Radiotherapy resources in Africa: an International Atomic Energy Agency update and analysis of projected needs.

The number of patients with cancer in Africa has been predicted to increase from 844 279 in 2012 to more than 1·5 million in 2030. However, many countries in Africa still lack access to radiotherapy as a part of comprehensive cancer care. The objective of this analysis is to present an updated overview of radiotherapy resources in Africa and to analyse the gaps and needs of the continent for 2030 in the context of the UN Sustainable Development Goals. Data from 54 African countries on teletherapy megavoltage units and brachytherapy afterloaders were extracted from the Directory for Radiotherapy Centres, an electronic, centralised, and continuously updated database of radiotherapy centres. Cancer incidence and future predictions were taken from the GLOBOCAN 2018 database of the International Agency for Research on Cancer. Radiotherapy need was estimated using a 64% radiotherapy utilisation rate, while assuming a machine throughput of 500 patients per year. As of March, 2020, 28 (52%) of 54 countries had access to external beam radiotherapy, 21 (39%) had brachytherapy capacity, and no country had a capacity that matched the estimated treatment need. Median income was an important predictor of the availability of megavoltage machines: US$1883 (IQR 914-3269) in countries without any machines versus $4485 (3079-12480) in countries with at least one megavoltage machine (p=0·0003). If radiotherapy expansion continues at the rate observed over the past 7 years, it is unlikely that the continent will meet its radiotherapy needs. This access gap might impact the ability to achieve the Sustainable Development Goals, particularly the target to reduce preventable, premature mortality by a third, and meet the target of the cervical cancer elimination strategy of 90% with access to treatment. Urgent, novel initiatives in financing and human capacity building are needed to change the trajectory and provide comprehensive cancer care to patients in Africa in the next decade.

Pulmonary Embolism Response Team utilization during the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) may predispose patients to venous thromboembolism (VTE). Limited data are available on the utilization of the Pulmonary Embolism Response Team (PERT) in the setting of the COVID-19 global pandemic. We performed a single-center study to evaluate treatment, mortality, and bleeding outcomes in patients who received PERT consultations in March and April 2020, compared to historical controls from the same period in 2019. Clinical data were abstracted from the electronic medical record. The primary study endpoints were inpatient mortality and GUSTO moderate-to-severe bleeding. The frequency of PERT utilization was nearly threefold higher during March and April 2020 (n = 74) compared to the same period in 2019 (n = 26). During the COVID-19 pandemic, there was significantly less PERT-guided invasive treatment (5.5% vs 23.1%, p = 0.02) with a numerical but not statistically significant trend toward an increase in the use of systemic fibrinolytic therapy (13.5% vs 3.9%, p = 0.3). There were nonsignificant trends toward higher in-hospital mortality or moderate-to-severe bleeding in patients receiving PERT consultations during the COVID-19 period compared to historical controls (mortality 14.9% vs 3.9%, p = 0.18 and moderate-to-severe bleeding 35.1% vs 19.2%, p = 0.13). In conclusion, PERT utilization was nearly threefold higher during the COVID-19 pandemic than during the historical control period. Among patients evaluated by PERT, in-hospital mortality or moderate-to-severe bleeding were not significantly different, despite being numerically higher, while invasive therapy was utilized less frequently during the COVID-19 pandemic.

Public health consequences after ten years of the Syrian crisis: a literature review.

Ten years of the Syrian war had a devastating effect on Syrian lives, including millions of refugees and displaced people, enormous destruction in the infrastructure, and the worst economic crisis Syria has ever faced. The health sector was hit hard by this war, up to 50% of the health facilities have been destroyed and up to 70% of the healthcare providers fled the country seeking safety, which increased the workload and mental pressure for the remaining medical staff. Five databases were searched and 438 articles were included according to the inclusion criteria, the articles were divided into categories according to the topic of the article.Through this review, the current health status of the Syrian population living inside Syria, whether under governmental or opposition control, was reviewed, and also, the health status of the Syrian refugees was examined according to each host country. Public health indicators were used to summarize and categorize the information. This research reviewed mental health, children and maternal health, oral health, non-communicable diseases, infectious diseases, occupational health, and the effect of the COVID - 19 pandemic on the Syrian healthcare system. The results of the review are irritating, as still after ten years of war and millions of refugees there is an enormous need for healthcare services, and international organization has failed to respond to those needs. The review ended with the current and future challenges facing the healthcare system, and suggestions about rebuilding the healthcare system.Through this review, the major consequences of the Syrian war on the health of the Syrian population have been reviewed and highlighted. Considerable challenges will face the future of health in Syria which require the collaboration of the health authorities to respond to the growing needs of the Syrian population. This article draws an overview about how the Syrian war affected health sector for Syrian population inside and outside Syria after ten years of war which makes it an important reference for future researchers to get the main highlight of the health sector during the Syrian crisis.

Shifting attention to an undervalued asset; the emergency department technician.

US emergency departments are facing a number of operational challenges related to chronic shortages of registered nurses. Many of the tasks done by registered nurses can be safely and successfully delegated to the emergency department technician (EDT), particularly if a hospital's nursing and administrative leadership are affirmatively engaged in a process to professionalize and train their EDT workforce. This paper examines the state, Joint Commission on Accreditation of Healthcare Organizations, and Centers for Medicare & Medicaid Services regulatory landscape for the EDT, reviews the literature on how hospital's utilize EDT's, discusses approaches to skills training, and examines the need for profession standardization that enables job role expansion.

Healthcare Utilization for Stroke Patients at the End of Life: Nationally Representative Data.

Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.

Healthcare factors associated with the risk of antepartum and intrapartum stillbirth in migrants in Western Australia (2005-2013): A retrospective cohort study.

BACKGROUND: Migrant women, especially from Indian and African ethnicity, have a higher risk of stillbirth than native-born populations in high-income countries. Differential access or timing of ANC and the uptake of other services may play a role. We investigated the pattern of healthcare utilisation among migrant women and its relationship with the risk of stillbirth (SB)-antepartum stillbirth (AnteSB) and intrapartum stillbirth (IntraSB)-in Western Australia (WA). METHODS AND FINDINGS: A retrospective cohort study using de-identified linked data from perinatal, birth, death, hospital, and birth defects registrations through the WA Data Linkage System was undertaken. All (N = 260,997) non-Indigenous births (2005-2013) were included. Logistic regression analysis was used to estimate odds ratios and 95% CI for AnteSB and IntraSB comparing migrant women from white, Asian, Indian, African, Maori, and 'other' ethnicities with Australian-born women controlling for risk factors and potential healthcare-related covariates. Of all the births, 66.1% were to Australian-born and 33.9% to migrant women. The mean age (years) was 29.5 among the Australian-born and 30.5 among the migrant mothers. For parity, 42.3% of Australian-born women, 58.2% of Indian women, and 29.3% of African women were nulliparous. Only 5.3% of Maori and 9.2% of African migrants had private health insurance in contrast to 43.1% of Australian-born women. Among Australian-born women, 14% had smoked in pregnancy whereas only 0.7% and 1.9% of migrants from Indian and African backgrounds, respectively, had smoked in pregnancy. The odds of AnteSB was elevated in African (odds ratio [OR] 2.22, 95% CI 1.48-2.13, P < 0.001), Indian (OR 1.64, 95% CI 1.13-2.44, P = 0.013), and other women (OR 1.46, 95% CI 1.07-1.97, P = 0.016) whereas IntraSB was higher in African (OR 5.24, 95% CI 3.22-8.54, P < 0.001) and 'other' women (OR 2.18, 95% CI 1.35-3.54, P = 0.002) compared with Australian-born women. When migrants were stratified by timing of first antenatal visit, the odds of AnteSB was exclusively increased in those who commenced ANC later than 14 weeks gestation in women from Indian (OR 2.16, 95% CI 1.18-3.95, P = 0.013), Maori (OR 3.03, 95% CI 1.43-6.45, P = 0.004), and 'other' (OR 2.19, 95% CI 1.34-3.58, P = 0.002) ethnicities. With midwife-only intrapartum care, the odds of IntraSB for viable births in African and 'other' migrants (combined) were more than 3 times that of Australian-born women (OR 3.43, 95% CI 1.28-9.19, P = 0.014); however, with multidisciplinary intrapartum care, the odds were similar to that of Australian-born group (OR 1.34, 95% CI 0.30-5.98, P = 0.695). Compared with Australian-born women, migrant women who utilised interpreter services had a lower risk of SB (OR 0.51, 95% CI 0.27-0.96, P = 0.035); those who did not utilise interpreters had a higher risk of SB (OR 1.20, 95% CI 1.07-1.35, P < 0.001). Covariates partially available in the data set comprised the main limitation of the study. CONCLUSION: Late commencement of ANC, underutilisation of interpreter services, and midwife-only intrapartum care are associated with increased risk of SB in migrant women. Education to improve early engagement with ANC, better uptake of interpreter services, and the provision of multidisciplinary-team intrapartum care to women specifically from African and 'other' backgrounds may reduce the risk of SB in migrants.

Paediatric emergency department utilisation rates and maternal migration status in the Born in Bradford cohort: A cross-sectional study.

BACKGROUND: Globally, international migration is increasing. Population growth, along with other demographic changes, may be expected to put new pressures on healthcare systems. Some studies across Europe suggest that emergency departments (EDs) are used more, and differently, by migrants compared to non-migrant populations, which may be a result of unfamiliarity with the healthcare systems and difficulties accessing primary healthcare. However, little evidence exists to understand how migrant parents, who are typically young and of childbearing age, utilise EDs for their children. This study aimed to examine the association between paediatric ED utilisation in the first 5 years of life and maternal migration status in the Born in Bradford (BiB) cohort study. METHODS AND FINDINGS: We analysed linked data from the BiB study-an ongoing, multi-ethnic prospective birth cohort study in Bradford. Bradford is a large, ethnically diverse city in the north of England. In 2017, more than a third of births in Bradford were to mothers who were born outside the UK. Between March 2007 and December 2010, pregnant women were recruited to BiB during routine antenatal care, and the children born to these mothers have been, and continue to be, followed over time to assess how social, genetic, environmental, and behavioural factors impact on health from childhood to adulthood. Data analysed in this study included baseline questionnaire data from BiB mothers, and Bradford Royal Infirmary ED episode data for their children. Main outcomes were likelihood of paediatric ED use (no visits versus at least 1 ED visit in the first 5 years of life) and ED utilisation rates (number and frequency of ED visits) for children who have accessed the ED. The main explanatory variable was mother's migrant status (foreign-born versus UK/Irish-born). Multivariable analyses (logistic and zero-truncated negative binomial regression) were conducted adjusting for socio-demographic and socio-economic factors. The final dataset included 10,168 children born between April 2007 and June 2011, of whom 35.6% were born to migrant mothers. Foreign-born mothers originated from South Asia (28.6%), Europe/Central Asia (3.2%), Africa (2.1%), East Asia/Pacific (1.1%), and the Middle East (0.6%). At recruitment the mothers ranged in age from 15 to 49 years old. Overall, 3,104 (30.5%) children had at least 1 ED visit in the first 5 years of life, with the highest proportion of visits being in the first year of life (36.7%). The proportion of children who visited the ED at least once was lower for children of migrant mothers as compared to children of non-migrant mothers (29.4% versus 31.2%). Children of migrant mothers were found to be less likely to visit the ED (odds ratio 0.88 [95% CI 0.80 to 0.97], p = 0.012). However, among children who visited the ED, the utilisation rate was significantly higher for children of migrant mothers (incidence rate ratio [IRR] 1.19 [95% CI 1.01 to 1.40], p = 0.040). Utilisation rates were higher for children born to mothers from Europe (IRR 1.71 [95% CI 1.07 to 2.71], p = 0.024) and established migrants (≥5 years living in UK) (IRR 1.24 [95% CI 1.02 to 1.51], p = 0.032) compared to UK/Irish-born mothers. Important limitations include being unable to measure children's underlying health status and the urgency of ED attendance, as well as the analysis being limited by missing data. CONCLUSIONS: In this study we observed that there is no higher likelihood of first paediatric ED attendance in the first 5 years of life for children in the BiB cohort for migrant mothers. However, among ED users, children of migrant mothers attend the service more frequently than children of UK/Irish-born mothers. Our findings show that patterns of ED utilisation differ by mother's region of origin and time since arrival in the UK.

An international multicenter study of protocols for liver transplantation during a pandemic: A case for quadripartite equipoise.

BACKGROUND & AIMS: The outbreak of COVID-19 has vastly increased the operational burden on healthcare systems worldwide. For patients with end-stage liver failure, liver transplantation is the only option. However, the strain on intensive care facilities caused by the pandemic is a major concern. There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources. METHODS: We performed an international multicenter study of transplant centers to understand the evolution of policies for transplant prioritization in response to the pandemic in March 2020. To describe the ethical tension arising in this setting, we propose a novel ethical framework, the quadripartite equipoise (QE) score, that is applicable to liver transplantation in the context of limited national resources. RESULTS: Seventeen large- and medium-sized liver transplant centers from 12 countries across 4 continents participated. Ten centers opted to limit transplant activity in response to the pandemic, favoring a "sickest-first" approach. Conversely, some larger centers opted to continue routine transplant activity in order to balance waiting list mortality. To model these and other ethical tensions, we computed a QE score using 4 factors - recipient outcome, donor/graft safety, waiting list mortality and healthcare resources - for 7 countries. The fluctuation of the QE score over time accurately reflects the dynamic changes in the ethical tensions surrounding transplant activity in a pandemic. CONCLUSIONS: This four-dimensional model of quadripartite equipoise addresses the ethical tensions in the current pandemic. It serves as a universally applicable framework to guide regulation of transplant activity in response to the increasing burden on healthcare systems. LAY SUMMARY: There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources during the COVID-19 pandemic. We describe a four-dimensional model of quadripartite equipoise that models these ethical tensions and can guide the regulation of transplant activity in response to the increasing burden on healthcare systems.

Addressing budget reduction and reallocation on health-related resources during COVID-19 pandemic in malaria-endemic countries.

The global COVID-19 pandemic has been affecting the maintenance of various disease control programmes, including malaria. In some malaria-endemic countries, funding and personnel reallocations were executed from malaria control programmes to support COVID-19 response efforts, resulting mainly in interruptions of disease control activities and reduced capabilities of health system. While it is principal to drive national budget rearrangements during the pandemic, the long-standing malaria control programmes should not be left behind in order to sustain the achievements from the previous years. With different levels of intensity, many countries have been struggling to improve the health system resilience and to mitigate the unavoidable stagnation of malaria control programmes. Current opinion emphasized the impacts of budget reprioritization on malaria-related resources during COVID-19 pandemic in malaria endemic countries in Africa and Southeast Asia, and feasible attempts that can be taken to lessen these impacts.

Impact of oral anticoagulation choice on healthcare utilization for the primary treatment of venous thromboembolism.

Little is known about the impact of oral anticoagulation (OAC) choice on healthcare encounters during venous thromboembolism (VTE) primary treatment. Among anticoagulant-naïve patients with VTE, we tested the hypotheses that healthcare utilization would be lower among users of direct OACs (DOACs; rivaroxaban or apixaban) than among users of warfarin. MarketScan databases for years 2016 and 2017 were used; healthcare utilization was identified in the first 6 months after initial VTE diagnoses. The 23,864 patients with VTE had on average 0.2 ± 0.5 hospitalizations, spent 1.3 ± 5.2 days in the hospital, had 5.7 ± 5.1 outpatient encounters, and visited an emergency department 0.4 ± 1.1 times. As compared to warfarin, rivaroxaban and apixaban were associated with fewer hospitalizations, days hospitalized, outpatient office visits, and emergency department visits after accounting for age, sex, comorbidities, and medications. Hospitalization rates were 24% lower (incidence rate ratio (IRR): 0.76; 95% CI: 0.69, 0.83) with rivaroxaban and 22% lower (IRR: 0.78; 95% CI: 0.71, 0.87) with apixaban, as compared to warfarin (IRR: 1.00 (reference)). Healthcare utilization was similar between apixaban and rivaroxaban users. Patients with VTE prescribed rivaroxaban and apixaban had lower healthcare utilization than those prescribed warfarin, while there was no difference when comparing apixaban to rivaroxaban. These findings complement existing literature supporting the use of DOACs over warfarin.

Functional neurological disorder: Characteristics and outcome in a limited-resources country (Sudan).

BACKGROUND: There is a scarcity of reports from limited-resources countries on functional neurological disorder (FND). We therefore carried out this descriptive study from Sudan to highlight the clinical characteristics of patients and the cultural, diagnostic, and management outcome. METHOD: Of 1000 new referrals and patients seen at a central neuropsychiatric clinic in Khartoum, Sudan, 40 fulfilled the criteria for FND. Subjects were diagnosed by excluding organic illness and confirming psychological distress through neuropsychological assessment and clinical interview. Mood was measured using the Beck Depression Inventory (BDI) and Hospital Anxiety and Depression (HAD) scales. RESULTS: Young unemployed women constituted 60% of our sample. Most subjects presented with psychogenic nonepileptic seizures (82.5%), speech abnormalities (47.5%), and limb paralysis or weakness was (35%). Associated mood disorder was found in 97.5% of all subjects. However, 95% of our sample showed a remarkable clinical response to combination therapy (antidepressants and psychotherapy). SIGNIFICANCE: Patients with FND showed strong evidence of comorbid affective disorders in the form of depression and anxiety disorder. Most patients (95%) responded well to combination therapy with antidepressants and psychotherapy. Sociodemographic correlates of FND in Sudan prove to be consistent with features found in Western cultures, with only minor idiosyncratic characteristics due to local culture.

Time Trends in Healthcare Utilization Due to Self-Reported Functional Diseases of the Stomach.

INTRODUCTION: Cohort studies from referral centers suggest an increasing burden of functional gastric disorders, with frequent emergency room (ER) visits, hospitalizations, or absenteeism. We hypothesized that recruitment from tertiary care sites skews results and thus investigated the burden of these illnesses, using the population-based data of the Medical Expenditure Panel Survey (MEPS). METHODS: Using MEPS data for the years 2000-2015, demographic, economic, healthcare-related, and quality-of-life indicators were extracted for adults reporting the diagnosis of functional gastric diseases to assess trends and to compare results with data from all adults surveyed. RESULTS: Between 2000 and 2015, 2.7 ± 0.2% of the adults surveyed reported a functional gastric illness. Within the period studied, 28.8 ± 2.8% and 17.9 ± 1.6% of this cohort reported ER visits or hospitalizations, respectively. Only a fraction of these persons attributed the ER visits (22.6 ± 0.9%) or admissions (10.9 ± 0.8%) to the functional gastric disorder. Rates remained stable rates during the period studied. Female sex, measures of physical function, comorbidities, and an income below the poverty line were predictors of healthcare utilization. While utilization was stable over time, annual costs increased by 113.9 ± 16.6% during the study period, outpacing the inflation rate of 37.6%. CONCLUSIONS: Persons with functional gastric disorders have significant healthcare needs and face increasing costs of care, largely due to coexisting illnesses. While it is important to recognize this impact, the need for emergency care or hospitalizations remained stable and lower than reported for patients seen in tertiary referral centers, providing reassuring information for patients and providers.

Healthcare resource utilization and costs of nonalcoholic steatohepatitis patients with advanced liver disease in Italy.

BACKGROUND AND AIMS: Nonalcoholic steatohepatitis (NASH) may progress to advanced liver disease (AdvLD). This study characterized comorbidities, healthcare resource utilization (HCRU) and associated costs among hospitalized patients with AdvLD due to NASH in Italy. METHODS AND RESULTS: Adult nonalcoholic fatty liver disease (NAFLD)/NASH patients from 2011 to 2017 were identified from administrative databases of Italian local health units using ICD-9-CM codes. Development of compensated cirrhosis (CC), decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC), or liver transplant (LT) was identified using first diagnosis date for each severity cohort (index-date). Patients progressing to multiple disease stages were included in >1 cohort. Patients were followed from index-date until the earliest of disease progression, end of coverage, death, or end of study. Within each cohort, per member per month values were annualized to calculate all-cause HCRU or costs(€) in 2017. Of the 9,729 hospitalized NAFLD/NASH patients identified, 97% were without AdvLD, 1.3% had CC, 3.1% DCC, 0.8% HCC, 0.1% LT. Comorbidity burden was high across all cohorts. Mean annual number of inpatient services was greater in patients with AdvLD than without AdvLD. Similar trends were observed in outpatient visits and pharmacy fills. Mean total annual costs increased with disease severity, driven primarily by inpatient services costs. CONCLUSION: NAFLD/NASH patients in Italy have high comorbidity burden. AdvLD patients had significantly higher costs. The higher prevalence of DCC compared to CC in this population may suggest challenges of effectively screening and identifying NAFLD/NASH patients. Early identification and effective management are needed to reduce risk of disease progression and subsequent HCRU and costs.

Changes in the number of suicide re-attempts in a French region since the inception of VigilanS, a regionwide program combining brief contact interventions (BCI).

BACKGROUND: Brief Contact Interventions (BCIs) after a suicide attempt (SA) are an important element of prevention against SA and suicide. They are easier to generalize to an entire population than other forms of intervention. VigilanS generalizes to a whole French region a BCI combining resource cards, telephone calls and mailings, according to a predefined algorithm. It was implemented gradually in the Nord-Pas-de-Calais (NPC), France, between 2015 and 2018. Here, we evaluate the effectiveness of VigilanS, in terms of SA reduction, using annual data collected by participating centers. Hypothesis tested: the higher the VigilanS implementation in a center (measured by penetrance), the greater the decrease in the number of SA observed in this center. METHODS: The study period was from 2014 to 2018, across all of NPC centers. We performed a series of linear regressions, each center representing a statistical unit. The outcome was the change in the number of SA, relative to the initial number, and the predictive variable was VigilanS' penetrance: number of patients included in VigilanS over the total number of SA. Search for influential points (points beyond threshold values of 3 influence criteria) and weighted least squares estimations were performed. RESULTS: Twenty-one centers were running VigilanS in 2018, with an average penetrance of 32%. A significant relationship was identified, showing a sharp decrease in SA as a function of penetrance (slope = - 1.13; p = 3*10- 5). The model suggested that a 25% of penetrance would yield a SA decrease of 41%. CONCLUSION: VigilanS has the potential to reduce SA. Subgroup analyzes are needed to further evaluate its effectiveness. Subgroup analyses remain to be done, in order to evaluate the specific variations of SA by group.

Advancing successful implementation of task-shifted mental health care in low-resource settings (BASIC): protocol for a stepped wedge cluster randomized trial.

BACKGROUND: The mental health treatment gap-the difference between those with mental health need and those who receive treatment-is high in low- and middle-income countries. Task-shifting has been used to address the shortage of mental health professionals, with a growing body of research demonstrating the effectiveness of mental health interventions delivered through task-shifting. However, very little research has focused on how to embed, support, and sustain task-shifting in government-funded systems with potential for scale up. The goal of the Building and Sustaining Interventions for Children (BASIC) study is to examine implementation policies and practices that predict adoption, fidelity, and sustainment of a mental health intervention in the education sector via teacher delivery and the health sector via community health volunteer delivery. METHODS: BASIC is a Hybrid Type II Implementation-Effectiveness trial. The study design is a stepped wedge, cluster randomized trial involving 7 sequences of 40 schools and 40 communities surrounding the schools. Enrollment consists of 120 teachers, 120 community health volunteers, up to 80 site leaders, and up to 1280 youth and one of their primary guardians. The evidence-based mental health intervention is a locally adapted version of Trauma-focused Cognitive Behavioral Therapy, called Pamoja Tunaweza. Lay counselors are trained and supervised in Pamoja Tunaweza by local trainers who are experienced in delivering the intervention and who participated in a Train-the-Trainer model of skills transfer. After the first sequence completes implementation, in-depth interviews are conducted with initial implementing sites' counselors and leaders. Findings are used to inform delivery of implementation facilitation for subsequent sequences' sites. We use a mixed methods approach including qualitative comparative analysis to identify necessary and sufficient implementation policies and practices that predict 3 implementation outcomes of interest: adoption, fidelity, and sustainment. We also examine child mental health outcomes and cost of the intervention in both the education and health sectors. DISCUSSION: The BASIC study will provide knowledge about how implementation of task-shifted mental health care can be supported in government systems that already serve children and adolescents. Knowledge about implementation policies and practices from BASIC can advance the science of implementation in low-resource contexts. TRIAL REGISTRATION: Trial Registration: ClinicalTrials.gov Identifier: NCT03243396. Registered 9th August 2017, https://clinicaltrials.gov/ct2/show/NCT03243396.

Women and substance use disorders in low- and middle-income countries: A call for advancing research equity in prevention and treatment.

Although the prevalence of substance use disorders (SUDs) is higher among men, women with SUDs in low- and middle-income countries (LMICs) face unique challenges. Poverty and adversity, inequality of women, and disparities in access to treatment and prevention services exacerbate biological, psychological and social correlates of substance use disorders for women living in low-resource settings. Increasing the inclusion of women in research has long been a goal, though even high income countries struggle to achieve parity. In LMICs, women with SUDs are often neglected from global research due to underreporting and the disproportionate focus of global substance use research on men. We will discuss risk factors for SUDs that are particularly relevant for women residing in LMICs in order to gain insight into neglected areas of research and opportunities for prevention and treatment.

Distributing Local Resources for Public Health Preparedness Grants: A Data-Driven Approach.

OBJECTIVES: To simulate allocations of Public Health Emergency Preparedness funds to counties using alternative metrics of need, minimum allocation amounts, and the proportion earmarked for discretionary considerations. DESIGN: We developed a county-level community resilience index of 57 New York State counties using publicly available indicators, which we incorporated into an interactive spreadsheet of 8 hypothetical allocation formulas with different combinations of population size, the index and its 5 domains, and population density. Simulations were compared with the 2013-2014 fiscal year grant allocation. RESULTS: New York allocated $6.27 million to counties outside New York City, with a median allocation of $78 038, ranging from $50 825 to $556 789. These allocations would vary under different strategies, with the largest changes among sparsely populated counties that currently receive a minimum allocation of $50 825. Allocations were sensitive to changes in minimum allocation, amount earmarked for discretionary allocation, and need indicator. CONCLUSIONS: Population-based approaches are commonly used but ignore important dimensions of need. It is feasible to include robust local community resilience measures in formulas, and interactive spreadsheet models can help stakeholders evaluate the consequences of alternative funding strategies.

How to keep up to date with medical information using web-based resources: a systematised review and narrative synthesis.

BACKGROUND: Keeping up to date with the latest medical information using Web-based resources has been sparsely described, and a comprehensive up-to-date review is needed. OBJECTIVES: To summarise the Web-based 'channels' that may assist the actors of the health care system (clinicians, medical researchers and students) to keep up to date with medical information. METHODS: We searched PubMed and Scopus for English language articles published between January 1990 and February 2019 that investigated ways for keeping up with medical information. We used the results from our search and relevant information from other sources to conduct a narrative synthesis. RESULTS: We found that resources that push information (e.g. web alerts, medical newsletters, listservs), resources that rely on the active information seeking (e.g. access to health librarians and electronic databases, podcasts, mobile apps), collaborative resources (e.g. web conferences, online journal clubs, web social media) and resources that synthesise information (e.g. bibliometrics, living systematic reviews) can contribute in keeping up with new findings and can enhance evidence-based medicine. Clinicians, medical researchers and students can benefit from the proper use of such Internet-based technological innovations. CONCLUSION: Internet provides many resources that can help the actors of the health care system stay up to date with the latest scientific findings.

Providing Ethical Healthcare in Resource-Poor Environments.

The ethics of providing health care in resource-poor environments is a complex topic. It implies two related questions: What can we do with the resources on hand? Of all the things we can do, which ones should we do? "Resource-poor" (i.e., resource-challenged, resource-constrained) environments are situations in which clinicians, organizations, or healthcare systems have the knowledge and skills, but not the means, to carry out highly effective and beneficial interventions. Determinants of a population's health often rely less on disease and injury management than on recognizing and meeting their basic needs. Many of the world's people with the greatest health problems live in fragile contexts and remote areas. Their access to food, safe water, personal safety, improved sanitation facilities, and health care remains elusive, with availability often based on socioeconomic status, gender, ethnicity, or geography. Of course, ethical international healthcare work also requires an understanding of the illnesses and injuries that most frequently plague the population. To function ethically and to know both what can and what should be done with available resources, individuals and organizations involved in international healthcare must be experienced, adaptable, culturally sensitive, inspired, situationally aware, beneficent, courageous, honest, and fair.

Mortality, Resource Utilization, and Inpatient Costs Vary Among Pediatric Heart Transplant Indications: A Merged Data Set Analysis From the United Network for Organ Sharing and Pediatric Health Information Systems Databases.

BACKGROUND: Merging United Network for Organ Sharing (UNOS) and Pediatric Health Information Systems databases has enabled a more granular analysis of pediatric heart transplant outcomes and resource utilization. We evaluated whether transplant indication at time of transplantation was associated with mortality, resource utilization, and inpatient costs during the first year after transplantation. METHODS AND RESULTS: We analyzed transplant outcomes and resource utilization from 2004 to 2015. Patients were categorized as congenital (CHD), myocarditis, or cardiomyopathy based on UNOS-defined primary indication. CHD complexity subgroup analyses (single-ventricle, complex, and simple biventricular CHD) were also performed. Of 2251 transplants (49% CHD, 5% myocarditis, 46% cardiomyopathy), CHD recipients were younger (2 [IQR 0-10], 6 [IQR 0-12], and 7 [IQR 1-14] years, respectively; P < .001) and less likely to have a ventricular assist device (VAD) at transplantation (3%, 27%, and 13%, respectively; P < .001). Patients with single-ventricle CHD had the longest time on the waitlist and were least likely to receive a VAD before transplantation. After adjusting for patient-level factors, transplant recipients with single-ventricle CHD had the greatest mortality during transplantation admission and within 1 year (odds ratio [OR] 11.8 [95% confidence interval (CI) 5.9-23.6] and OR 6.0 [95% CI 3.6-10.2], respectively, vs cardiomyopathy). Mortality was similar between patients with myocarditis and cardiomyopathy. Post-transplantation length of stay (LOS) was longer in transplant recipients with CHD than myocarditis or cardiomyopathy (25 [interquartile range [IQR] 15-45] vs 21 [IQR 12-35] vs 16 [IQR 12-25] days; P < .001), related in part to longer duration of intensive care unit-level care (ICU LOS 8 [IQR 4-20] vs 6 [IQR 4-13] vs 5 [IQR 3-8] days; P < .001). Similarly, patients with CHD had higher median post-transplantation costs than myocarditis or cardiomyopathy ($415K [IQR $201K-503K] vs $354K [IQR $179K-390K] vs $284K [IQR $145K-319K]; P < .001) that persisted after adjusting for patient-level factors (adjusted cost ratio 1.4 [95% CI 1.4-1.5], CHD vs cardiomyopathy) and was primarily driven by longer LOS. More than 50% were readmitted during the first year after transplantation, although readmission rates were similar across transplant indications (P = .42). CONCLUSIONS: Children with CHD, particularly single-ventricle patients, require substantially greater hospital resource utilization and have significantly worse outcomes during the first year after heart transplantation compared with other indications. Further work is aimed at identifying modifiable pre-transplantation risk factors, such as pre-transplantation conditioning with VAD support and cardiac rehabilitation, to improve post-transplantation outcomes and reduce resource utilization in this complex population.