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Although developing countries are rapidly urbanizing, many of their citizens still live in rural environments and the majority of the energy use is dominated by the built environment. This study aims to demonstrate the adaptation of the European typology approach for building stock energy Assessment (TABULA) project to the developing world to enable leapfrogging rural regions to sustainable energy-based societies. A case study is performed that considers ten locations across different geopolitical zones and the different climatic zones of the most populous country in sub-Saharan Africa: Nigeria. The objective is to analyse the energy performance of the low-cost building stock and assess the potential for energy and economic savings. Applying the reference building approach, building typologies were identified consisting residential and non-residential function buildings. Building simulation and composite scenario analyses were carried out and considered indoor environmental quality for adaptive comfort strategies, building retrofits by improving the building envelope and energy efficiency measures for equipment and building operation. The results for Nigeria are provided as examples of disaggregated energy characteristics of the built environment and low-cost building stock, and then a wider application to other developing countries is discussed with inherent policy implications for an effective policy mix such that takes cognisance of the tenets of Energy Modelling for Policy Support (EMoPS) and inform the design of de-factor green energy polices geared towards rehabilitating the local built environment.

Efforts towards achieving high access to cooking with clean energy have not been transformative due to a limited understanding of the clean-energy drivers and a lack of evidence-based clean-energy policy recommendations. This study addresses this gap by building a high-performing machine learning model to predict and understand the mechanisms driving energy poverty - specifically access to cooking with clean energy. In a first-of-a-kind, the estimated cost of US$14.5 trillion to enable universal access to cooking with clean energy encompasses all the intermediate inputs required to build self-sufficient ecosystems by creating value-addition sectors. Unlike previous studies, the data-driven clean-cooking transition pathways provide foundations for shaping policy and building energy models that can transform the complex energy and cooking landscape. Developing these pathways is necessary to increase people's financial resilience to tackle energy poverty. The findings also show the absence of a linear relationship between electricity access and clean cooking - evidencing the need for a rapid paradigm shift to address energy poverty. A new fundamental approach that focuses on improving and sustaining the financial capacity of households through a systems approach is required so that they can afford electricity or fuels for cooking.

Recently, a lot of studies have been conducted on what factors and strategies affect the successful implementation of e-government programs around the world. Most of these studies lack a clear plan for selecting strategies and setting their priorities for implementation and thus ensuring the success of such programs. In a previous study conducted by the same researchers, these strategies and their implementation priorities were defined based on the opinions of 20 government experts who were interviewed and asked to rank the strategies based on 23 factors resulting from the SWOT analysis that summarizes the context under study, specifically Jordan as an example of a developing country. However, there is a problem that still exists facing many of these countries, which is the divergence of opinions of government decision-makers in ranking their priorities for implementing various government strategies, including e-government programs, and thus affecting the quality of the strategic decision taken. Therefore, this study will address the problem by finding a new methodology that enables to obtain a stable ranking of strategies in order to make the best strategic decision to implement the e-government program in the context under study or other similar contexts in the region. This study assumes that we can obtain a stable ranking of strategies related to implementing e-government programs when we only use the SWOT factors that produce stable ranking votes. To validate this, three main experiments with a number of proposed scenarios were developed to aggregate expert rankings on the implementation of e-government strategies using some common vote ranking methods, namely, parametric methods such as Borda, Copeland and Maximin, and algorithmic methods such as Stuart and Robust Rank Aggregation (RRA). Then, to evaluate the results of the three experimental scenarios, two new measures were proposed, namely the Similarity Index measure and the Matching Index measure. The results confirmed the validity of the assumption regarding the importance of obtaining a stable vote ranking in selecting the best strategies to ensure success in implementing e-government program in the context under study or other similar contexts in the region.

Anthropogenic pollution of water has become an urgent management challenge across the world. We explored benthic macroinvertebrates community structure in relation to physicochemical conditions of the water column and sediments along an anthropogenic stress gradient in a southern Nigeria stream. We used Principal Component Analysis (PCA) followed by Canonical Corresponding Analysis (CCA) to analyse the original monitoring dataset (33 water quality indexes), identify the important physicochemical variables, and evaluate the relationship between the concluded important physicochemical variables and macroinvertebrates assemblages. PCA and CCA showed that sediment heavy metals explained larger part of variance in benthic macroinvertebrates assemblage. CCA showed a strong relationship between species metrics and environmental predictors. Sediment heavy metals pollution residues from industries that have relocated from the catchments of Site 2 affected the sediment and water quality as well as the benthic community structure at this site, demonstrated by the dominance of organic and heavy metal pollution tolerant taxa. Due to rapid urbanization, gradients of anthropogenic impacts resulted in an increase in the profile of heavy metal and nutrient concentrations along Sites 2, 3, and 4, indicated by the dominance of pollution-tolerant taxa of Oligochaete and Diptera groups. Our results supply useful baseline knowledge on urban chemical pollution in a developing world perspective. The long-term impression from sediment heavy metals pollution residues resulting from relocated industries should be a concern to environmental managers. For ecological restoration, objective management policies, legislation, and participatory scientific monitoring are key.

The meta-analysis dataset presented is a convenience sample from 218 separate studies of agricultural technology adoption in Africa, Asia, and Latin America. Each study uses survey data to estimate a form of multiple regression of adoption of a technology (dependent variable) with a diverse array of predictor variables. Fifteen predictor variable categories are included in this dataset: Age, education, gender, household size, farming experience, land size, soil fertility, land slope, distance to inputs/outputs, access to credit, land tenure, livestock ownership, non-farm income, access to extension, and organization membership. Data have been cleaned and transformed to common units. A total of 384 statistical models are recorded, with a total of 2875 effect size estimates.

Biochar is frequently made using high-tech, high-control methods which will no doubt better optimize the final material for its intended purpose and increase its value. In contrast, we used low-tech, low-control methods to produce a developing world biochar (DWB) from two common crop wastes, cottonseed (CS) and pecan shell (PS). We created DWB biochar using a top-lit updraft microgasifier (TLUD) made from paint cans, and compared it to a biochar created in a muffle furnace held at 450 °C (MF450). We first used modern material characterization methods (yield, BET, SEM/EDS, TGA, XRD, FTIR) to understand the difference in biochar production methods on the feedstock. We then used batch equilibrium adsorption with cationic and anionic dyes (methyl orange, MO and crystal violet, CV) to examine environmental performance. The TLUD method generally has a lower biochar production yield than MF450 because we believe much of the material in the TLUD achieves temperatures > 450 °C and is sometimes difficult to retain in the device. The higher temperatures in the TLUD device lead to a biochar which is more microporous, has greater surface area, has less surface functional groups, has greater ash content, is more carbonized, and has lower residual cellulose crystallinity.There were differences in adsorption performance whereby the MF450 biochar adsorbs CV more strongly than the TLUD. For MO, PS-TLUD is less effective at adsorbing the dye when compared to PS-MF450, while CS-TLUD has a much higher adsorption strength than CS-MF450. We are not certain why the two methods show opposite effects in different feedstock but speculate that it may have to do with the much higher mineral content in the PS-TLUD compared to its MF450 counterpart. Out of many isotherms examined Freundlich and Langmuir isotherms provide a best-fit to our data only about half the time. Sometimes an S-shaped isotherm was the best fit or still fit the data reasonably well. Comparing the dye adsorption to other studies, the DWB does not adsorb as well, yet it is still effective for removal at environmental dye concentrations of relevance. Overall, we conclude that DWB, made in this uncontrolled fashion, can make a reasonably high quality biochar based on material properties and environmental performance. We suggest that additional research be done on other low-tech biochar production methods to see how to scale-up and optimize them according a developing world community's intended use.

This article analyzes the urban form and socioeconomic determinants of commute time at the individual trip level in México City. Average commute times were mapped and regression models were applied for four groups of workers according to transportation mode and educational attainment: Car-College, Car-Non College, Transit-College, and Transit-Non College. The most evident pattern of lower commute times in the inner city corresponded to college workers using transit. Regression results showed a complex interplay between socioeconomic variables, the urban form, and commute time. Overall, for car commuters there was limited and weak evidence of differential commutes among socioeconomic classes. However, for transit users, there was a trend of longer commutes for lower socioeconomic categories. Other socioeconomic factors associated with lower commute times were female, spouse, less educational attainment, the young, and the elderly. Important urban form determinants were the jobs-housing ratio at the destination associated with increased travel times and mixed-land use at the origin associated with a decrease in travel times.

Summary: Background: Indiscriminate antimicrobial use is one of the greatest contributors to antimicrobial resistance. A low level of asepsis in hospitals and inadequate laboratory support have been adduced as reasons for indiscriminate use of antimicrobials among surgical patients. At present, there are no guidelines for presumptive antibiotic use in Nigeria and sub-Saharan Africa. Aim: Surgical inpatients at the study hospital were surveyed to determine the level of antimicrobial use and degree of compliance with prescription quality indicators. Methods: A cross-sectional survey was conducted among all surgical inpatients in May 2019 using a standardized tool developed by the University of Antwerp to assess the point prevalence of antimicrobials. Inpatients who were admitted from 08:00 h on the day of the survey were included. Data on patients' demographics, indication for antimicrobial use, reason for antimicrobial use, stop/review date, adherence to guidelines and laboratory use were collected. The prevalence of antimicrobial use in the surgical department was estimated. Results: Eighty-two inpatients were included in the survey. Of these, 97.6% were receiving at least one antimicrobial agent. Only 5.4% of the prescriptions were targeted, and 37.6% of prescriptions were for empirical treatment of infections. Approximately half (50.7%) of the patients were receiving presumptive antibiotics, and 6% were receiving prophylactic antibiotics. In total, 58.7% of prescriptions were administered parenterally, and 98.2% of patients had documentation of a stop/review date. Metronidazole (P=32.3%, T=29.2%), ceftriaxone (P=28.4%, T=19.8%) and ciprofloxacin (P=14.2%, T=14.6%) were the most common antimicrobials used. Conclusions: There is a high rate of antimicrobial use among surgical inpatients, and the rate of indiscriminate antimicrobial prescribing among these patients needs to be reduced. This can be achieved by developing antimicrobial guidelines for presumptive antimicrobial therapy.

Acute kidney injury (AKI) is independently associated with new-onset chronic kidney disease (CKD), end-stage kidney disease, cardiovascular disease, and all-cause mortality. However, only a minority of patients receive follow-up care after an episode of AKI in the developing world, and the optimal strategies to promote rehabilitation after AKI are ill-defined. On this background, a working group of the 18th Acute Dialysis Quality Initiative applied the consensus-building process informed by a PubMed review of English-language articles to address questions related to rehabilitation after AKI. The consensus statements propose that all patients should be offered follow-up within 3 months of an AKI episode, with more intense follow-up (e.g.,

Patient perceptions and experiences of mobile health (m-health) systems have been recognised as an important element to consider in the adoption of m-health based technologies. Though much research supports this, published studies that identify m-health use by patients appear to highlight these issues in an indirect rather than a holistic manner. Consequently, there is no encompassing framework that serves as a guide for effective implementation and maximum adoption of m-health from the perspective of patients in the developing world. This review identifies patient adoption issues specifically and uses these to develop a framework of patient adoption issues for m-health in the developing world. A structured literature search was conducted using PubMed and Scopus. For PubMed, a consolidated search string combined ‘MeSH’ terms and ‘All Fields’ terms for selected keywords. For Scopus, an equally consolidated search string was used. The searches were restricted to articles in English during the period January 1, 2000 to 31 December2019 and relevant to the developing world. Duplicate articles were removed. Titles and abstracts were screened by all authors for inclusion, and those studies that met the inclusion criteria were selected for full-text review. Review and data abstraction was performed by two authors. Fifty-four (54) articles reported factors that impact patient adoption. Initial review and data abstraction identified 22 categories that promote or impede m-health adoption by patients in the developing world. Continued iterative review reduced these to 7 primary categories, with 20 subcategories, which were used to design the proposed framework. The review showed: great inconsistency in the approach and tools used in published studies; multiple factors impact patient adoption of m-health in the developing world; the specific factors vary from setting to setting and by recency of findings. Successful adoption of m-health by patients in the developing world critically depends on addressing the factors identified in the proposed framework and assessing them prior to the implementation of m-health initiatives in any specific setting. The proposed framework will serve to increase the consistency of patient adoption studies and provide the foundation for greater success of future m-health implementations for patients in the developing world.

One of the main challenges for emergency healthcare services in low to middle income countries (LMICs) is limited capacity to deal with heavy emergency caseloads. The process of triage is one mechanism for mitigating this challenge. Methods: In a two-round consensus building process (the Delphi process), a panel of emergency centre (EC) experts were asked to independently triage 50 clinical vignettes using one of four acuity levels: emergency (patient to be seen immediately), very urgent (patient to be seen within 10 min), urgent (patient to be seen within 60 min), or routine (patient to be seen within four hours). The vignettes were based on real paediatric EC cases in South Africa. Vignettes that reached a minimum of 80% group consensus for acuity ratings on either round one or two were included in the final set of reference vignettes. Results: Of the 50 vignettes presented to 11 EC experts, in the first round, 80% group consensus on acuity ratings was obtained for 10 (20%) of the vignettes. In the second round, 80% consensus was reached for 30 of the 40 remaining vignettes. Thus, overall, 40 (80%) of the vignettes reached a minimum group consensus of 80% (emergency n = 4; very urgent n = 8; urgent n = 12; routine n = 16). Conclusion: This study demonstrates how context-specific reference vignettes can be developed to provide a cheap, effective, and feasible means by which to evaluate paediatric triage systems in LMICs.

This study uses a spatial bio-economic modelling framework to estimate the impact of the 2012 weather extreme in the USA on food security in the developing world. The study also quantifies the potential effects of a similar weather extreme occurring in 2050 under climate change. The study results indicate that weather extremes that affect maize productivity in key grain baskets can negatively affect food security in vulnerable countries. The 2012 weather extreme which occurred in the USA reduced US and global maize production by 29% compared to trend; maize consumption in the country decreased by 5% only and this resulted in less surplus maize for exports from the largest maize exporter in the world. Global maize production decreased by 6% compared to trend. The decrease in global maize production coupled with a reduction in the volume of global maize exports worsened food insecurity in eastern Africa, the Caribbean and Central America and India. The effects of the weather extreme on global food security would be worse, if the latter were to occur under climate change in 2050, assuming no climate change adaptation worldwide over the years. In addition, the hardest-hit regions would remain the same, whether the weather extreme occurs in 2012 instead of 2050: Sub-Saharan Africa (SSA), South Asia and the Latin America and Caribbean (LAC) region. However, sustained growth in per capita income across world economies between 2000 and 2050 would allow few countries in SSA and the LAC region to virtually eliminate hunger within their borders. In these countries, per capita income would be high enough by 2050 to completely offset the negative effect of the weather extreme. The study results are also consistent with USDA׳s estimates on US and global maize production and consumption in 2012 after the weather extreme. Some discrepancy is found on the volume of global maize trade; this implies that the bio-economic model likely overestimates the effect of the weather extreme on food insecurity. However, the trends from the analysis are likely to be valid. Further research would involve using a CGE model that can capture the net effects of weather extremes.

Livestock play a significant role in rural livelihoods and the economies of developing countries. They are providers of income and employment for producers and others working in, sometimes complex, value chains. They are a crucial asset and safety net for the poor, especially for women and pastoralist groups, and they provide an important source of nourishment for billions of rural and urban households. These socio-economic roles and others are increasing in importance as the sector grows because of increasing human populations, incomes and urbanisation rates. To provide these benefits, the sector uses a significant amount of land, water, biomass and other resources and emits a considerable quantity of greenhouse gases. There is concern on how to manage the sector's growth, so that these benefits can be attained at a lower environmental cost. Livestock and environment interactions in developing countries can be both positive and negative. On the one hand, manures from ruminant systems can be a valuable source of nutrients for smallholder crops, whereas in more industrial systems, or where there are large concentrations of animals, they can pollute water sources. On the other hand, ruminant systems in developing countries can be considered relatively resource-use inefficient. Because of the high yield gaps in most of these production systems, increasing the efficiency of the livestock sector through sustainable intensification practices presents a real opportunity where research and development can contribute to provide more sustainable solutions. In order to achieve this, it is necessary that production systems become market-orientated, better regulated in cases, and socially acceptable so that the right mix of incentives exists for the systems to intensify. Managing the required intensification and the shifts to new value chains is also essential to avoid a potential increase in zoonotic, food-borne and other diseases. New diversification options and improved safety nets will also be essential when intensification is not the primary avenue for developing the livestock sector. These processes will need to be supported by agile and effective public and private institutions.

Most articles in top general surgical journals seem to originate from a limited few developed countries. The purpose of this study was to establish which countries publish the most in leading general surgical journals. Methods: We analysed all the studies, reviews and case reports published in 2003-2004 in 10 leading English-language general surgical journals with the highest impact factors to obtain country-wise data with regard to the origin of articles. Editorials, historical articles, commentaries, guidelines, biographies, interviews and letters to editors were excluded from the analysis. Results: A total of 5,081 articles were reviewed. Out of these, 834 were excluded as detailed above and the remaining 4,247 articles were analysed. Most of these were from USA, European countries, Japan, and Australia. It seems that the vast majority of the world's population living in the developing countries do not find adequate representation in leading general surgical journals. Conclusion: Very few articles are published from developing countries in leading general surgical journals. Both developing countries and medical journals need to take steps to curb this trend. Steps are suggested to improve the situation so that the developing world is also adequately represented in the surgical literature.

Since the introduction of the implantable cardioverter defibrillator (ICD) by Michel Mirowski in the 1980's, these devices have become an important tenet in management of ventricular arrhythmias1. Numerous observational and randomized trials have demonstrated the superiority of this device over antiarrhythmic drugs in treating ventricular arrhythmias. The clinical implications of these trials are tremendous as sudden cardiac death (SCD) maybe the presenting symptom in these arrhythmias. It is estimated that in the United States alone around 350,000 deaths occur each year due to SCD alone2 . As resuscitation is seldom successful in the community, methods to identify and appropriately treat such patients alone can prevent these events. However, the public health impact of this approach is tremendous, as the ICD is extremely expensive and is out of reach for many individuals. Moreover, not all patients with structural heart disease and ventricular arrhythmias have a malignant outcome. Thus efforts to appropriately stratify patients according to their risk profile and accordingly advocate ICD implant has important fiscal implications for the state with meager health resources, especially in those patients in whom survival benefit with the ICD is modest.

Background: Low-middle-income countries (LMICs) share a substantial proportion of global surgical complications. This is compounded by the seemingly deficient documentation of postsurgical complications and the lack of a national average for comparison. In this context, the implementation of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) that compares hospital performance based on postsurgical complication data provided by a wide array of centers, could be a major initiative in a resource-challenged setting. Implementation of the NSQIP has provenly mitigated postoperative morbidity and mortality across many centers all over the world. To our knowledge, this report is the first from an LMIC to report its postoperative neurosurgical complications in comparison with international benchmarks., Methods: Our hospital joined the NSQIP in 2019. Through a standardized ACS protocol, ACS-trained surgical clinical reviewers (SCRs) reviewed and extracted data from randomly assigned neurosurgical patients' medical records from preoperative to postoperative (30-day) data using validated, standardized data definitions. SCRs entered deidentified data in an online Health Insurance Portability and Accountability Act web-based secure platform. The validated data were then consigned to the ACS NSQIP head office in the United States where the data were analyzed and compared with similar data from other centers registered with the NSQIP. In this way, our hospital was rated for each of the variables related to postsurgical complications after both spinal and cranial procedures, and the results were sent back to us in the form of text, tables, and graphs., Results: Our initial report suggested a relatively higher odds ratio for sepsis and readmissions after spinal procedures at our hospital, and a similarly higher odds ratio for morbidity, sepsis, urinary tract infection, and surgical site infection for cranial procedures. For these variables, our hospital fell in the needs improvement category of the NSQIP. For the rest of the variables studied for both spinal and cranial procedures, the hospital fell in the as expected category of the NSQIP., Conclusions: Implementation of the NSQIP is an important first step in creating a culture of transparency, safety, and quality. This is the first report of NSQIP implementation in an LMIC, and we have shown comparable results to developed countries., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Residual free chlorine is not monitored continuously at scale in drinking water distribution systems because existing real-time sensor technologies require frequent maintenance, cleaning, and calibration, which makes these products too costly to be used throughout a distribution system. As a result, current measurement approaches require manual sampling, which is not feasible for the consistent monitoring of free chlorine because chlorine concentrations vary significantly throughout pipeline distribution and over time and space. This research presents an alternative and cost-effective method of predicting free chlorine levels in drinking water using graphite electrodes coated with naturally grown microbial biofilms. This Microbial Potentiometric Sensor (MPS) array was installed in a Continuously Mixed Batch Reactor (CMBR), and drinking water containing variable free chlorine concentrations. The chlorine concentrations were introduced in a controlled manner, and the MPS signals were monitored over time. MPS signals were measured from the change in Open Circuit Potential (OCP) across the MPS array in real-time. An empirically derived relationship between the normalized change in OCP and free chlorine was established by fitting individual and average MPS data to a decaying exponential growth function in order to predict free chlorine levels. The results show that free chlorine can be predicted with reasonable accuracy, with model validation showing an average absolute error of ±0.09 ppm below 1.1 ppm and ±0.30 ppm between 1.1 and 2.7 ppm. However, the accuracy of predictions was reduced at higher free chlorine levels. The researchers conclude that MPS systems may benefit drinking water distribution systems by measuring free chlorine. These advantages of the MPS are especially pronounced in the developing world because this system is inexpensive and does not require routine maintenance or cleaning. The system relies on a naturally forming and regenerating biofilm and an inexpensive potentiometric meter to produce stable measurements., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Open tibial fractures are rare and difficult-to-treat injuries because of the involvement of bony, skin and neuromuscular injury along with co-morbidities. Often, during the management of very severe cases these injuries, the question arises, should we amputate or salvage the limb? This question has been explored previously in civilian and military contexts in the US and UK but remains unstudied in the alternative sociocultural and economic context of the developing world., Methods: We studied 78 adult patients with severe open tibial fracture that presented to our institution, a Level 1 trauma center in India, from February 2018 to June 2019. 20 patients underwent above-knee amputation (AKA), 16 underwent below-knee amputation (BKA), and 42 underwent limb salvage. We assessed injury severity using [our institution's] Open Injury Severity Score (GHOISS), which has separate sub-scores for bony injury, skin injury, neuromuscular injury and co-morbidities, and patients were only included with GHOISS > 13. We assessed functional outcome measures as well as economic costs as primary cost levied by our institution and other secondary costs., Results: Salvage (LEFS: mean=51, SF-12 PCS: mean=48, SF-12 MCS: mean=49) provided better outcomes to BKA (LEFS: mean=39, p=0.005, SF-12 PCS: mean=40, p=0.003, SF-12 MCS: mean=43, p=0.052) and AKA (LEFS: mean=31, p<0.001, SF-12 PCS: mean=34, p<0.001, SF-12 MCS: mean=43, p=0.043). Primary costs were higher for limb salvage (index: mean=$3100, total: mean=$4400) than both BKA (index: mean=$2500, p=0.012, total: mean=$2600, p<0.001) and AKA (index: mean=$2800, p=0.020, total: mean=$3200, p<0.001). Secondary costs were higher for limb salvage than both BKA and AKA (p<0.001). Patients who underwent salvage were more likely to return to work at 36 months post-injury compared to below-knee amputees (adjusted OR=0.11, p=0.010)., Conclusions: Limb salvage results in better functional outcomes compared with amputation at a higher upfront cost but a likely lower lifetime cost. Unlike other literature on the topic, amputation carries a heavy mental and physical toll in India, likely due to sociocultural differences and stigma. Amputation is a difficult decision for patients to accept and results in poorer outcomes; therefore, we believe that limbs should be aggressively salvaged in our developing country., Study Design: Therapeutic Level II Prospective Cohort Study., (Copyright © 2021. Published by Elsevier Ltd.)

Background: The launch of novel pharmaceuticals in the developing world faces significant barriers that can delay or ultimately inhibit uptake. Implementation research can provide an understanding of factors influencing the introduction and scale up of a new product and thus can inform implementation strategy development., Objective: This study explored the factors likely to influence introduction of a novel oxytocin formulation for the prevention of postpartum hemorrhage in Ethiopia., Methods: Qualitative research methods were used to assess barriers and enablers associated with pre-determined domains: regulatory approval, pricing, supply and demand side advocacy, policy inclusion, end-user training and drug supply. Data were collected through focus group discussions and in-depth interviews with community members, healthcare providers and key informants. Verbatim transcripts were translated to English and analyzed using a thematic content framework., Results: Approval from stringent regulatory bodies was an enabler for gaining national regulatory approval. Purchasers (government and patients) expressed price sensitivity but would be willing to pay a price comparable to or higher than current alternatives if improved quality is delivered. Endorsement from the World Health Organization was described as critical for national policy inclusion. Supply side advocacy should be directed towards the Ministry of Health, which is receptive to advice from reputable agencies with whom they have an existing relationship. Demand side advocacy should be delivered through existing health system channels such as Ministry of Health authorities (for healthcare workers) and community health workers (for community members). The requirement to purchase the product directly from a single manufacturer was highlighted as a potential barrier for entry into the local supply chain., Conclusion: This study highlighted several barriers and enablers associated with the introduction of a new drug product into the health system of Ethiopia. An advanced understanding of these influences can inform the design of locally-appropriate implementation strategies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Hand surgery outreach programs to low- and middle-income countries (LMICs) provide much-needed surgical care to the underserved populations and education to local providers for improved care. The cost-effectiveness of these surgical trips has not been studied despite a long history of such efforts. This study aimed to examine the economic impact of hand surgery trips to LMICs using data from the Touching Hands Project and ReSurge International. We hypothesized that hand surgery outreach would be cost-effective in LMICs., Methods: We analyzed data on the cost of each trip and the surgical procedures performed. Using methods from the World Health Organization (WHO-Choosing Interventions That Are Cost-Effective [WHO-CHOICE]), we determined whether the procedures performed during the outreach trips would be cost-effective., Results: For the 14 hand surgery trips, 378 patients received surgical treatment. Trips varied in the country where interventions were provided, the number of patients served, the severity of the conditions, and the total cost. The cost per disability-adjusted life-year averted ranged from United States (US)$222 to $1,525, all of which were very cost-effective according to WHO-CHOICE thresholds. The cost-effectiveness of global hand surgery was comparable to that of other medical interventions such as multidrug-resistant tuberculosis treatment in similar regions. We also identified a lack of standardized record keeping for these surgical trips., Conclusions: Hand surgeries performed in LMICs are cost-effective based on WHO-CHOICE criteria. However, a standardized record-keeping method is needed for future research and longitudinal comparison. Understanding the economic impact of hand surgery global outreach is important to the success and sustainability of these efforts, both to allocate resources effectively and to identify areas for improvement., Type of Study/level of Evidence: Economic/Decision Analysis III., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: The neurosurgical literature rarely describes managing open head injuries caused by machetes, although this is a common head injury in developing countries. We present our experience managing cranial machete injuries in Nicaragua over a 5-year period., Methods: A retrospective chart review identified patients admitted to a neurosurgery service for cranial machete injury., Results: Among 51 patients studied, the majority (n = 42, 82%) presented with mild neurologic deficits (Glasgow Coma Scale score ≥14). Nondepressed skull fracture (25/37, 68%) was the most common injury identified on skull radiography, and pneumocephalus (15/29, 52%) was the most common injury identified with computed tomography. Overall, 38 patients (75%) underwent surgical intervention for 1 or more conditions, including laceration length ≥10 cm (n = 20), open intracranial wound (n = 8), pneumocephalus (n = 7), cerebral contusion (n = 6), intracranial hemorrhage (n = 5), and depressed fracture (n = 5). All patients received aggressive antibiotic therapy. Patients without intracranial injury received a 7-day course of intravenous ceftriaxone, followed by a 10-day course of oral ciprofloxacin. Patients with violation of the dura received a 7- to 14-day course of intravenous metronidazole, ceftriaxone, and vancomycin, followed by a 10-day course of oral ciprofloxacin. Postoperative complications included a visible skull defect (n = 6), infection (n = 3), and unspecified neurologic (n = 2) and mixed (n = 1) complications. At discharge, most patients had only minimal disabilities (47/51, 92%). In-hospital mortality rate was zero., Conclusions: An aggressive approach to managing open head injury caused by machete yields good outcomes, with the majority of patients experiencing minimal disability at hospital discharge and a low rate of infection., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Telemedicine is increasingly applied in developed settings to facilitate transfer of information to and from burn surgeons across vast geographic areas. WhatsApp is a widely available and extremely user-friendly encrypted smartphone application that does not require the expensive physical and personnel infrastructure that characterizes many of these telemedicine systems. The aim of this study was to review the use of WhatsApp to facilitate paediatric burn injury consultations to a regional burn centre in a developing country, where burn care continues to be thwarted by administrative apathy, poor resource allocation and lack of attention to medical and nursing education at all levels., Methods: A retrospective review was undertaken of all consultations using WhatsApp over an 18-month period, received by the burn centre's two senior medical practitioners. The specific origin and nature of the telemedicine requests for advice, transfer or follow-up were collected, as were data relating to the demographics of the patients, the aetiology, mechanism and extent of the burn injury. The impact of the system of communication in terms of reductions in admissions and clinic visits was assessed, and a cost analysis was undertaken. Feedback was also obtained from those health practitioners regularly using the service., Results: 838 communications occurred during the study period, which included 1562 distinct clinical queries. 486 interactions (58%) originated from within the hospital, the majority of which were initiated by surgeons in training or burn nurse practitioners. 352 (42%) consultations were from outside the hospital. Queries related to the full spectrum of burn care, including emergency management and stabilization, triage and transfer, the need for escharotomy, fluid resuscitation, wound care, the timing and nature of surgical intervention, as well as follow-up and rehabilitation. While no significant changes in the number of surgical interventions or admissions were observed when compared to the five years prior to the intervention, outpatient visits reduced significantly during the study period. It was estimated that over 150 unnecessary admissions were also avoided as a result of the triage made possible by WhatsApp, which translated into considerable cost saving for the institution., Discussion: Incorporating WhatsApp technology into the daily processes of burn care has significantly improved the quality of paediatric burn care referrals to specialist burn services. Specifically, WhatsApp has contributed to reductions in unnecessary referrals and outpatient visits, facilitated opportunities for continuing medical education, improved the care of major burn injuries through more effective prehospital communication, and enabled greater allocation of scarce specialist resources at the burn centre. This study motivates for the wider application of WhatsApp for burn care referrals, especially in developing countries., (Copyright © 2017 Elsevier Ltd and ISBI. All rights reserved.)

As a subset of the growing epidemic of cardiovascular morbidity and mortality in low-income and middle-income countries (LMICs), the significant burdens of heart rhythm disorders also increase. Effective diagnostic and treatment modalities exist, but financial resources and expertise are limited. Cost-effective strategies exist to address most of these limitations, but many surmountable barriers need to be overcome to introduce and improve electrophysiologic care in LMICs. In this article, current and potential solutions are offered for the diagnostic and therapeutic challenges of managing bradyarrhythmias and tachyarrhythmias., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Capacity building is key to the advance of health care in the developing world, but capacity building can take several forms, and it is not yet clear which forms and funding models are most effective. The International Society of Nephrology (ISN) has developed and sustained a portfolio of global outreach programs that make a unique contribution at low cost to the appropriate training and continuing support of nephrologists throughout the developing world. We describe the programs and present encouraging findings of their outcomes. Finally, we reflect on how the ISN interventions and evaluations measure up against recommended approaches in the literature and consider lessons for ISN and other organizations involved in planning, evaluating, and benchmarking similar programs.

The developing world often lacks the resources to effectively treat the most serious injuries including osteomyelitis following open fractures or surgical fracture treatment. Antibiotic cement beads are a widely accepted method of delivering antibiotics locally to the infected area following trauma. This study is based in Cambodia, a low income country struggling to recover from a recent genocide. The study aims to test the effectiveness of locally made antibiotic beads and analyse their effectiveness after being gas sterilised, packaged and kept in storage Different antibiotic beads were manufactured locally using bone cement and tested against MRSA bacteria grown from a case of osteomyelitis. Each antibiotic was tested before and after a process of gas sterilisation as well as later being tested after storage in packaging up to 42 days. The gentamicin, vancomycin, amikacin and ceftriaxone beads all inhibited growth of the MRSA on the TSB and agar plates, both before and after gas sterilisation. All four antibiotics continued to show similar zones of inhibition after 42 days of storage. The results show significant promise to produce beads with locally obtainable ingredients in an austere environment and improve cost effectiveness by storing them in a sterilised condition., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: The Edendale Hospital Burn Service was initiated in 2011 to improve the quality of burn care at a regional hospital. This audit reviews the merits and challenges in developing such a service and identifies areas on which to focus quality improvement initiatives., Methodology: The burn admission records were retrospectively interrogated for the years 2012-2013., Results: This audit covers an 18-month period in which 490 patients were admitted. Admitted days per percentage burn were 2.6 days per percentage total body surface area burnt. The mortality rate was 13%. Fourteen percent of patients met the criteria for referral to the provincial burn centre but for a variety of logistical reasons only 3% were transferred., Conclusion: We have redesigned the process of care without alteration of resources. Outcomes of burns less than 30% total body surface area are not acceptable which we believe reflects the lack of infrastructure and systems development. This audit has revealed a number of areas, which are suitable for dedicated quality improvement initiatives., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Prophylactic antibiotics for tube thoracostomy (TT) for the prevention of post-traumatic empyema (PTE) remain controversial. Literature specifically focusing on the developing world setting is limited., Materials and Methods: A retrospective study was conducted over a four-year period on patients managed with TT alone in which prophylactic antibiotics was not utilised. We documented the actual incidence of PTE in a high volume trauma service in South Africa., Results: A total of 1002 patients who had TT in the trauma room were eligible for inclusion. Ninety-one percent (912/1002) were males and the mean age for all patients was 26 years (SD 7). Seventy-five percent (755/1002) sustained penetrating trauma (PT), while the remaining 25% (247/1002) sustained blunt trauma (BT). Six hundred and twenty patients (62%) sustained HTXs and the remaining 382 patients (38%) had PTXs. Of the 1002 patients who underwent TT, 15 (1.5%, 95% CI: 0.8-2.5%) developed PTE. The incidence of empyema in those with PT was 1.9% (14/755) and 0.4% (1/247) for BT. This difference was not statistically significant (p=0.166). All 15 patients who developed PTE were males, with a mean age of 31 years (SD 6). All 15 patients had HTX as the initial thoracic pathology. This difference was highly statistically significant when compared to PTX (p=0.002). The mean length of hospital stay was 11 days (SD 7). There were no mortalities in these patients., Conclusions: In our setting where prophylactic antibiotics are not routinely used, the actual incidence of PTE in our population is extremely low. In the absence of further definitive evidence to support its use, routine prophylactic antibiotics for TT is difficult to justify in a developing world setting at present., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Simulation has become a significant training tool in the operating room (OR). It can be used in both simple task training and complex scenarios. The challenge for simulation in the OR is how to translate that which is learned, and perceived to beneficial, into behavioral change and improved patient outcomes. Simulation in the developing world is progressing, but is still hampered by a shortage of material, personnel funding., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Maternal and newborn health poses one of the greatest health challenges in the developing world. Many low-income countries are now experiencing a demographic and epidemiological transition and changing of lifestyles. Thus, apparent "Western" diseases such as diabetes and obesity have been reaching the Third World countries. There is a paucity of reliable data on diabetes in pregnancy in many low-income countries. Adequate information about maternal and perinatal mortality and morbidity as a consequence of diabetes in pregnancy is scarce. This chapter presents evidence of the magnitude and impact of diabetes in pregnancy. Additionally, we discuss interventions in screening and managing diabetes in pregnancy in these specific patient populations., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Data on air quality are remarkably limited in the poorest of the world's countries. This is especially true for post-conflict and disaster zones, where international relief efforts focus largely on more salient public health challenges such as water and sanitation, infectious diseases, and housing. Using post-earthquake Haiti as the example case, this commentary explores air quality challenges in the developing world, highlighting concerns related to infrastructure damage from post-conflict and disaster settings. We contend that there is a growing and presently unmet need for further research and attention from the global health community to address these issues., (Copyright © 2014 Elsevier B.V. All rights reserved.)

The social and economic impact of neurologic disorders is being increasingly recognized in the developing world. Demographic transition, especially in large Asian populations, has resulted in a significant increase in the elderly population, bringing to the fore neurologic illnesses such as strokes, Alzheimer's disease, and Parkinson's disease. CNS infections such as retroviral diseases, tuberculosis, and malaria still account for high mortality and morbidity. Traumatic brain injury due to traffic accidents takes a high toll of life. Epilepsy continues to be a major health concern with large segments of the developing world's population receiving no treatment. A significant mismatch between the provision of specialized neurologic services and the requirement for them exists, especially in rural areas. Also, health insurance is not available for the majority, with patients having bear the costs themselves, thus limiting the procurement of available healthcare facilities. Neurologic training centers are few and the availability of laboratory facilities and equipment is largely limited to the metropolitan areas. Cultural practices, superstitious beliefs, ignorance, and social stigma may also impede the delivery of neurologic care. Optimizing available human resources, integrating primary, secondary, and tertiary healthcare tiers and making medical treatment more affordable will improve the neurologic care in the developing world., (© 2014 Elsevier B.V. All rights reserved.)

Introduction: The Pietermaritzburg Metropolitan Trauma Service formerly lacked a robust computerised trauma registry. This made surgical audit difficult for the purpose of quality of care improvement and development. We aimed to design, construct and implement a computerised trauma registry within our service. Twelve months following its implementation, we sought to examine and report on the quality of the registry., Methodology: Formal ethical approval to maintain a computerised trauma registry was obtained prior to undertaking any design and development. Appropriate commercial software was sourced to develop this project. The registry was designed as a flat file. A flat file is a plain text or mixed text and binary file which usually contains one record per line or physical record. Thereafter the registry file was launched onto a secure server. This provided the benefits of access security and automated backups. Registry training was provided to clients by the developer. The exercise of data capture was then integrated into the process of service delivery, taking place at the endpoint of patient care (discharge, transfer or death). Twelve months following its implementation, the compliance rates of data entry were measured., Results: The developer of this project managed to design, construct and implement an electronic trauma registry into the service. Twelve months following its implementation the data were extracted and audited to assess the quality. A total of 2640 patient entries were captured onto the registry. Compliance rates were in the order of eighty percent and client satisfaction rates were high. A number of deficits were identified. These included the omission of weekend discharges and underreporting of deaths., Conclusion: The construction and implementation of the computerised trauma registry was the beginning of an endeavour to continue improvements in the quality of care within our service. The registry provided a reliable audit at twelve months post implementation. Deficits and limitations were identified and new strategies have been planned to overcome these problems and integrate the trauma registry into the process of clinical care., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: In the developing world, data about the burden of injury, injury outcomes, and complications of care are limited. Hospital-based trauma registries are a data source that can help define this burden. Under the trauma care component of the Bloomberg Global Road Safety Partnership, trauma registries have been implemented at three sites in Kenya. We describe the challenges and lessons learned from this effort., Methods: A paper-based trauma surveillance form was developed, in collaboration with local hospital partners, to collect data on all trauma patients presenting for care. The form includes demographic information, pre-hospital care given, and patient care and clinical information necessary to calculate estimated injury surveillance. The type of data collected was standardized across all three sites. Frequent reviews of the data collection process, quality, and completeness, in addition to regular meetings and conference calls, have allowed us to optimize the process to improve efficiency and make corrective actions where required., Results: Trauma registries have been implemented in three hospitals in Kenya, with potential for expansion to other hospitals and facilities caring for injured patients. The process of establishing registries was associated with both general and site-specific challenges. Problems were identified in planning, data collection, entry processes, and analysis. Problems were addressed when identified, resulting in improved data quality., Conclusions: Trauma registries are a key data source for defining the burden of injury and developing quality improvement processes. Trauma registries were implemented at three sites in Kenya. Problems and challenges in data collection were identified and corrected. Through the registry data, gaps in care were identified and systemic changes made to improve the care of the injured., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

North Africa (NAF) is composed of six countries located in the African Sahara, namely the Western Sahara, Morocco, Algeria, Tunisia, Libya, and Egypt. Common features between these countries include similar climate, ecology, population genetics, and the socioeconomic environment. This commonality reflects on the chronic kidney disease (CKD) profile in these countries. While there are some estimates on the epidemiology of end-stage kidney disease, that of earlier stages is unknown. Several national screening programs are currently addressing this issue, such as the EGIPT-CKD project in Egypt and the MAREMAR study in Morocco. Preliminary results from the former suggest a prevalence of proteinuria in 10.6% of the relatives of patients on regular dialysis treatment. Despite the lack of reliable registries, it was possible to gather information on the etiology of CKD by direct contact with leading nephrologists in those countries. It turns out that glomerulonephritis (GN) accounts for 9-20%, diabetes 11-18%, hypertensive nephrosclerosis 10-35%, chronic interstitial nephritis 7-17%, and polycystic disease 2-3%. Compared to two decades earlier, diabetes has become more common at the expense of GN, proliferative GN, and amyloidosis regressed in favor of IgA and membranous nephropathies in Tunisian adults. Conventional schistosomal nephropathies are regressing in favor of hepatitis C viral (HCV) nephropathy in Egyptians. Focal segmental glomerulosclerosis is increasing at the expense of proliferative GNs in the region at large. Access to regular dialysis has been optimized during the past decade, with favorable outcomes despite the high incidence of HCV infection, tuberculosis, and protein-calorie malnutrition. Kidney transplantation is available in all NAF countries except the Western Sahara. About 650 transplants are performed annually from live donors, the majority in Egypt, where data from the largest center in Mansoura display a 10-year graft survival of 62%. Many transplants are performed from living unrelated donors, particularly in Egypt, which creates an ethical debate. Legislation for deceased-donor transplantation has been passed successively over the past two decades in Tunisia, Morocco, Algeria, and Egypt, which is expected to reflect quantitatively and qualitatively on the transplantation activity in the near future.

In the developing world, the emphasis of care for the patient with chronic kidney disease is, in general, focused on the basics of care and patient survival; attention is not primarily focused on quality of life assessments. However, this arena is beginning to attract more attention. It is important to determine if standardized instruments are valid in the developing world and which unique assessments need to be utilized in individual cultural settings.