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Women's mental health during the perinatal period is a major public health problem in Pakistan. Many challenges and competing priorities prevent progress to address the large treatment gap. Aim To quantify the long-term impacts of untreated perinatal depression and anxiety in economic terms, thus highlighting its overall burden based on country-specific evidence. Cost estimates were generated for a hypothetical cohort of women giving birth in 2017, and their children. Women and children experiencing adverse events linked to perinatal mental health problems were modelled over 40 years. Costs assigned to adverse events included were those linked to losses in quantity and quality-of-life, productivity, and healthcare-related expenditure. Present values were derived using a discount rate of 3 %. Data were taken from published cohort studies, as well as from sources of population, economic and health indicators. The total costs were $16.5 billion for the cohort and $2680 per woman giving birth. The by far largest proportion referred to quality-of-life losses ($15.8 billion). Productivity losses and out-of-pocket expenditure made up only a small proportion of the costs, due to low wages and market prices. When the costs of maternal suicide were included, total costs increased to $16.6 billion. Important evidence gaps prevented the inclusion of all cost consequences linked to perinatal mental health problems. Total national costs are much higher compared with those in other, higher middle-income countries, reflecting the excessive disease burden. This study is an important first step to inform resource allocations. • Perinatal mental health problems are a major public health problem in Pakistan. • This study is the first to quantify the costs of perinatal mental health problems in a lower-middle income country. • Costs of $6.2 billion nationally exceed those found in higher middle income countries. • Estimates highlight the urgent need to allocate resources to meet Strategic Development Goals. [ABSTRACT FROM AUTHOR]

Urgent global action is required to combat climate change, with radiographers poised to play a significant role in reducing healthcare's environmental impact. This paper explores radiography-related activities and factors in resource-limited departments contributing to the carbon footprint and proposes strategies for mitigation. The rationale is to discuss the literature regarding these contributing factors and to raise awareness about how to promote sustainability activities in clinical radiography practice and education in resource-limited countries. The radiography-related activities and factors contributing to the carbon footprint in resource-limited countries include the use of old equipment and energy inefficiency, insufficient clean energy to power equipment, long-distance commuting for radiological examinations, high film usage and waste, inadequate training and research on sustainable practices, as well as limited policies to drive support for sustainability. Addressing these issues requires a multifaceted approach. Firstly, financial assistance and partnerships are needed to adopt eco-friendly technologies and clean energy sources to power equipment, thus tackling issues related to old equipment and energy inefficiency. Transitioning to digital radiography can mitigate the environmental impact of high film usage and waste, while collaboration between governments, healthcare organisations, and international stakeholders can improve access to radiological services, reducing long-distance commuting. Additionally, promoting education programmes and research efforts in sustainability will empower radiographers with the knowledge to practice sustainably, complemented by clear policies such as green imaging practices to guide and incentivise the adoption of sustainable practices. These integrated solutions can significantly reduce the carbon footprint of radiography activities in resource-limited settings while enhancing healthcare delivery. Radiography-related activities and factors in resource-limited departments contributing to the carbon footprint are multifaceted but can be addressed through concerted efforts. Addressing the challenges posed by old equipment, energy inefficiency, high film usage, and inadequate training through collaborative efforts and robust policy implementation is essential for promoting sustainable radiography practices in resource-limited countries. Radiographers in these countries need to be aware of these factors contributing to the carbon footprint and begin to work with the relevant stakeholders to mitigate them. Furthermore, there is a need for them to engage in education programmes and research efforts in sustainability to empower them with the right knowledge and understanding to practice sustainably. [ABSTRACT FROM AUTHOR]

To promote global equity in research, innovation, and care, sharing knowledge and grasping current benchmarks is crucial. Despite LIC/LMIC constituting around 80% of the global population, their contribution to neurosurgery research is less than 5%. This study aims to assess the status of neurosurgical oncology in LIC/LMIC using published data, offering strategic insights for progress. Conducting a retrospective bibliometric analysis via PubMed and Scopus databases, we documented reports published (2015–2021) by neurosurgical department-affiliated investigators in LICs/LMICs. World Bank classifications identified LIC and LMIC. Reviewed papers underwent further scrutiny based on independent and associated keyword lists. Our systematic approach revealed 189 studies from LMIC in 10 neurosurgery journals. Of these, 53% were case reports, with 88% focusing on brain pathologies and 12% on the spine. Intra-axial brain tumors (45.8%), extra-axial/skull base (38.4%), and metastasis (3.68%) were prominent. Among noncase report publications, surgical technique and outcome were common themes. India, Egypt, and Tunisia led in publications, with 94% appearing in journals with an impact factor below 5. No papers originated from LIC. This study reinforces existing findings that data from LMIC inadequately represent their populations, impeding a comprehensive understanding of their neurosurgical oncology landscape. Language barriers and data collection difficulties contribute to this gap. Addressing these challenges could significantly enhance progress in shaping the future of neurosurgical oncology in these regions. [ABSTRACT FROM AUTHOR]

• Influenza vaccines are not widely used in resource-limited settings. • Clinical endpoints in vaccine efficacy trials in children are highly variable. • Vaccine trials were not designed to measure severe illness outcomes. • Broad vaccine implementation will require focus on clinically relevant outcomes. We conducted a systematic review of pediatric influenza vaccine efficacy trials to assess clinical outcome measures and whether the trials defined important public health endpoints. We systematically identified phase 3 or 4 influenza vaccine randomized controlled trials among children ≤18 years of age with laboratory-confirmed influenza outcomes since 1980. We recorded countries, age groups, vaccine formulations, specimen collection criteria, laboratory diagnostics, primary and secondary outcome measures, and funders, and we determined income category for study countries. We used descriptive statistics to summarize study characteristics. We analyzed the studies overall and a subset of studies conducted in at least one low- and middle-income country (LMIC). From 6455 potentially relevant articles, we identified 41 eligible studies. Twenty-one studies (51%) were conducted in at least one LMIC, while the remaining studies (49%) were conducted in high-income countries only. Thirty-one studies (76%) included children younger than six years. We found 40 different primary outcome measures among the 41 eligible studies. Thirty-three studies (80%) reported standardized symptoms or findings which defined a primary outcome or triggered specimen collection. One study defined a primary outcome which captured more severe illness; however, cases were mostly due to high body temperature without other severity criteria. Of the 21 studies from at least one LMIC, 15 (71%) were published since 2010 and 17 (81%) enrolled children younger than six years. Eighteen (86%) studies from at least one LMIC reported standardized symptoms or findings which defined a primary outcome or triggered specimen collection. Among pediatric influenza vaccine efficacy trials, primary outcome measures and clinical specimen collection criteria were highly variable and, with one exception, focused on capturing any influenza illness. As most LMICs do not have influenza vaccination programs, our study highlights a potential data limitation affecting policy and implementation decisions in these settings. [ABSTRACT FROM AUTHOR]

Background Serum insulin-like growth factor 1 (sIGF-1) is an important growth factor in childhood. However, studies on sIGF-1 among children from low-income countries are few, and the role of body composition is unknown. Objectives To assess the associations of anthropometry, body composition, inflammation, and breastfeeding with sIGF-1 among children with moderate acute malnutrition (MAM). Methods A cross-sectional study based on admission data from 6- to 23-mo-old children with MAM participating in a nutrition intervention trial (Treatfood) in Burkina Faso. Linear regression analysis was used to identify correlates of sIGF-1. Results Among 1546 children, the median (IQR) sIGF-1 was 12 (8.2–18.3) ng/mL. sIGF-1 was highest at 6 mo, with a nadir ∼10–11 mo, and higher in girls than boys. Length-for-age z score (LAZ), weight-for-length z score (WLZ), and midupper arm circumference were positively associated with sIGF-1 (P  ≤ 0.001). Fat-free mass (FFM) was also positively associated, as sIGF-1 increased 1.5 (95% CI: 0.5, 2.5) ng/mL for each 1-kg increase in FFM. However, the association disappeared after adjustment for height. Elevated serum C-reactive protein and α1-acid glycoprotein were negatively associated with sIGF-1 (P  ≤ 0.001), as was fever (P  < 0.001) but not a positive malaria test per se (P  = 0.15). Children never breastfed had lower sIGF-1 (–5.1; 95% CI: –9.8, –0.3). Conclusions LAZ and WLZ were positively and inflammation negatively associated with sIGF-1. As all children were moderately malnourished and many had inflammation, this probably explains the very low median sIGF-1. The association of FFM with sIGF-1 was fully explained by height. There was a marked age pattern, with a nadir in late infancy, confirming findings from smaller studies from well-nourished populations. There is a need for prospective studies to disentangle the role of sIGF-1 in growth and health. This trial was registered at https://www.isrctn.com as ISRCTN42569496. [ABSTRACT FROM AUTHOR]

• The "Airway, Breathing, Circulation, Disability and Exposure" (ABCDE) approach should be used whenever an injury is suspected, as it provides quick identification and management of life-threatening problems. • Identification of any deviation from standardized care is a crucial part of improving patient care and thus reducing morbidity and mortality. • This study found that the mean percentage of adherence to the ABCDE approach was low (37.9 %). And, the ABCDE sequence was usually not followed. • Overcrowding and un-prepared facilities were common obstacles to adherence to the "ABCDE" approach in Khartoum, Sudan. Early recognition and initial treatment of trauma patients prevents deterioration and buys time for making a definitive diagnosis. The "Airway, Breathing, Circulation, Disability and Exposure" (ABCDE) approach should be used whenever an injury is suspected. It provides quick identification and management of life-threatening problems. Still, there is limited knowledge regarding adherence to the ABCDE approach. This research aims to assess the adherence of the trauma team members to the ABCDE approach in the management of major trauma patients and the factors affecting it. The study is a cross-sectional hospital-based study conducted in the trauma and resuscitation rooms of major governmental hospitals in Khartoum in the period from Jan.30, 2022, to Mar.29, 2022. It was done among the medical staff dealing with major trauma cases. Data were collected by observation using a modified standardized checklist for assessing the ABCDE approach and via a self-administered questionnaire for identifying the factors affecting adherence. Total coverage of all major trauma cases resuscitation (n = 50) was done. Also, a sample size of 158 medical staff was covered for the questionnaire. The data was analyzed in Statistical Package for the Social Science (SPSS) V.23. The mean percentage of adherence to the ABCDE approach was 37.9 % (SD 15.44). When the ABCDE sequence was not followed, the ACB was the commonest sequence. Also, adherence had no significant relation with any patient or staff-related factor. The main present obstacles to adherence to the ABCDE approach were overcrowding in the room and unprepared facilities. While the major present facilitator was the clinical experience. The adherence rate was low, but initiation of the ABCDE approach was rapid. The factors participating in low adherence rates were usually facility or population-based factors. We recommend further studies, further training and embedment of guidelines, and the provision of larger trauma rooms with adequate supplies. [ABSTRACT FROM AUTHOR]

In low-income countries with poor SARS-CoV-2 monitoring and high HIV burden, the prevalence of SARS-CoV-2 is scarcely studied in people living with HIV (PLWH). We set out to measure SARS-CoV-2 seroprevalence in this group. Serosurvey of SARS-CoV-2 in PLWH. We measured IgG/IgM antibodies using point-of-care rapid tests in 294 PLWH with HIV-1, HIV-2 or HIV-1/2 dual infection at an HIV clinic in Guinea–Bissau between June 1, 2021, and October 1, 2021. Unvaccinated PLWH (n = 195), constituting 66% of the total study population, had a seroprevalence of SARS-CoV-2 antibodies of 27.7%. Of SARS-CoV-2 seropositive unvaccinated PLWH, 71.2% reported no symptoms of COVID-19 since the start of the epidemic up to the inclusion date. Among all participants, 90.1% reported never having been tested for SARS-CoV-2 by any test (n = 292). Six participants reported a household death, corresponding to a crude annual death rate of 3.3 per 1000 people. Despite a low number of officially registered cases of SARS-CoV-2 in Bissau, we found a high seroprevalence of SARS-CoV-2 of 27.7% in unvaccinated PLWH. Coupled with few ever tested for SARS-CoV-2, it indicates that official PCR testing likely underestimates prevalence and that SARS-CoV-2 monitoring is challenged for PLWH. The low number of symptoms from seropositives may stem from survival bias, some effect of herd immunity or, coupled with a low crude annual death rate, that disease symptomatology and severity could be lower than expected. [ABSTRACT FROM AUTHOR]

Sustainable milk production and consumption in low-income countries must address food security and climate change mitigation simultaneously. Socioeconomic sustainability is paramount in low-income countries, where milk production and consumption represent a vehicle to improve human nutrition and health, as well as the potential for economic opportunity and improved livelihood of subsistence farmers. These benefits can only be achieved with judicious use of animal stocks and agricultural practices that do not exhaust available natural resources, which are often shared by regional farming communities. Milk and dairy foods provide variety to the diet and make significant contributions to meeting the needs for high-quality protein, calcium, magnesium, selenium, riboflavin, vitamin B12, and pantothenic acid (vitamin B5) in at-risk populations, particularly children, pregnant women, and the elderly. Milk production in low-income countries occurs largely in smallholder mixed crop-livestock systems where animals play multiple roles and may suffer from undernutrition, leading to negligible or no milk production during several months of the year. Non-food roles of livestock include draft, fuel (manure), store of capital, and insurance against crop failure. These roles and the social standing associated with animal ownership may incentivize the maintenance of large herds that place stress on feed (land) and water resources. Under these circumstances, sustainable intensification (i.e., increasing milk production from currently available resources) represents the single most important and practical strategy to improve the sustainability of milk production and consumption in low-income countries. Improving the genetic potential of animals and the availability of quality feed, and providing balanced nutrition are the most promising strategies to improve milk production and sustainability in low-income countries. For example, the deficit for milk in Ethiopia is estimated at 4.5 billion liters/year, which can be closed, in part, with balanced animal nutrition. Milk production in low-income countries will be more sustainable if it relies on natural resources available locally and regionally to supply essential nutrients to at-risk human populations. [ABSTRACT FROM AUTHOR]

Hospital-acquired tuberculosis infection among healthcare workers is a global concern due to the increased attributable risk of tuberculosis infection among this group. To reduce healthcare workers' exposure to airborne Mycobacterium tuberculosis , various policies and guidelines have been developed and updated by the World Health Organisation (WHO) since 1999. In March 2019, the WHO published the updated tuberculosis infection control guidelines. It had previously been suggested that the existence of multiple guidelines and the changes in the contents across versions may confuse end-users and challenge the implementation. With this issue in mind, we examined the updated WHO 2019 TB infection control guidelines. The WHO 2019 updated guideline is a shorter and more focused document that includes more of the evidence from published systematic reviews for TB infection prevention and control. The guidelines focus on implementing TB infection control as an integrated infection control and prevention 'package'. However, a few key elements have been omitted or integrated with other WHO policies that were previously included in the guidelines, many of which are also still present in other international and in many national level TB infection control guidelines. In this commentary, we highlighted the inconsistencies in the different versions of the guidelines, the challenges that the high TB burden and low-income countries may face while implementing the guidelines and some factors that may be considered in the future guidelines. The arguments we made have important implications for tuberculosis infection control strategy development and implementation in low-income and high TB burden countries. [ABSTRACT FROM AUTHOR]

• Bathing infants with chlorhexidine reduced rates of bloodstream infection in NICUs. • Antiseptic baths were not associated with any adverse events. • Modern statistical methods provide interpretable estimates of causal effects. Sepsis is the leading cause of infectious morbidity and mortality among hospitalized neonates. In high-resource pediatric and adult intensive care units, use of aqueous chlorhexidine (CHG) solution has been associated with reduced risk of bloodstream infections (BSI). To assess the impact of bathing of neonates with 2% CHG on BSI, suspected sepsis, and mortality in a low-income country neonatal care unit. We conducted a secondary analysis of data from the Sepsis Prevention in Neonates in Zambia (SPINZ) study, a prospective observational cohort study performed at a large public referral hospital in Lusaka, Zambia. The SPINZ study assessed the impact of an infection control bundle (consisting of alcohol hand rub, SMS hygiene reminders, enhanced environmental cleaning, and CHG baths for babies ≥1.5 kg) on sepsis, BSI, and all-cause mortality. Episodic shortages in study staffing resulted in some enrolled babies not receiving a CHG bath. Using Longitudinal Targeted Maximum Likelihood Estimation and Cox proportional hazards regression to adjust for observed confounding, we estimated the causal effect of receiving a CHG bath within the first 3 days of life on suspected sepsis, BSI, and death among inborn babies enrolled during the study implementation and intervention phases. The majority of inborn, enrolled babies ≥1.5 kg received a CHG bath within 3 days of NICU admission (864 of 1233, 70%). We found that CHG bathing reduced the hazard rate of BSI among inborn babies ≥1.5 kg by a factor of 0.58 (p = 0.10, 95% CI: 0.31, 1.11), corresponding to an absolute risk reduction of 9.6 percentage points within a week of admission (p = 0.002, 95% CI: 3.4–15.7 percentage points). We did not find a statistically significant effect of CHG bathing on culture-negative sepsis (p = 0.54) or death (p = 0.85). In our single center study, CHG bathing at admission was associated with a reduced risk of BSI due to a pathogenic organism after adjusting for potential confounding. Our results suggest that CHG may be an effective intervention for preventing neonatal sepsis in high-risk, low-income country settings. [ABSTRACT FROM AUTHOR]

Background: Milk intake stimulates linear growth and improves cognition in children from low-income countries. These effects may be mediated through insulin-like growth factor-1 (IGF-1).Objective: The objective was to assess the effect of milk supplement on circulating IGF-1 and to assess IGF-1 as a correlate of growth and cognition in children.Methods: Secondary data on blood spot IGF-1 from a randomized, double-blind, controlled trial in 6-9-y-old children from rural Ghana were analyzed. Intervention groups received porridge with non-energy-balanced supplements: 8.8 g milk protein/d, 100 kcal/d (Milk8); 4.4 g milk and 4.4 g rice protein/d, 100 kcal/d (Milk/rice); 4.4 g milk protein/d, 48 kcal/d (Milk4); or a control (no protein, 10 kcal/d). IGF-1, length, body composition, and Cambridge Neuropsychological Test Automated Battery (CANTAB) were measured at 3.5 or 8.5 mo. Linear regressions were used to assess the effect of milk interventions on IGF-1 and IGF-1 as a correlate of growth and cognition.Results: The increase in IGF-1 was 15.3 (95% CI: 3.3, 27.3) ng/mL higher in children receiving Milk8 compared with the control. The IGF-1 increases in the isonitrogenous, isoenergetic Milk/rice or the Milk4 groups were not different from the control (P ≥ 0.49). The increase in IGF-1 was associated with improvements in 4 out of 5 CANTAB domains. The strongest associations included reductions in "mean correct latency" from Pattern Recognition Memory and "pre-extradimensional (pre-ED) shift errors" from Intra/Extradimensional Set Shift (P ≤ 0.005). In addition, change in IGF-1 was positively associated with changes in height, weight, and fat-free mass (P ≤ 0.001).Conclusions: Intake of skimmed milk powder corresponding to one, but not half a glass of milk on school days stimulates IGF-1 in 6-9-y-old Ghanian children. IGF-1 seems to mediate the effect of milk intake on growth and cognition. The association between IGF-1 and cognition in relation to milk intake is novel and opens possibilities for dietary interventions to improve cognition. [ABSTRACT FROM AUTHOR]

In patients with disorders of sex development (DSD), surgical/medical treatments are undertaken after sex assignment to ensure congruent bodily appearance and function. Genital reconstruction in these patients can be daunting with varied outcome. Understanding these outcomes is imperative, more especially in a developing country where added challenges exist. This study evaluates the outcome of genital surgery in patients with DSD assigned female sex. A retrospective analysis of 25 cases of female sex assigned DSD managed in two tertiary centers in southeast Nigeria was performed. Data of these cases were collected from the case notes, discharge summaries, and theater records. IBM SPSS Statistics Data Editor, version 21, was used for data entry and analysis. The patients presented at median age of 12 months (range 2 days–30 years), with 15 (60%) cases reared as female and 10 (40%) reared as male before presentation. The predominant phenotype was phallus with empty fused/unfused labioscrotum and urethra opening in the labioscrotum or perineum in 21 (84%) patients. Evaluation revealed features suggestive of 46XX DSD in 21 (84%) patients, ovotesticular DSD in two (8%), and androgen insensitivity in two (8%). A total of 10 cases required sex reassignment after evaluation. Overall, 24 of the 25 cases had feminizing genital procedures. After a median follow-up period of 2 years (range 2 months–8 years), six (25%) cases developed procedure-related complications, three (12.5%) had social maladjustment, and two (8.3%) patients reported features of gender dysphoria. The procedures of feminizing genitoplasty in this study did not differ from the established procedure. However, as a result of challenges of delayed presentation, inadequate early management, sociocultural factors, and a lack of facilities for full evaluation, some cases may require sex reassignment and more daunting reconstructive procedures. This may give rise to less than optimal outcome. The study was limited by the retrospective nature, small number of cases, and the short duration of follow-up of the cases. Feminizing genital procedures for DSD in our setting may be associated with procedure-related complications and non-surgical complications. Improving surgical technique and addressing the challenges of delayed presentation and fixation on male gender may improve overall outcome. The operative procedures and the outcome are summarized in the following table. Feminizing genital procedures and the outcome in the female sex assigned DSD patients Procedure n (%) Surgical complications Psychosocial sequelae Nil Surgical wound infection Vaginal stenosis *Social maladjustment Gender dysphoria Clitoroplasty and vulvoplasty 12 (48%) 12 0 0 0 0 Clitoroplasty, vulvoplasty, and prepubertal cutback vaginoplasty 5 (20%) 1 0 4 1 1 Clitoroplasty, vulvoplasty, and postpubertal cutback vaginoplasty 3 (12%) 0 0 0 2 1 Orchidectomy, clitoroplasty, labioscrotal reduction vulvoplasty, and colon substitution vaginoplasty 2 (8%) 1 1 0 0 0 Orchidectomy, clitoroplasty, labioscrotal reduction vulvoplasty, and awaiting colon substitution vaginoplasty 2 (8%) 1 1 0 0 0 No procedure (parents refused assigned gender) 1 (4%) – – – – – Total 25 15 2 4 3 2 ∗CAIS, complete androgen insensitivity syndrome [ABSTRACT FROM AUTHOR]

Abstract Objectives With increasing global interest in hospital antimicrobial stewardship (AMS) programmes, there is a strong demand for core elements of AMS to be clearly defined on the basis of principles of effectiveness and affordability. To date, efforts to identify such core elements have been limited to Europe, Australia, and North America. The aim of this study was to develop a set of core elements and their related checklist items for AMS programmes that should be present in all hospitals worldwide, regardless of resource availability. Methods A literature review was performed by searching Medline and relevant websites to retrieve a list of core elements and items that could have global relevance. These core elements and items were evaluated by an international group of AMS experts using a structured modified Delphi consensus procedure, using two-phased online in-depth questionnaires. Results The literature review identified seven core elements and their related 29 checklist items from 48 references. Fifteen experts from 13 countries in six continents participated in the consensus procedure. Ultimately, all seven core elements were retained, as well as 28 of the initial checklist items plus one that was newly suggested, all with ≥80% agreement; 20 elements and items were rephrased. Conclusions This consensus on core elements for hospital AMS programmes is relevant to both high- and low-to-middle-income countries and could facilitate the development of national AMS stewardship guidelines and adoption by healthcare settings worldwide. [ABSTRACT FROM AUTHOR]

Abstract Background Rotaviruses mortality among infants and young children is high in Sub-Saharan Africa. Recently, Ethiopia introduced the monovalent rotavirus vaccine in its national immunization program to decrease the burden of rotavirus disease and mortality. Rotavirus surveillance in Ethiopia is based largely on data provided by sentinel hospitals in its capital Addis Ababa. Objective To assess rotavirus abundancy and diversity in outpatient infants and children outside of Addis Ababa in the early post-introduction period. Method Fecal samples were obtained from children aged less than five years presenting with diarrhea at outpatient health institutions in two cities in Northwest Ethiopia, Gondar and Bahir Dar, from November 2015 to April 2016. Basic demographic data were assessed. Real-time RT-PCR was used to detect rotavirus A RNA. Based on sequences of VP4 and VP7 gene segments phylogenetic analysis was performed. Results Rotavirus wildtype positivity was 25% (113/450). Rotavirus infection was less common in infants below 6 months than in children of all other age-groups. Rotavirus genotype distributions were distinct between Bahir Dar and Gondar. In total, wildtype G3P[8], G2P[4], G9P[8], G12P[8], and G3P[6] rotaviruses were detected in 68 (60.2%), 21 (18.6%), 13 (11.5%), 9 (8.0%), and 2 (1.8%) of the positive samples, respectively. Wildtype G1P[8] strains were absent. The phylogenetic analysis revealed close relatedness of current rotaviruses with Ethiopian strains of the pre-vaccination period. Conclusion In the early period after the introduction of vaccination, rotaviruses in Northwestern Ethiopia were frequent in children of 6–59 months and diverse. High phylogenetic relatedness with strains of the pre-vaccine era, indicate absence of early vaccine-induced strain replacement. Future surveillance studies should be carried out throughout the country to gain comprehensive data on rotavirus strain diversity and to monitor the effect of the ongoing vaccine program on the disease burden and eventual rotavirus strain replacement. Highlights • High rotavirus positivity in samples at early post-vaccination stage • Less common rotavirus infections in infants <6 months than in children 6–59 months • Distinct strain diversity in two geographically proximate sampling sites • High phylogenetic relatedness of rotaviruses of the current and pre-vaccine era • Absence of G1P[8] wildtype rotaviruses [ABSTRACT FROM AUTHOR]

Background There is a need for a pediatric trauma outcomes benchmarking model that is adapted for Low-and-Middle-Income Countries (LMICs). We used the National-Trauma-Data-Bank (NTDB) and applied constraints specific to resource-poor environments to develop and validate an LMIC-specific pediatric trauma score. Methods We selected a sample of pediatric trauma patients aged 0–14 years in the NTDB from 2007 to 2012. Primary outcome was in-hospital death. Logistic regression was used to create the Pediatric Resuscitation and Trauma Outcome (PRESTO) score, which includes only low-tech predictor variables — those easily obtainable at point-of-care. Internal validation was performed using 10-fold cross-validation. External validation compared PRESTO to TRISS using ROC analyses. Results Among 651,030 patients, there were 64% males. Median age was 7. In-hospital mortality-rate was 1.2%. Mean TRISS predicted mortality was 0.04% (range 0%–43%). Independent predictors included in PRESTO (p < 0.01) were age, blood pressure, neurologic status, need for supplemental oxygen, pulse, and oxygen saturation. The sensitivity and specificity of PRESTO were 95.7% and 94.0%. The resulting model had an AUC of 0.98 compared to 0.89 for TRISS. Conclusion PRESTO satisfies the requirements of low-resource settings and is inherently adapted to children, allowing for benchmarking and eventual quality improvement initiatives. Further research is necessary for in-situ validation using prospectively collected LMIC data. Level of evidence Level III — Case–Control (Prognostic) Study. [ABSTRACT FROM AUTHOR]

• TBAs and community health workers need to be better trained. • In-service education for hospital professional to improve communication and teamwork. • National Maternal death surveillance needs to be commencement. Somaliland has one of the highest rates of maternal deaths in the world. An estimated 732 women die for every 100,000 live births. This study aims to identify the prevalence of facility-based maternal deaths, the causes and their underlying circumstances by interviewing relatives and health care providers at the main referral hospital. A hospital-based mixed method study. The prospective cross-sectional design of the WHO Maternal Near Miss tool was combined with narrative interviews with 28 relatives and 28 health care providers in direct contact with maternal deaths. The quantitative data was analysed with descriptive statistics using SPSS and the qualitative part of the study was analysed with content analysis using NVivo. From the 6658 women included 28 women died. The highest direct cause of maternal death was severe obstetric haemorrhage (46.4%), followed by hypertensive disorders (25%) and severe sepsis (10.7%). An indirect obstetric cause of death was medical complications (17.9%). Twenty-five per cent of these cases were admitted to ICU and 89% had referred themselves to the hospital for treatment. The qualitative data identifies two categories of missed opportunities that could have prevented these maternal mortalities: poor risk awareness in the community and inadequate interprofessional collaboration at the hospital. The referral system needs to be strengthened utilizing Traditional Birth Attendants as community resource supporting the community facilities. The communication skills and interprofessional collaboration of the health care providers at the hospital needs to be addressed and a national maternal death surveillance system needs to be commenced. [ABSTRACT FROM AUTHOR]

This paper examines the characteristics of teacher education that helped and/or hindered the implementation of learner-centred pedagogy (LCP) in low- and middle-income countries. Methodologically, a systematic review was employed, with a final total of 59 relevant texts being identified. The review found that teacher education was influenced by: length of training, amount of ongoing support, degree of engagement and activeness, extent to which practical experiences were included, extent to which courses incorporated reflection, degree of contextual flexibility, and degree of teacher collaboration. These factors should be considered by those implementing teacher education provision in contexts where LCP is explicitly encouraged. • Systematic review of learner-centred pedagogy in low-to middle-income countries, with focus on teacher education. • Findings indicate that training needs to be "long enough" and incorporate ongoing support. • To be effective, teacher training must be active, practical and model learner-centred practices. • Training must provide opportunities for self-reflection and incorporate flexibility to adapt to local classroom contexts. • Finally, teacher collaboration is also vitally important to enable implementation of learner-centred pedagogy. [ABSTRACT FROM AUTHOR]

Background: Hospital-associated infections (HAIs) are more frequently encountered in low- than in high-resource settings. There is a need to identify and implement feasible and sustainable approaches to strengthen HAI prevention in low-resource settings.Aim: To evaluate the biological contamination of routinely cleaned mattresses in both high- and low-resource settings.Methods: In this two-stage observational study, routine manual bed cleaning was evaluated at two university hospitals using adenosine triphosphate (ATP). Standardized training of cleaning personnel was achieved in both high- and low-resource settings. Qualitative analysis of the cleaning process was performed to identify predictors of cleaning outcome in low-resource settings.Findings: Mattresses in low-resource settings were highly contaminated prior to cleaning. Cleaning significantly reduced biological contamination of mattresses in low-resource settings (P < 0.0001). After training, the contamination observed after cleaning in both the high- and low-resource settings seemed comparable. Cleaning with appropriate type of cleaning materials reduced the contamination of mattresses adequately. Predictors for mattresses that remained contaminated in a low-resource setting included: type of product used, type of ward, training, and the level of contamination prior to cleaning.Conclusion: In low-resource settings mattresses were highly contaminated as noted by ATP levels. Routine manual cleaning by trained staff can be as effective in a low-resource setting as in a high-resource setting. We recommend a multi-modal cleaning strategy that consists of training of domestic services staff, availability of adequate time to clean beds between patients, and application of the correct type of cleaning products. [ABSTRACT FROM AUTHOR]

Gastroschisis is a congenital birth defect of the abdominal wall, with a high mortality rate in middle-income countries, especially among twins. We report a monozygotic twin pregnancy in a 14-year-old girl with a low socioeconomic status and living in a rural area 4 hours away from our II-III health care level hospital, which has medical expertise for handling gastroschisis, in a developing country (Mexico). Prenatal screening was performed using ultrasonography and magnetic resonance imaging, followed by close monitoring and lung maturity induction. A caesarean section was scheduled at 36 weeks, with three available operating rooms for the mother, twin 1, and twin 2, with three teams of specialists. Birth management was done under sedation and analgesia, without intubation. Primary closure was performed for twin 1 and a preformed silo was used for twin 2, who had associated arthrogryposis. Both twins underwent defect sealing with hydrocolloid dressings and sutureless closures, and subsequent neonatal intensive care unit treatment. They had 46XY chromosomes and an identical genetic profile, and were discharged on days 23 and 49, respectively. A specialized multidisciplinary team with state-of-the-art technology, adapted to the hospital conditions of a middle-income country, is paramount for the positive outcomes of twins with gastroschisis. • A novel report of twin gastroschisis, one twin with associated arthrogryposis. • Successful handling involves adapting advanced technology to a developing country. • Planned caesarean sections for twin gastroschisis cases in developing countries. [ABSTRACT FROM AUTHOR]

Background Central nervous system (CNS) tumors are the most common cause of cancer-related death in children. Little is known about the demographics and treatment of pediatric brain tumors in low- and middle-income countries (LMICs). Methods We performed a retrospective chart review of all pediatric patients who presented to the neurosurgical service at Tribhuvan University Teaching Hospital in Kathmandu, Nepal from 2009–2014 and collected information on patients <18 years old who received a diagnosis of a CNS tumor. We analyzed age, gender, clinical presentation, extent of surgical resection, histopathology, and length of hospital stay. We also conducted a literature review using specific terminology to capture studies of pediatric neuro-oncologic epidemiology conducted in LMICs. Study location, length of study, sample size, study type, and occurrence of 4 common pediatric brain tumors were extracted. Results We identified 39 cases of pediatric CNS tumors, with 62.5% observed in male children. We found that male children (median = 13 years) presented later than female children (median = 8 years). The most frequently observed pediatric brain tumor type was ependymoma (17.5%), followed by astrocytoma (15%) and medulloblastoma (15%). Surgical resection was performed for 80% of cases, and gross total resection reported in 62.9% of all surgeries. More than half (54.1%) of patients had symptoms for more than 28 days before seeking treatment. Symptomatic hydrocephalus was noted in 57.1% of children who presented with CNS tumors. The literature review yielded studies from 18 countries. Study length ranged from 2–20 years, and sample sizes varied from 35–1948. Overall, we found more pronounced variation in the relative frequencies of the most common pediatric brain tumors, compared with high-income countries. Conclusions We present the first operative series of childhood CNS tumors in Nepal. Children often had delayed diagnosis and treatment of a tumor, despite symptoms. More comprehensive data are required to develop improved treatment and management algorithms in the context of a given country's demographics and medical capabilities for childhood CNS tumors. [ABSTRACT FROM AUTHOR]

Induction of labor in resource-limited settings has the potential to significantly improve health outcomes for both mothers and infants. However, there are relatively little context-specific data to guide practice, and few specific guidelines. Also, there may be considerable issues regarding the facilities and organizational capacities necessary to support safe practices in many aspects of obstetrical practice, and for induction of labor in particular. Herein we describe the various opportunities as well as challenges presented by induction of labor in these settings. [ABSTRACT FROM AUTHOR]

The electrification of the world's rural poor is an important aim of the United Nations. Off-grid technologies, such as electric mini-grids are seen as appropriate solutions. However, their diffusion rate in developing countries is not sufficient to reach poverty reduction targets. In this paper we analyze the case of remote electric mini-grids in Laos, a least-developed country characterized by many barriers to the diffusion of modern technology. We apply the Technological Innovation Systems (TIS) approach in order to derive policy recommendations on how to increase the diffusion rate. As the TIS framework has hardly been applied to such challenging contexts, we also aim to produce insights for the theoretical advancement of the TIS literature. Our analysis, which draws from secondary and primary data collected through field work, points to two systemic root causes for the low diffusion rate: institutional mismatches within and across geographical levels as well as hampered flows of resources across these levels. Based on these findings we derive policy recommendations proposing to formulate a national technology-specific electrification strategy. In terms of insights for the TIS community, we suggest to strengthen the role of culture in empirical TIS analyses and to extend the definition of one specific TIS function. [ABSTRACT FROM AUTHOR]

There has been a growing empirical literature on the relationship between household socioeconomic status (SES) and children's health, and in particular, whether this SES gradient is constant or varies in strength across different life stages. Much of this literature focuses on the developed countries and less evidence has been presented for developing countries. Using Vietnam's rich National Health Survey (2001–02) and appropriate multilevel modeling this study empirically assesses the SES gradient in health and whether it varies in strength across different life stages of children aged 15 and younger (N = 45,448). The results for the interaction terms between the natural logarithm of household consumption and age groups indicate no evidence of a steeper health gradient for older children. However, health-consumption gradients are found to be sensitive to the functional form of the regression model as well as the model specification. The results for the interaction terms between consumption expenditure quintiles and age groups indicate that gradients vary in strength across ages. Not only are children from the poorest households worse off, compared to those from the richest households, but this relative disadvantage is greater among the 0–3 year olds. The inclusion of parental health status in the regression model weakens the gradients for all age groups as does the inclusion of household sources of drinking water. However, poorer children are still relatively worse off, specially the 0–3 year olds. This suggests that absolute deprivation may help explain the relative health disadvantage of younger children. Better measures of poverty alleviation are hence needed to improve children's health in a low-income country such as Vietnam. [ABSTRACT FROM AUTHOR]

Clinical practice guidelines are one of the tools available to improve the quality of health care. However, it may be difficult for countries to develop their own national guidelines ''from scratch'' because of limitations in time, expertise, and financial resources. The Estonian Health Insurance Fund (EHIF), in collaboration with other stakeholders, has launched a national effort to develop and implement evidence-based clinical practice guidelines aimed at improving the quality of care. Although the first EHIF handbook for preparing guidelines was published in 2004, there has been wide variation in the format and quality of guidelines prepared by medical specialty societies, EHIF, and other organizations in Estonia. An additional challenge to guideline development in Estonia is that it is a country with limited human resources. Therefore, revision of the Estonian guideline process was aimed at developing an efficient method for adapting current high-quality guidelines to the Estonian setting without compromising their quality. In 2010, a comprehensive assessment of guideline development in Estonia was made by the World Health Organization, EHIF, the Medical Faculty at the University of Tartu, and selected national and international experts in an effort to streamline and harmonize the principles and processes of guideline development in Estonia. This study summarizes the evaluation of and revisions to the process. Estonia has made substantial changes in its processes of clinical practice guideline development and implementation as part of an overall program aiming for systematic quality improvement in health care. This experience may be relevant to other small or resource-limited countries. [ABSTRACT FROM AUTHOR]

Abstract: Neuro-psychiatric disorders are associated with a considerable burden of disease, not only globally, but also in low- and middle-income countries. Epidemiological information about treatment of these disorders is required to help formulate treatment and prevention strategies. The aim of this study was to describe different types of mental health care providers, and examine patients’ knowledge of the treatments and their views about its effectiveness in rural Punjab, Pakistan. We conducted a cross-sectional survey of attenders at a 1-day psychiatric consultation clinic in rural Punjab, Pakistan. Patients sought help from five different types of providers and were treated with physical, psychotherapeutic and spiritual treatments. Most recognised psychiatric problems as treatable. There was a discrepancy between belief and knowledge of the treatment of mental disorders; most had a very basic understanding of treatment. They reported general practitioner (GP) treatments as more effective (56%) compared to other practitioners (20%). We argue that treatments given by primary mental health care providers need to be standardised. A systematic appraisal of the theoretical rationale of the mental health treatments prescribed in primary care settings is required in low-income countries like Pakistan. This will help ensure standardisation of care especially regarding spiritual/psychological therapies so that in future valid inferences can be made about their effectiveness in populations. Further work should include improving mental health literacy with special reference to treatments available for mental health problems. [Copyright &y& Elsevier]

• Applying sociotechnical systems thinking to road safety in Bangladesh. • The analysis of three high-profile road traffic collisions using the Accimap approach. • Recommendations for road safety interventions that target all levels of the system. • Systems thinking should influence collision investigation in low-income settings. Road traffic collisions are increasing at an alarming rate in Bangladesh. Many have caught the attention of the public, and the administration and government. In this study, the Accimap methodology is used to analyse three high-profile road traffic collisions from a sociotechnical point of view. Sociotechnical approaches have gained popularity in high income countries for investigating such incidents, but it is still very new to practitioners in low-income countries. The integrated framework provides an insight into the interactions between different levels of a studied system, and supports the development of recommendations that could mitigate or prevent the outcomes of such incidents in the future. In this comparative analysis it was revealed that blaming the drivers cannot help mitigate accidents, rather reformations in the whole sociotechnical system need to be made that go beyond the traditional three E's of engineering, enforcement, and education. By integrating the different levels of the system, from international committees to end users, a systematic approach can be developed to improve road traffic collision analysis and reporting in Bangladesh. [ABSTRACT FROM AUTHOR]

• 72% of older people with mental illness are physically inactive. • Autonomous motivation is key to motivating older people with mental illness to be active. • Somatization symptoms should be considered when motivating older people with mental illness to be active. Within the trans-theoretical model (stages of change) and self-determination theory frameworks, we investigated motives for physical activity adoption and maintenance in middle-aged and old age people with a mental disorder from a low-income setting. Ninety Ugandan outpatients completed the Behavioral Regulation in Exercise Questionnaire-3 (BREQ-3) to assess exercise motives and the Patient-centred Assessment and Counselling for Exercise (PACE) to determine stage of change. The relationship between motives for physical activity and stage of change was investigated using MANOVA with post-hoc Scheffe tests. Higher amotivation levels were observed in the pre-action compared with action and maintenance stages, while except for external regulation, all regulation scores were significantly lower in the pre-action compared with action and maintenance stages. There were no significant differences in levels of motivational types between the action and maintenance stage. The study provides a platform for future research to investigate relationships between motivational factors and physical and mental health outcomes within physical activity interventions for middle-aged and old age people with a mental disorder. [ABSTRACT FROM AUTHOR]

Objective: To assess predictors of diarrhea and dehydration and to investigate the role of diarrhea in mortality among children with complicated severe acute malnutrition.Study Design: A prospective cohort study, nested in a probiotic trial, was conducted in children with complicated severe acute malnutrition. Children were treated according to World Health Organization and national guidelines, and diarrhea and dehydration were assessed daily. Multiple linear and log-linear Poisson regression models were used to identify predictors of days with diarrhea and dehydration, respectively, and multiple logistic regression was used to assess their role in mortality.Results: Among 400 children enrolled, the median (IQR) age was 15.0 months (11.2-19.2 months), 58% were boys, and 61% had caregiver-reported diarrhea at admission. During hospitalization, the median (range) number of days with diarrhea was 5 (0-31), the median duration of hospitalization was 17 days (1-69 days), and 39 (10%) died. Of 592 diarrhea episodes monitored, 237 were admission episodes and 355 were hospital acquired. During hospitalization, young age was associated with days with diarrhea, and young age and HIV infection were associated with dehydration. Both days with diarrhea and dehydration predicted duration of hospitalization as well as mortality. The odds of mortality increased by a factor of 1.4 (95% CI, 1.2-1.6) per day of diarrhea and 3.5 (95% CI, 2.2-6.0) per unit increase in dehydration score.Conclusions: Diarrhea is a strong predictor of mortality among children with complicated severe acute malnutrition. Improved management of diarrhea and prevention of hospital-acquired diarrhea may be critical to decreasing mortality. [ABSTRACT FROM AUTHOR]