Acute kidney injury requiring dialysis in children: a multicentric, emerging country perspective

BACKGROUND

Acute kidney injury (AKI) is a life-threatening condition, especially in extreme age groups and when kidney replacement therapy (KRT) is necessary. Studies worldwide report mortality rates of 10-63% in pediatric patients undergoing KRT.

METHODS

Over 13 years, this multicenter study analyzed data from 693 patients with AKI, all receiving KRT, across 74 hospitals and medical facilities in Rio de Janeiro, Brazil.

RESULTS

The majority were male (59.5%), under one year old (55.6%), and treated in private hospitals (76.5%). Sixty-six percent had comorbidities. Pneumonia and congenital heart disease were the most common admission diagnoses (21.5% and 20.2%, respectively). The mortality rate was 65.2%, with lower rates in patients over 12 years (50%). Older age was protective (HR: 2.35, IQR [1.52-3.62] for neonates), and primary kidney disease had a three-fold lower mortality rate. ICU team experience (HR: 0.74, IQR [0.60-0.91]) correlated with lower mortality, particularly in hospitals treating 20 or more patients. Among the deceased, 40% died within 48 h of KRT initiation, suggesting possible late referral or treatment futility.

CONCLUSIONS

This study confirms the high mortality in pediatric dialytic AKI in middle-income countries, underlining early mortality and offering critical insights for improving outcomes.

The cost-utility analysis of antifungal prophylaxis for invasive fungal infections in acute myeloid leukaemia patients receiving chemotherapy: a study from a middle-income country

BACKGROUND

Invasive fungal infections (IFIs) contribute to morbidity and mortality during acute myeloid leukaemia (AML) treatment. Without prophylaxis, IFI rate during AML treatment in Thailand is high and results in a high mortality rate and a prolonged hospital stay.

AIM

To evaluate the cost-utility of antifungal therapy (AFT) prophylaxis during AML treatment.

METHODS

We assessed the cost-utility of AFT available in Thailand, including posaconazole (solution), itraconazole (solution and capsule), and voriconazole. A hybrid model consisting of a decision tree and the Markov model was established.

RESULTS

The costs to prevent overall IFI using any AFT were all lower than the treatment cost of a non-prophylaxis group, resulting in a saving of 808-1507 USD per patient. Prevention with voriconazole prophylaxis showed the highest quality-adjusted life years (QALYs = 3.51, incremental QALYs = 0.23), followed by posaconazole (QALYs = 3.46, incremental QALY = 0.18) and itraconazole solution (QALYs = 3.45, incremental QALYs = 0.17). Itraconazole capsule reduced QALY in the model. For invasive aspergillosis prevention, posaconazole and voriconazole both resulted in better QALYs and life year savings compared with no prophylaxis. However, posaconazole prophylaxis was the only cost-saving option (976 USD per patient).

CONCLUSION

Posaconazole, itraconazole solution and voriconazole were all cost saving compared with no prophylaxis for overall IFI prophylaxis, with voriconazole being the most cost-effective option. Posaconazole and voriconazole were both cost effective for invasive aspergillosis prevention but only posaconazole was cost saving. A change in reimbursement policy for the use of AFT prophylaxis during intensive AML treatment could provide both clinical benefits to patients and substantial economic benefits to healthcare systems.

Survival and factors associated with mortality among infants with anorectal malformation: a population-based study from a middle-income country

Limited data on the survival of anorectal malformation (ARM) patients from lower- and middle-income countries is available. This retrospective population-based study from the State of Johor, Malaysia, determines the incidence, mortality rate, and survival of ARM patients and factors associated with mortality. Kaplan-Meier survival analysis was used to estimate the survival of ARM patients at 1, 5, and 10 years. In addition, multivariate Cox regression analysis was used to analyze mortality-related factors. There were 175 ARM patients among 803,850 live births, giving an overall ARM incidence of 2.2 (95% confidence interval [CI], 1.9 to 2.5) per 10,000 live births. The male-to-female ratio was 1.5:1. There were 122 (69%) non-isolated ARM, of which 41 were Trisomy-21 and 34 had VACTERL association. Seventy-three (42%) had congenital heart disease (CHD), with 38 severe and 35 non-severe CHD. Overall, 33 (19%) patients died, with a median age of death of 5.7 months (interquartile range (IQR) 25 days to 11.2 months). The overall estimated 1-, 5-, and 10-year survival rate for ARM patients was 82% (95% CI, 76-89%), 77% (95% CI, 70-84%), and 77% (95% CI, 70-84%), respectively. Univariate analysis shows that non-isolated ARM, VACTERL association, and severe CHD were associated with mortality. However, only severe CHD is the independent factor associated with mortality, with a hazard ratio of 4.0 (95% CI, 1.9-8.4).  Conclusion: CHD is common among ARM patients, and one in five ARM patients had a severe cardiac defect, significantly affecting their survival. What is Known: • VACTERL association and congenital heart disease are common in patient with anorectal malformation. • Low birth weight and prematurity are associated with a lower rate of survival. What is New: • Congenital heart disease is common in ARM patients in a middle-income country. • Severe congenital heart disease plays a significant role in the survival of patients with an anorectal malformation in lower- and middle-income countries.

Estimating the cumulative incidence of SARS-CoV-2 infection in Costa Rica: modelling seroprevalence data in a population-based cohort

Background

The true incidence of SARS-CoV-2 infection in Costa Rica was likely much higher than officially reported, because infection is often associated with mild symptoms and testing was limited by official guidelines and socio-economic factors.

Methods

Using serology to define natural infection, we developed a statistical model to estimate the true cumulative incidence of SARS-CoV-2 in Costa Rica early in the pandemic. We estimated seroprevalence from 2223 blood samples collected from November 2020 to October 2021 from 1976 population-based controls from the RESPIRA study. Samples were tested for antibodies against SARS-CoV-2 nucleocapsid and the receptor-binding-domain of the spike proteins. Using a generalized linear model, we estimated the ratio of true infections to officially reported cases. Applying these ratios to officially reported totals by age, sex, and geographic area, we estimated the true number of infections in the study area, where 70% of Costa Ricans reside. We adjusted the seroprevalence estimates for antibody decay over time, estimated from 1562 blood samples from 996 PCR-confirmed COVID-19 cases.

Findings

The estimated total proportion infected (ETPI) was 4.0 times higher than the officially reported total proportion infected (OTPI). By December 16th, 2021, the ETPI was 47% [42-52] while the OTPI was 12%. In children and adolescents, the ETPI was 11.0 times higher than the OTPI.

Interpretation

Our findings suggest that nearly half the population had been infected by the end of 2021. By the end of 2022, it is likely that a large majority of the population had been infected.

Funding

This work was sponsored and funded by the National Institute of Allergy and Infectious Diseases through the National Cancer Institute, the Science, Innovation, Technology and Telecommunications Ministry of Costa Rica, and Costa Rican Biomedical Research Agency-Fundacion INCIENSA (grant N/A).

Trends in all-cause mortality among adults with diagnosed type 2 diabetes in West Malaysia: 2010 - 2019

AIMS

We determined 10-year all-cause mortality trends in diagnosed type 2 diabetes (T2D) population in West Malaysia, a middle-income country in the Western-Pacific region.

METHODS

One million T2D people aged 40-79 registered in the National Diabetes Registry (2009-2018) were linked to death records (censored on 31 December 2019). Standardized absolute mortality rates and standardized mortality ratios (SMRs) were estimated relative to the Malaysian general population, and standardized to the 2019 registry population with respect to sex, age group, and disease duration.

RESULTS

Overall all-cause standardized mortality rates were unchanged in both sexes. Rates increased in males aged 40-49 (annual average percent change [AAPC]: 2.46 % [95 % CI 0.42 %, 4.55 %]) and 50-59 (AAPC: 1.91 % [95 % CI 0.73 %, 3.10 %]), and females aged 40-49 (AAPC: 3.39 % [95 % CI 1.32 %, 5.50 %]). In both sexes, rates increased among those with 1) > 15 years disease duration, 2) prior cardiovascular disease, and 3) Bumiputera (Malay/native) ethnicity. The overall SMR was 1.83 (95 % CI 1.80, 1.86) for males and 1.85 (95 % CI 1.82, 1.89) for females, being higher in younger age groups and showed an increasing trend in those with either > 15 years disease duration or prior cardiovascular disease.

CONCLUSIONS

Mortality trends worsened in certain T2D population in Malaysia.

Changes in trauma-related emergency medical services during the COVID-19 lockdown in the Western Cape, South Africa

BACKGROUND

To limit virus spread during the COVID pandemic, extensive measures were implemented around the world. In South Africa, these restrictions included alcohol and movement restrictions, factors previously linked to injury burden in the country. Consequently, reports from many countries, including South Africa, have shown a reduction in trauma presentations related to these restrictions. However, only few studies and none from Africa focus on the impact of the pandemic restrictions on the Emergency Medical System (EMS).

METHODS

We present a retrospective, observational longitudinal study including data from all ambulance transports of physical trauma cases collected during the period 2019-01-01 and 2021-02-28 from the Western Cape Government EMS in the Western Cape Province, South Africa (87,167 cases). Within this timeframe, the 35-days strictest lockdown level period was compared to a 35-days period prior to the lockdown and to the same 35-days period in 2019. Injury characteristics (intent, mechanism, and severity) and time were studied in detail. Ambulance transport volumes as well as ambulance response and on-scene time before and during the pandemic were compared. Significance between indicated periods was determined using Chi-square test.

RESULTS

During the strictest lockdown period, presentations of trauma cases declined by > 50%. Ambulance transport volumes decreased for all injury mechanisms and proportions changed. The share of assaults and traffic injuries decreased by 6% and 8%, respectively, while accidental injuries increased by 5%. The proportion of self-inflicted injuries increased by 5%. Studies of injury time showed an increased share of injuries during day shift and a reduction of total injury volume during the weekend during the lockdown. Median response- and on-scene time remained stable in the time-periods studied.

CONCLUSION

This is one of the first reports on the influence of COVID-19 related restrictions on EMS, and the first in South Africa. We report a decline in trauma related ambulance transport volumes in the Western Cape Province as well as changes in injury patterns, largely corresponding to previous findings from hospital settings in South Africa. The unchanged response and on-scene times indicate a well-functioning EMS despite pandemic challenges. More studies are needed, especially disaggregating the different restrictions.

Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality and long-term functional impairment. Data on clinical management and functional outcomes from developing countries are scarce. We aimed to define patient profiles and clinical practices and evaluate long-term outcomes after SAH in a middle-income country.

METHODS

This was a prospective study including consecutive adult patients admitted with SAH to two reference centers in Brazil from January 2016 to February 2020. The primary outcome was functional status at 6 months using the modified Rankin Scale. Mixed multivariable analysis was performed to determine the relationship between clinical variables and functional outcomes.

RESULTS

From 471patients analyzed, the median time from symptom onset to arrival at a study center was 4 days (interquartile range 0-9). Median age was 55 years (interquartile range 46-62) and 353 (75%) patients were women. A total of 426 patients (90%) were transferred from nonspecialized general hospitals, initial computed tomography revealed thick hemorrhage in 73% of patients (modified Fisher score of 3 or 4), and 136 (29%) had poor clinical grade (World Federation of Neurological Surgeons score of 4 or 5). A total of 312 (66%) patients underwent surgical clipping, and 119 (25%) underwent endovascular coiling. Only 34 patients (7%) underwent withdrawal or withholding of life-sustaining therapy during their hospital stay, and in-hospital mortality was 24%. A total of 187 (40%) patients had an unfavorable long-term functional outcome (modified Rankin Scale score of 4 to 6). Factors associated with unfavorable outcome were age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.03-1.08), hypertension (adjusted OR 1.81, 95% CI 1.04-3.16), poor clinical grade (adjusted OR 4.92, 95% CI 2.85-8.48), external ventricular drain (adjusted OR 3.8, 95% CI 2.31-6.24), postoperative deterioration (adjusted OR 2.33, 95% CI 1.32-4.13), cerebral infarction (adjusted OR 3.16, 95% CI 1.81-5.52), rebleeding (adjusted OR 2.95, 95% CI 1.13-7.69), and sepsis (adjusted OR 2.68, 95% CI 1.42-5.05).

CONCLUSIONS

Our study demonstrated that SAH management in a middle-income country diverges significantly from published cohorts and current guidelines, despite comparable clinical profiles on presentation and admission to high-volume referral centers. Earlier aneurysm occlusion and increased use of endovascular therapy could potentially reduce modifiable in-hospital complications and improve functional outcomes in Brazil.

The association of exposure to air pollution and depression in women; a cross-sectional study of a middle-income country

Air pollution exposure has been related with mental disorders, especially depression; however, the available evidence on these associations in Low and Middle-Income Countries (LMICs) is scarce. Therefore, we aimed to assess the relationship between particulate matter (PM) exposure and indicators of traffic with depressive symptoms in women of Sabzevar, Iran. This cross-sectional study was based on 741 women aged 15-45 years (adults) in 2019. The annual average of PM₁₀, PM_2.5 and PM₁ at home was estimated using land use regression (LUR) models. Street map of Sabzevar was used to calculate the indicators of traffic, i.e., the proximity to major roads and total street length buffers with 100, 300 and 500 m radii around the participants' homes. We used the Center for Epidemiological Studies- Depression (CESD-20) Scale in the general population to measure depression scores. Quasi-Poisson models and logistic regression were used to examine the association and odds ratios of exposure to air pollution and depression scores adjusted for relevant covariates. Exposure to PM₁₀, PM_2.5 and PM₁ and total street length in 100 m buffer were significantly associated with higher depression scores. In fully adjusted model, an interquartile range (IQR) increase in PM₁₀, PM_2.5 and PM₁ concentration as well as total street length in 100 m buffer was associated with 1.25 (95% CI:1.03, 1.52, P-value = 0.02), 1.16 (95% CI: 1.06, 1.26, P-value< 0.01), 1.16 (95% CI: 1.03, 1.29, P-Value = 0.01) and 1.15 (95% CI: 1.06, 1.25, P-value< 0.01) odds of clinical depression, respectively. For street length in 300 and 500 m buffers and proximity to major roads, no statistically significant increased risk of clinical depression were observed. Overall, our findings recommended that air pollution exposure has increased the risk of clinical depression in women.

Non-operative management of solid organ injuries in a middle-income country, how does it stack up?

INTRODUCTION

The first trauma surgery unit in Malaysia was established in 2011. After 10 years, we examine our experience in the management, and outcomes of blunt liver, spleen, and kidney injuries.

METHODS

This is a cross-sectional study of patients with blunt liver, spleen, and kidney injuries in a level 1 trauma centre in Malaysia between January 2018 to June 2021. Patients' characteristics, new injury severity score, organ-specific AAST injury score, type of primary management (operative management [OM], non-operative management [NOM]), causes of failed NOM, management of failed NOM, and outcome of treatment were recorded and analysed.

RESULTS

Among 448 patients, 83.9% were male and in the working-age range of 15-64 years old (93.5%). Road traffic crashes made up 92.0% of blunt trauma resulting in 65.5% of isolated organ injuries and 34.5% combined injuries. An overwhelming 84.2% of the patients had major trauma (NISS>15). Three hundred and thirty-four patients (74.6%) underwent initial non-operative management. Patients in the OM group showed lower mean GCS scores (p = 0.022) and higher NISS scores (p < 0.001). High-grade liver and kidney injuries were mostly treated with NOM (p < 0.001). In contradistinction, patients with high-grade spleen injuries had more OM performed (p < 0.001). NOM had been successful in 325 patients (97.3%) with 9 failures. Underlying causes for NOM failure were hemodynamic instability due to secondary bleeding and infectious complications. Overall mortality was 11.2%, which was significantly higher in the OM group (23.7%) than in the NOM group (6.9%).

CONCLUSION

This study represents one of the largest single centre experiences on the blunt liver, spleen, and kidney injuries in Malaysia and South-East Asia. With good selection and adequate resources, non-operative management of blunt liver, spleen, and kidney injuries is a safe and effective therapeutic approach with a high success rate of 97.3%, avoiding the morbidity of unnecessary laparotomies.

Clinical endpoints to inform vaccine policy: A systematic review of outcome measures from pediatric influenza vaccine efficacy trials

INTRODUCTION

We conducted a systematic review of pediatric influenza vaccine efficacy trials to assess clinical outcome measures and whether the trials defined important public health endpoints.

MATERIAL AND METHODS

We systematically identified phase 3 or 4 influenza vaccine randomized controlled trials among children ≤18 years of age with laboratory-confirmed influenza outcomes since 1980. We recorded countries, age groups, vaccine formulations, specimen collection criteria, laboratory diagnostics, primary and secondary outcome measures, and funders, and we determined income category for study countries. We used descriptive statistics to summarize study characteristics. We analyzed the studies overall and a subset of studies conducted in at least one low- and middle-income country (LMIC).

RESULTS

From 6455 potentially relevant articles, we identified 41 eligible studies. Twenty-one studies (51%) were conducted in at least one LMIC, while the remaining studies (49%) were conducted in high-income countries only. Thirty-one studies (76%) included children younger than six years. We found 40 different primary outcome measures among the 41 eligible studies. Thirty-three studies (80%) reported standardized symptoms or findings which defined a primary outcome or triggered specimen collection. One study defined a primary outcome which captured more severe illness; however, cases were mostly due to high body temperature without other severity criteria. Of the 21 studies from at least one LMIC, 15 (71%) were published since 2010 and 17 (81%) enrolled children younger than six years. Eighteen (86%) studies from at least one LMIC reported standardized symptoms or findings which defined a primary outcome or triggered specimen collection.

CONCLUSIONS

Among pediatric influenza vaccine efficacy trials, primary outcome measures and clinical specimen collection criteria were highly variable and, with one exception, focused on capturing any influenza illness. As most LMICs do not have influenza vaccination programs, our study highlights a potential data limitation affecting policy and implementation decisions in these settings.

Cross-national examination of adolescent suicidal behavior: a pooled and multi-level analysis of 193,484 students from 53 LMIC countries

INTRODUCTION

Suicide is a leading cause of adolescent mortality worldwide. We aimed to estimate the prevalence and identify individual-level and country-level factors which might explain the variability in suicidal behavior among students in 53 low to middle income countries.

METHODS

We used data on adolescents aged 12-16 years from the Global School-based Student Health Surveys from 2009-2016. The suicidal behaviors investigated included suicide ideation, suicidal planning and suicide attempt. The prevalence was estimated for 53 countries, while a multilevel logistic regression analysis (33 countries) was used to investigate the associations of these behaviors with individual and country-level contextual risk factors. The contextual variables included the Gini Coefficient, Gross Domestic Product per capita, pupil-to-teacher ratios, population density, homicide rates, law criminalizing suicide and the night light index.

RESULTS

The overall prevalence of suicide ideation, making a plan and suicide attempt were 10.4%, 10.3% and 11.0%, respectively. The highest prevalence rates reported were from the Americas. The strongest risk factors associated with suicidal behavior included anxiety, loneliness, no close friends and the substance abuse. Among the country level variables, the night light index was associated with making a suicide plan and attempting suicide.

CONCLUSION

The non-significant country level findings were not entirely surprising given the mixed results from prior studies. Additional knowledge is thus achieved with regard to country level factors associated with suicidal behavior across adolescent populations.

Correlates and impact of DSM-5 binge eating disorder, bulimia nervosa and recurrent binge eating: a representative population survey in a middle-income country

PURPOSE

Binge eating disorder (BED), bulimia nervosa (BN) and recurrent binge eating (RBE) are binge eating spectrum conditions causing a significant impact in individual's health and functioning. Information regarding those conditions came mostly from high-income countries. The objective of this study was to assess the prevalence of DSM-5 BED, BN and RBE and correlates in a representative sample from a metropolitan area of a middle-income country.

METHODS

The data were obtained from a cross-sectional population-based household survey in two stages in Rio de Janeiro, Brazil. Noninstitutionalized residents aged 18-60 years were assessed by lay interviewers using the Questionnaire of Eating and Weight Patterns-5 (QEWP-5). Positive cases and a paired sample screen-negative cases were reassessed by phone with the Eating Disorders Section of SCID-I-P (adapted for DSM-5). The data were collected from September 2019 to February 2020.

RESULTS

Overall, 2297 individuals were interviewed. Prevalence of BED was 1.4%, BN 0.7%, RBE 6.2%. Psychiatric comorbidities, such as depression, anxiety and ADHD were significantly more prevalent in people with BED, BN and RBE than in people without these eating problems. Several medical conditions, when controlling for body mass index, were significantly more prevalent in people with BED, BN and RBE. People with BED and BN had marked impairments in work/school, social and family life, reduced mental and physical HRQoL and under half had sought treatment.

CONCLUSION

As in high income countries, in Rio de Janeiro, Brazil, BED, BN and RBE are prevalent conditions and are associated with elevated BMI, functional impairment, psychiatric and medical comorbidity and poorer HRQoL.

Performance of Sepsis-3 Definitions in a Middle Income Country Intensive Care Unit

Background

Since they were first published in 2016, Sepsis-3 definitions have not been universally accepted. Rather, they have become a source of controversy because the clinical and laboratory parameters used had been derived mainly from patients hospitalized in Intensive Care Units (ICU) in the United States.

Purpose

The aim of this study was to evaluate the performance of the Sepsis-3 definitions for the prediction of ICU-mortality in a Tunisian ICU population as compared to the 2003 Consensus Definitions (Sepsis-2 definitions).

Method

The study, conducted in an 18-bed medical-surgical ICU at the Military Hospital of Tunis (Tunisia), was retrospective in nature. From January 2012 to January 2016, all patients admitted to the ICU for sepsis, severe sepsis, or septic shock as defined according to the 2003 Consensus Definitions (Sepsis-2 consensus) were eligible for this study. The new Sepsis-3 definition was then used to classify the included patients. The primary area of interest was ICU mortality, defined as death before ICU discharge.

Results

A total of 1080 patients were included during the recruitment period. When Sepsis-2 definitions were used, there was a difference in mortality only between septic shock and sepsis patients. Sepsis-3 definitions show that mortality increased from 16 % among no-dysfunction-infected patients to 30 % among patients with qSOFA ≥ 2 and 44% and 46% for sepsis or septic shock patients, respectively.

Conclusions

Sepsis-3 definitions were better than sepsis-2 definitions at stratifying mortality among septic patients admitted to an ICU of a middle-income country (Tunisia).

Towards an inclusive digital literacy: An experimental intervention study in a rural area of Brazil

About half of the world's population remains without access to internet in an era of digital transformation. In this study, we aimed to investigate the impact of implementing the use of logic and mathematics through digital literacy on a population of elementary school students in a town in Northeast Brazil. In a non-randomized experimental longitudinal intervention study, 5th-grade students were followed during one semester. They underwent observational testing during class with the use of scales to evaluate their activities in a digital environment, and they were evaluated with respect to their ability to use digital devices. A logic/math assessment was applied prior to and at the end of the course for intervention group and compared to a control group. Questionnaires were used to assess the educators', legal guardians' and students' perceptions on digital habits and their respective sociodemographic features. The intervention consisted of a 16-h long course developed consisting of 8 2-h long classes which focused on digital technology, digital culture, and computational thinking. The students had a strong interest in the classes. Although some students did not have prior contact with computers, their development was outstanding. Digital literacy competencies and technology-use behavior increased throughout the semester independent of family income and use of digital devices at home. Students progressively improved their interaction with the computer (e.g. touchpad and typing skills) and their confidence in the digital environment. Students' scores on the logic/math assessment showed significant improvement. This was not observed in the control group, demonstrating the importance of this type of intervention even with one provided by a 16-h course.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10639-021-10711-z.

Racial and socioeconomic disparities in multimorbidity and associated healthcare utilisation and outcomes in Brazil: a cross-sectional analysis of three million individuals

BACKGROUND

Evidence is limited on racial/ethnic group disparities in multimorbidity and associated health outcomes in low- and middle-income countries hampering effective policies and clinical interventions to address health inequalities.

METHODS

This study assessed race/ethnic and socioeconomic disparities in the prevalence of multimorbidity and associated healthcare utilisation, costs and death in Rio de Janeiro, Brazil. A cross-sectional analysis was carried out of 3,027,335 individuals registered with primary healthcare (PHC) services. Records included linked data to hospitalisation, mortality, and welfare-claimant (Bolsa Família) records between 1 Jan 2012 and 31 Dec 2016. Logistic and Poisson regression models were carried out to assess the likelihood of multimorbidity (two or more diagnoses out of 53 chronic conditions), PHC use, hospital admissions and mortality from any cause. Interactions were used to assess disparities.

RESULTS

In total 13,509,633 healthcare visits were analysed identifying 389,829 multimorbid individuals (13%). In adjusted regression models, multimorbidity was associated with lower education (Adjusted Odds Ratio (AOR): 1.26; 95%CI: 1.23,1.29; compared to higher education), Bolsa Família receipt (AOR: 1.14; 95%CI: 1.13,1.15; compared to non-recipients); and black race/ethnicity (AOR: 1.05; 95%CI: 1.03,1.06; compared to white). Multimorbidity was associated with more hospitalisations (Adjusted Rate Ratio (ARR): 2.75; 95%CI: 2.69,2.81), more PHC visits (ARR: 3.46; 95%CI: 3.44,3.47), and higher likelihood of death (AOR: 1.33; 95%CI: 1.29,1.36). These associations were greater for multimorbid individuals with lower educational attainment (five year probability of death 1.67% (95%CI: 1.61,1.74%) compared to 1.13% (95%CI: 1.02,1.23%) for higher education), individuals of black race/ethnicity (1.48% (95%CI: 1.41,1.55%) compared to 1.35% (95%CI: 1.31,1.40%) for white) and individuals in receipt of welfare (1.89% (95%CI: 1.77,2.00%) compared to 1.35% (95%CI: 1.31,1.38%) for non-recipients).

CONCLUSIONS

The prevalence of multimorbidity and associated hospital admissions and mortality are greater in individuals with black race/ethnicity and other deprived socioeconomic groups in Rio de Janeiro. Interventions to better prevent and manage multimorbidity and underlying disparities in low- and middle-income country settings are needed.

Cross-Cultural Adaptation and Validation of the Quality of Life Questionnaire for Caregivers of Patients with Schizophrenia (S-CGQoL) in Latin America

OBJECTIVES

The aim of this study was to adapt and validate the Schizophrenia Caregiver's Quality of Life Questionnaire (S-CGQoL) for use in the Hispanic-American population from the caregiver's perspective.

METHODS

A cross-sectional instrumental model was used, with a sample of 253 caregivers of patients suffering of Schizophrenia in Bolivia, Peru and Chile. The psychometric properties of the S-CGQoL were tested through construct validity, reliability and some aspects of external validity. In addition, in order to assess the nature of the different items across the three countries, a Differential Performance Analysis (DPA) was conducted.

RESULTS

A confirmatory factor analysis showed that the scale structure was well correlated to the initial structure of the QoL-MDS. The results confirmed the existence of adequate reliability indicators (α>.70 and ω>.80) and the absence of FIDs supporting the invariance of item calibrations among the three Latin American countries.

CONCLUSIONS

The adaptation and validation of the S-CGQoL questionnaire demonstrate adequate psychometric properties to assess the quality of life of caregivers in samples of middle-income countries in Latin America.

Why magnesium sulfate 'coverage' only is not enough to reduce eclampsia: Lessons learned in a middle-income country

OBJECTIVES

Determine the eclampsia prevalence and factors associated with eclampsia and recurrent seizures in Suriname and evaluate quality-of-care indicator 'magnesium sulfate (MgSO4) coverage'.

STUDY DESIGN

A two-year prospective nationwide cohort study was conducted in Suriname and included women with eclampsia at home or in a healthcare facility.

MAIN OUTCOME MEASURES

We calculated the prevalence by the number of live births obtained from vital registration. Risk factor denominator data concerned hospital births. Descriptive statistics and multivariate regression analysis were performed.

RESULTS

Seventy-two women with eclampsia (37/10.000 live births) were identified, including two maternal deaths (case-fatality 2.8%). Nulliparity, African-descent and adolescence were associated with eclampsia. Adolescents with eclampsia had significantly lower BPs (150/100 mmHg) than adult women (168/105 mmHg). The first seizure occurred antepartum in 54% (n = 39/72), intrapartum in 19% (n = 14/72) and postpartum in 26% (n = 19/72). Recurrent seizures were observed in 60% (n = 43/72). MgSO4 was administered to 99% (n = 69/70) of women; however 26% received no loading dosage and, in 22% of cases MgSO4 duration was <24 h, i.e. guideline adherence existed in only 43%. MgSO4 was ceased during CS in all women (n = 40). Stable BP was achieved before CS in 46%. The median seizure-to-delivery interval was 27 h, and ranged from four to 36 h.

CONCLUSION

Solely 'MgSO4 coverage' is not a reliable quality-of-care indicator, as it conceals inadequate MgSO4 dosage and timing, discontinuation during CS, stabilization before delivery, and seizure-to-delivery interval. These other quality-of-care indicators need attention from the international community in order to reduce the prevalence of eclampsia.

Enablers and barriers of maternal and neonatal immunization programs in Latin America

BACKGROUND

The Region of the Americas has a long history of implementing maternal and neonatal immunization (MNI) programs. Our study aimed to understand the state of MNI policies, strategies and implementation practices in Latin America (LA).

METHODS

Study conducted in 5 middle-income countries: Argentina, Brazil, Honduras, Mexico and Peru. The methods included a desk review, interviews with national stakeholders and health care providers, focus groups with pregnant women and observations in health facilities. Enablers and barriers were identified and categorized as individual, societal or related to the health system.

RESULTS

All 5 participating countries had similar MNI policies and high access to antenatal care. Key enablers were the high acceptability of vaccination during pregnancy, high-level of political will and a national legal framework ensuring free access to vaccines. At the health system level, implementation was facilitated by the existence of immunization advisory committees, a pooled vaccine procurement mechanism, complementary vaccine delivery strategies, conditional cash transfer to users and performance incentives to health facilities. The main programmatic barriers were the lack of adequate MNI information; limited coordination between antenatal and immunization services; inadequate supply, resources and infrastructure; high staff turnover; insufficient training for health care providers; and weak monitoring and reporting systems.

CONCLUSION

Middle-income countries in LA have successfully implemented MNI programs and several enablers were identified. To overcome remaining barriers, there is a need to focus on improving the "immunization journey" for pregnant women through providing more clear and timely information to users and providers; removing barriers to access; ensuring adequate supply, human resources and infrastructure; making the health service experience positive; and establishing integrated information systems that allow for monitoring the progress toward achieving MNI goals. Strengthening the MNI programs can also improve equitable access to health services and prepare for the introduction of future vaccines for pregnant women.

Lessons to be learnt from the COVID-19 public health response in Mauritius

Objectives

This study had the following objectives: (1) To look into the public health response of the country facing the COVID-19 outbreak, and (2) To examine the effectiveness of the measures being undertaken to contain the outbreak.

Methods

The research method used was the analysis of all documents/discourses pertaining to the public health response of Mauritius towards COVID-19. We compiled data over the period of 17 January 2020 to 15 May 2020 as and when they were communicated.

Results

This study revealed three main themes: (1) Prevention strategy, (2) Outbreak management strategy and (3) Communication strategy. In light of the qualitative findings and the numerical data provided by the Mauritian authorities, we appraise the public health response of Mauritius.

Conclusions

After demonstrating the effectiveness of the public health strategies undertaken by the Mauritian government, we draw the lessons learnt from the experience of Mauritius. These lessons have implications for practice by middle-income countries and/or small island developing states facing a communicable disease outbreak.

•

COVID-19 in Mauritius: A success story?

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How well did Mauritius to tackle the COVID-19 outbreak?

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The public health response of Mauritius was fast and bold.

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The COVID-19 outbreak causes ten deaths in Mauritius.

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The BBC News Channel praised Mauritius for its confinement measures.

A broad-spectrum beta-lactam-sparing stewardship program in a middle-income country public hospital: antibiotic use and expenditure outcomes and antimicrobial susceptibility profiles

Background

Antimicrobial stewardship programs are an efficient way to reduce inappropriate use of antimicrobials and costs; however, supporting data are scarce in middle-income countries. The aim of this study was to evaluate antibiotic use, bacterial susceptibility profiles, and the economic impact following implementation of a broad-spectrum beta-lactam-sparing antimicrobial stewardship program.

Methods

An interrupted time-series analysis was performed to evaluate antibiotic use and expenditure over a 24-month period (12 months before the antimicrobial stewardship program and in the 12 months after implementation of the antimicrobial stewardship program). Antibiotics were classified into one of two groups: beta-lactam antibiotics and beta-lactam-sparing antibiotics. We also compared the antimicrobial susceptibility profiles of key pathogens in each period.

Results

Beta-lactam antibiotics use decreased by 43.04 days of therapy/1000 patient-days (p = 0.04) immediately following antimicrobial stewardship program implementation, whereas beta-lacta-sparing antibiotics use increased during the intervention period (slope change 6.17 days of therapy/1000 patient-days, p < 0.001). Expenditure decreased by $2089.99 (p < 0.001) immediately after intervention and was maintained at this level over the intervention period ($−38.45; p = 0.24). We also observed that a greater proportion of pathogens were susceptible to cephalosporins and aminoglycosides after the antimicrobial stewardship program.

Conclusions

The antimicrobial stewardship program significantly reduced the use of broad-spectrum beta-lactam-antibiotics associated with a decrease in expenditure and maintenance of the susceptibility profile in Gram-negative bacteria.

Oral and Maxillofacial Surgery in Low-Income and Middle-Income Countries

Five billion people worldwide do not have access to safe, affordable surgical and anesthesia care. The burden of inadequate access to safe and affordable surgical care falls heaviest on individuals living in low-income and middle-income countries (LMIC), where 9 out of 10 people do not have access to basic surgical care. Global oral and maxillofacial surgical care is included in the global burden of surgical disease, and increased awareness of the need for global oral and maxillofacial surgery (OMS), with the initiation, support, and funding of research on the need to develop a global OMS capacity-building strategy is imperative.

Childbirth outcomes and ethnic disparities in Suriname: a nationwide registry-based study in a middle-income country

Background

Our study aims to evaluate the current perinatal registry, analyze national childbirth outcomes and study ethnic disparities in middle-income country Suriname, South America.

Methods

A nationwide birth registry study was conducted in Suriname. Data were collected for 2016 and 2017 from the childbirth books of all five hospital maternity wards, covering 86% of all births in the country. Multinomial regression analyses were used to assess ethnic disparities in outcomes of maternal deaths, stillbirths, teenage pregnancy, cesarean delivery, low birth weight and preterm birth with Hindustani women as reference group.

Results

18.290 women gave birth to 18.118 (98%) live born children in the five hospitals. Hospital-based maternal mortality ratio was 112 per 100.000 live births. Hospital-based late stillbirth rate was 16 per 1000 births. Stillbirth rate was highest among Maroon (African-descendent) women (25 per 1000 births, aOR 2.0 (95%CI 1.3–2.8) and lowest among Javanese women (6 stillbirths per 1000 births, aOR 0.5, 95%CI 0.2–1.2). Preterm birth and low birthweight occurred in 14 and 15% of all births. Teenage pregnancy accounted for 14% of all births and was higher in Maroon women (18%) compared to Hindustani women (10%, aOR 2.1, 95%CI 1.8–2.4). The national cesarean section rate was 24% and was lower in Maroon (17%) than in Hindustani (32%) women (aOR 0.5 (95%CI 0.5–0.6)). Cesarean section rates varied between the hospitals from 17 to 36%.

Conclusion

This is the first nationwide comprehensive overview of maternal and perinatal health in a middle income country. Disaggregated perinatal health data in Suriname shows substantial inequities in outcomes by ethnicity which need to be targetted by health professionals, researchers and policy makers.

A review of maternal mortality trends in Lebanon, 2010-2018

Lebanon invested in the prevention of maternal mortality after the civil war, which left a deficient vital registration system leading to unreliable estimates of maternal mortality ratio (MMR). Starting in 2004, the Ministry of Public Health integrated reproductive health into primary health care and established a national notification system of maternal and neonatal deaths. From 1990 to 2013, Lebanon achieved an annual change in MMR of -7.5%, which was the highest rate of reduction in the region and met the requirements of Millennium Development Goal 5. For the period 2010-2018, data collected through the national notification system indicate an MMR of 14.9, which is below the officially reported MMR of 23. Since the influx of Syrian refugees, Lebanon has experienced a rise in the number of live births with a slightly increasing trend in MMR, especially in regions with the highest concentration of refugees. Causes of maternal mortality in Lebanon align with the three-delays model, pointing to deficiencies in the quality of maternity care. More efforts are needed toward strengthening the national notification system to include cases that occur outside hospitals, identifying near-miss cases, reinforcing the emergency response system, and engaging with all stakeholders to improve quality of care.

Bottom-up development of national obstetric guidelines in middle-income country Suriname

Background

Obstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, however the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the ‘bottom-up’ development process of context-tailored national obstetric guidelines in middle-income country Suriname.

Methods

Local obstetric health care providers initiated the guideline development process in Suriname in August 2016 for two common obstetric conditions: hypertensive disorders of pregnancy (HDP) and post partum haemorrhage (PPH).

Results

The process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clinical practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion on the guidelines content and (6) establishment of the final guidelines based on consensus. Maternal enquiry of HDP- and PPH-related maternal deaths revealed substandard care in 90 and 95% of cases, respectively. An assessment of the management through interviews and labour observations identified gaps in quality of the provided care and large discrepancies in the management of HDP and PPH between the hospitals. International recommendations were considered unfeasible and were inconsistent when compared to each other. Local health care providers and stakeholders convened to create national context-tailored guidelines based on adapted international recommendations. The guidelines were developed within four months and locally implemented.

Conclusion

Development of national context-tailored guidelines is achievable in a middle-income country when using a ‘bottom-up’ approach that involves all obstetric health care providers and stakeholders in the earliest phase. We hope the descriptive process of guideline development is helpful for other countries in need of nationwide guidelines.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4377-6) contains supplementary material, which is available to authorized users.

Ten-year trend in prevalence and outcome of Down syndrome with congenital heart disease in a middle-income country

Limited data are available on the survival of patients with Down syndrome and congenital heart disease (CHD) from middle-income countries. This retrospective cohort study was performed to determine the trends in the prevalence and survival of such patients born from January 2006 to December 2015 in Malaysia. Among 754 patients with Down syndrome, 414 (55%) had CHD, and no significant trend was observed during the 10 years. Of these 414 patients, 30% had lesions that closed spontaneously, 35% underwent surgery/intervention, 9% died before surgery/intervention, and 10% were treated with comfort care. The overall mortality rate was 23%, the median age at death was 7.6 months, and no significant changes occurred over time. The early and late post-surgery/intervention mortality rates were 0.7% and 9.0%, respectively. Most deaths were of non-cardiac causes. The overall 1-, 5-, and 10-year survival rates were 85.5%, 74.6%, and 72.9%, respectively. Patients with severe lesions, persistent pulmonary hypertension of the newborn, atrioventricular septal defect, and pulmonary hypertension had low survival at 1 year of age.Conclusion: The prevalence of CHD in patients with Down syndrome is similar between Malaysia and high-income countries. The lower survival rate is attributed to limited expertise and resources which limit timely surgery. What is Known: • The survival of patients with Down syndrome with congenital heart disease (CHD) has improved in high-income countries. However, little is known about the survival of patients with Down syndrome with CHD from middle-income countries. • In the Caucasian population, atrioventricular septal defect is the most common type of CHD associated with Down syndrome. What is New: • In middle-income countries, the prevalence of CHD is the same as in high-income countries, but with a lower survival rate. • In the Asian population, ventricular septal defect is the most common type of CHD in patients with Down syndrome.

Assessing trauma care health systems in low- and middle-income countries, a protocol for a systematic literature review and narrative synthesis

BACKGROUND

Trauma represents a major global health problem projected to increase in importance over the next decade. The majority of deaths occur in low- and middle-income countries (LMICs) where survival rates are lower than their high-income country (HIC) counterparts. Health system level changes in care for injured patients have been attributed to significant improvements in care quality and outcomes in HIC settings. There is a need for further research to assess trauma care health systems in LMICs to inform health system strengthening for the care of the injured. This study aims to conduct a narrative synthesis of a systematic search of the literature on the assessment of trauma care health systems in LMICs in order to inform the further development of trauma care health system assessment.

METHODS

The review will include primary quantitative, qualitative or mixed method studies and secondary literature reviews. No restriction will be placed on language or date. Reports and publications identified from the grey literature including from relevant national and international health organisations will be included. Articles will be screened by two independent reviewers with a third reviewer resolving any persisting disagreement. The search will reveal heterogenous studies not suitable for meta-analysis. A narrative synthesis of the identified papers will be conducted to identify key methodological ideas and paradigms used to assess trauma care health systems. The analysis will consider how the differing methodological approaches could be adopted to understand barriers and delays to seeking, reaching and receiving care within a "Three Delays" framework. An iterative approach will be adopted to categorise identified articles, with the results presented as both within and across study analysis.

DISCUSSION

The results of the review will be disseminated through publication in a peer-reviewed academic journal. The study forms part of a PhD project. The results will inform the development of a trauma care health system assessment applicable to LMICs. As this is a review of secondary data, no formal ethical approval is required.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018112990.

Adequate and excessive food consumption in Suriname: a multiethnic middle-income country

OBJECTIVES

To explore food consumption among different sex, age, ethnic, urban, education and income groups in Suriname.

METHODS

Data from a cross-sectional population study (n = 5748; 15-64 year) were used. Food consumption was defined adequate if (1) fruit and vegetable intake was conformable to WHO recommendations, (2) mostly vegetable oil was used, and (3) whole-wheat products were used ≥ 3 days/week. Food consumption was defined excessive if 3 out of the following 5 items scored positive: consumption of (1) snack, (2) sweet, (3) fast food, or (4) soft drink ≥ 3 days/week, or (5) salt was always added while preparing a hot meal.

RESULTS

6.4% (95% CI 5.8-7.1) had an adequate and 21.9% (95% CI 20.9-23.0) an excessive food consumption pattern, with differences among ethnic groups (p < 0.05). Adequate consumption increased, while excessive consumption decreased with increasing age (p < 0.05). Both adequate and excessive consumption increased with higher degree of urbanization, level of education and income (p < 0.05). Except for level of education for adequate consumption, all characteristics remained in both models with adequate and excessive consumption as outcome (p < 0.09).

CONCLUSIONS

Our study suggests interventions to promote adequate food consumption in general and to limit excessive food consumption mainly focused on youngsters and those living in urbanized areas of higher socioeconomic status.

Applying the capture-recapture method to estimate road traffic deaths and injuries in three non-contiguous cities in the Philippines

In establishing goals for the Philippine road safety plan, police data were used. Police reports are likely underreporting. We apply capture-recapture analysis to determine expansion factors and estimate the true incidence. Three cities were visited where data on deaths (2014) and injury (January-March 2014) from hospitals, police and civil registry were collected. Matching was done to generate a final list of injured and dead individuals. The Chapman method was used for estimating the true number of cases. Police data exhibited underreporting in all site. Expansion factors of the police data range from 5.4 to 29× for deaths and 3.2 to 47× for non-fatal injuries. Expansion factors are likely useful to estimate the true incidence of road traffic injuries in areas with weak injury surveillance systems such as the Philippines.

Developing core elements and checklist items for global hospital antimicrobial stewardship programmes: a consensus approach

OBJECTIVES

With increasing global interest in hospital antimicrobial stewardship (AMS) programmes, there is a strong demand for core elements of AMS to be clearly defined on the basis of principles of effectiveness and affordability. To date, efforts to identify such core elements have been limited to Europe, Australia, and North America. The aim of this study was to develop a set of core elements and their related checklist items for AMS programmes that should be present in all hospitals worldwide, regardless of resource availability.

METHODS

A literature review was performed by searching Medline and relevant websites to retrieve a list of core elements and items that could have global relevance. These core elements and items were evaluated by an international group of AMS experts using a structured modified Delphi consensus procedure, using two-phased online in-depth questionnaires.

RESULTS

The literature review identified seven core elements and their related 29 checklist items from 48 references. Fifteen experts from 13 countries in six continents participated in the consensus procedure. Ultimately, all seven core elements were retained, as well as 28 of the initial checklist items plus one that was newly suggested, all with ≥80% agreement; 20 elements and items were rephrased.

CONCLUSIONS

This consensus on core elements for hospital AMS programmes is relevant to both high- and low-to-middle-income countries and could facilitate the development of national AMS stewardship guidelines and adoption by healthcare settings worldwide.

Lifelong robbery victimisation and mental disorders at age 18 years: Brazilian population-based study

PURPOSE

Urban violence is a major problem in Brazil and may contribute to mental disorders among victims. The aim of this study was to assess the association between robbery victimisation and mental health disorders in late adolescence.

METHODS

At age 18 years, 4106 participants in the 1993 Pelotas Birth Cohort Study were assessed. A questionnaire about history of robbery victimisation was administered, the Self-Report Questionnaire was used to screen for common mental disorders, and the Mini International Neuropsychiatric Interview was used to assess major depressive disorder and generalised anxiety disorder. Cross-sectional prevalence ratios between lifetime robbery victimisation and mental disorders were estimated using Poisson regression with robust standard errors, adjusting for socioeconomic variables measured at birth and violence in the home and maltreatment measured at age 15.

RESULTS

There was a dose-response relationship between frequency of lifetime robberies and risk of mental disorders. Adolescents who had been robbed three or more times had twice the risk (PR 2.04; 95% CI 1.64-2.56) for common mental disorders, over four times the risk for depression (PR 4.59; 95% CI 2.60-8.12), and twice the risk for anxiety (PR 1.93; 95% CI 1.06-3.50), compared with non-victims, adjusting for covariates. Experiencing frequent robberies had greater impact on common mental disorders than experiencing an armed robbery. Population attributable fractions with regard to robbery were 9% for common mental disorders, 13% for depression, and 8% for anxiety.

CONCLUSIONS

Robberies are associated with common mental disorders in late adolescence, independently of violence between family members. Reducing urban violence could significantly help in preventing common mental illnesses.

Development and validation of a new pediatric resuscitation and trauma outcome (PRESTO) model using the U.S. National Trauma Data Bank

BACKGROUND

There is a need for a pediatric trauma outcomes benchmarking model that is adapted for Low-and-Middle-Income Countries (LMICs). We used the National-Trauma-Data-Bank (NTDB) and applied constraints specific to resource-poor environments to develop and validate an LMIC-specific pediatric trauma score.

METHODS

We selected a sample of pediatric trauma patients aged 0-14years in the NTDB from 2007 to 2012. Primary outcome was in-hospital death. Logistic regression was used to create the Pediatric Resuscitation and Trauma Outcome (PRESTO) score, which includes only low-tech predictor variables - those easily obtainable at point-of-care. Internal validation was performed using 10-fold cross-validation. External validation compared PRESTO to TRISS using ROC analyses.

RESULTS

Among 651,030 patients, there were 64% males. Median age was 7. In-hospital mortality-rate was 1.2%. Mean TRISS predicted mortality was 0.04% (range 0%-43%). Independent predictors included in PRESTO (p<0.01) were age, blood pressure, neurologic status, need for supplemental oxygen, pulse, and oxygen saturation. The sensitivity and specificity of PRESTO were 95.7% and 94.0%. The resulting model had an AUC of 0.98 compared to 0.89 for TRISS.

CONCLUSION

PRESTO satisfies the requirements of low-resource settings and is inherently adapted to children, allowing for benchmarking and eventual quality improvement initiatives. Further research is necessary for in-situ validation using prospectively collected LMIC data.

LEVEL OF EVIDENCE

Level III - Case-Control (Prognostic) Study.

Maternal mortality audit in Suriname between 2010 and 2014, a reproductive age mortality survey

BACKGROUND

The fifth Millennium Development Goal (MDG-5) aimed to improve maternal health, targeting a maternal mortality ratio (MMR) reduction of 75% between 1990 and 2015. The objective of this study was to identify all maternal deaths in Suriname, determine the extent of underreporting, estimate the reduction, audit the maternal deaths and assess underlying causes and substandard care factors.

METHODS

A reproductive age mortality survey was conducted in Suriname (South-American upper-middle income country) between 2010 and 2014 to identify all maternal deaths in the country. MMR was compared to vital statistics and a previous confidential enquiry from 1991 to 1993 with a MMR 226. A maternal mortality committee audited the maternal deaths and identified underlying causes and substandard care factors.

RESULTS

In the study period 65 maternal deaths were identified in 50,051 live births, indicating a MMR of 130 per 100.000 live births and implicating a 42% reduction of maternal deaths in the past 25 years. Vital registration indicated a MMR of 96, which marks underreporting of 26%. Maternal deaths mostly occurred in the urban hospitals (84%) and the causes were classified as direct (63%), indirect (32%) or unspecified (5%). Major underlying causes were obstetric and non-obstetric sepsis (27%) and haemorrhage (20%). Substandard care factors (95%) were mostly health professional related (80%) due to delay in diagnosis (59%), delay or wrong treatment (78%) or inadequate monitoring (59%). Substandard care factors most likely led to death in 47% of the cases.

CONCLUSION

Despite the reduction in maternal mortality, Suriname did not reach MDG-5 in 2015. Steps to reach the Sustainable Development Goal in 2030 (MMR ≤ 70 per 100.000 live births) and eliminate preventable deaths include improving data surveillance, installing a maternal death review committee, and implementing national guidelines for prevention and management of major complications of pregnancy, childbirth and puerperium.

Childhood maltreatment preceding depressive disorder at age 18 years: A prospective Brazilian birth cohort study

BACKGROUND

Childhood maltreatment is linked with increased risk for mental illness in adolescence and adulthood. However, little evidence is available on whether different forms of maltreatment have specific effects, and no prospective studies in low- or middle-income countries have addressed this issue.

METHODS

Participants in a population-based, birth cohort study in Pelotas, Brazil (N=3715) self-reported exposure to maltreatment (emotional abuse, physical neglect, physical abuse, sexual abuse, domestic violence) in confidential questionnaires at age 15 years, and were assessed for major depression in interviews at age 18 years, using the MINI. Confounding variables concerning family characteristics were measured in interviews with mothers in the perinatal period and at age 11 years.

RESULTS

Females exposed to emotional abuse (OR=2.7; 95%CI=1.9, 3.8) and domestic violence (OR=1.9; 95%CI=1.2, 2.9) were at increased risk for depression after adjustment for confounders and other types of maltreatment. Females exposed to two or more forms of maltreatment were at particularly high risk for depression (OR=4.1; 95%Cl=2.8, 6.1) compared with females not exposed to maltreatment. In adjusted analyses, maltreatment was not associated with depression for males.

LIMITATIONS

Detailed information about maltreatment such as timing and frequency was not available, and 1534 individuals were not included in the analyses, who had poorer and less educated mothers.

CONCLUSIONS

Emotional abuse and domestic violence are strong risk factors for major depression for females. Early intervention to prevent maltreatment and its consequences is critical, especially for girls exposed to poly-maltreatment.

Policy approaches to improve availability and affordability of medicines in Mexico - an example of a middle income country

BACKGROUND

The World Health Organization recommends establishing and implementing a national pharmaceutical policy (NPP) to guarantee effective and equitable access to medicines. Mexico has implemented several policy approaches to regulate the pharmaceutical sector, but it has no formal NPP. This article describes the approach that the Mexican government has taken to improve availability and affordability of essential medicines.

METHODS

Descriptive policy analysis of public pharmaceutical policy proposals and health action plans on the basis of publicly available data and health progress reports, with a focus on availability and affordability of medicines.

RESULTS

The government has implemented pooled procurement, price negotiations, and an information platform in the public sector to improve affordability and availability. The government mainly reports on the savings that these strategies have generated in the public expenditure but their full impact on availability and affordability has not been assessed.

CONCLUSIONS

To increase availability and affordability of medicines in the public sector, the Mexican government has resorted on isolated strategies. In addition to efficient procurement, price negotiations and price information, other policy components and pricing interventions are needed. All these strategies should be included in a comprehensive NPP.

Equipment for neonatal resuscitation in a middle-income country: a national survey in Vietnam

BACKGROUND

Interventions to improve neonatal resuscitation are considered a priority for reducing neonatal mortality. In addition to training programs for health caregivers, the availability of adequate equipment in all delivery settings is crucial. In this study, we assessed the availability of equipment for neonatal resuscitation in a large sample of delivery rooms in Vietnam, exploring regional differences.

METHODS

In 2012, a structured questionnaire on 2011 neonatal resuscitation practice was sent to the heads of 187 health facilities, representing the three levels of hospital-based maternity services in eight administrative regions in Vietnam, allowing national and regional estimates to be calculated.

RESULTS

Overall the response rate was an 85.7 % (160/187 hospitals). There was a limited availability of equipment considered as "essential" in the surveyed centres: stethoscopes (68.0 %; 95 % CI: 60.3-75.7), clock (50.3 %; 42.0-58.7), clothes (29.5 %; (22.0-36.9), head covering (12.3 %; 7.2-17.4). The percentage of centres equipped with polyethylene bags (2.2 %; 0.0-4.6), pulse oximeter (9.4 %; 5.2-13.6) and room air source (1.9 %; 0.1-3.6) was very low.

CONCLUSION

Adequate equipment for neonatal resuscitation was not available in a considerable proportion of hospitals in Vietnam. This problem was more relevant in some regions. The assessment strategy used in this study could be useful for organizing the procurement and distribution of supplies and equipment in other low and/or middle resource settings.

Preterm cranial ultrasound scanning is both feasible and effective in a middle-income country

AIM

Cranial ultrasound is seldom used in middle-income countries, and the burden of preterm brain injury and its relationship to perinatal data is unknown. We assessed cranial ultrasound abnormalities in very low-birthweight (VLBW) infants and correlated the findings with perinatal data.

METHODS

VLBW Armenian infants receiving neonatal intensive care in 2012 were scanned from birth to term-equivalent age (TEA). Clinical data were collected prospectively.

RESULTS

We studied 100 VLBW infants with a median gestation of 30 weeks. Periventricular white matter echogenicity (PVE) lasting more than two weeks was seen in 34 infants, grade III intraventricular haemorrhage (IVH) in 10, haemorrhagic parenchymal infarction (HPI) in seven and cystic periventricular leukomalacia in two. Caudothalamic notch echogenicity appeared in 36 infants after two to three weeks, with cystic transformation in 22. At TEA, 17 infants had persisting PVEs and 55 had increased basal ganglia/thalamic (BGT) echogenicity. Lack of antenatal steroids was significantly associated with IVH and HPI and intubation at birth with IVH. Late BGT echogenicity was generally seen in infants without perinatal problems.

CONCLUSION

Our study demonstrated that cranial ultrasound can be used effectively in a middle-income country to identify high-risk infants and monitor quality of care.

Therapeutic hypothermia for neonatal hypoxic-ischaemic encephalopathy had favourable outcomes at a referral hospital in a middle-income country

AIM

This South African study documented the survival and neurodevelopmental outcomes of infants with hypoxic-ischaemic encephalopathy (HIE) after introducing cooling to a neonatal intensive care unit and identified early markers for neurodevelopmental outcome.

METHODS

We retrospectively reviewed infants that received cooling according to the Total Body Hypothermia trial protocol from 2008 to 2011. Infants were screened with the Bayley Scales of Infant and Toddler Development, Third Edition, at one year of age and underwent neurological and hearing assessments.

RESULTS

Data on 99 infants with HIE showed that 45% of cases were moderate, 23% severe and 32% mild. An abnormal amplitude integrated electro-encephalogram (aEEG) background was documented in 45 cases within 24 hours. Magnetic resonance imaging (MRI) scans were consistent with HIE in all but one case. We reviewed 50 traceable survivors at one year. Development was significantly impaired in nine and 41 were normal or mildly impaired. A severely abnormal aEEG background, severe HIE and an abnormal MRI were associated with death and severe impairment. A good suck, mild HIE, primiparity and normal MRI were associated with good outcomes.

CONCLUSION

Most infants with HIE survived without major impairment. Previously described predictors of neurodevelopmental outcome were good surrogate markers in this population.

Disparities in the Magnitude of Human Immunodeficiency Virus-related Opportunistic Infections Between High and Low/Middle-income Countries: Is Highly Active Antiretroviral Therapy Changing the Trend?

Opportunistic infections (OIs) cause significant morbidity/mortality in human immunodeficiency virus (HIV)-infected individuals globally. Disparities between high-income countries (HICs) and low/middle-income countries (LMICs) in the magnitude of HIV-related OIs in pre-highly active antiretroviral therapy (HAART) populations was reviewed, and HAART-induced decline in OIs was further compared between the two settings. Studies published in English from onset of HIV epidemic up to December 2013 were searched in PubMed, Google, Google Scholar, and African Journal online. An article was included if (a) the study was conducted in HIC or LMIC, (b) the age of the participants was ≥12 years, (c) the HAART status of the participants was stated, and (d) various types of OIs were investigated. In predominantly pre-HAART populations, the incidence and prevalence of overall HIV-related OIs in HIC ranged from 5.5 to 50.0 per 100 person-years (PY) and 27.4-56.7%, respectively. In LMIC, the respective overall incidence and prevalence of OIs were 12.2-93.9 per 100 PY and 32.0-77.7%. Pneumocystis jirovecii pneumonia, candidiasis, Cytomegalovirus disease, Mycobacterium avium complex disease, and Kaposi's sarcoma were the most frequent OIs in HICs while tuberculosis, candidiasis, chronic diarrhea, and cryptococcosis were predominant in LMICs. The introduction of HAART led to substantial reduction in the incidence of OIs with more impressive percentage decline in HICs (43-97%) compared to 30-79% in LMICs. Disparities in the magnitude of HIV-related OIs between HICs and LMICs are evident both in the pre-HAART and post-HAART era. Efforts to optimize HAART-induced decline in HIV-related OIs should become a global health priority irrespective of prevailing socioeconomic circumstances.

Manual cleaning of hospital mattresses: an observational study comparing high- and low-resource settings

BACKGROUND

Hospital-associated infections (HAIs) are more frequently encountered in low- than in high-resource settings. There is a need to identify and implement feasible and sustainable approaches to strengthen HAI prevention in low-resource settings.

AIM

To evaluate the biological contamination of routinely cleaned mattresses in both high- and low-resource settings.

METHODS

In this two-stage observational study, routine manual bed cleaning was evaluated at two university hospitals using adenosine triphosphate (ATP). Standardized training of cleaning personnel was achieved in both high- and low-resource settings. Qualitative analysis of the cleaning process was performed to identify predictors of cleaning outcome in low-resource settings.

FINDINGS

Mattresses in low-resource settings were highly contaminated prior to cleaning. Cleaning significantly reduced biological contamination of mattresses in low-resource settings (P < 0.0001). After training, the contamination observed after cleaning in both the high- and low-resource settings seemed comparable. Cleaning with appropriate type of cleaning materials reduced the contamination of mattresses adequately. Predictors for mattresses that remained contaminated in a low-resource setting included: type of product used, type of ward, training, and the level of contamination prior to cleaning.

CONCLUSION

In low-resource settings mattresses were highly contaminated as noted by ATP levels. Routine manual cleaning by trained staff can be as effective in a low-resource setting as in a high-resource setting. We recommend a multi-modal cleaning strategy that consists of training of domestic services staff, availability of adequate time to clean beds between patients, and application of the correct type of cleaning products.

Cardiac rehabilitation in low- and middle-income countries: a review on cost and cost-effectiveness

BACKGROUND

By 2030, more than 80% of cardiovascular disease-related deaths and disability-adjusted life years will occur in the 139 low- and middle-income (LMIC) countries. Cardiac rehabilitation (CR) has been demonstrated to be effective and cost-effective mainly based on data from high-income countries. The purpose of this paper was to review the literature for cost and cost-effectiveness data on CR in LMICs.

METHODS

MEDLINE (Ovid) and EMBASE (Ovid) electronic databases were searched for CR 'cost' and 'cost-effectiveness' data in LMICs.

RESULTS

Five CR publications with cost and cost-effectiveness data from middle-income countries were identified with none from low-income countries. Studies from Brazil demonstrated mean monthly savings of US$190 for CR, with a US$48 increase in a control group with mean costs of US$503 for a 3-month CR program. Mean costs to the public health care system of US$360 and US$540 when paid out-of-pocket were reported for a 3-month CR program in seven Latin American middle-income countries. Cardiac rehabilitation is reported to be cost-effective in both Brazil and Colombia.

CONCLUSIONS

Cardiac rehabilitation for patients with heart failure in Brazil and Colombia was estimated to be cost-effective. However, given the limited health care budgets in many LMICs, affordable CR models will need to be developed for LMICs, particularly for low-income countries.

Neonatal resuscitation in Vietnam: a national survey of a middle-income country

AIM

Interventions that improve neonatal resuscitation are critical if we are to reduce perinatal mortality. We evaluated the consistency of resuscitation practices, and adherence to the international guidelines for neonatal resuscitation, in a large representative sample of hospitals in Vietnam.

METHODS

A questionnaire was sent to 187 public central, provincial and district hospitals, representing the three levels of public hospital-based maternity services in Vietnam.

RESULTS

The overall response rate was 85.7% (160/187 hospitals), and the response rate was 100%, 90.3% and 81.7% for central, provincial and district hospitals, respectively. There were 620 300 births in the surveyed hospitals during the year 2011, representing almost half of all inpatient births in Vietnam. Neonatal resuscitation was provided by obstetricians and, or, midwives at all levels. Half of the hospitals did not follow recommendations for delaying cord clamping. The majority of the hospitals did not have a wall thermometer in the delivery room (80.5%) and did not monitor neonatal temperature after birth (64.1%). A large proportion of hospitals (39.9%) used 100% oxygen to initiate resuscitation and only central hospitals avoided this practice.

CONCLUSION

Our survey identified significant variations in resuscitation practices between central, provincial and district hospitals and limited adherence to international recommendations.

Spanish cross-cultural adaptation and psychometric properties of the Schizophrenia Quality of Life short-version questionnaire (SQoL18) in 3 middle-income countries: Bolivia, Chile and Peru

OBJECTIVE

The aim of this study was to adapt the Schizophrenia - Quality of Life short-version questionnaire (SQoL18) for use in three middle-income countries in Latin America and to evaluate the factor structure, reliability, and external validity of this questionnaire.

METHODS

The SQoL18 was translated into Spanish using a well-validated forward-backward process. We evaluated the psychometric properties of the SQoL18 in a sample of 253 patients with schizophrenia attending outpatient mental health services in three Latin American countries. For participants in each country (Bolivia, N=83; Chile, N=85; Peru, N=85), psychometric properties were compared to those reported from the reference population (507 patients with schizophrenia) assessed in the validation study. In addition, differential item functioning (DIF) analyses were performed to see whether all items behave in the same way in each country.

RESULTS

Factor analysis performed in the 3 countries showed that the questionnaire's structure adequately matched the initial structure of the SQoL18. The unidimensionality of the dimensions was preserved, and the internal/external validity indices were close to those of the reference population. However, one dimension of the SQoL18 (resilience) presented some unsatisfactory properties including low Cronbach's alpha coefficients, one INFIT value higher than 1.2, and one item showing DIF between the 3 countries.

CONCLUSIONS

These results demonstrate the satisfactory acceptability and psychometric properties of the SQoL18, suggesting the relevance of this questionnaire among patients with schizophrenia in these 3 Latin American countries.

Crime and violence in Brazil: Systematic review of time trends, prevalence rates and risk factors

Between 1980 and 2010 there were 1 million homicides in Brazil. Dramatic increases in homicide rates followed rises in inequality, more young men in the population, greater availability of firearms, and increased drug use. Nevertheless, disarmament legislation may have helped reduce homicide rates in recent years. Despite its very high rate of lethal violence, Brazil appears to have similar levels of general criminal victimization as several other Latin American and North American countries. Brazil has lower rates of drug use compared to other countries such as the United States, but the prevalence of youth drug use in Brazil has increased substantially in recent years. Since 1990, the growth of the Brazilian prison population has been enormous, resulting in the fourth largest prison population in the world. Through a systematic review of the literature, we identified 10 studies assessing the prevalence of self-reported offending in Brazil and 9 studies examining risk factors. Levels of self-reported offending seem quite high among school students in Brazil. Individual and family-level risk factors identified in Brazil are very similar to those found in high-income countries.