qSOFA) score based on bedside assessment alone was a promising tool for risk prediction in low-resource settings.

Methods

A retrospective cohort of adult patients admitted to the intensive care unit (ICU) at Edendale Hospital in Pietermaritzburg, South Africa (SA), was recruited into the study between 2014 and 2018. The association of qSOFA with in-ICU mortality was measured using multivariable logistic regression. Discrimination was assessed using the area under the receiver operating characteristic curve and the additive contribution to a baseline model using likelihood ratio testing.

Results

The qSOFA scores of 0, 1 and 2 were not associated with increased odds of in-ICU mortality (adjusted odds ratio (aOR) 1.24, 95% confidence interval (CI) 0.86 - 1.79; p=0.26) in patients with infection, while the qSOFA of 3 was associated with in-ICU mortality in infected patients (aOR 2.82; 95% CI 1.91 - 4.16; p<0.001). On the other hand, the qSOFA scores of 2 (aOR 3.25; 95% CI 1.91 - 5.53; p<0.001) and 3 (aOR 6.26, 95% CI 0.38 - 11.62, p<0.001) were associated with increased odds of in-ICU mortality in patients without infection. Discrimination for mortality was fair to poor and adding qSOFA to a baseline model yielded a statistical improvement in both cases (p<0.001).

Conclusion

qSOFA was associated with, but weakly discriminant, for in-ICU mortality for patients with and without infection in a resource-limited, public hospital in SA. These findings add to the growing body of evidence that support the use of qSOFA to deliver low-cost, high-value critical care in resource-limited settings.

Contributions of the study

This study expanded the data supporting the use of qSOFA in resource-limited settings beyond the emergency department or ward to include patients admitted to the ICU. Additionally, this study demonstrated stronger predictive abilities in a population of patients admitted with trauma without suspected or confirmed infection, thus providing an additional use of qSOFA as a risk-prediction tool for a broader population.

Building regional anesthesia capacity in limited-resource settings: a pilot study evaluating a 4-week curriculum

Aim: To pilot a 4-week regional anesthesia curriculum for limited-resource settings. Intervention: A baseline needs assessment and knowledge test were deployed. The curriculum included lectures and hands-on teaching, followed by knowledge attainment tests. Results: Scores on the knowledge test improved from a mean of 37.1% (SD 14.7%) to 50.9% (SD 18.6%) (p = 0.017) at 4 weeks and 49% at 24 months. An average of 1.7 extremity blocks per month was performed in 3 months prior to the curriculum, compared with an average of 4.1 per month in 8 months following. Conclusion: This collaborative curriculum appeared to have a positive impact on the knowledge and utilization of regional anesthesia.

Cost-effectiveness of public health strategies for COVID-19 epidemic control in South Africa: a microsimulation modelling study

Background

Healthcare resource constraints in low and middle-income countries necessitate selection of cost-effective public health interventions to address COVID-19.

Methods

We developed a dynamic COVID-19 microsimulation model to evaluate clinical and economic outcomes and cost-effectiveness of epidemic control strategies in KwaZulu-Natal, South Africa. Interventions assessed were Healthcare Testing (HT), where diagnostic testing is performed only for those presenting to healthcare centres; Contact Tracing (CT) in households of cases; Isolation Centres (IC), for cases not requiring hospitalisation; community health worker-led Mass Symptom Screening and molecular testing for symptomatic individuals (MS); and Quarantine Centres (QC), for household contacts who test negative. Given uncertainties about epidemic dynamics in South Africa, we evaluated two main epidemic scenarios over 360 days, with effective reproduction numbers (R_e) of 1·5 and 1·2. We compared HT, HT+CT, HT+CT+IC, HT+CT+IC+MS, HT+CT+IC+QC, and HT+CT+IC+MS+QC, considering strategies with incremental cost-effectiveness ratio (ICER) <US$3,250/year-of-life saved (YLS) cost-effective. In sensitivity analyses, we varied R_e, molecular testing sensitivity, and efficacies and costs of interventions.

Findings

With R_e 1·5, HT resulted in the most COVID-19 deaths over 360 days. Compared with HT, HT+CT+IC+MS+QC reduced mortality by 94%, increased costs by 33%, and was cost-effective (ICER $340/YLS). In settings where quarantine centres cannot be implemented, HT+CT+IC+MS was cost-effective compared with HT (ICER $590/YLS). With R_e 1·2, HT+CT+IC+QC was the least costly strategy, and no other strategy was cost-effective. HT+CT+IC+MS+QC was cost-effective in many sensitivity analyses; notable exceptions were when R_e was 2·6 and when efficacies of ICs and QCs for transmission reduction were reduced.

Interpretation

In South Africa, strategies involving household contact tracing, isolation, mass symptom screening, and quarantining household contacts who test negative would substantially reduce COVID-19 mortality and be cost-effective. The optimal combination of interventions depends on epidemic growth characteristics and practical implementation considerations.

Emergency paediatric blood transfusion practices in Mozambique

OBJECTIVES

To analyse adherence to World Health Organization (WHO) indications for transfusion requests and capacity to meet the demand in the paediatric emergency units of a tertiary hospital in Mozambique.

BACKGROUND

Severe anaemia is a relevant paediatric problem in Sub-Saharan Africa. Transfusion can be a life-saving intervention, but in this setting, blood supply is often limited, and there is a high risk of transfusion-related complications.

METHODS/MATERIALS

Data were gathered from transfusion request forms (n = 3161) sent from the Pediatric Emergency Unit (n = 2319) and Neonatology (n = 842) to the blood bank of the Central Hospital of Beira for the years 2015 to 2016.

RESULTS

We found that 22% of transfusion recipients had haemoglobin levels greater than WHO recommendations. For patients within the WHO guidelines, 3% were not given transfusions.

CONCLUSION

Our findings indicate that there may be room for education on when transfusion should be given. By optimising the allocation of limited blood supply, all children with an effective indication for transfusion could probably receive it. This objective could be achieved through the implementation of national transfusion guidelines and health care provider training.

Chronic Pulmonary Aspergillosis: Notes for a Clinician in a Resource-Limited Setting Where There Is No Mycologist

Chronic pulmonary aspergillosis (CPA) is a spectrum of several progressive disease manifestations caused by Aspergillus species in patients with underlying structural lung diseases. Duration of symptoms longer than three months distinguishes CPA from acute and subacute invasive pulmonary aspergillosis. CPA affects over 3 million individuals worldwide. Its diagnostic approach requires a thorough Clinical, Radiological, Immunological and Mycological (CRIM) assessment. The diagnosis of CPA requires (1) demonstration of one or more cavities with or without a fungal ball present or nodules on chest imaging, (2) direct evidence of Aspergillus infection or an immunological response to Aspergillus species and (3) exclusion of alternative diagnoses, although CPA and mycobacterial disease can be synchronous. Aspergillus antibody is elevated in over 90% of patients and is the cornerstone for CPA diagnosis. Long-term oral antifungal therapy improves quality of life, arrests haemoptysis and prevents disease progression. Itraconazole and voriconazole are alternative first-line agents; voriconazole is preferred for patients with contra-indications to itraconazole and in those with severe disease (including large aspergilloma). In patients co-infected with tuberculosis (TB), it is not possible to treat TB with rifampicin and concurrently administer azoles, because of profound drug interactions. In those with pan-azole resistance or intolerance or progressive disease while on oral triazoles, short-term courses of intravenous liposomal amphotericin B or micafungin is used. Surgery benefits patients with well-circumscribed simple aspergillomas and should be offered earlier in low-resource settings.

Safety, Tolerability, and Efficacy of Generic Dolutegravir-containing Antiretroviral Therapy Regimens Among South Indian Human Immunodeficiency Virus-infected Patients

In this first study of generic dolutegravir (DTG)-containing regimens in a low-resource setting, we assessed safety, tolerability, and efficacy within a prospective cohort of 564 patients with at least 6 months of clinical follow-up. We provide support for a large-scale transition to DTG as part of first-line regimens.

Impact of COVID-19 pandemic on primary care research in a resource-limited setting: a commentary

The COVID-19 pandemic has impacted on several aspects of human existence including primary care research activities in resource-limited settings. Opportunities exist for initiating multi-disciplinary collaborative research teams that may examine current controversial areas of the disease such as prevention, diagnosis and treatment; experiences of stakeholders like COVID-19 survivors and frontline health workers; and individuals and community experiences during lockdowns. Challenges associated with initiating new studies and/or sustaining old ones and publication of research outcomes may need to be curtailed through alternative strategies and support from stakeholders.