Assessing the implementation of a multi-component hypertension program in a Guatemalan under-resourced dynamic context: an application of the RE-AIM/PRISM extension for sustainability and health equity.

BACKGROUND: The COVID-19 pandemic necessitated rapid changes in healthcare delivery in Guatemala's public primary care settings. A new hypertension program, implemented as part of a type 2 hybrid trial since 2019, exemplifies an implementation effort amidst a changing context in an under-resourced setting. We assessed the implementation of an evidence-based intervention (EBI; protocol-based hypertension treatment) and one of its main implementation strategies (team-based collaborative care), raising implications for health equity and sustainability. We present innovative application of systems thinking visuals. METHODS: Conducting a convergent mixed methods analysis, we assessed implementation in response to contextual changes across five Ministry of Health (MoH) districts at the pandemic's onset. Utilizing quantitative programmatic data and qualitative interviews with stakeholders (n=18; health providers, administrators, study staff), we evaluated dimensions of "Reach, Effectiveness, Adoption, Implementation and Maintenance," RE-AIM (Reach, Implementation delivery + adaptations), and "Practical Robust Implementation and Sustainability Model," PRISM (Organizational perspective on the EBI, Fit, Implementation and sustainability infrastructure) frameworks. We assessed representativeness by comparing participants to census data. To assess implementation delivery, we built behavior-over-time (BOT) graphs with quantitative programmatic data (July 2019-July 2021). To assess adaptations and contextual changes, we performed matrix-based thematic qualitative analysis. We converged quantitative implementation delivery data + qualitative adaptations data in joint displays. Finally, we analyzed qualitative and quantitative results across RE-AIM/PRISM and health districts to identify equity and sustainability considerations. RESULTS: Contextual factors that facilitated program delivery included the perception that the EBI was beneficial, program champions, and staff communication. Key barriers to implementation delivery included competition with other primary care activities and limited implementation infrastructure (e.g., equipment, medications). Contextual changes related to COVID-19 hindered implementation delivery, threatened sustainability, and may have exacerbated inequities. However, adaptations that were planned enhanced implementation delivery and may have supported improved equity and sustainability. CONCLUSIONS: Recognition of an EBI's benefits and program champions are important for supporting initial uptake. The ability to plan adaptations amid rapid contextual changes has potential advantages for sustainability and equitable delivery. Systems thinking tools and mixed methods approaches may shed light on the relations between context, adaptations, and equitable and sustainable implementation. TRIAL REGISTRATION: NCT03504124.

Aligning the planning, development, and implementation of complex interventions to local contexts with an equity focus: application of the PRISM/RE-AIM Framework.

For the fields of implementation science and health equity, understanding and being responsive to local contexts is of utmost importance to better inform the development, implementation, and evaluation of healthcare and public health interventions to increase their uptake and sustainment. Contexts are multi-level and include political, historical, economic, and social factors that influence health, as well as organizational characteristics, reflecting the richness of members' views, resources, values, and needs. Poor alignment between solutions and those contextual characteristics could have an impact on inequities. The PRISM (Practical Robust Implementation and Sustainability Model) is a context-based implementation science framework that incorporates RE-AIM outcomes (Reach, Effectiveness, Adoption, Implementation, Maintenance) and offers guidance to researchers, practitioners, and their patient and community partners on how to conceptualize, assess, and address contextual domains with a focus on health equity. Drawing from systems thinking, participatory engagement, and health equity principles, this commentary expands on previous work to 1) offer a novel perspective on how to align an intervention's core functions and forms with the PRISM's contextual domains, and 2) foster an ongoing and iterative engagement process with diverse partners throughout the research and practice process using a co-creation approach. We recommend intervention-to-context alignment through iterative cycles. To that end, we present the RE-AIM Framework's 'outcomes cascade' to illustrate touch points of opportunity and gaps within and across each of the five RE-AIM outcomes to illustrate 'where things go wrong'. We present a case study to illustrate and offer recommendations for research and practice efforts to increase contextual responsiveness, and enhance alignment with context before, during, and after implementation efforts and to ensure equity is being addressed. We strive to make a conceptual contribution to advance the field of pragmatic research and implementation of evidence-based practices through the application of the contextually-based PRISM framework with a focus on health equity.

Human Nephrogenesis can Persist Beyond 40 Postnatal Days in Preterm Infants.

Introduction: Human nephrogenesis is typically completed by 36 weeks gestation; however, it is impacted by preterm birth. Early studies suggested that nephrogenesis persisted for ≤40 postnatal days in preterm infants. However, the postmenstrual age (PMA) of the preterm infants who survived >40 days was uncertain. In this study, we sought to reexamine postnatal kidney development in preterm infants surviving >40 days. Methods: Human kidney samples were obtained from an institutional biobank. Samples were considered controls if survival was ≤4 days after birth with PMA of 30 to ≤36 weeks. Kidneys from preterm neonates with postnatal survival >40 days and PMA of 30 to ≤36 weeks were compared to controls. We counted glomerular generations, measured nephrogenic zone widths (NZW), and performed immunofluorescence (IF) with SIX1 and RET. We compared kidney weights and quantified the cross-sectional area of proximal (lotus tetragonolobus lectin [LTL], SL22A2), distal (SLC12A3, KCNJ10), and glomerular (nephrin) markers using IF. Results: Seven preterm infants surviving >40 days and 8 controls were analyzed. Four of 7 preterm infants had histologic and molecular evidence of nephrogenesis. Cessation of nephrogenesis in preterm infants occurred 2 weeks earlier than PMA-matched controls with attenuated expression of both SIX1 and RET. We found increased kidney weight-to-body weight ratio, increased distal tubular cross-sectional staining in the superficial nephrons, and distal tubular hypertrophy and hyperplasia in the preterm infant kidneys. Conclusion: Our study supports that nephrogenesis in preterm infants persists longer than previously thought with evidence of early nephron stress, placing importance on the neonatal environment.

Impact of COVID-19 on diabetes care: mixed methods study in an Indigenous area of Guatemala.

INTRODUCTION: SARS-CoV-2 has impacted globally the care of chronic diseases. However, direct evidence from certain vulnerable communities, such as Indigenous communities in Latin America, is missing. We use observational data from a health district that primarily serves people of Maya K'iche' ethnicity to examine the care of type 2 diabetes in Guatemala during the pandemic. METHODS: We used a parallel convergent mixed methods design. Quantitative data (n=142 individuals with diabetes) included glycated haemoglobin (HbA1c), blood pressure, body mass index and questionnaires on diabetes knowledge, self-care and diabetes distress. Quantitative data was collected at two points, at baseline and after COVID restrictions were lifted. For quantitative outcomes, we constructed multilevel mixed effects models with multiple imputation for missing data. Qualitative data included interviews with providers, supervisors and individuals living with diabetes (n=20). We conducted thematic framework analysis using an inductive approach. RESULTS: Quantitative data was collected between June 2019 and February 2021, with a median of 487 days between data collection points. HbA1c worsened +0.54% (95% CI, 0.14 to 0.94) and knowledge about diabetes decreased -3.54 points (95% CI, -4.56 to -2.51). Qualitatively, the most important impact of the pandemic was interruption of the regular timing of home visits and peer group meetings which were the standard of care. CONCLUSIONS: The deterioration of diabetes care was primarily attributed to the loss of regular contact with healthcare workers. The results emphasize the vulnerability of rural and Indigenous populations in Latin America to the suspension of chronic disease care.

Caffeine and kidney function at two years in former extremely low gestational age neonates.

BACKGROUND: Extremely low gestational age neonates (ELGANs) are at risk for chronic kidney disease. The long-term kidney effects of neonatal caffeine are unknown. We hypothesize that prolonged caffeine exposure will improve kidney function at 22-26 months. METHODS: Secondary analysis of the Preterm Erythropoietin Neuroprotection Trial of neonates <28 weeks' gestation. Participants included if any kidney outcomes were collected at 22-26 months corrected age. Exposure was post-menstrual age of caffeine discontinuation. PRIMARY OUTCOMES: 'reduced eGFR' <90 ml/min/1.73 m2, 'albuminuria' (>30 mg albumin/g creatinine), or 'elevated blood pressure' (BP) >95th %tile. A general estimating equation logistic regression model stratified by bronchopulmonary dysplasia (BPD) status was used. RESULTS: 598 participants had at least one kidney metric at follow up. Within the whole cohort, postmenstrual age of caffeine discontinuation was not associated with any abnormal measures of kidney function at 2 years. In the stratified analysis, for each additional week of caffeine, the no BPD group had a 21% decreased adjusted odds of eGFR <90 ml/min/1.73m2 (aOR 0.78; CI 0.62-0.99) and the BPD group had a 15% increased adjusted odds of elevated BP (aOR 1.15; CI: 1.05-1.25). CONCLUSIONS: Longer caffeine exposure during the neonatal period is associated with differential kidney outcomes at 22-26 months dependent on BPD status. IMPACT: In participants born <28 weeks' gestation, discontinuation of caffeine at a later post menstrual age was not associated with abnormal kidney outcomes at 22-26 months corrected age. When assessed at 2 years of age, later discontinuation of caffeine in children born <28 weeks' gestation was associated with a greater risk of reduced eGFR in those without a history of BPD and an increased odds of hypertension in those with a history of BPD. More work is necessary to understand the long-term impact of caffeine on the developing kidney.

Operative and non-operative management for intestinal emergencies: findings from a single-centre retrospective cohort study.

BACKGROUND: Patients with an intestinal emergency who do not have surgery are poorly characterised. This study used electronic healthcare records to provide a rapid insight into the number of patients admitted with an intestinal emergency and compare short-term outcomes for non-operative and operative management. METHODS: A single-centre retrospective cohort study was conducted at a tertiary NHS hospital (from 1 December 2013 to 31 January 2020). Patients were identified using diagnosis codes for intestinal emergencies, based on the inclusion criteria for the National Emergency Laparotomy Audit. Relevant data were extracted from electronic healthcare records (n=3,997). RESULTS: Nearly half of patients admitted with an intestinal emergency received nonoperative management (43.7%). Of those who underwent surgery, 63.7% were started laparoscopically. The non-operative group had a shorter hospital stay (median: 5.4 days vs 8.2 days [started laparoscopically] or 16.8 days [started open]) and fewer unintended intensive care admissions than the surgical group (2.4% vs 8.7% [started laparoscopically] 21.1% [started open]). However, 30-day mortality for non-operative treatment was double that for surgery (22.4% vs 10.1%). The 30-day mortality rate was found to be even higher for non-operative management (50.3%) compared with surgery (19.5%) in a sub-analysis of patients with admission National Early Warning Score ≥4 (n=683). CONCLUSION: The proportion of patients with intestinal emergencies who do not have surgery is greater than expected, and it appears that many respond well to non-operative treatment. However, 30-day mortality for non-operative management was high, and the low number of admissions to intensive care suggests that major invasive treatment was not appropriate for most in this group.

Characterizing post-branching nephrogenesis in the neonatal rabbit.

Human nephrogenesis ends prior to birth in term infants (34-36 week gestation), with most (60%) nephrons forming in late gestation in two post-branching nephrogenesis (PBN) periods: arcading and lateral branch nephrogenesis. Preterm infants, however, must execute PBN postnatally. Extreme prematurity is associated with low nephron counts. Identifying additional model(s) that undergo PBN postnatally will help support postnatal PBN in preterm infants. The rabbit exhibits longer postnatal nephrogenesis than the mouse but whether it forms nephrons through PBN has not been determined. We performed morphologic and immunohistological assessments of rabbit nephrogenesis from birth (post-conceptual day 31 or 32) to PC49 using H&E and antibodies against SIX1, SIX2, WT1, ZO-1, and JAG1 in the postnatal period. We performed 3D rendering of the nephrogenic niche to assess for PBN, and supplemented the staining with RNAScope to map the expression of Six1, Six2 (nephron progenitors, NPC), and Ret (ureteric bud tip) transcripts to determine the nephrogenic niche postnatal lifespan. Unlike the mouse, rabbit SIX2 disappeared from NPC before SIX1, resembling the human niche. Active nephrogenesis as defined by the presence of SIX1 + naïve NPC/tip population persisted only until PC35-36 (3-5 postnatal days). 3D morphologic assessments of the cortical nephrons identified an elongated tubule with attached glomeruli extending below the UB tip, consistent with PBN arcades, but not with lateral branch nephrogenesis. We conclude that the rabbit shows morphologic and molecular evidence of PBN arcades continuing postnatally for a shorter period than previously thought. The rabbit is the first non-primate expressing SIX1 in the progenitor population. Our findings suggest that studies of arcading in postnatal nephrogenic niche should be performed within the first 5 days of life in the rabbit.

The iPRISM webtool: an interactive tool to pragmatically guide the iterative use of the Practical, Robust Implementation and Sustainability Model in public health and clinical settings.

BACKGROUND: To increase uptake of implementation science (IS) methods by researchers and implementers, many have called for ways to make it more accessible and intuitive. The purpose of this paper is to describe the iPRISM webtool (Iterative, Practical, Robust Implementation and Sustainability Model) and how this interactive tool operationalizes PRISM to assess and guide a program's (a) alignment with context, (b) progress on pragmatic outcomes, (c) potential adaptations, and (d) future sustainability across the stages of the implementation lifecycle. METHODS: We used an iterative human-centered design process to develop the iPRISM webtool. RESULTS: We conducted user-testing with 28 potential individual and team-based users who were English and Spanish speaking from diverse settings in various stages of implementing different types of programs. Users provided input on all aspects of the webtool including its purpose, content, assessment items, visual feedback displays, navigation, and potential application. Participants generally expressed interest in using the webtool and high likelihood of recommending it to others. The iPRISM webtool guides English and Spanish-speaking users through the process of iteratively applying PRISM across the lifecycle of a program to facilitate systematic assessment and alignment with context. The webtool summarizes assessment responses in graphical and tabular displays and then guides users to develop feasible and impactful adaptations and corresponding action plans. Equity considerations are integrated throughout. CONCLUSIONS: The iPRISM webtool can intuitively guide individuals and teams from diverse settings through the process of using IS methods to iteratively assess and adapt different types of programs to align with the context across the implementation lifecycle. Future research and application will continue to develop and evaluate this IS resource.

Global implementation research capacity building to address cardiovascular disease: An assessment of efforts in eight countries.

Cardiovascular diseases are the leading causes of morbidity and mortality worldwide, but implementation of evidence-based interventions for risk factors such as hypertension is lacking, particularly in low and middle income countries (LMICs). Building implementation research capacity in LMICs is required to overcome this gap. Members of the Global Research on Implementation and Translation Science (GRIT) Consortium have been collaborating in recent years to establish a research and training infrastructure in dissemination and implementation to improve hypertension care. GRIT includes projects in Ghana, Guatemala, India, Kenya, Malawi, Nepal, Rwanda, and Vietnam. We collected data from each site on capacity building activities using the Potter and Brough (2004) model, mapping formal and informal activities to develop (a) structures, systems and roles, (b) staff and infrastructure, (c) skills, and (d) tools. We captured information about sites' needs assessments and metrics plus program adaptations due to the COVID-19 pandemic. All sites reported capacity building activities in each layer of the Capacity Pyramid, with the largest number of activities in the Skills and Tools categories, the more technical and easier to implement categories. All sites included formal and informal training to build Skills. All sites included a baseline needs assessment to guide capacity building activities or assess context and inform intervention design. Sites implementing evidence-based hypertension interventions used common implementation science frameworks to evaluate implementation outcomes. Although the COVID-19 pandemic affected timelines and in-person events, all projects were able to pivot and carry out planned activities. Although variability in the activities and methods used existed, GRIT programs used needs assessments to guide locally appropriate design and implementation of capacity building activities. COVID-19 related changes were necessary, but strong collaborations and relationships with health ministries were maintained. The GRIT Consortium is a model for planning capacity building in LMICs.

Increasing use of systems science in cardiovascular disease prevention to understand how to address geographic health disparities in communities with a disproportionate burden of risk.

Objective: Marginalized communities shoulder a disproportionate burden of cardiovascular disease (CVD) driven by concentrated neighborhood social risk factors. We provide a case study of systems science application to address geographic CVD health disparities at the community level - informing the science of CVD health disparities research. Methods: We conducted a two-phased, multi-methods needs assessment in the Denver, Colorado area. Phase I consisted of a social network analysis to map a two-mode network of existing CVD prevention interventions and their implementing organizations. In Phase II, group model building (GMB) sessions with key community, public health, and healthcare provider stakeholders, were utilized to identify and visualize community factors contributing to disparities in CVD risk, producing a consensus-based causal loop diagram. Results: Between May 2021 and June 2022, we conducted 24 virtual, semi-structured interviews in Phase I to describe CVD prevention interventions, and 7 virtual GMB sessions in Phase II to describe experiences of disparities in CVD risk. For the purposes of this paper, we focus on a subset of results for both phases. In Phase I we identified 89 active CVD prevention interventions, 29 of which addressed tobacco use. In Phase II, causal loop diagrams revealed root causes of disparities in CVD risk. We provide an example of a causal loop diagram that focuses on the community prevalence of tobacco use, identifying stress as a key underlying factor driving disparities. The integration of findings from both phases highlighted the alignment and misalignment between quit tobacco intervention goals and how they are being experienced in marginalized communities. Conclusion: Systems science methods were useful to organize a large number of CVD prevention efforts, and evaluate the root causes of CVD health disparities in a high risk community. By integrating these two aspects, interventions may be reoriented to more effectively address the root causes of CVD health disparities.

Protocol for a scoping review of health equity frameworks and models applied in empirical studies of chronic disease prevention and control.

BACKGROUND: Chronic diseases, such as cancers and cardiovascular diseases, present the greatest burden of morbidity and mortality worldwide. This burden disproportionately affects historically marginalized populations. Health equity is rapidly gaining increased attention in public health, health services, and implementation research, though many health inequities persist. Health equity frameworks and models (FM) have been called upon to guide equity-focused chronic disease and implementation research. However, there is no clear synthesis of the health equity FM used in chronic disease research or how these are applied in empirical studies. This scoping review seeks to fill this gap by identifying and characterizing health equity FM applied in empirical studies along the chronic disease prevention and control continuum, describing how these FM are used, and exploring potential applications to the field of implementation science. METHODS: We follow established guidance for conducting scoping reviews, which includes six stages: (1) identify the research question; (2) identify relevant studies; (3) select studies for inclusion; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) consultation. This protocol presents the iterative, collaborative approach taken to conceptualize this study and develop the search strategy. We describe the criteria for inclusion in this review, methods for conducting two phases of screening (title and abstract, full text), data extraction procedures, and quality assurance approaches taken throughout the project. DISCUSSION: The findings from this review will inform health-equity focused chronic disease prevention and control research. FM identified through this review will be added to an existing website summarizing dissemination and implementation science frameworks, and we will offer case examples and recommendations for utilizing a health equity FM in empirical studies. Our search strategy and review methodology may serve as an example for scholars seeking to conduct reviews of health equity FM in other health disciplines. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework Registration https://doi.org/10.17605/OSF.IO/SFVE6.

Understanding the Geographic Distribution of Diverticulitis Hospitalizations in Washington State.

BACKGROUND: The incidence of diverticulitis in the United States is increasing, and hospitalization remains a surrogate for disease severity. State-level characterization of diverticulitis hospitalization is necessary to better understand the distribution of disease burden and target interventions. METHODS: A retrospective cohort of diverticulitis hospitalizations from 2008 through 2019 was created using Washington State's Comprehensive Hospital Abstract Reporting System. Hospitalizations were stratified by acuity, presence of complicated diverticulitis, and surgical intervention using ICD diagnosis and procedure codes. Patterns of regionalization were characterized by hospital case burden and distance travelled by patients. RESULTS: During the study period, 56,508 diverticulitis hospitalizations occurred across 100 hospitals. Most hospitalizations were emergent (77.2%). Of these, 17.5% were for complicated diverticulitis, and 6.6% required surgery. No single hospital received more than 5% (n = 235) of average annual hospitalizations. Surgeons operated in 26.5% of total hospitalizations (13.9% of emergent hospitalizations, and 69.2% of elective hospitalizations). Operations for complicated disease made up 40% of emergent surgery and 28.7% of elective surgery. Most patients traveled fewer than 20 miles for hospitalization, regardless of acuity (84% for emergent hospitalization and 77.5% for elective hospitalization). DISCUSSION: Hospitalizations for diverticulitis are primarily emergent, nonoperative, and broadly distributed across Washington State. Hospitalization and surgery occur close to patients' homes, regardless of acuity. This decentralization needs to be considered if improvement initiatives and research in diverticulitis are to have meaningful, population-level impact.

Applying an equity lens to assess context and implementation in public health and health services research and practice using the PRISM framework.

Dissemination and implementation science seeks to enhance the uptake, successful implementation, and sustainment of evidence-based programs and policies. While a focus on health equity is implicit in many efforts to increase access to and coverage of evidence-based programs and policies, most implementation frameworks and models do not explicitly address it. Disparities may in fact be increased by emphasizing high intensity interventions or ease of delivery over meeting need within the population, addressing deep-rooted structural inequities, and adapting to local context and priorities. PRISM (Practical, Robust Implementation and Sustainability Model), the contextual expansion of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework has several elements that address health equity, but these have not been explicated, integrated, or illustrated in one place. We present guidance for applying PRISM with an equity lens across its four context domains (external environment; multi-level perspectives on the intervention; characteristics of implementers and intended audience; and the implementation and sustainability infrastructure-as well as the five RE-AIM outcome dimensions. We then present an example with health equity considerations and discuss issues of representation and participation, representativeness and the importance of ongoing, iterative assessment of dynamic context and structural drivers of inequity. We also elaborate on the importance of a continuous process that requires addressing community priorities and responding to capacity and infrastructure needs and changes. We conclude with research and practice recommendations for applying PRISM with an increased emphasis on equity.

First-Time Use of the Seraph® 100 Microbind® Affinity Blood Filter in an Adolescent Patient with Severe COVID-19 Disease: A Case Report.

The Seraph® 100 Microbind® Affinity Blood Filter (Seraph® 100) is a hemoperfusion device designed to adsorb bacteria, viruses, and toxins when added to extracorporeal circuits. The FDA granted emergency use authorization in adults, but this device had never been utilized in children. A 17-year-old patient with asthma presented with respiratory distress due to COVID-19. His course was complicated by respiratory failure, rhabdomyolysis, and stage 3 AKI requiring initiation of continuous kidney replacement therapy (CKRT) on ICU day 3. The Seraph® 100 filter was added on ICU day 4. He was treated with 3 filters from ICU day 4 to 8. On ICU day 8, he was extubated and CKRT discontinued. He required no further kidney replacement therapy but did not have laboratory work post-discharge. In conclusion, this adolescent patient with COVID-19 and AKI requiring CKRT tolerated treatment with the Seraph® 100 Microbind® Affinity Blood Filter without significant adverse events.

Kentucky's abortion landscape, 2010 to 2019: an analysis of pre-Dobbs abortion disparities in a rural, restrictive state.

Background: Since 2010, many US states have passed laws restricting abortion providers' ability to provide care. Such legislation has no demonstrated health benefits and creates inequitable barriers for patients. Methods: To examine how Kentucky's abortion policies coincided with facility closures and abortion utilisation, we conducted a review of state abortion policies from 2010 to 2019 using newspapers and websites. We calculated abortion rates (abortions per 1000 women ages 15-44) by state of residence and provision for Kentucky, the South, and the US using data from the CDC and Kentucky Department of Health. We calculated percentages leaving and from out-of-state, and analysed abortions by race, pregnancy duration, and method. Findings: Of 17 policies passed between 2010 and 2019, ten were enacted, including 20-week and telemedicine bans. One of Kentucky's two abortion facilities closed in 2017. The pooled average abortion rate in Kentucky (4.1) and for Kentuckians (5.8) was lower than national averages (11.8 and 11.1). An average of 38% of Kentuckians left their state for care, compared to 7% nationally. In 2019, the abortion rate in Kentucky was 5.8 times higher for Black patients than White patients (compared to 4.8 times nationally). The majority (62%) of abortions in Kentucky took place at 7-13 weeks' gestation. Interpretation: Abortions in Kentucky were less frequent than in the South and US. The larger Black-White abortion rate gap reflects race- and class-based structural inequities in healthcare. Without federal protections, abortion access in Kentucky will continue waning. Funding: This study was supported by a philanthropic foundation that makes grants anonymously.

Novel predictors of mortality in emergency bowel surgery: a single-centre cohort study.

Pre-operative risk stratification is a key part of the care pathway for emergency bowel surgery, as it facilitates the identification of high-risk patients. Several novel risk scores have recently been published that are designed to identify patients who are frail or significantly unwell. They can also be calculated pre-operatively from routinely collected clinical data. This study aimed to investigate the ability of these scores to predict 30-day mortality after emergency bowel surgery. A single centre cohort study was performed using our local data from the National Emergency Laparotomy Audit database. Further data were extracted from electronic hospital records (n = 1508). The National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score were then calculated. The most abnormal National or Laboratory Decision Tree Early Warning Score in the 24 or 72 h before surgery was used in analysis. Individual scores were reasonable predictors of mortality (c-statistic 0.699-0.740) but all were poorly calibrated. A National Early Warning Score ≥ 4 was associated with a high overall mortality rate (> 10%). A logistic regression model was developed using age, National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score as predictor variables, and its performance compared with other established risk models. The model demonstrated good discrimination and calibration (c-statistic 0.827) but was marginally outperformed by the National Emergency Laparotomy Audit score (c-statistic 0.861). All other models compared performed less well (c-statistics 0.734-0.808). Pre-operative patient vital signs, blood tests and markers of frailty can be used to accurately predict the risk of 30-day mortality after emergency bowel surgery.

Assessing the implementation of a multi-component hypertension program in a Guatemalan under-resourced dynamic context: An application of the RE-AIM/PRISM extension for sustainability and health equity.

Background: The COVID-19 pandemic necessitated rapid changes in the delivery of care across public primary care settings in rural Guatemala in 2020. In response, a hypertension program implemented within the public primary care system required multiple adaptations, providing an illustrative example of dynamic implementation amidst changing context in an under-resourced setting. This study describes the evolvability of an evidence-based intervention (EBI; protocol-based hypertension treatment) and one of its main implementation strategies (team-based collaborative care) during the COVID-19 pandemic and discusses implications for health equity and sustainability. Methods: This convergent mixed methods analysis assessed implementation across five Ministry of Health districts during the initial phase of the pandemic. Qualitative and quantitative data were collected, analyzed, and integrated, informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation Maintenance) Framework's extension for sustainability, and its contextual enhancement, PRISM (Pragmatic, Robust, Implementation and Sustainability Model). For RE-AIM, we focused on the "Implementation" domain, operationalizing it qualitatively as continued delivery and adaptations to the EBI and implementation strategy, and quantitatively as the extent of delivery over time. We conducted 18 in-depth interviews with health providers / administrators (n=8) and study staff (n=10) and performed a matrix-based thematic-analysis. Qualitative results informed the selection of quantitative implementation summarized as behavior over time graphs. Quantitative implementation data and illustrative quotes are presented as joint displays. Results: In relation to implementation, several organic adaptations hindered delivery, threatened sustainability, and may have exacerbated health inequities. Planned adaptations enhanced program delivery and may have supported improved equity and sustainability. Salient PRISM factors that influenced implementation included "Organizational perspective of the EBI", "Fit" and "Implementation and sustainability infrastructure". Facilitators to continued delivery included the perception that the EBI is beneficial, program champions, and healthcare team organization. Barriers included the perception that the EBI is complicated, competition with other primary care activities, and temporary suspension of services due to COVID-19. Conclusions: Multi-level contextual changes led to numerous adaptations of the EBI and implementation strategy. Systems thinking approaches may shed light on how a program's sustainability and its equitable delivery are influenced by adaptations over time in response to dynamic, multi-level contextual factors. Trial registration: NCT03504124.

The double-edged sword of abortion regulations: Decreasing training opportunities while increasing knowledge requirements.

PURPOSE: The authors explore how abortion regulations in Ohio, an abortion-restrictive state in the USA, impact obstetrician-gynecologists' (OB/GYNs) training in reproductive healthcare and describe what OB/GYNs believe to be the broader impact of Ohio's regulations on skill-building, skills maintenance, and professional retention of reproductive healthcare providers in the state. Authors discuss how their findings foreshadow abortion training limitations in Ohio and other abortion-restrictive states now that abortion regulations have returned to the states. METHODS: The authors conducted four semi-structured focus groups and five in-depth interviews between April 2019 and March 2020. Participants included OB/GYNs practicing obstetrics and gynecology in Ohio between 2010 and 2020. Thematic analysis was conducted using Atlas.ti. RESULTS: Twenty attending physicians and 15 fellows and residents participated in the study. Participants discussed the impact of Ohio's written transfer agreement, gestational-limit, and abortion method and facility bans on training and skill-building opportunities. Participants felt that Ohio's strict abortion regulations 1) limit opportunities to observe and perform abortion procedures during training; 2) require learning the ever-changing legality of abortion provision; 3) limit the number of abortions OB/GYNs can provide, leading to the atrophy of their skills over time; and 4) may prevent prospective medical students and residents from choosing to study in Ohio and may lead to physician attrition from the state. CONCLUSION: Prior to the reversal of federal protections for abortion in 2022, OB/GYNs in Ohio and other abortion-hostile states experienced barriers to training in abortion care. In returning abortion regulation to the states, access to training is likely to be increasingly restricted. This research demonstrates how abortion-restrictions hamper physicians' skills needed to care for patients, particularly in emergent situations. This puts patients at risk and places physicians in precarious ethical positions. Expanding protections and reducing restrictions on abortion will ensure OB/GYNs and trainees have the skills necessary to care for patients presenting for reproductive healthcare.

Training in eight low-and middle-income countries: lessons learned from a pilot study using the WHO-TDR dissemination and implementation massive open online course.

Introduction: Non-communicable diseases (NCDs) are a leading cause of morbidity and mortality in low-and middle- income countries (LMICs). Despite this, a lack of funding, training and mentorship for NCD investigators in LMICs exists. In an effort to gain knowledge and skills to address these gaps, participants from the Global Research on Implementation and Translation Science (GRIT), a consortium of studies in eight LMICs and their networks, attended the dissemination and implementation (D&I) massive open online course (MOOC) developed by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization to strengthen D&I capacity building. Here, we report on the pilot of this MOOC, which was implemented during the SARS COVID-19 pandemic from April- November 2020. Methods: Participants completed pre-and post-training questionnaires to assess self-reported D&I competencies, general research skills, and research mentor access and quality. D&I competencies were measured by use of a scale developed for a US-based training program, with change in competency scores assessed by paired t test. We used univariate statistics to analyze the data for all other outcomes. Results: Of the 247 participants enrolled, 32 (13%) completed all course requirements, 21 (9%) completed the pre-and post-surveys and are included in the analysis. D&I competency scores suggest improvement for those who had complete pre- and post-assessments. Trainee's average score on the full competency scale improved 1.45 points (0-5 scale) from pre- to post-test; all four subscales also showed evidence of improvements. There were small but not significant increases in competencies for grant writing, proposal/ manuscript writing and presentations from pre- to post-test assessment. 40% of trainees reported access to a research mentor and 12% reported access to a D&I specific mentor. Participants reported barriers (e.g., unstable internet access and challenges due to COVID-19) and facilitators (e.g., topical interests, collaboration with colleagues) to completing the MOOC. Conclusions: Although COVID-19 affected program usage and completion, the MOOC was feasible. We also had signals of effectiveness, meaning among LMIC participants completing the course, there was improvement in self-report D&I competency scores. Recommendations for future D&I trainings in LMICs include (1) adding more topic specific modules (i.e., NCD research, general research skills) for scalability; (2) fostering more collaboration with participants across LMICs; and (3) establishing partnerships with D&I mentors for course participants.

Explanatory models of hypertension in Guatemala: recognizing the perspectives of patients, family members, health care providers and administrators, and national-level health system stakeholders.

BACKGROUND: Uncontrolled hypertension is a major public health burden and the most common preventable risk factor for cardiovascular diseases in Guatemala and other low- and middle-income countries. Prior to an initial trial that evaluated a hypertension intervention in rural Guatemala, we collected qualitative information on the needs and knowledge gaps of hypertension care within Guatemala's public healthcare system. This analysis applied Kleinman's Explanatory Models of Illness to capture how patients, family members, community-, district-, and provincial-level health care providers and administrators, and national-level health system stakeholders understand hypertension.  METHODS: We conducted in-depth interviews with three types of participants: 1) national-level health system stakeholders (n = 17), 2) local health providers and administrators from district, and health post levels (25), and 3) patients and family members (19) in the departments of Sololá and Zacapa in Guatemala. All interviews were conducted in Spanish except for 6 Maya-Kaqchikel interviews. We also conducted focus group discussions with auxiliary nurses (3) and patients (3), one in Maya-Tz'utujil and the rest in Spanish. Through framework and matrix analysis, we compared understandings of hypertension by participant type using the Explanatory Model of Illness domains -etiology, symptoms, pathophysiology, course of illness, and treatment. RESULTS: Health providers and administrators, and patients described hypertension as an illness that spurs from emotional states like sadness, anger, and worry; is inherited and related to advanced age; and produces symptoms that include a weakened body, nerves, pain, and headaches. Patients expressed concerns about hypertension treatment's long-term consequences, despite trying to comply with treatment. Patients stated that they combine biomedical treatment (when available) with natural remedies (teas and plants). Health providers and administrators and family members stated that once patients feel better, they often disengage from treatment. National-level health system stakeholders referred to lifestyle factors as important causes, considered patients to typically be non-compliant, and identified budget limitations as a key barrier to hypertension care. The three groups of participants identified structural barriers to limited hypertension care (e.g., limited access to healthy food and unaffordability of medications). CONCLUSION: As understandings of hypertension vary between types of participants, it is important to describe their similarities and differences considering the role each has in the health system. Considering different perceptions of hypertension will enable better informed program planning and implementation efforts.