Outcomes of neoadjuvant chemotherapy and radical hysterectomy for locally advanced cervical cancer at Kigali University Teaching Hospital, Rwanda: a retrospective descriptive study

BACKGROUND

Half of countries in Africa lack access to radiation (RT), which is essential for standard treatment of locally advanced cervical cancers. We evaluated outcomes for patients treated with neoadjuvant chemotherapy (NACT) followed by radical hysterectomy in settings where no RT is available.

METHODS

We performed a retrospective descriptive study of all patients with FIGO stage IB2-IIA2 and some exceptional stage IIB cases who received NACT and surgery at Kigali University Teaching Hospital in Rwanda. Patients were treated with NACT consisting of carboplatin and paclitaxel once every 3 weeks for 3-4 cycles before radical hysterectomy. We calculated recurrence rates and overall survival (OS) rate was determined by Kaplan-Meier estimates.

RESULTS

Between May 2016 and October 2018, 57 patients underwent NACT and 43 (75.4%) were candidates for radical hysterectomy after clinical response assessment. Among the 43 patients who received NACT and surgery, the median age was 56 years, 14% were HIV positive, and FIGO stage distribution was: IB2 (32.6%), IIA1 (7.0%), IIA2 (51.2%) and IIB (9.3%). Thirty-nine (96%) patients received 3 cycles and 4 (4%) received 4 cycles of NACT. Thirty-eight (88.4%) patients underwent radical hysterectomy as planned and 5 (11.6%) had surgery aborted due to grossly metastatic disease. Two patients were lost to follow up after surgery and excluded from survival analysis. For the remaining 41 patients with median follow-up time of 34.4 months, 32 (78%) were alive with no evidence of recurrence, and 8 (20%) were alive with recurrence. One patient died of an unrelated cancer. The 3-year OS rate for the 41 patients who underwent NACT and surgery was 80.8% with a recurrence rate of 20%.

CONCLUSIONS

Neoadjuvant chemotherapy with radical hysterectomy is a feasible treatment option for locally advanced cervical cancer in settings with limited access to RT. With an increase in gynecologic oncologists skilled at radical surgery, this approach may be a more widely available alternative treatment option in countries without radiation facilities.

Indicator-condition-guided HIV testing in rural DRC

BACKGROUND

HIV testing services are a key component of the 95-95-95-0 goals. In many parts of the Democratic Republic of the Congo the availability of test kits is limited for multiple reasons. Targeted testing of patients with HIV indicator conditions is therefore the only feasible option in these settings.

METHODS

We introduced an indicator condition-guided HIV testing project in the Emergency Room of the Hôpital Géneral de Référence de Kikwit, DRC.

RESULTS

We screened 1274 patients for indicator condition. In 94 (7.4%) patients, the treating physician diagnosed at least one HIV indicator. 34 (36.2%) tested HIV-positive (2.7% of screened patients). 52% of the newly diagnosed patients were lost to follow-up two months after the first diagnosis of HIV.

CONCLUSION

In a resource-limited setting with insufficient availability of HIV-Tests, indicator-triggered testing is a useful tool to find a high number of HIV-positive patients. Loss to follow-up is one of the major challenges.

Barriers to early diagnosis of cervical cancer: a mixed-method study in Côte d'Ivoire, West Africa

BACKGROUND

Cervical cancer, a major public health problem in many developing countries, is usually associated with a poor survival related to an advanced disease at diagnosis. In Côte d'Ivoire and other developing countries with high cervical cancer prevalence, little is known about factors associated with advanced cervical cancer stages in a context of limited access to screening services.

METHODS

From May to July 2019, we conducted a cross-sectional study using a mixed, quantitative and qualitative method. Information on socio-demographic and history of the disease was extracted from a rapid case ascertainement study performed by the cancer registry of Côte d'Ivoire that enrolled all women diagnosed with cervical cancer between July 2018 and June 2019. In-depth semi-structured interviews were conducted among a subset of these women (12 women) and six healthcare providers to further capture barriers to early cervical cancer diagnosis. Factors associated with an advanced stage III, IV (according to FIGO classification) were estimated by a logistic regression model. Qualitative data were analyzed using a thematic analysis technique guided by the treatment pathway model and triangulated with quantitative data.

RESULTS

In total, 95 women with cervical cancer [median age = 51 (IQR 42-59)] years, were included. Among them, 18.9% were living with HIV and only 9.5% were covered by a health insurance. The majority (71.5%) were diagnosed with advanced cervical cancer. Being HIV-uninfected (aOR = 5.4; [1.6-17.8], p = 0.006) and being uninsured (aOR = 13.1; [2.0-85.5], p = 0.007) were independently associated with advanced cervical cancer in multivariable analysis. Qualitative data raised additional factors potentially related to advanced cervical cancer stages at diagnosis, including the lack of patient information on cervical cancer by healthcare providers and inadequate national awareness and screening campaigns.

CONCLUSION

In a context of challenges in access to systematic cervical cancer screening in Côte d'Ivoire, access to health insurance or integrated healthcare program appear to be key determinants of early diagnosis of cervical cancer.

Pakistani healthcare professionals' perceptions of communication with patients and their relatives about hereditary breast cancer: a qualitative study in a LMIC

Pakistan has the highest incidence and mortality rates of breast cancer in Asia, with high numbers of patients diagnosed at a young age suggesting the possibility of an inherited cancer syndrome. Communication of hereditary breast cancer (HBC) risk information with patients could enable earlier detection of the condition in relatives and reduce mortality rates. This study aimed to explore perceptions of healthcare professionals (HCPs) in Pakistan about communication with patients and their relatives about HBC. Semi-structured qualitative interviews were conducted with eighteen HCPs during March to May 2020 in Lahore. Thematic analysis shows the HCPs were generally supportive of informing patients themselves about HBC, but believed it was the patients' role to inform their relatives. HCPs also highlighted important barriers to communication with patients about HBC, including (i) patients' low socioeconomic status and educational attainment; (ii) high prevalence of the social stigma of breast cancer; and (iii) lack of health resources and facilities to provide genetic testing for HBC. In conclusion, HCPs would value the development of interventions to support communication between HCPs and patients. They also highlighted the need for interventions to support intrafamilial communication about HBC. Much research and political support are needed to address patient, social, and systemic-level barriers to facilitate communication about HBC.

Evaluation of pooling strategy of SARS-CoV-2 RT-PCR in limited resources setting in Egypt at low prevalence

Sample pooling testing for SARS-COV-2 can be an effective tool in COVID-19 screening when resources are limited, yet it is important to assess the performance before implementation as pooling has its limitations. Our objective was to assess the efficacy of pooling samples for coronavirus 2019 (COVID-19) compared to an individual analysis by using commercial platforms for nucleic acid testing. A total of 2200 nasopharyngeal swabs for SARS-COV-2 were tested individually and in pools of 4, 8, and 10. The cycle threshold (Ct) values of the positive pooled samples were compared to their corresponding individual positive samples. In pool size 10 samples, an estimated increase of 3-Ct was obtained, which led to false negative results in low viral load positive samples. Pooling SARS COV-2 samples is an effective strategy of screening to increase laboratories' capacity and reduce costs without affecting diagnostic performance. A pool size of 8 is recommended.

Understanding the Ghanaian Neurosurgical Literature: A Scoping Review and Bibliometric Analysis

BACKGROUND

Research serves to bolster clinical neurosurgery by critically assessing various disease pathologies, while identifying important challenges and opportunities. However, there is limited information on the landscape of the Ghanaian neurosurgical literature.

METHODS

A scoping review and bibliometric analysis was conducted in accordance with PRISMA guidelines. PubMed, Embase, Global Index Medicus, and Web of Science electronic databases were searched from inception until December 21, 2021 for English language articles about neurosurgery in Ghana.

RESULTS

927 articles were identified and 66 were ultimately included in the analysis. A majority of them, 42.4%, were retrospective cohort studies, with 62.1% published after 2010. There were no randomized controlled or basic science studies. Most articles were published in the West African Journal of Medicine (24.2%) and non-infectious/non-traumatic spinal pathology was the most commonly discussed topic (22.7%); 66.7% of articles included only authors affiliated with Ghanaian institutions, and international collaborators frequently originated from the United States (15.9%). Only 22.7% of the manuscripts reported a funding source. Commonly reported challenges included limited sample sizes, delays in diagnosis and treatment, and lack of proper diagnostic tools and specialized care.

CONCLUSIONS

This review revealed that while the Ghanaian academic neurosurgery output has been increasing over time, these have been limited to cohort studies largely assessing spine pathology. The Ghanaian neurosurgical research environment may be bolstered by an increase in research funding, the establishment of longitudinal clinical databases, training in research methodology, increased incentives for researchers, strengthening of research collaborative networks, and increased engagement of neurosurgical trainees in research.

Assessment of the Neurosurgical Capacity in Ghana: Challenges and Opportunities

BACKGROUND

Low- and middle-income countries experience numerous challenges in the provision of neurosurgical care. However, limited information exists on the neurosurgical workforce and the constraints under which care is delivered in Ghana, West Africa.

METHODS

A 19-item survey assessing neurosurgical workforce, infrastructure, and education was administered to Ghanaian consultant neurosurgeons and neurosurgeon trainees between November 8, 2021, and January 20, 2022. The data were analyzed using summary descriptions, and qualitative data were categorized into themes.

RESULTS

There were 25 consultant neurosurgeons and 8 neurosurgical trainees (from 2 training centers) identified at 11 hospitals in Ghana totaling a workforce density of 1 neurosurgeon per 1,240,000. Most neurosurgical centers were located in Accra, the capital city. Almost half of the population did not have access to a hospital with a neurosurgeon in their region. Of hospitals, 82% had in-house computed tomography and/or magnetic resonance imaging scanners. In the operating room, most neurosurgeons had access to a high-speed drill (91%) but lacked microscopes and endoscopic sets (only 64% and 36% had these tools, respectively). There were no neurointensivists or neurological intensive care units in the entire country, and there was a paucity of neurovascular surgeries and functional neurosurgical procedures.

CONCLUSIONS

The provision of neurosurgical care in Ghana has come a long way since the 1960s. However, the neurosurgical community continues to face significant challenges. Alleviating these barriers to care will call for systems-level changes that allow for the prioritization of neurosurgical care within the Ghanaian health care system.

Optimal Allocation of Finite Sampling Capacity in Accumulator Models of Multialternative Decision Making

When facing many options, we narrow down our focus to very few of them. Although behaviors like this can be a sign of heuristics, they can actually be optimal under limited cognitive resources. Here, we study the problem of how to optimally allocate limited sampling time to multiple options, modeled as accumulators of noisy evidence, to determine the most profitable one. We show that the effective sampling capacity of an agent increases with both available time and the discriminability of the options, and optimal policies undergo a sharp transition as a function of it. For small capacity, it is best to allocate time evenly to exactly five options and to ignore all the others, regardless of the prior distribution of rewards. For large capacities, the optimal number of sampled accumulators grows sublinearly, closely following a power law as a function of capacity for a wide variety of priors. We find that allocating equal times to the sampled accumulators is better than using uneven time allocations. Our work highlights that multialternative decisions are endowed with breadth–depth tradeoffs, demonstrates how their optimal solutions depend on the amount of limited resources and the variability of the environment, and shows that narrowing down to a handful of options is always optimal for small capacities.

The role of whole exome sequencing in the UBE3A point mutation of Angelman Syndrome: A case report

INTRODUCTION

Angelman Syndrome (AS) is a rare disorder with a relatively well-defined phenotype caused by lack of expression of the maternally inherited ubiquitin-protein ligase E3A (UBE3A) gene in the brain. This article describes the role of genetic testing using whole-exome sequencing (WES) in detecting rare AS variants, a point mutation in the UBE3A gene.

CASE PRESENTATION

We describe a rarely reported clinical presentation of AS in a two year and ten months old girl with severe developmental delay, movement and balance disorder, frequent smiling, apparent happy demeanor, speech impairment, absence of seizure, lack of sleep, and abnormal food-related behavior. Physical examination showed microcephaly, with facial characteristics of AS, ataxia gait, and truncal hypotonia. The electroencephalogram showed medium amplitude rhythmic 2-3c/s. Brain Magnetic Resonance Imaging revealed microcephaly, corpus callosum dysgenesis, and heterotopia grey matter on the bilateral lateral ventricle. WES was conducted to search pathogenic variants and showed a heterozygous mutation in exon 9 of the UBE3A gene, c.1513C > T (p.Arg505Ter).

CONCLUSION

Angelman syndrome is a neurodevelopmental disorder that has several underlying genetic etiologies. WES could detect a rare variant of Angelman syndrome, identified as the point mutation of the UBE3A gene, which cannot be seen with other modalities.

Variant-specific interventions to slow down replacement and prevent outbreaks

Emergency and establishment of variants of concern (VOC) impose significant challenges for the COVID-19 pandemic control specially when a large portion of the population has not been fully vaccinated. Here we develop a mathematical model and utilize this model to examine the impact of non pharmaceutical interventions, including the COVID-test (PCR, antigen and antibody test) and whole genome sequencing (WGS) test capacity and contact tracing and quarantine strength, on the VOC-induced epidemic wave. We point out the undesirable and unexpected effect of lukewarm tracing and quarantine that can potentially increase the VOC-cases at the outbreak peak time, and we demonstrate the significance of strain-specific interventions to either prevent a VOC-induced outbreak, or to mitigate the epidemic wave when this outbreak is unavoidable.

Extremity soft tissue coverage in the combat zone: use of pedicled flap transfers by the deployed orthopedic surgeon

BACKGROUND

In theaters of operation, military orthopedic surgeons have to deal with complex open extremity injuries and perform soft-tissue reconstruction on local patients who cannot be evacuated. Our objective was to evaluate the outcomes and discuss practical issues regarding the use of pedicled flap transfers performed in the combat zone on local national patients.

METHODS

A retrospective study was conducted on data from patients treated by a single orthopedic surgeon during four tours in Chad, Afghanistan and Mali between 2010 and 2017. All pedicled flap transfers performed on extremity soft-tissue defects were included, and two groups were analyzed: combat-related injuries (CRIs) and non-combat related injuries (NCRIs).

RESULTS

Forty-one patients with a mean age of 25.6 years were included. In total, 46 open injuries required flap coverage: 19 CRIs and 27 NCRIs. Twenty of these injuries were infected. The mean number of prior debridements was significantly higher in the CRIs group. Overall, 63 pedicled flap transfers were carried out: 15 muscle flaps, 35 local fasciocutaneous flaps and 13 distant fasciocutaneous flaps. The flap types used did not differ for CRIs or NCRIs. Complications included one flap failure, one partial flap necrosis and six deep infections. At the mean follow-up time of 71 days, limb salvage had been successful in 38 of the 41 cases. There were no significant differences between CRIs and NCRIs in terms of endpoint assessment.

CONCLUSIONS

Satisfying results can be achieved by simple pedicled flaps performed by orthopedic surgeons deployed in forward surgical units. Most complications were related to failure of bone infection treatment. The teaching of such basic reconstructive procedures should be part of the training for any military orthopedic surgeon.

TRIAL REGISTRATION

Retrospectively registered on January 2019 (n°2019-090 1-001).

Management of neuroblastoma in limited-resource settings

BACKGROUND

Neuroblastoma (NB) is a heterogeneous disease with variable outcomes among countries. Little is known about NB in low- and middle-income countries (LMICs).

AIM

The aim of this review was to evaluate regional management protocols and challenges in treating NB in paediatric oncology units in LMICs compared to high-income countries (HICs).

METHODS

PubMed, Global Health, Embase, SciELO, African Index Medicus and Google Scholar were searched for publications with keywords pertaining to NB, LMICs and outcomes. Only English language manuscripts and abstracts were included. A descriptive review was done, and tables illustrating the findings were constructed.

RESULTS

Limited information beyond single-institution experiences regarding NB outcomes in LMICs was available. The disease characteristics varied among countries for the following variables: sex, age at presentation, MYCN amplification, stage and outcome. LMICs were found to be burdened with a higher percentage of stage 4 and high-risk NB compared to HICs. Implementation of evidence-based treatment protocols was still a barrier to care. Many socioeconomic variables also influenced the diagnosis, management and follow-up of patients with NB.

CONCLUSION

Patients presented at a later age with more advanced disease in LMICs. Management was limited by the lack of resources and genetic studies for improved NB classification. Further research is needed to develop modified diagnostic and treatment protocols for LMICs in the face of limited resources.

Lessons from a methanol poisoning outbreak in Egypt: Six case reports

BACKGROUND

Mass methanol poisonings are challenging, especially in regions with no preparedness, management guidelines and available antidotes.

CASE SUMMARY

Six Ukrainian patients were referred to our emergency department in Cairo, Egypt several hours after drinking an alcoholic beverage made of 70%-ethanol disinfectant bought from a local pharmacy. All patients presented with severe metabolic acidosis and visual impairments. Two were comatose. Management was based on the clinical features and chemistry tests due to deficient resources for methanol leveling. No antidote was administered due to fomepizole unavailability and the difficulties expected to obtain ethanol and safely administer it without concentration monitoring. One patient died from multiorgan failure, another developed blindness and the four other patients rapidly improved.

CONCLUSION

This methanol poisoning outbreak strongly highlights the lack of safety from hazardous pharmaceuticals sold in pharmacies and limitations due to the lack of diagnostic testing, antidote availability and staff training in countries with limited-resources such as Egypt.

Overcoming barriers for the establishment of a consolidated hematopoietic cell transplantation program in a developing country

The first hematopoietic cell transplantation (HCT) in Mexico was performed at our institution; however, outcomes were suboptimal the following years, until 1998, when a consolidated HCT was established. The aim of this study was to describe the barriers and the implemented strategies to establish a successful HCT program at a referral center in Mexico and to analyze the outcomes. Barriers were detected based on the results from 1980 to 1997. For the analysis of outcomes, a retrospective study was performed including consecutive patients undergoing autologous, allogeneic, and haploidentical HCT. From November 1998 to December 2018, 363 HCTs were performed (autologous, 59%) in 323 patients. Overall non-relapse mortality (NRM) in autologous and allogeneic HCT was 2% and 14%, respectively. The 5-year overall survival was 71% and 57% for autologous and allogeneic HCT, respectively. The cost of the medications was one of the main limitations for the patients and was successfully overcome by the creation of the non-governmental organization "Unidos". NRM was diminished after reducing the BuCy2 regimen along with the use of bone marrow. Our results highlight that the implementation of unique strategies at our center, led HCT to represent a financially viable and feasible procedure with optimal results.

Clinical, Radiological Features and Outcome of COVID-19 patients in a Secondary Hospital in Jakarta, Indonesia

INTRODUCTION

The numbers of people infected with SARS-CoV-2 in Indonesia especially in Jakarta as the epicenter continue to rise. Limited published clinical data, scarcity and long turn over time of diagnostic testing put clinician in dilemma to make diagnosis.

METHODOLOGY

This is an observational case series study from confirmed COVID-19 patient in our hospital from first case admission on 17 March 30 April, 2020. We collected patient's demography, symptoms, comorbidities, therapy, laboratory, chest x-ray and ECG consecutively.

RESULTS

Between 17 March 2020 and 30 April 2020, there were 30 confirmed COVID-19 cases, 16 (53.3%) were male. Clinical symptoms were dyspnea in 22 (73.3%) and dry cough 16 (53.3%). Comorbidities were diabetes in 14 (46.6%), hypertension 10 (33.3%) and Coronary Artery Disease (CAD) in 10 (33.3%) patients respectively. Laboratory findings showed lymphopenia in 21 (70%) patients, increased inflammation marker in Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP) and Lactate Dehydrogenase (LDH) 21 (70%), 23 (76.6%) and 12 (40%) patients respectively. Twenty-seven (90%) cases had abnormal Chest X-Ray (CXR) and mostly severe 18 (60%). Descriptive finding for images included consolidation 16 (53.3%) and Ground Glass Opacities (GGO) in 10 (33.3%) patients.

CONCLUSIONS

Based on our findings, most cases of COVID-19 admitted in secondary referral hospital were already in moderate to severe stages. This is most likely due to late referral from primary care and unspecific clinical features resemblance of other infectious diseases. Inflammation marker and CXR are cost effective findings and can be used as marker to determine further referral.

A ten-year study of Retinoblastoma in Uganda: An approach to improving outcome with limited resources

BACKGROUND

Survival of children with cancer in resource-limited regions is very poor compared to better-resourced regions. Retinoblastoma (RB) is a childhood cancer that is commonly reported in many regions of Africa. RB may be safely and effectively treated by non-specialists, which could facilitate more widespread availability of treatment in under-resourced areas.

METHODS

A ten-year consecutive series of children with RB treated at Ruharo Eye Centre between December 2009 and November 2019 was prospectively followed up. Chemoreduction followed by surgery is the standard approach to therapy. Costs of therapy and also of travel and food are borne by the program which is unaffordable to most families and necessitates donors. Survival by stage of RB and number of eyes affected was described using Kaplan-Meier plots. Visual acuity was assessed for all children with bilateral disease and the retention of sight during follow-up assessed.

RESULTS

Among 665 children with RB, 18.2 % (121 children) presented with metastatic (Stage 4) RB with only two of these children surviving >24 months. Five-year survival was 60.2 % among all children with RB rising to 93.3 % and 87.2 % for children with unilateral and bilateral Stage 1 disease, respectively. Among 184 children with bilateral disease, 130 (70.7 %) retained some level of sight following primary treatment with 91 of those (49.5 % of all bilateral children) retaining vision up to their death or to the end of follow-up.

CONCLUSION

Many children in Uganda present with advanced RB and curative treatment is not possible in this setting. Children diagnosed and treated early have good prospects of survival. Retention of sight among many bilaterally affected children is achievable, facilitating access to normal education. Therefore, the strategic priorities for improving survival are changing community perceptions so that children with eye problems are brought without delay, and widening access to modern treatment by using genereal health workers with standard drugs, backed by financial, social and peer support.

Modeling the impact of mass influenza vaccination and public health interventions on COVID-19 epidemics with limited detection capability

The emerging coronavirus SARS-CoV-2 has caused a COVID-19 pandemic. SARS-CoV-2 causes a generally mild, but sometimes severe and even life-threatening infection, known as COVID-19. Currently, there exist no effective vaccines or drugs and, as such, global public authorities have so far relied upon non pharmaceutical interventions (NPIs). Since COVID-19 symptoms are aspecific and may resemble a common cold, if it should come back with a seasonal pattern and coincide with the influenza season, this would be particularly challenging, overwhelming and straining the healthcare systems, particularly in resource-limited contexts, and would increase the likelihood of nosocomial transmission. In the present study, we devised a mathematical model focusing on the treatment of people complaining of influenza-like-illness (ILI) symptoms, potentially at risk of contracting COVID-19 or other emerging/re-emerging respiratory infectious agents during their admission at the health-care setting, who will occupy the detection kits causing a severe shortage of testing resources. The model is used to assess the effect of mass influenza vaccination on the spread of COVID-19 and other respiratory pathogens in the case of a coincidence of the outbreak with the influenza season. Here, we show that increasing influenza vaccine uptake or enhancing the public health interventions would facilitate the management of respiratory outbreaks coinciding with the peak flu season, especially, compensate the shortage of the detection resources. However, how to increase influenza vaccination coverage rate remains challenging. Public health decision- and policy-makers should adopt evidence-informed strategies to improve influenza vaccine uptake.

Postpartum environmental challenges alter maternal responsiveness and offspring development

Because many threats exist in an animal's natural habitat, it is important to understand the impact of environmental challenges on maternal-offspring interactions and outcomes. In the current study, a rodent model incorporating the presence of restricted resources and an environmental threat (e.g. predator-related odors and sounds) was investigated. Specifically, pregnant females were assigned to one of four treatments: standard resources, without threat (SR; n = 7); standard resources plus threat (SR-T; n = 8); restricted resources, without threat (RR; n = 7); and restricted resources plus threat (RR-T; n = 6). Maternal rats were moved into the assigned conditions on postnatal day 2 and remained until pups were weaned. Following a standard pup retrieval task on postnatal days 2 and 6, maternal rats were exposed to a retrieval challenge task on postnatal day 8 in which each rat had to traverse a novel barrier to retrieve pups. For neurobiological measures of stress/resilience responsiveness, fecal samples were collected for detection of corticosterone and DHEA metabolites; additionally, immunohistochemistry was conducted on the maternal brains to indicate the presence of Neuropeptide Y (NPY) and Brain Derived Neurotrophic Factor (BDNF) immunoreactivity in the hippocampus, amygdala and hypothalamus. Pup development measures, including body weight and tail length, were also collected. Results suggest that maternal rats with restricted resources exhibited diminished maternal responsiveness that resulted in altered pup development measures; further, restricted resource rats exhibited endocrine markers of compromised emotional resilience (lower DHEA) and decreased neural markers of neuroplasticity (BDNF) and emotional resilience (NPY). Interestingly, predator threat affected various aspects of maternal-pup interactions but had no effect on neurobiological variables, suggesting that restricted resources had a more negative impact on maternal-related outcomes than the presence of predator threat.

Characteristics of diabetes diagnosis and control in toddlers and preschoolers from families with limited resources: A single center experience

AIM

To describe the characteristics of diabetes diagnosis, insulin therapy regarding type, dose and frequency also the degree of glycemic control achieved in toddlers and preschoolers coming from families with limited resources.

METHODS

Over one year, 69 toddlers and preschoolers clinically diagnosed as type 1 diabetes were included. Data related to presentation at diagnosis, insulin therapy and glycemic control was reviewed from patients' care givers and medical records.

RESULTS

Diabetic ketoacidosis (DKA) was recorded in 71% of the children at initial diagnosis. The mean time since diabetes diagnosis was 2 ± 1 years. Most of children (65/69, 94%) were on basal-bolus regimen while four (6%) were on basal insulin only. NPH and long acting analogues were used as basal insulin in (74%) and (26%). Regular insulin and rapid acting analogues were used as bolus insulin (27%) and (73%).The mean frequency of daily self monitoring of blood glucose was (2.9 ± 1). The arithmetic mean of HbA1c done over past 6 months to one year before inclusion in the study was 8.2 ± 1.5% (66 ± 12 mmol/mol) with 65% having HbA1c ≥ 7.5% (≥58 mmol/mol).

CONCLUSION

Toddlers and preschoolers with diabetes coming from families with limited resources frequently present with DKA at diagnosis and have suboptimal self-monitoring of blood glucose and glycemic control. NPH is more commonly used in this age group, combined with postprandial rapid analogues and less commonly preprandial regular insulin and that yields more favorable HbA1c but with a greater risk of hypoglycemia. The most common cause of hospital readmission was ketoacidosis and uncontrolled hyperglycemia.

Treating Hand Trauma in Low-Resource Setting: A Challenge for Low- and Middle-Income Countries

Hand trauma surgical treatment and perioperative therapy are often lacking in low- and middle-income countries resulting in high rates of patient morbidity following injury. Providing education through a multifaceted approach including in-person teaching, written resources, videos, and Internet and social media platforms and facilitating skill acquisition through simulation permits local providers to gain expertise in hand trauma care and thus benefits patients. This article outlines challenges faced by low- and middle-income countries in caring for hand trauma patients and possible implementable solutions.

Optimal control of epidemic size and duration with limited resources

The total number of infections (epidemic size) and the time needed for the infection to go extinct (epidemic duration) represent two of the main indicators for the severity of infectious disease epidemics in human and livestock. However, few attempts have been made to address the problem of minimizing at the same time the epidemic size and duration from a theoretical point of view by using optimal control theory. Here, we investigate the multi-objective optimal control problem aiming to minimize, through either vaccination or isolation, a suitable combination of epidemic size and duration when both maximum control effort and total amount of resources available during the entire epidemic period are limited. Application of Pontryagin's Maximum Principle to a Susceptible-Infected-Removed epidemic model, shows that, when the resources are not sufficient to maintain the maximum control effort for the entire duration of the epidemic, the optimal vaccination control admits only bang-bang solutions with one or two switches, while the optimal isolation control admits only bang-bang solutions with one switch. We also find that, especially when the maximum control effort is low, there may exist a trade-off between the minimization of the two objectives. Consideration of this conflict among objectives can be crucial in successfully tackling real-world problems, where different stakeholders with potentially different objectives are involved. Finally, the particular case of the minimum time optimal control problem with limited resources is discussed.

Practical approaches to managing postpartum haemorrhage with limited resources

Mortality from postpartum haemorrhage (PPH) is higher in low resource settings due to increased incidence, higher case fatality rates and poor general health of the population. The challenges of managing PPH with limited resources are presented. Feasible interventions for preventing and treating PPH for home births are described. Given that maternity care is organised around levels of care in low resource settings, guidance is provided for what measures can be performed to manage PPH at different levels of care (clinic, community health centre, district hospital, regional and central hospital); and by which cadre (midwife, clinical officer, general doctor, specialist). Effective management of PPH requires on-going training and emergency drills. Reducing mortality from PPH is not possible without available urgent transport from home to facility and between levels of care. In addition, the essential building blocks of the health system must be functional to enable effective management of PPH.

Surgery with Limited Resources in Natural Disasters: What Is the Minimum Standard of Care?

Purpose of Review

In a challenging scenario, such as in the aftermath of a natural disaster, minimum standards of care must be in place from the moment surgical care activities are launched.

Recent Findings

Natural disasters cause destruction and human suffering, especially in low- and middle-income countries, which suffer the most when exposed to their consequences. Health systems can quickly get overwhelmed and can collapse under the burden of injured patients during this event, while qualified surgical care remains crucial. Medécins Sans Frontières (MSF) has a vast experience providing surgical care after natural disasters, and quality is assured through the Donabedian model. Minimum structure standards are put in place from the beginning of an emergency response, together with standard operating procedures providing guidance to professionals working in challenging conditions.

Summary

MSF believes that it is always possible to deliver surgical care, ensuring the best possible quality guaranteeing adequate levels of structure and process. The "do no harm" principle must always be respected as adherence to medical ethics is a must in any context, even a challenging one.

Creation of Minimum Standard Tool for Palliative Care in India and Self-evaluation of Palliative Care Programs Using It

Background:

It is important to ensure that minimum standards for palliative care based on available resources are clearly defined and achieved.

Aims:

(1) Creation of minimum National Standards for Palliative Care for India. (2) Development of a tool for self-evaluation of palliative care organizations. (3) Evaluation of the tool in India. In 2006, Pallium India assembled a working group at the national level to develop minimum standards. The standards were to be evaluated by palliative care services in the country.

Materials and Methods:

The working group prepared a “standards” document, which had two parts – the first composed of eight “essential” components and the second, 22 “desirable” components. The working group sent the document to 86 hospice and palliative care providers nationwide, requesting them to self-evaluate their palliative care services based on the standards document, on a modified Likert scale.

Results:

Forty-nine (57%) palliative care organizations responded, and their self-evaluation of services based on the standards tool was analyzed. The majority of the palliative care providers met most of the standards identified as essential by the working group. A variable percentage of organizations had satisfied the desirable components of the standards.

Conclusions:

We demonstrated that the “standards tool” could be applied effectively in practice for self-evaluation of quality of palliative care services.

Relevance of health economics in breast cancer treatment: integration of economics in the management of breast cancer at the clinic level

Since the introduction of the diagnosis-related groups (DRG) system with cost-related and entity-specific flat-rate reimbursements for all in-patients in 2004 in Germany, economics have become an important focus in medical care, including breast centers. Since then, physicians and hospitals have had to gradually take on more and more financial responsibilities for their medical care to avoid losses for their institutions. Due to financial limitations of resources, most medical services have to be adjusted to correlating revenues, which results in the development of a variety of active measures to understand, steer, and optimize costs, resources and related processes for breast cancer treatment. In this review, the challenging task to implement microeconomic management at the clinic level for breast cancer treatment is analyzed from breast cancer-specific publications. The newly developed economic management perspective is identified for different stakeholders in the healthcare system, and successful microeconomic projects and future aspects are described.

Management of epilepsy in resource-limited areas: establishing an epilepsy surgery program in Iran

Background Of about 40 million people with epilepsy, who live in developing countries, the majority do not receive appropriate treatment. Nonetheless, there are striking disparities among the so-called developing countries, however generally speaking, access to and availability of epilepsy management programs in developing countries are very limited and therefore, the issue of developing epilepsy centers in resource-limited settings in a large scale is very essential. The surgery for epilepsy, including temporal lobotomy, lesionectomy and corpus colostomy, for patients with medically-refractory seizures, defined as failure of adequate trials of two tolerated, appropriately chosen and using antiepileptic drug to achieve sustained freedom, from seizure has been proved to be feasible and cost-effective in developing countries. However, the success of epilepsy surgery depends upon the accurate identification of good surgical candidates based on the available resources and technologies without jeopardizing safety. In the current paper, we will share our experiences of establishing an epilepsy surgery program in Iran, despite all short-comings and limitations and try to provide some answers to those challenges, which helped us establish our program.