BACKGROUND AND OBJECTIVE: Despite the growing importance of global health (GH) training for pediatric residents, few mechanisms have cataloged GH educational opportunities offered by US pediatric residency programs. We sought to characterize GH education opportunities across pediatric residency programs and identify program characteristics associated with key GH education elements.METHODS: Data on program and GH training characteristics were sought from program directors or their delegates of all US pediatric residency programs during 2013 to 2014. These data were used to compare programs with and without a GH track as well as across small, medium, and large programs. Program characteristics associated with the presence of key educational elements were identified by using bivariate logistic regression.RESULTS: Data were collected from 198 of 199 active US pediatric residency programs (99.5%). Seven percent of pediatric trainees went abroad during 2013 to 2014. Forty-nine programs (24.7%) reported having a GH track, 66.1% had a faculty lead, 58.1% offered international field experiences, and 48.5% offered domestic field experiences. Forty-two percent of programs reported international partnerships across 153 countries. Larger programs, those with lead faculty, GH tracks, or partnerships had significantly increased odds of having each GH educational element, including pretravel preparation. CONCLUSIONS:The number of pediatric residency programs offering GH training opportunities continues to rise. However, smaller programs and those without tracks, lead faculty, or formal partnerships lag behind with organized GH curricula. As GH becomes an integral component of pediatric training, a heightened commitment is needed to ensure consistency of training experiences that encompass best practices in all programs. WHAT'S KNOWN ON THIS SUBJECT:In response to growing demand from trainees, many pediatric residency programs offer global health (GH) experiences for their residents. There is diversity in what is offered at programs across the country. WHAT THIS STUDY ADDS:This is the most comprehensive assessment of US pediatric residency training opportunities in GH. These opportunities are prevalent and increasingly formalized as tracks. However there remain gaps in universal pretravel preparation and coordination across GH partnerships nationally.

In March 2014, the Asian toad Duttaphrynus melanostictus was reported from Madagascar's second largest city and main port Toamasina, raising immediate concerns about the invasive nature of the newly introduced toad and its environmental impact should it spread throughout the island. As part of a study on the feasibility of eradication, we conducted 516 interviews and 120 visual encounter surveys between April and November 2014. We found the toad to be widespread to the south and west of city center and estimate its minimum range to include an area of at least 108 km2. Social surveys indicate that the toad may have already been present for some years and potentially introduced prior to 2010, with the site of its introduction likely south of Toamasina near National Route 2 and the Ambatovy Plant. We discuss limitations of our survey methodology, proposed improvements for future work, and the implications of our results on eradication and control measures.

BackgroundCancer services are inaccessible in many low-income countries, and few published examples describe oncology programs within the public sector. In 2011, the Rwanda Ministry of Health (RMOH) established Butaro Cancer Center of Excellence (BCCOE) to expand cancer services nationally. In hopes of informing cancer care delivery in similar settings, we describe program-level experience implementing BCCOE, patient characteristics, and challenges encountered.MethodsButaro Cancer Center of Excellence was founded on diverse partnerships that emphasize capacity building. Services available include pathology-based diagnosis, basic imaging, chemotherapy, surgery, referral for radiotherapy, palliative care and socioeconomic access supports. Retrospective review of electronic medical records (EMR) of patients enrolled between July 1, 2012 and June 30, 2014 was conducted, supplemented by manual review of paper charts and programmatic records.ResultsIn the program’s first 2 years, 2326 patients presented for cancer-related care. Of these, 70.5 % were female, 4.3 % children, and 74.3 % on public health insurance. In the first year, 66.3 % (n = 1144) were diagnosed with cancer. Leading adult diagnoses were breast, cervical, and skin cancer. Among children, nephroblastoma, acute lymphoblastic leukemia, and Hodgkin lymphoma were predominant. As of June 30, 2013, 95 cancer patients had died. Challenges encountered include documentation gaps and staff shortages.ConclusionButaro Cancer Center of Excellence demonstrates that complex cancer care can be delivered in the most resource-constrained settings, accessible to vulnerable patients. Key attributes that have made BCCOE possible are: meaningful North–south partnerships, innovative task- and infrastructure-shifting, RMOH leadership, and an equity-driven agenda. Going forward, we will apply our experiences and lessons learned to further strengthen BCCOE, and employ the developed EMR system as a valuable platform to assess long-term clinical outcomes and improve care.

The black-spined toad, Duttaphrynus melanostictus, is widespread in South and South-East (SE) Asia, although recent molecular analyses have revealed that it represents a species complex (here called the D. melanostictus complex). Invasive populations of this toad have been detected in Madagascar since, at least, 2014. We here trace the origin of this introduction based on mitochondrial DNA sequences of 340 samples. All 102 specimens from Madagascar have identical sequences pointing to a single introduction event. Their haplotype corresponds to a lineage occurring in Cambodia, China, Laos, Thailand, Vietnam, and some locations of eastern Myanmar and northern Malaysia, here named the SE Asian lineage. Within this lineage, specimens from one location in Cambodia and three locations in Vietnam have the same haplotype as found in Madagascar. This includes Ho Chi Minh City, which has a major seaport and might have been the source for the introduction. Species distribution models suggest that the current range of the Madagascan invasive population is within the bioclimatic space occupied by the SE Asian lineage in its native range. The potential invasion zone in Madagascar is narrower than suggested by models from localities representing the full range of the D. melanostictus complex. Thus, an accurate taxonomy is essential for such inferences, but it remains uncertain if the toad might be able to spread beyond the potential suitable range because (1) knowledge on species-delimitation of the complex is insufficient, and (2) the native range in SE Asia might be influenced by historical biogeography or competition.

Our experience demonstrates that anatomic pathology services can be established in resource-limited settings and local capacity can be built to support accurate diagnoses. Our approach included leveraging partnerships, volunteer experts, and task shifting and will be expanded to include telepathology.

PurposeChildren with acute lymphoblastic leukemia (ALL) in low-income countries have disproportionately lower cure rates than those in high-income countries. At Butaro Cancer Center of Excellence (BCCOE), physicians treated patients with ALL with the first arm of the Hunger Protocol, a graduated-intensity method tailored for resource-limited settings. This article provides the first published outcomes, to our knowledge, of patients with ALL treated with this protocol.MethodsThis is a retrospective descriptive study of patients with ALL enrolled at BCCOE from July 1, 2012 to June 30, 2014; data were collected through December 31, 2015. Descriptive statistics were used to calculate patient demographics, disease characteristics, and outcomes; event-free survival was assessed at 2 years using the Kaplan-Meier method.ResultsForty-two consecutive patients with ALL were included. At the end of the study period, 19% (eight) were alive without evidence of relapse: three completed treatment and five were continuing treatment. Among the remaining patients, 71% (30) had died and 10% (four) were lost to follow-up. A total of 83% (25) of the deaths were disease related, 3% (one) treatment-related, and 13% (four) unclear. Event-free survival was 22% (95% CI, 11% to 36%), considering lost to follow-up as an event, and 26% (95% CI, 13% to 41%) if lost to follow-up is censored.ConclusionAs expected, relapse was the major cause of failure with this low-intensity regimen. However, toxicity was acceptably low, and BCCOE has decided to advance to intensity level 2. These results reflect the necessity of a data-driven approach and a continual improvement process to care for complex patients in resource-constrained settings.

Without an adequate understanding of the socio-political context in which a natural environment is embedded, it is impossible to prevent, mitigate and adapt to future unwanted changes in the socio-ecological system. It is advantageous for environmental managers to see the social aspects of the socio-ecological system so that they can understand not only the effects but also the motivations of natural resource use.

Deep partisan conflict in the mass public threatens the stability of American democracy. We conducted a megastudy (n=32,059) testing 25 interventions designed by academics and practitioners to reduce Americans’ partisan animosity and anti-democratic attitudes. We find nearly every intervention reduced partisan animosity, most strongly by highlighting sympathetic and relatable individuals with different political beliefs. We also identify several interventions that reduced support for undemocratic practices and partisan violence, most strongly by correcting misperceptions of outpartisans’ views – showing that anti-democratic attitudes, although difficult to move, are not intractable. Furthermore, both factor analysis and patterns of intervention effect sizes provide convergent evidence for limited overlap between these sets of outcomes, suggesting that, contrary to popular belief, different strategies are most effective for reducing partisan animosity versus anti-democratic attitudes. Taken together, our findings provide a toolkit of promising strategies for practitioners and shed new theoretical light on challenges facing American democracy.