Effectiveness of greenhouse gas mitigation intervention for health-care systems: a systematic review.

Objective: To identify evidence-based interventions that reduce greenhouse gas emissions in health-care systems in low- and middle-income countries and explore potential synergies from these interventions that aid climate change adaptation while mitigating emissions. Methods: We systematically searched 11 electronic databases for articles published between 1990 and March 2023. We assessed risk of bias in each article and graded the quality of evidence across interventions in health-care operations, energy and supply chains. Findings: After screening 25 570 unique records, we included 22 studies published between 2000 and 2022 from 11 countries across six World Health Organization regions. Identified articles reported on interventions spanning six different sources of emissions, namely energy, waste, heating and cooling, operations and logistics, building design and anaesthetic gases; all of which demonstrated potential for significant greenhouse gas emission reductions, cost savings and positive health impacts. The overall quality of evidence is low because of wide variation in greenhouse gas emissions measuring and reporting. Conclusion: There are opportunities to reduce the greenhouse gas emissions from health-care systems in low- and middle-income countries, but gaps in evidence were identified across sources of emissions, such as the supply chain, as well as a lack of consideration of interactions with adaptation goals. As efforts to mitigate greenhouse gas intensify, rigorous monitoring, evaluation and reporting of these efforts are needed. Such actions will contribute to a strong evidence base that can inform policy-makers across contexts.

Epidemiological Predictors of Financial Toxicity in Surgical Burn Injuries: A Multicenter, Longitudinal, Cohort Study.

BACKGROUND: Burns constitute a major global health challenge, causing over 11 million injuries and 300,000 deaths annually and surpassing the economic burden of cervical cancer and HIV combined. Despite this, patient-level financial consequences of burn injuries remain poorly quantified, with a significant gap in data from low- and middle-income countries. In this study, we evaluate financial toxicity in burn patients. METHODS: A prospective, multicenter cohort study was conducted across two tertiary care hospitals in India, assessing 123 adult surgical in-patients undergoing operative interventions for burn injuries. Patient sociodemographic, clinical, and financial data were collected through surveys and electronic records during hospitalization and at 1, 3, and 6 months postoperatively. Out-of-pocket costs (OOPCs) for surgical burn treatment were evaluated during hospitalization. Longitudinal changes in income, employment status, and affordability of basic subsistence needs were assessed at the 1-, 3-, and 6-month postoperative time point. Degree of financial toxicity was calculated using a combination of the metrics catastrophic health expenditure and financial hardship. Development of financial toxicity was compared by sociodemographic and clinical characteristics using logistic regression models. RESULTS: Of the cohort, 60% experienced financial toxicity. Median OOPCs was US$555.32 with the majority of OOPCs stemming from direct nonmedical costs (US$318.45). Cost of initial hospitalization exceeded monthly annual income by 80%. Following surgical burn care, income decreased by US$318.18 within 6 months, accompanied by a 53% increase in unemployment rates. At least 40% of the cohort consistently reported inability to afford basic subsistence needs within the 6-month perioperative period. Significant predictors of developing financial toxicity included male gender (odds ratio, 4.17; 95% confidence interval, 1.25-14.29; P = 0.02) and hospital stays exceeding 20 days (odds ratio, 11.17; 95% confidence interval, 2.11-59.22; P ≤ 0.01). CONCLUSIONS: Surgical treatment for burn injuries is associated with substantial financial toxicity. National and local policies must expand their scope beyond direct medical costs to address direct nonmedical and indirect costs. These include burn care insurance, teleconsultation follow-ups, hospital-affiliated subsidized lodging, and resources for occupational support and rehabilitation. These measures are crucial to alleviate the financial burden of burn care, particularly during the perioperative period.

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

BACKGROUND: International Student Surgical Network (InciSioN) is the largest student and trainee global surgery interest group worldwide and its members have contributed significantly to global surgery research. The InciSioN Research Capacity-Building (IReCaB) program aimed to enhance the research skills and confidence of participants via a peer mentorship model. METHODS: After an open call to members of InciSioN to enroll, participants' knowledge of research methods and the process was evaluated through a test to assign mentor and mentee roles, with mentors being those who scored ≥ 20/25. Mentors then delivered a series of four webinars to help disseminate research methodology to mentees. Finally, mentees were tested on their knowledge of research and their satisfaction with the program was also evaluated. RESULTS: Fifty-two participants, mostly from LMICs (n = 23/52, 44.2%) were enrolled, and 36 completed the program. There was a significant improvement in the proportion of questions answered correctly on the post-program test (R = 0.755, p < 0.001). Post-IReCaB test scores were greater than pre-IReCaB scores (p < 0.001). The difference in confidence after the course was also significant (p < 0.001). IReCaB participants successfully designed, implemented, and published an international cross-sectional study. CONCLUSION: This study showed improvements in participants' understanding of theoretical components of scientific research. We offer a model for research capacity building that can be implemented, modeled, and further refined by similar organizations with academic research goals.

Evaluation of Financial Interventions in Breast Cancer Care Worldwide: A Systematic Review.

Background: Out-of-pocket costs are burdensome for breast cancer patients. Cost-reducing interventions, though implemented, have unclear comparative efficacy. This study aimed to critically evaluate characteristics of successful versus unsuccessful interventions designed to decrease out-of-pocket costs for breast cancer patients. Methods: A systematic review was conducted in accordance with the PRISMA checklist. Embase, PubMed, Global Index Medicus, and Global Health were queried from inception to February 2021. Articles describing a financial intervention targeting costs for breast cancer screening, diagnosis, or treatment and addressing clinical or patient-level financial outcomes were included. Methodological quality was evaluated using the QualSyst tool. Interventions were organized in accordance with timing of implementation, with narrative description of intervention type, success, and outcomes. Results: Of the 11,086 articles retrieved, 21 were included in this review. Of these, 14 consisted of interventions during screening, and seven during diagnosis or treatment. Free/subsidized screening mammography was the most common screening intervention; 91% of these programs documented successful outcomes. Patient navigation and gift voucher programs demonstrated mixed success. The most successful intervention implemented during diagnosis/treatment was reducing medication costs. Low-cost programs and direct patient financial assistance were also successful. Limitations included lack of standardization in outcome metrics across studies. Conclusions: Financial interventions reducing prices through free screening mammography and decreasing medication costs were most successful. Less successful interventions were not contextually tailored, including gift card incentivization and low-cost treatment modalities. These findings can facilitate implementation of broader, more generalizable programs to reduce costs and improve outcomes during evaluation and management of breast cancer.

The Paradoxical Criticism of Gender Parity in Surgery.

The present work explores a controversy surrounding gender equity in surgical residency programs, particularly focusing on the Stanford University and University of Washington (UW) General Surgery Residency cohorts. While the Stanford cohort, which consisted mostly of women, faced criticism from nonmedical audiences claiming that gender was prioritized over qualifications, the all-male radiology residents received less attention and fewer criticisms. The article highlights the double standards and challenges the notion of meritocracy. It discusses the gender and racial disparities in surgical residency programs, emphasizing the need for diversity and inclusion. The presence of diverse female representation is seen as a valuable asset that brings compassion, teamwork, and inclusive leadership to the field. The article calls for active support from institutions, male allies, and transparency in collecting applicant demographic data to address biases and promote gender diversity in surgery.

Understanding the reasons for refusal of polio vaccine by families in Quetta Block, Pakistan.

Background: Global polio eradication is a goal yet to be achieved in countries like Pakistan. In recent years, the Polio Eradication Initiative has been making steady progress with good campaign coverage and low numbers of polio cases. However, in 2019 Pakistan reported 146 cases compared to 12 in 2018. A major factor cited for this regression was a surge in vaccine refusals by parents and caretakers. Aims: To assess the reasons for the refusal of polio vaccination in Quetta Block, Balochistan. Methods: The study was conducted using data acquired from 2 polio vaccination campaigns over 3 months in 2019. The data were collected in Quetta Block, a highly endemic zone having continuous transmission of the polio virus over several years. The data were analysed using the statistical software, SPSS, version 20. We used descriptive statistics to demonstrate the characteristics of the study population. Categorical variables were measured as frequencies and percentages. Results: Refusal rates were almost 8.6% for the polio campaign of April and 8.1% for June 2019. Misconceptions about vaccines made up 56.4% of reasons for refusals, followed by religion 16%. Conclusion: Misconceptions about the vaccine are the main driving force behind vaccine refusals in the study setting. Efficient strategies are required to address misconceptions in this red zone of poliovirus transmission in Balochistan.

A systematic review protocol for identifying the effectiveness of greenhouse gas mitigation interventions for health care systems in low- and middle-income countries.

Background: Climate change is predicted to be our century's most significant health threat. In 2021, 46 countries committed to environmentally sustainable low carbon health care systems. Of those, 34 were from low- and middle-income countries (LMICs). Currently, health systems are responsible for 4.4% of global greenhouse gas (GHG) emissions, with health systems in high-income countries (HICs) contributing the largest proportion to the sector's GHG emissions. However, future increases are predicted in LMICs in the absence of robust GHG mitigation. This systematic review aims to identify evidence-based GHG mitigation interventions to guide the transformation of health care systems towards net zero, specifically in LMICs. Additionally, potential synergies between interventions that aid adaption to climate change and mitigate GHG emissions will be investigated. Methods: This protocol will follow the 'Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) checklist of recommended items to address in a systematic review protocol'. A comprehensive search will be conducted on electronic databases identified as relevant. Search terms were identified to capture all relevant peer-reviewed, primary research published between 1990 and 2022. The risk of bias will be assessed, and the quality of evidence graded. The eventual narrative synthesis will feed into a theory of change framework on GHG mitigation of health care systems in LMICs. Discussion: This systematic review will synthesise the existing evidence around GHG mitigation interventions across all scopes of emissions, including scope 1 (health care operations), scope 2 (energy), and scope 3 (supply chains). It can be used to inform recommendations on how health care systems in LMICs can reduce emissions while prioritising which actions to take to gain the most significant reductions in GHG emissions, considering ease of implementation, scope and cost. Finally, this can catalyse further research in this area which is urgently needed.

Relationship Between Villous Atrophy and tTGA Levels in Dyspeptic Patients: A Case Series.

Aim The objective of the study was to observe the association of villous atrophy with anti-tissue transglutaminase levels in the identified subjects that met our addressed inclusion criteria. Methods A case series study was conducted among 40 patients presenting with dyspepsia along with signs and symptoms of celiac disease at the Bolan Medical Complex Hospital, Quetta over a period of five months from 25/5/17 to 25/10/17. The patients were referred to undergo tissue transglutaminase antibody serum test. The positive ones underwent biopsies to assess pathological entities including villous atrophy, blunting (focal or total), crypts, Intestinal layers and the number of Intraepithelial lymphocytes. The results collected were analyzed by using IBM SPSS version 20 (IBM Corp., Armonk, NY). Results There was a weak, negative correlation between tTGA and focal villous blunting (r = -0.345, p = 0.029) showing that high levels of tTGA are associated with lower risk of focal villous blunting. Correlation of tTGA and total villous blunting was a weak positive correlation (r = 0.282, p = 0.07) showing that high levels of tTGA are associated with increased risk of total villous blunting. There was a weak, negative correlation between tTGG and focal villous blunting (r = 0.409, p = 0.009) showing thathigh levels of tTGG are associated with a greater risk of focal villous blunting (p < 0.01) while tTGG and total villous blunting was a weak negative correlation (r = -0.330, p = 0.03) showing that high levels of tTGG are associated with lower risk of total villous blunting. Conclusion The study concludes by providing evidence of the absence of tissue transglutaminase antibodies in patients with histology-proven celiac disease. It implies that serology tests may be negative in some of the patients with typical chronic symptoms. Therefore, in such cases, histopathology may be conclusive in defining the status of celiac disease.

Association of clinical features of typhoid fever with socioeconomic status in Pakistan.

BACKGROUND: Typhoid fever is spread by ingestion of contaminated food or water, which is linked to infrastructure; specifically, sewage and sanitation. In developing countries, infrastructure varies according to socioeconomic status (SES). Balochistan is the least developed province of Pakistan. AIMS: To analyse the association between the clinical features of typhoid fever and socioeconomic status. METHODS: A quantitative, cross-sectional study was conducted in Quetta, Balochistan, Pakistan. Between May and October 2017, 143 patients presented to tertiary care hospitals and private clinics with a complaint of fever lasting ~3 days, along with a clinical history of headache, malaise, diarrhoea or constipation, abdominal pain, dry cough, and anorexia. All patients had a positive blood culture for Salmonella enterica serotype Typhi. Eighteen patients dropped out of the study, leaving 125. RESULTS: Seventy (56%) participants had low socioeconomic status (SES), 40 (32%) middle SES and 15 (12%) high SES. The strongest predictors of presenting with typhoid fever were patients' clinical condition when presenting to health facilities, followed by SES. Most respondents had a treatment duration of 1-2 weeks. SES had a high impact on source of drinking water supply. CONCLUSION: The strongest predictor of reporting typhoid fever was the current clinical condition of the patients, followed closely by SES. The incidence of typhoid fever in the low SES patients was almost the same as in the middle and high SES patients. Patients with low SES were more susceptible to contracting typhoid fever due to poor health status and facilities.