Recent efforts to prevent post-partum haemorrhage (PPH) in low-income countries have focused on providing women with access to oral misoprostol during home birth. The WHO recommends using lay health workers (LHWs) to administer misoprostol in settings where skilled birth attendants are not available. This review synthesizes current knowledge about the barriers and facilitators affecting implementation of advance community distribution of misoprostol to prevent PPH, where misoprostol may be self-administered or administered by an LHW.We searched for and summarized available empirical evidence, and collected primary data from programme stakeholders about their experiences of programme implementation.We present key outcomes and features of advanced distribution programmes that are in operation or have been piloted globally. We categorized factors influencing implementation into those that operate at the health system level, factors related to the community and policy context and those factors more closely connected to the end user.Debates around advance distribution have centred on the potential risks and benefits of making misoprostol available to pregnant women and community members during pregnancy for administration in the home. However, the risks of advance distribution appear manageable and the benefits of self-administration, especially for women who have little chance of expert care for PPH, are considerable.
Treatment of chronic hepatitis C virus (HCV) infection included use of pegylated interferon-based regimens before 2014 and direct-acting agents (DAA) since 2014 at the VA Medical Center in Washington, DC. We compared the continua of care between our HCV/HIV coinfected and HCV mono-infected patients during 2008-2015. A review of summary data from our local HCV Clinical Case Registry was conducted for the interferon treatment era (2008-2013) and the DAA era (2014-2015). Data were analyzed on a modified HCV Continuum of Care based on these stages: HCV diagnosis, engagement in medical care, HCV treatment, and HCV sustained virologic response (SVR) for differences between HCV/HIV coinfected and HCV mono-infected patients. All patients had 88% engagement in primary care during 2008-2013. HCV mono-infected and HCV/HIV coinfected patients had similar treatment (6% vs. 5%, p = .6622) and HCV SVR (1% vs. 0.5%, p = .1737) rates in the interferon era. However, more HCV/HIV coinfected patients were engaged in care (93% vs. 87%, p = .0044), accessed HCV treatment (36% vs. 23%, p < .0001), and achieved HCV SVR (31% vs. 21% p = .0002) compared to mono-infected patients in the DAA era. Both HCV/HIV coinfected and HCV mono-infected patients achieved higher SVR of ≥86% after DAA treatment. Although improvements were seen for treatment and SVR among HCV mono-infected patients, better rates for care engagement, HCV treatment, and SVR were realized for HCV/HIV coinfected patients in the DAA era.
Background The COVID-19 pandemic has resulted in large-scale healthcare restrictions to control viral spread, reducing operating room censuses to include only medically necessary surgeries. The impact of restrictions on which patients undergo surgical procedures and their perioperative outcomes is less understood. Methods Adult patients who underwent medically necessary surgical procedures at our institution during a restricted operative period due to the COVID-19 pandemic (March 23-April 24, 2020) were compared to patients undergoing procedures during a similar time period in the pre-COVID-19 era (March 25-April 26, 2019). Cardinal matching and differences in means were utilized to analyze perioperative outcomes. Results 857 patients had surgery in 2019 (pre-COVID-19) and 212 patients had surgery in 2020 . The COVID-19 era cohort had a higher proportion of patients who were male (61.3% vs. 44.5%, P \ 0.0001), were White (83.5% vs. 68.7%, P \ 0.001), had private insurance (62.7% vs. 54.3%, p 0.05), were ASA classification 4 (10.9% vs. 3%, P \ 0.0001), and underwent oncologic procedures (69.3% vs. 42.7%, P \ 0.0001). Following 1:1 cardinal matching, COVID-19 era patients (N = 157) had a decreased likelihood of discharge to a nursing facility (risk difference-8.3, P \ 0.0001) and shorter median length of stay (risk difference-0.6, p 0.04) compared to pre-COVID-19 era patients. There was no difference between the two patient cohorts in overall morbidity and 30-day readmission.Conclusions COVID-19 restrictions on surgical operations were associated with a change in the racial and insurance demographics in patients undergoing medically necessary surgical procedures but were not associated with worse postoperative morbidity. Further study is necessary to better identify the causes for patient demographic differences.
Background: The coronavirus disease 2019 outbreak has spread worldwide and has resulted in hospital restrictions. The perceived impact of these practices on patients undergoing essential surgeries is less understood. Methods: Adult (18 years) patients who underwent medically necessary surgical procedures spanning multiple surgical specialties from March 23, 2020, to April 24, 2020, during the coronavirus disease 2019 pandemic were identified as eligible for a phone survey. Survey responses were analyzed using a mixedmethods approach involving descriptive statistics and thematic analysis of coded and annotated survey results. Results: Of the 212 patients who underwent medically necessary surgical procedures during the coronavirus disease 2019 pandemic, the majority of these patients were male (61.3%), White (83.5%), married or with a domestic partner (68.9%), and underwent oncologic procedures (69.3%). Of the 46 patients (21.7%) who completed the survey, the majority of these patients indicated that coronavirus disease 2019 pandemic restrictions had no impact on their inpatient hospital stay and were satisfied with their decision to proceed with surgery. Severity of patient condition (44.4%), the risk/benefit discussion with the surgeon (24.4%), and coronavirus disease 2019 education and testing (19.5%) were the most important factors in proceeding with surgery during the pandemic; 34.4% of patients said their inpatient postoperative course was negatively affected by the lack of visitors. Conclusion: Medically necessary, time-sensitive surgical procedures, as determined by the surgeon, can be performed during a pandemic with good patient satisfaction provided there is an appropriate discussion between the surgeon and patient about the risks and benefits.
Wound excision and temporary coverage with a biologic dressing can improve survival for patients with large burns. Healthcare systems in low- and middle-income countries (LMICs) rarely have access to allografts, which may contribute to limited survival of patients with large burns in these settings. Therefore, we aimed to describe the lessons learned from the implementation and maintenance of tissue banks in LMICs to guide system planning and organization.
PubMed, MEDLINE, CINAHL, and World Health Organization (WHO) Catalog were systematically searched with database-specific language to represent a priori terms (e.g., skin, allograft, tissue bank) and all LMICs as defined by The World Bank. Data regarding tissue banking programs were extracted and described in a narrative synthesis.
The search returned 3,346 records, and 33 reports from 17 countries were analyzed. Commonly reported barriers to ideal or planned implementation included high capital costs and operational costs per graft, insufficient training opportunities, opt-in donation schemes, and sociocultural stigma around donation and transplantation.
Many lessons were learned from the implementation and management of tissue banks around the world. The availability of skin allografts can be improved through strategic investments in governance and regulatory structures, international cooperation initiatives, training programs, standardized protocols, and inclusive public awareness campaigns. Further, capacity-building efforts that involve key stakeholders may increase rates of pledges, donations, and transplantations. Some issues were ubiquitously reported and could be addressed by current and future tissue banking programs to ensure allograft availability for patients living in countries of all income levels.
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