Contextual Barriers to Implementing Open-Source Electronic Health Record Systems for Low- and Lower-Middle-Income Countries: Scoping Review.

BACKGROUND: Low- and lower-middle-income countries account for a higher percentage of global epidemics and chronic diseases. In most low- and lower-middle-income countries, there is limited access to health care. The implementation of open-source electronic health records (EHRs) can be understood as a powerful enabler for low- and lower-middle-income countries because it can transform the way health care technology is delivered. Open-source EHRs can enhance health care delivery in low- and lower-middle-income countries by improving the collection, management, and analysis of health data needed to inform health care delivery, policy, and planning. While open-source EHR systems are cost-effective and adaptable, they have not proliferated rapidly in low- and lower-middle-income countries. Implementation barriers slow adoption, with existing research focusing predominantly on technical issues preventing successful implementation. OBJECTIVE: This interdisciplinary scoping review aims to provide an overview of contextual barriers affecting the adaptation and implementation of open-source EHR systems in low- and lower-middle-income countries and to identify areas for future research. METHODS: We conducted a scoping literature review following a systematic methodological framework. A total of 7 databases were selected from 3 disciplines: medicine and health sciences, computing, and social sciences. The findings were reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. The Mixed Methods Appraisal Tool and the Critical Appraisal Skills Programme checklists were used to assess the quality of relevant studies. Data were collated and summarized, and results were reported qualitatively, adopting a narrative synthesis approach. RESULTS: This review included 13 studies that examined open-source EHRs' adaptation and implementation in low- and lower-middle-income countries from 3 interrelated perspectives: socioenvironmental, technological, and organizational barriers. The studies identified key issues such as limited funding, sustainability, organizational and management challenges, infrastructure, data privacy and protection, and ownership. Data protection, confidentiality, ownership, and ethics emerged as important issues, often overshadowed by technical processes. CONCLUSIONS: While open-source EHRs have the potential to enhance health care delivery in low- and lower-middle-income-country settings, implementation is fraught with difficulty. This scoping review shows that depending on the adopted perspective to implementation, different implementation barriers come into view. A dominant focus on technology distracts from socioenvironmental and organizational barriers impacting the proliferation of open-source EHRs. The role of local implementing organizations in addressing implementation barriers in low- and lower-middle-income countries remains unclear. A holistic understanding of implementers' experiences of implementation processes is needed. This could help characterize and solve implementation problems, including those related to ethics and the management of data protection. Nevertheless, this scoping review provides a meaningful contribution to the global health informatics discipline.

The Neurosurgical Research Progress of 98 Low and Lower Middle-Income Countries from 1928 to 2024.

OBJECTIVE: The aim of the present study was to analyze the trends of neurosurgical research in low and lower middle-income countries (LLMICs). METHODS: The data was retrieved from Scopus database and 82 neurosurgical journals were analyzed. RESULTS: Initially the global research scholarly output (n = 195,658) was explored and later papers originating solely from LLMICs, without international collaboration with advance countries (n = 8408) were analyzed. The per decade number of publications (from 1920 to May 2024), top ten authors, universities, countries and sources of all (global) countries, and 98 LLMICs is provided. Eighty countries have published less than 50 papers. Even more striking, 68, 55, 38, and 36 LLMICs countries have produced less than 20, 10, 5, and 3 papers, respectively. The keywords analysis was performed to present the main focus of 8408 publications. The top 1000 most cited documents were also identified, and later relevant scientometrics details were provided. The top countries dynamic and most prolific authors (on the basis of number of publications, total citations, h-index, g-index, and m-index) in the top 1000 cited documents (from LLMICs) are highlighted. CONCLUSIONS: The findings suggest that neurosurgical research in LLMICs is low, which could be attributed to several factors including limited funding, inadequate infrastructure, and insufficient training opportunities.

Excess mortality during the COVID-19 pandemic in low-and lower-middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Although the COVID-19 pandemic claimed a great deal of lives, it is still unclear how it affected mortality in low- and lower-middle-income countries (LLMICs). This review summarized the available literature on excess mortality during the COVID-19 pandemic in LLMICs, including methods, sources of data, and potential contributing factors that might have influenced excess mortality. METHODS: We conducted a systematic review and meta-analysis on excess mortality during the COVID-19 pandemic in LLMICs in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines We searched PubMed, Embase, Web of Science, Cochrane Library, Google Scholar, and Scopus. We included studies published from 2019 onwards with a non-COVID-19 period of at least one year as a comparator. The meta-analysis included studies reporting data on population size, as well as observed and expected deaths. We used the Mantel-Haenszel method to estimate the pooled risk ratio with 95% confidence intervals. The protocol was registered in PROSPERO (ID: CRD42022378267). RESULTS: The review covered 29 countries, with 10 countries included in the meta-analysis. The pooled meta-analysis included 1,405,128,717 individuals, for which 2,152,474 deaths were expected, and 3,555,880 deaths were reported. Calculated excess mortality was 100.3 deaths per 100,000 population per year, with an excess risk of death of 1.65 (95% CI: 1.649, 1.655, p < 0.001). The data sources used in the studies included civil registration systems, surveys, public cemeteries, funeral counts, obituary notifications, burial site imaging, and demographic surveillance systems. The primary techniques used to estimate excess mortality were statistical forecast modelling and geospatial analysis. One out of the 24 studies found higher excess mortality in urban settings. CONCLUSION: Our findings demonstrate that excess mortality in LLMICs during the pandemic was substantial. However, estimates of excess mortality are uncertain due to relatively poor data. Understanding the drivers of excess mortality, will require more research using various techniques and data sources.

Pediatric neuropathology practice in a low- and middle-income country: capacity building through institutional twinning.

Background: Accurate and precise diagnosis is central to treating central nervous system (CNS) tumors, yet tissue diagnosis is often a neglected focus in low- and middle-income countries (LMICs). Since 2016, the WHO classification of CNS tumors has increasingly incorporated molecular biomarkers into the diagnosis of CNS tumors. While this shift to precision diagnostics promises a high degree of diagnostic accuracy and prognostic precision, it has also resulted in increasing divergence in diagnostic and management practices between LMICs and high-income countries (HICs). Pathologists and laboratory professionals in LMICs lack the proper training and tools to join the molecular diagnostic revolution. We describe the impact of a 7-year long twinning program between Canada and Pakistan on pathology services. Methods: During the study period, 141 challenging cases of pediatric CNS tumors initially diagnosed at Aga Khan University Hospital (AKUH), Karachi, were sent to the Hospital for Sick Children in Toronto, Canada (SickKids), for a second opinion. Each case received histologic review and often immunohistochemical staining and relevant molecular testing. A monthly multidisciplinary online tumor board (MDTB) was conducted to discuss the results with pathologists from both institutions in attendance. Results: Diagnostic discordance was seen in 30 cases. Expert review provided subclassification for 53 cases most notably for diffuse gliomas and medulloblastoma. Poorly differentiated tumors benefited the most from second review, mainly because of the resolving power of specialized immunohistochemical stains, NanoString, and targeted gene panel next-generation sequencing. Collaboration with expert neuropathologists led to validation of over half a dozen immunostains at AKUH facilitating diagnosis of CNS tumors. Conclusions: LMIC-HIC Institutional twinning provides much-needed training and mentorship to pathologists and can help in infrastructure development by adopting and validating new immunohistochemical stains. Persistent unresolved cases indicate that molecular techniques are indispensable in for diagnosis in a minority of cases. The development of affordable alternative molecular techniques may help with these histologically unresolved cases.

The impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries: a systematic review of the evidence.

BACKGROUND: Low- and middle-income countries have committed to achieving universal health coverage (UHC) as a means to enhance access to services and improve financial protection. One of the key health financing reforms to achieve UHC is the introduction or expansion of health insurance to enhance access to basic health services, including maternal and reproductive health care. However, there is a paucity of evidence of the extent to which these reforms have had impact on the main policy objectives of enhancing service utilization and financial protection. The aim of this systematic review is to assess the existing evidence on the causal impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries. METHODS: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search included six databases: Medline, Embase, Web of Science, Cochrane, CINAHL, and Scopus as of 23rd May 2023. The keywords included health insurance, impact, utilisation, financial protection, and maternal and reproductive health. The search was followed by independent title and abstract screening and full text review by two reviewers using the Covidence software. Studies published in English since 2010, which reported on the impact of health insurance on maternal and reproductive health utilisation and or financial protection were included in the review. The ROBINS-I tool was used to assess the quality of the included studies. RESULTS: A total of 17 studies fulfilled the inclusion criteria. The majority of the studies (82.4%, n = 14) were nationally representative. Most studies found that health insurance had a significant positive impact on having at least four antenatal care (ANC) visits, delivery at a health facility and having a delivery assisted by a skilled attendant with average treatment effects ranging from 0.02 to 0.11, 0.03 to 0.34 and 0.03 to 0.23 respectively. There was no evidence that health insurance had increased postnatal care, access to contraception and financial protection for maternal and reproductive health services. Various maternal and reproductive health indicators were reported in studies. ANC had the greatest number of reported indicators (n = 10), followed by financial protection (n = 6), postnatal care (n = 5), and delivery care (n = 4). The overall quality of the evidence was moderate based on the risk of bias assessment. CONCLUSION: The introduction or expansion of various types of health insurance can be a useful intervention to improve ANC (receiving at least four ANC visits) and delivery care (delivery at health facility and delivery assisted by skilled birth attendant) service utilization in low- and lower-middle-income countries. Implementation of health insurance could enable countries' progress towards UHC and reduce maternal mortality. However, more research using rigorous impact evaluation methods is needed to investigate the causal impact of health insurance coverage on postnatal care utilization, contraceptive use and financial protection both in the general population and by socioeconomic status. TRIAL REGISTRATION: This study was registered with Prospero (CRD42021285776).

Postpartum psychosis: a public involvement perspective across three continents.

Postpartum psychosis is a psychiatric emergency that is currently not represented in diagnostic systems, to the detriment of people with lived experience. Engaging with stakeholders offers an important avenue to improve clinical practice and make research more impactful, by providing perspectives based on first-hand, expert experience. There is a paucity of reports on stakeholders' engagement in psychiatry. Activities have thus far been limited to Western countries and there are few reports on postpartum psychosis. We report the results of public involvement activities (in the form of discussion groups) with key stakeholders in India, Malawi and the UK. These discussions centred around the clinical picture of postpartum psychosis and the terminologies used to describe these episodes. Seven major areas were highlighted: how postpartum psychosis is handled within services, common symptoms and characteristics, impact of episode, barriers to care, non-medical approaches, terminology and research areas of interest. According to the discussions, postpartum psychosis presents similarly across countries, although there are differences in access to services, approaches to mental health and terminologies used within and across countries. With this understanding comes the foundation for cross-cultural assessment, service improvement and a stakeholder-informed research agenda.

Psychosocial interventions for autistic children and adolescents delivered by non-specialists in low- and middle-income countries: a scoping review.

Background: Most autistic individuals reside in low- and middle-income countries (LMIC) and have limited access to medical providers and specialists. Support for delivery of psychosocial interventions by non-specialists is growing to address this mental health care gap. This scoping review involved a systematic analysis of studies of non-specialist delivered psychosocial interventions for children and adolescents diagnosed with autism and living in low- and middle-income countries. Methods: The primary objective of this review was to identify psychosocial interventions for autistic children and adolescents in LMIC delivered by non-specialists (parent, teacher, peer, community, multi-level) and to summarize resulting effects on targeted outcomes. The search strategy was completed in four databases with predetermined inclusion and exclusion criteria. The systematic search generated 3,601 articles. A total of 18 studies met inclusion/exclusion criteria. Data extraction was completed, and results summarized by; (1) participant sample; (2) intervention procedures; (3) implementation by non-specialists; (4) effect on evaluated outcomes; and (5) assessment of risk of bias. Studies examined a range of child and adolescent outcomes including assessment of communication skills, social skills, motor skills, functional and adaptive behaviors, emotional regulation, attention and engagement, sensory challenges, depression, anxiety, and quality of life. Several studies also evaluated intervention effects on family relationships, parent/caregiver stress and parent/caregiver mental health. Results: Collectively, the 18 studies included a total of 952 ASC participants ranging in age from 2 to 16 years. Of the included studies, 8 studies were parent/caregiver-mediated, 1 study was peer-mediated, 2 studies were teacher-mediated, and 7 studies included multi-level non-specialist mediated components. Effects on evaluated outcomes are reported. Conclusion: Non-specialist delivered interventions for autistic children and adolescents are effective for an array of outcomes and are particularly well suited for low- and middle-income countries. Implications for future research are discussed.

Continuing professional development (CPD) system development, implementation, evaluation and sustainability for healthcare professionals in low- and lower-middle-income countries: a rapid scoping review.

BACKGROUND: Policymakers and program developers in low-and lower-middle-income countries (LLMICs) are increasingly seeking evidence-based information and guidance on how to successfully develop and implement continuing professional development (CPD) systems. We conducted a rapid scoping review to map and synthesize what is known regarding the development, implementation, evaluation and sustainability of CPD systems for healthcare professionals in LLMICs. METHODS: We searched MEDLINE, CINAHL and Web of Science. Reference lists were screened and a cited reference search of included articles was conducted. Supplementary information on the CPD systems identified in the articles was also identified via an online targeted grey literature search. English, French and Spanish literature published from 2011 to 2021 were considered. Data were extracted and combined and summarized according to country/region and healthcare profession via tables and narrative text. RESULTS: We included 15 articles and 23 grey literature sources. Africa was the region most represented followed by South and Southeast Asia and the Middle East. The literature most often referred to CPD systems for nurses and midwives; CPD systems for physicians were frequently referred to as well. Findings show that leadership and buy-in from key stakeholders, including government bodies and healthcare professional organizations, and a framework are essential for the development, implementation and sustainability of a CPD system in a LLMIC. The guiding framework should incorporate a regulatory perspective, as well as a conceptual lens (that informs CPD objectives and methods), and should consider contextual factors (support for CPD, healthcare context and population health needs). In terms of important steps to undertake, these include: a needs assessment; drafting of a policy, which details the regulations (laws/norms), the CPD requirements and an approach for monitoring, including an accreditation mechanism; a financing plan; identification and production of appropriate CPD materials and activities; a communication strategy; and an evaluation process. CONCLUSION: Leadership, a framework and a clearly delineated plan that is responsive to the needs and context of the setting, are essential for the development, implementation and sustainability of a CPD system for healthcare professionals in a LLMIC.

Comparing outcomes of ultra-low-cost hearing aids to programmable, refurbished hearing aids for adults with high frequency hearing loss in Malawi: a feasibility study.

Introduction: Access to ear and hearing health services are limited or non-existent in low-income countries, with less than 10% of the global production of hearing aids distributed to this population. The aim of this feasibility study was to compare the outcomes of an ultra-low-cost hearing aid (LoCHAid) to programmable, refurbished hearing aids for adults with high-frequency hearing loss, in Blantyre, Malawi. Methods: Sixteen adults with high frequency hearing loss, and no prior experience of hearing aids, took part in this study, nine were fitted with the LoCHAid and seven were fitted with refurbished, programmable hearing aids, for a one-month trial. Five standardized hearing qualities questionnaires were used to compare outcomes pre and post device fitting and between devices. Questionnaire scales were analysed using general linear models and inductive thematic analysis was used to evaluate qualitative data. Results: Overall, there was no significant difference found between LoCHAid and refurbished hearing aids, and the two device types each showed a similar degree of improvement after fitting. Qualitative data analysis identified two key themes: Sound Quality and User experience. Conclusion: The results from this feasibility study are encouraging, but a comprehensive, larger clinical study is needed to draw firm conclusions about the LoCHAid's performance. This study has identified key improvement indicators required to enhance sound quality and user experience of the LoCHAid.

Planning, implementation, and sustaining high coverage of human papillomavirus (HPV) vaccination programs: What works in the context of low-resource countries?

Cervical cancer due to human papillomavirus (HPV) infection is a leading cause of mortality among women in low-resource settings. Many Sub-Saharan African countries have introduced HPV vaccination programs at the national level in the last few years. However, countries are struggling to maintain sustainable coverage. This study focuses on the introduction and sustainability challenges, context-specific key lessons learned, and mechanisms of action to achieve high sustainable coverage from low and lower-middle-income countries (LLMICs) that have introduced HPV vaccination programs by collating evidence from a literature review and key informant interviews. Local data availability was a challenge across countries, with the lack or absence of registries, data collection and reporting mechanisms. Multi-sectoral coordination and early involvement of key stakeholders were cited as an integral part of HPV programs and facilitators for sustainable coverage. Key informants identified periodic sensitization and training as critical due to high staff turnover. Health workforce mobilization was fundamental to ensure that the health workforce is aware of the disease etiology, eligibility requirements, and can dispel misinformation. Schools were reported to be an ideal sustainable platform for vaccination. However, this required teachers to be trained, which was often not considered in the programs. District-level staff were often poorly informed and lacked the technical and logistic capacity to support vaccination rounds and data collection. To improve the sustainability of HPV vaccination programs, there is a need for timely microplanning, efficient preparedness assessment, assessing training approaches, periodic training, finding innovative ways to achieve equity and adoption of a bottom-up approach to ensure that processes between districts and central level are well-connected and resources are distributed efficiently.

eHealth policy framework in Low and Lower Middle-Income Countries; a PRISMA systematic review and analysis.

BACKGROUND: Low and lower middle-income countries suffer lack of healthcare providers and proper workforce education programs, a greater spread of illnesses, poor surveillance, efficient management, etc., which are addressable by a central policy framework implementation. Accordingly, an eHealth policy framework is required specifically for these countries to successfully implement eHealth solutions. This study explores existing frameworks and fills the gap by proposing an eHealth policy framework in the context of developing countries. METHODS: This PRISMA-based (PRISMA Preferred Reporting Items For Systematic Reviews and Meta-Analyses) systematic review used Google Scholar, IEEE, Web of Science, and PubMed latest on 23rd May 2022, explored 83 publications regarding eHealth policy frameworks, and extracted 11 publications scrutinizing eHealth policy frameworks in their title, abstract, or keywords. These publications were analyzed by using both expert opinion and Rstudio programming tools. They were explored based on their developing/developed countries' context, research approach, main contribution, constructs/dimensions of the framework, and related categories. In addition, by using cloudword and latent semantic space techniques, the most discussed concepts and targeted keywords were explored and a correlation test was conducted to depict the important concepts mentioned in the related literature and extract their relation with the targeted keywords in the interest of this study. RESULTS: Most of these publications do not develop or synthesize new frameworks for eHealth policy implementation, but rather introduce eHealth implementation frameworks, explain policy dimensions, identify and extract relevant components of existing frameworks or point out legal or other relevant eHealth implementation issues. CONCLUSION: After a thorough exploration of related literature, this study identified the main factors affecting an effective eHealth policy framework, found a gap in the context of developing countries, and proposed a four-step eHealth policy implementation guideline for successful implementation of eHealth in the context of developing. The limitation of this study is the lack of a proper amount of practically implemented eHealth policy framework cases in developing countries published in the literature for the review. Ultimately, this study is part of the BETTEReHEALTH (More information about the BETTEReHEALTH project at https://betterehealth.eu ) project funded by the European Union Horizon's 2020 under agreement number 101017450.

Biosafety and biosecurity challenges during the COVID-19 pandemic and beyond.

As the world continues to battle the SARS-CoV-2 pandemic, it is a stark reminder of the devastation biological threats can cause. In an unprecedented way the global community saw a massive surge in the demand for diagnostic capacities, which had a substantial impact on biosafety and biosecurity. Laboratories had to cope with a surge in laboratory testing capacity, while resources and training possibilities were limited. In addition, the pandemic highlighted the impact biological threats can have, thereby giving rise to new dialogue about biosecurity and new biological threats. This paper aims to highlight some of the most pressing issues regarding biosafety and biosecurity observed during the COVID-19 pandemic with special focus on low and lower middle-income countries. The authors provide lessons learned, tools and recommendations to improve future biosafety and biosecurity and increase preparedness for the next global health crisis.

Case report: Managing multisystem inflammatory syndrome in children (MIS-C) in Lao People's Democratic Republic, a success story.

Introduction: Multisystem inflammatory syndrome in children (MIS-C) is believed to be one of the most important life-threatening complications of COVID-19 infection among children. In any setting, early recognition, investigations, and management of MIS-C is crucial, but it is particularly difficult in resource-limited settings (RLS). This is the first case report of MIS-C in Lao People's Democratic Republic (Lao PDR) that was promptly recognized, treated, and resulted in full recovery with no known complications despite the resource limitations. Case presentation: A healthy 9-year-old boy presented to a central teaching hospital fulfilling the World Health's Organization's MIS-C criteria. The patient had never received a COVID-19 vaccine and had a history of COVID-19 contact. The diagnosis was based upon the history, changes in the patient's clinical status, and response to treatment and negative testing and response to treatment for alternative diagnoses. Despite management challenges relating to limited access to an intensive care bed and the high cost of IVIG; the patient received a full course of treatment and appropriate follow-up cares post discharge. There were several aspects to this case that may not hold true for other children in Lao PDR. First, the family lived in the capital city, close to the central hospitals. Second, the family was able to afford repeated visits to private clinics, and the cost of IVIG, and other treatments. Third, the physicians involved in his care promptly recognized a new diagnosis. Conclusions: MIS-C is a rare but life-threatening complication of COVID-19 infection among children. The management of MIS-C requires early recognition, investigations, and interventions which may be difficult to access, cost-prohibitive, and further increase demand on healthcare services that are already limited in RLS. Nevertheless, clinicians must consider means for improving access, determine which tests and interventions are worth the cost, and establishing local clinical guidelines for working within resource constraints while awaiting additional assistance from local and international public health systems. Additionally, using COVID-19 vaccination to prevent MIS-C and its complication for children may be cost-effective.

Risk factors of congenital hydrocephalus: a case-control study in a lower-middle-income country (Egypt).

OBJECTIVE: Hydrocephalus is the most common brain disorder in children and is more common in low- and middle-income countries. Research output on hydrocephalus remains sparse and of lower quality in low- and middle-income countries compared with high-income countries. Most studies addressing hydrocephalus epidemiology are retrospective registry studies entailing their inherent limitations and biases. This study aimed to investigate child-related, parental, and socioeconomic risk factors of congenital hydrocephalus (CH) in a lower-middle-income country. METHODS: An investigator-administered questionnaire was used to query parents of patients with CH and controls who visited the authors' institution from 2017 until 2021. Patients with secondary hydrocephalus and children older than 2 years of age at diagnosis were excluded. Uni- and multivariable logistic regression was performed to identify the factors affecting CH development. RESULTS: Seven hundred forty-one respondents (312 cases and 429 controls) were included in this study. The authors showed that maternal diseases during pregnancy (OR 3.12, 95% CI 1.96-5.03), a lack of periconceptional folic acid intake (OR 1.92, 95% CI 1.32-2.81), being a housewife (OR 2.66, 95% CI 1.51-4.87), paternal illiteracy (OR 1.65, 95% CI 1.02-2.69), parental consanguinity (OR 3.67, 95% CI 2.40-5.69), a history of other CNS conditions in the family (OR 2.93, 95% CI 1.24-7.34), conceiving a child via assisted fertilization techniques (OR 3.93, 95% CI 1.57-10.52), and the presence of other congenital anomalies (OR 2.57, 95% CI 1.38-4.87) were associated with an independent higher odds of a child having CH. Conversely, maternal hypertension (OR 0.22, 95% CI 0.09-0.48), older maternal age at delivery (OR 0.93, 95% CI 0.89-0.97), and having more abortions (OR 0.80, 95% CI 0.67-0.95) were negatively correlated with CH. CONCLUSIONS: Multiple parental, socioeconomic, and child-related factors were associated with higher odds for developing CH. These results can be utilized to guide parental counseling and management, and direct social education and prevention programs.

Utility of healthcare-worker-targeted antimicrobial stewardship interventions in hospitals of low- and lower-middle-income countries: a scoping review of systematic reviews.

BACKGROUND: Antimicrobial stewardship (AMS) initiatives in hospitals often include the implementation of clustered intervention components to improve the surveillance and targeting of antibiotics. However, impacts of the individual components of AMS interventions are not well known, especially in low- and lower-middle-income countries (LLMICs). OBJECTIVE: A scoping review was conducted to summarize evidence from systematic reviews (SRs) on the impact of common hospital-implemented healthcare-worker-targeted components of AMS interventions that may be appropriate for LLMICs. METHODS: Major databases were searched systematically for SRs of AMS interventions that were evaluated in hospitals. For SRs to be eligible, they had to report on at least one intervention that could be categorized according to the Effective Practice and Organisation of Care taxonomy. Clinical and process outcomes were considered. Primary studies from LLMICs were consulted for additional information. RESULTS: Eighteen SRs of the evaluation of intervention components met the inclusion criteria. The evidence shows that audit and feedback, and clinical practice guidelines improved several clinical and process outcomes in hospitals. An unintended consequence of interventions was an increase in the use of antibiotics. There was a cumulative total of 547 unique studies, but only 2% (N=12) were conducted in hospitals in LLMICs. Two studies in LLMICs reported that guidelines and educational meetings were effective in hospitals. CONCLUSION: Evidence from high- and upper-middle-income countries suggests that audit and feedback, and clinical practice guidelines have the potential to improve various clinical and process outcomes in hospitals. The lack of evidence in LLMIC settings prevents firm conclusions from being drawn, and highlights the need for further research.

Haploidentical stem cell transplantation with post-transplant cyclophosphamide challenges and outcome from a tertiary care center in Lebanon.

This letter describes the experience of the American University of Beirut Medical Center in Lebanon with haploidentical stem cell transplant (haplo-SCT) for hematological malignancies in adult patients. Haplo-SCT made it possible through universal and rapid donor availability for most of the adult patients with leukemia or lymphoma not only in the Middle East but also globally. Moreover, the use of post-transplant cyclophosphamide (PTCy) and reduced intensity conditioning (RIC) regimens when indicated improved the outcome and decreased the toxicity of haploidentical stem cell transplant.RIC regimens also allowed its use in the elderly population. Patients from throughout the Middle East come to our center, the American university of Beirut Medical Center, to receive this transformative type of stem cell transplant. In this paper, we discuss the results of haplo-SCT with PTCy done on adult patients with hematological malignancies in our center from 2015 to 2021. The results are encouraging and show that haplo-SCT should be considered more often in the Middle Eastern countries. The subgroup analysis showed the importance of achieving complete remission of the disease prior to transplant to improve outcomes in our center. There is a paucity of literature on the outcomes of haplo-SCT in the Middle East which may contribute to the limited number of centers that offer this type of SCT. Herein, we aim to fill this gap in the hopes of encouraging the implementation of this potentially curative modality of treatment to a larger extent in the Middle East.

Labor augmentation with oxytocin in low- and lower-middle-income countries: a systematic review and meta-analysis.

OBJECTIVE: Despite its worldwide use, reviews of oxytocin for labor augmentation include mainly studies from high-income countries. Meanwhile, oxytocin is a potentially harmful medication and risks may be higher in low-resource settings. We conducted a systematic review and meta-analysis of practices, benefits, and risks of oxytocin for labor augmentation in low- and lower-middle-income countries. DATA SOURCES: PubMed, Embase, PsycINFO, Index Medicus, Cochrane, and Google Scholar were searched for publications until January 1, 2022. STUDY ELIGIBILITY CRITERIA: All studies evaluating oxytocin augmentation rates were included. To investigate benefits and risks, randomized and quasi-randomized trials comparing oxytocin augmentation with placebo or no oxytocin were included. To explore risks more broadly, cohort and case-control studies were also included. METHODS: Data were extracted and quality-assessed by 2 researchers using a modified Newcastle-Ottawa scale. Generic inverse variance outcome and a random-effects model were used. Adjusted or crude effect measures with 95% confidence intervals were used. RESULTS: In total, 42 studies were included, presenting data from 885 health facilities in 25 low- and lower-middle-income countries (124,643 women). Rates of oxytocin for labor augmentation varied from 0.7% to 97.0%, exceeding 30% in 14 countries. Four studies investigated timing of oxytocin for augmentation and found that 89.5% (2745) of labors augmented with oxytocin did not cross the partograph's action line. Four cohort and 7 case-control studies assessed perinatal outcomes. Meta-analysis revealed that oxytocin was associated with: stillbirth and day-1 neonatal mortality (relative risk, 1.45; 95% confidence interval, 1.02-2.06; N=84,077; 6 studies); low Apgar score (relative risk, 1.54; 95% confidence interval, 1.21-1.96; N=80,157; 4 studies); neonatal resuscitation (relative risk, 2.69; 95% confidence interval, 1.87-3.88; N=86,750; 3 studies); and neonatal encephalopathy (relative risk, 2.90; 95% confidence interval, 1.87-4.49; N=1383; 2 studies). No studies assessed effects on cesarean birth rate and uterine rupture. CONCLUSION: This review discloses a concerning level of oxytocin use, including in labors that often did not fulfill criteria for dystocia. Although this finding is limited by confounding by indication, oxytocin seems associated with increased perinatal risks, which are likely mediated by inadequate fetal monitoring. We call for cautious use on clear indications and robust implementation research to support evidence-based guidelines for labor augmentation, particularly in low-resource settings.

Factors influencing survival and short-term outcomes of very low birth weight infants in a tertiary hospital in Johannesburg.

Background: The neonatal mortality rate in South Africa is lower than the global average, but still approximately five times higher than some European and Scandinavian countries. Prematurity, and its complications, is the main cause (35%) of neonatal deaths. Objective: To review the maternal, delivery period and infant characteristics in relation to mortality in very low birth weight (VLBW) infants at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Methods: This was a retrospective descriptive study of VLBW infants admitted to CMJAH between 1 January 2017 and 31 December 2018. All infants with a birth weight between 500 to ≤ 1,500 grams were included. The characteristics and survival of these infants were described using univariate analysis. Results: Overall survival was 66.5%. Provision of antenatal steroids, antenatal care, Cesarean section, female sex, resuscitation at birth, and 5-min Apgar score more than five was related with better survival to discharge. Among respiratory diagnoses, 82.8% were diagnosed with RDS, 70.8% received surfactant therapy and 90.7% received non-invasive respiratory support after resuscitation. At discharge, 59.5% of the mothers were breastfeeding and 30.8% spent time in kangaroo mother care. Conclusion: The two-thirds survival rate of VLBW infants is similar to those in other developing countries but still remains lower than developed countries. This may be improved with better antenatal care attendance, coverage of antenatal steroids, temperature control after birth, improving infection prevention and control practices, breastfeeding rates and kangaroo mother care. The survival rate was lowest amongst extremely low birth weight (ELBW) infants.