Protocol: identifying policy, system, and environment change interventions to enhance availability of blood for transfusion in Kenya, a mixed-methods study

BACKGROUND

Safe blood is essential for the care of patients with life-threatening anemia and hemorrhage. Low blood donation rates, inefficient testing procedures, and other supply chain disruptions in blood administration affect patients in low-resource settings across Sub-Saharan countries, including Kenya. Most efforts to improve access to transfusion have been unidimensional, usually focusing on only point along the blood system continuum, and have excluded community stakeholders from early stages of intervention development. Context-appropriate interventions to improve the availability of safe blood at the point of use in low-resource settings are of paramount importance. Thus, this protocol proposes a multifaceted approach to characterize the Kenyan blood supply chain through quantitative and qualitative analyses as well as an industrial engineering approach.

METHODS

This study will use a mixed-methods approach in addition to engineering process mapping, modeling and simulation of blood availability in Kenya. It will be guided by a multidimensional three-by-three-by-three matrix: three socioeconomic settings, three components of the blood system continuum, and three levels of urgency of blood transfusion. Qualitative data collection includes one-on-one interviews and focus group discussions with stakeholders across the continuum to characterize ground-level deficits and potential policy, systems, and environment (PSE) interventions. Prospectively-collected quantitative data will be used to estimate blood collection and transfusion of blood. We will create a process map of the blood system continuum to model the response to PSE changes proposed by stakeholders. Lastly, we will identify those PSE changes that may have the greatest impact on blood transfusion availability, accounting for differences across socioeconomic settings and levels of urgency.

DISCUSSION

Identifying and prioritizing community-driven interventions to improve blood supply in low-resource settings are of utmost importance. Varied constraints in blood collection, processing, delivery, and use make each socioeconomic setting unique. Using a multifaceted approach to understand the Kenyan blood supply and model the response to stakeholder-proposed PSE changes may lead to identification of contextually appropriate intervention targets to meet the transfusion needs of the population.

The Association of Blood Banks per City with Mortality Due to Traumatic Hemorrhagic Shock in Colombia: A Population-Based Analysis

Background

Hemorrhagic shock is the second leading cause of death for injured people and disproportionately affects low resource economies. The potential role of spatial allocation of blood banks and the unmet transfusion needs of patients are yet to be characterized. We aimed to estimate the effect of the number of blood banks in mortality due to traumatic hemorrhagic shock (THS) in Colombia.

Methods

We performed a population-based cross-sectional study using secondary data from the Colombian Government: including annual reports from the Blood Bank Network, mortality, and population estimates for 2015-2016. International Classification of Disease 10th code T79.4 identified THS as the primary cause of death. A city-clustered multivariate negative binomial regression, weighted by violent deaths rate, was used to obtain incidence rate ratios (IRR) of death due to THS with 95% confidence intervals (95%CI).

Results

Of the 59,030 violent deaths in Colombia in 2015-2016, 36.76% were due to THS. Only 3.13% of Colombian municipalities had a blood bank. THS incidence decreased as the number of blood banks in a city increased, and the lowest incidence was observed at ten banks (IRR:0.18, 95%CI:0.15-0.22). Receiving medical care in a city with blood banks had a more substantial impact on THS (IRR:0.85; 95%CI:0.76-0.96).

Conclusion

The number of blood banks per city was associated with lower incidence of THS deaths. These findings may highlight the inequitable distribution of blood systems and their association with preventable deaths. Further studies with more focused clinical and geographical data might clarify the geographic determinants of blood products' availability.

Peer mentorship to build research capacity among members of the International Student Surgical Network (InciSioN): a proof of concept study

BACKGROUND

International Student Surgical Network (InciSioN) is the largest student and trainee global surgery interest group worldwide and its members have contributed significantly to global surgery research. The InciSioN Research Capacity-Building (IReCaB) program aimed to enhance the research skills and confidence of participants via a peer mentorship model.

METHODS

After an open call to members of InciSioN to enroll, participants' knowledge of research methods and the process was evaluated through a test to assign mentor and mentee roles, with mentors being those who scored ≥ 20/25. Mentors then delivered a series of four webinars to help disseminate research methodology to mentees. Finally, mentees were tested on their knowledge of research and their satisfaction with the program was also evaluated.

RESULTS

Fifty-two participants, mostly from LMICs (n = 23/52, 44.2%) were enrolled, and 36 completed the program. There was a significant improvement in the proportion of questions answered correctly on the post-program test (R = 0.755, p < 0.001). Post-IReCaB test scores were greater than pre-IReCaB scores (p < 0.001). The difference in confidence after the course was also significant (p < 0.001). IReCaB participants successfully designed, implemented, and published an international cross-sectional study.

CONCLUSION

This study showed improvements in participants' understanding of theoretical components of scientific research. We offer a model for research capacity building that can be implemented, modeled, and further refined by similar organizations with academic research goals.

Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific ZIP Code Determine the Patient's Reconstructive Journey?

BACKGROUND

Postmastectomy breast reconstruction (BR) has been shown to provide long-term quality of life and psychosocial benefits. Despite the policies initiated to improve access to BR, its delivery continues to be inequitable, suggesting that barriers to access have not been fully identified and/or addressed. The purpose of this study was to assess the influence of geographic location, socioeconomic status, and race in access to immediate BR (IBR).

METHODS

An institutional review board-approved observational study was conducted. All patients who underwent breast cancer surgery from 2014 to 2019 were queried from our institutional Breast Cancer Registry. A geographical analysis was conducted using demographic characteristics and patient's ZIP codes. Euclidean distance from patient home ZIP code to UPMC Magee Women's Hospital was calculated, and χ2, Student t test, Mann-Whitney, and Kruskal-Wallis tests was used to evaluate differences between groups, as appropriate. Statistical significance was set at P < 0.05.

RESULTS

Overall, 5835 patients underwent breast cancer surgery. A total of 56.7% underwent lumpectomy or segmental mastectomy, and 43.3% underwent modified, total, or radical mastectomy. From the latter group, 33.5% patients pursued BR at the time of mastectomy: 28.6% autologous, 48.1% implant-based, 19.4% a combination of autologous and implant-based, and 3.9% unspecified reconstruction. Rates of IBR varied among races: White or European (34.1%), Black or African American (27.7%), and other races (17.8%), P = 0.022. However, no difference was found between type of BR among races (P = 0.38). Moreover, patients who underwent IBR were significantly younger than those who did not pursue reconstruction (P < 0.0001). Patients who underwent reconstruction resided in ZIP codes that had approximately US $2000 more annual income, a higher percentage of White population (8% vs 11% non-White) and lower percentage of Black or African American population (1.8% vs 2.9%) than the patients who did not undergo reconstruction.

CONCLUSIONS

While the use of postmastectomy BR has been steadily rising in the United States, racial and socioeconomic status disparities persist. Further efforts are needed to reduce this gap and expand the benefits of IBR to the entire population without distinction.

War on Ukraine: Impact on Ukrainian Medical Students

The ongoing Russian invasion of Ukraine has taken a tremendous toll on the physical and mental wellbeing of the Ukrainian people. Accordingly, medical trainees and institutions must adapt to a high degree of uncertainty and turmoil. In 2022, Ukraine has 23 medical institutions filled with not only Ukrainian nationals but medical students from around the world. It is estimated that approximately 18,000 students from India alone study in Ukraine, many of whom are medical learners. Many of these national and foreign medical students are now displaced refugees looking to escape to Western Europe or their country of origin. Even by escaping the ongoing conflict, the question remains as to how many of these students will complete their medical education and cope with the trauma of political unrest. This is the first time that the International Journal of Medical Students Editorial Team has commented on a political conflict. We have learned in our tenure that medical students and their education worldwide is affected by many factors, including global warming and conflict. We have raised our voice before for actions to prevent climate change. We are adding our voice of support to those suffering from political unrest and acts of violence globally, with specific focus on the Ukraine. The path of war and vengeance is an easy one when compared to political dialogue and collaboration. We, the new generation of scientists of the world, claim for the use of reason over emotions to keep us all safe and promote progress worldwide.