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Authors: Siddhant Yadav, Rylea Ranum, Hannah Alberts, Abdul Kalaiger, Brent Bauer, Ryan Hurt, Ann Vincent, Loren Toussaint, Sanjeev Nanda

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Background and significance: Fibromyalgia (FM) is a chronic pain disorder also characterized by chronic fatigue, morning stiffness, sleep, and cognitive symptoms, psychological disturbances (anxiety, depression), and is comorbid with multiple medical and psychiatric conditions. It has an incidence of 2-4% in the general population and is reported more commonly in women. Oxidative stress and inflammation are thought to contribute to pain in patients with FM, and the adoption of an antioxidant/anti-inflammatory diet has been suggested as a modality to alleviate symptoms. The aim of this systematic review was to evaluate the efficacy of specialized diets (ketogenic, gluten free, Mediterranean, and low carbohydrate) in improving FM symptoms. Methodology: A comprehensive search of the following databases from inception to July 15th, 2021, was conducted: Ovid MEDLINE and Epub ahead of print, in-process and other non-indexed citations and daily, Ovid Embase, Ovid EBM reviews, Cochrane central register of controlled trials, EBSCO host CINAHL with full text, Elsevier Scopus, website and citation index, web of science emerging sources citation and clinicaltrials.gov. We included randomized controlled trials, non-randomized experimental studies, cross-sectional studies, cohort studies, case series, and case reports in adults with fibromyalgia. The risk of bias was assessed with the Agency for Health Care Research and Quality designed, specific recommended criteria (AHRQ). Results: Thirteen studies were eligible for inclusion. This included a total of 761 participants. Twelve out of the 13 studies reported improvement in widespread body pain, joint stiffness, sleeping pattern, mood, and gastrointestinal symptoms, and one study reported no changes in symptomatology in patients with FM on specialized diets. None of the studies showed the worsening of symptoms associated with a specific diet. Most of the patient population was female, with the mean age at which fibromyalgia was diagnosed being 48.12 years. Improvement in symptoms was reported by the patient's adhering to a gluten-free diet, raw vegan diet, tryptophan- and magnesium-enriched Mediterranean diet, aspartame- and msg- elimination diet, and specifically a Khorasan wheat diet. Risk of bias assessment noted that 6 studies had a low risk of bias (5 clinical trials and 1 case series), four studies had a moderate risk of bias, and 3 had a high risk of bias. In many of the studies, the allocation of treatment (diets) was not adequately concealed, and the researchers did not rule out any potential impact from a concurrent intervention or an unintended exposure that might have biased the results. On the other hand, there was a low risk of attrition bias in all the trials; all were conducted with an intention-to-treat, and the inclusion/exclusion criteria, exposures/interventions, and primary outcomes were valid, reliable, and implemented consistently across all study participants. Concluding statement: Patients with fibromyalgia who followed specialized diets experienced a variable degree of improvement in their widespread body pain. Improvement was also seen in stiffness, fatigue, moods, sleeping patterns, and gastrointestinal symptoms. Additionally, the majority of the patients also reported improvement in overall quality of life.

Keywords: fibromyalgia, specialized diet, vegan, gluten free, Mediterranean, systematic review

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Authors: Aparajita Bhattacharya, Mousumi Dutta, Zakir Husain, Dionne Sequeira, Asima Mukhopadhyay

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Background: Tata Medical Centre (TMC), Kolkata is a major cancer referral centre in Eastern India and neighbouring countries providing state of the art facilities; however, it is a non-profit organisation with patients requiring to pay at subsidised rates. Although a system for social assessment and applying for governmental/ non-governmental (NGO) funds is in place, access is challenging. Amongst gynaecological cancers (GC), ovarian cancer (OC) is associated with the highest treatment cost; majority of which is required at the beginning when complex surgery is performed and funding arrangements cannot be made in time. We therefore appointed a dedicated Medical Social Worker (MSW) in 2016, supported by NGO for GC patients in order to assist patients/family members to access/avail these funds more readily and assist in economic evaluation for both direct and opportunity costs. Objectives: To reflect on our experience and challenges in collecting data on economic evaluation of cancer patients and compare success rates in achieving fund mobilization after introduction of MSW. Methods: A Retrospective survey. Patients with OC and their relatives were seen by the MSW during the initial outpatients department visit and followed though till discharge from the hospital and during follow-up visits. Assistance was provided in preparing the essential documents/paperwork/contacts for the funding agencies including both governmental (Chief-Minister/Prime-Minister/President) and NGO sources. In addition, a detailed questionnaire was filled up for economic assessment of direct/opportunity costs during the entire treatment and 12 months follow up period which forms a part of the study called HEPTROC (Health economic evaluation of primary treatment for ovarian cancer) developed in collaboration with economics departments of Universities. Results: In 2015, 102 patients were operated for OC; only 16 patients (15.68 %) had availed funding of a total sum of INR 1640000 through the hospital system for social assessment. Following challenges were faced by majority of the relatives: 1. Gathering important documents/proper contact details for governmental funding bodies and difficulty in following up the current status 3. Late arrival of funds. In contrast in 2016, 104 OC patients underwent surgery; the direct cost of treatment was significantly higher (median, INR 300000- 400000) compared to other GCs (n=274). 98/104 (94.23%) OC patients could be helped to apply for funds and 90/104(86.56%) patients received funding amounting to a total of INR 10897000. There has been a tenfold increase in funds mobilized in 2016 after the introduction of dedicated MSW in GC. So far, in 2017 (till June), 46/54(85.18%) OC patients applied for funds and 37/54(68.51%) patients have received funding. In a qualitative survey, all patients appreciated the role of the MSW who subsequently became the key worker for patient follow up and the chief portal for patient reported outcome monitoring. Data collection quality for the HEPTROC study was improved when questionnaires were administered by the MSW compared to researchers. Conclusion: Introduction of cancer specific MSW can expedite the availability of funds required for cancer patients and it can positively impact on patient satisfaction and outcome reporting. The economic assessment will influence fund allocation and decision for policymaking in ovarian cancer. Acknowledgement: Jivdaya Foundation Dallas, Texas.

Keywords: economic evaluation, funding, medical social worker, ovarian cancer

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Authors: Dean Sinković, Tea Golja, Morena Paulišić

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Upon the end of the vicious war in former Yugoslavia in 1995, international development community widely promoted microfinance as the key development framework to eradicate poverty, create jobs, increase income. Widespread claims were made that microfinance institutions would play vital role in creating a bedrock for sustainable ‘bottom-up’ economic development trajectory, thus, helping newly formed states to find proper way from economic post-war depression. This uplifting neoliberal narrative has no empirical support in the Republic of Croatia. Firstly, the type of enterprises created via microfinance sector are small, unskilled, labor intensive, no technology and with huge debt burden. This results in extremely high failure rates of microenterprises and poor individuals plunging into even deeper poverty, acute indebtedness and social marginalization. Secondly, evidence shows that microcredit is exact reflection of dangerous and destructive sub-prime lending model with ‘boom-to-bust’ scenarios in which benefits are solely extracted by the tiny financial and political elite working around the microfinance sector. We argue that microcredit providers are not proper financial structures through which developing countries should look way out of underdevelopment and poverty. In order to achieve sustainable long-term growth goals, public policy needs to focus on creating, supporting and facilitating the small and mid-size enterprises development. These enterprises should be technically sophisticated, capable of creating new capabilities and innovations, with managerial expertise (skills formation) and inter-connected with other organizations (i.e. clusters, networks, supply chains, etc.). Evidence from South-East Europe suggest that such structures are not created via microfinance model but can be fostered through various forms of social enterprises. Various legal entities may operate as social enterprises: limited liability private company, limited liability public company, cooperative, associations, foundations, institutions, Mutual Insurances and Credit union. Our main hypothesis is that cooperatives are potential agents of social and economic transformation and community development in the region. Financial cooperatives are structures that can foster more efficient allocation of financial resources involving deeper democratic arrangements and more socially just outcomes. In Croatia, pioneers of the first social enterprises were civil society organizations whilst forming a separated legal entity. (i.e. cooperatives, associations, commercial companies working on the principles of returning the investment to the founder). Ever since 1995 cooperatives in Croatia have not grown by pursuing their own internal growth but mostly by relying on external financial support. The greater part of today’s registered cooperatives tend to be agricultural (39%), followed by war veterans cooperatives (38%) and others. There are no financial cooperatives in Croatia. Due to the above mentioned we look at the historical developments and the prevailing social enterprises forms and discuss their advantages and disadvantages as potential agents for social and economic transformation and community development in the region. There is an evident lack of understanding of this business model and of its potential for social and economic development followed by an unfavorable institutional environment. Thus, we discuss the role of governance and management in the formation of social enterprises in Croatia, stressing the challenges for the governance of the country’s social enterprise movement.

Keywords: financial cooperatives, governance and management models, microfinance institutions, social enterprises

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Authors: Benjamin J. Kuo, Silvia D. Vaca, Joao Ricardo Nickenig Vissoci, Catherine A. Staton, Linda Xu, Michael Muhumuza, Hussein Ssenyonjo, John Mukasa, Joel Kiryabwire, Lydia Nanjula, Christine Muhumuza, Henry E. Rice, Gerald A. Grant, Michael M. Haglund

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Background: Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The disparities in the injury incidence and outcome between LMICs and resource-rich settings have led to increased health outcomes research for TBIs and their associated risk factors in LMICs. While there have been increasing TBI studies in LMICs over the last decade, there is still a need for more robust prospective registries. In Uganda, a trauma registry implemented in 2004 at the Mulago National Referral Hospital (MNRH) showed that RTI is the major contributor (60%) of overall mortality in the casualty department. While the prior registry provides information on injury incidence and burden, it’s limited in scope and doesn’t follow patients longitudinally throughout their hospital stay nor does it focus specifically on TBIs. And although these retrospective analyses are helpful for benchmarking TBI outcomes, they make it hard to identify specific quality improvement initiatives. The relationship among epidemiology, patient risk factors, clinical care, and TBI outcomes are still relatively unknown at MNRH. Objective: The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to a single tertiary hospital in Uganda. Methods: Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June – 30 November 2016. Research Electronic Data Capture (REDCap) was used to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality. Results: 563 TBI patients were enrolled from 1 June – 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3-5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours. Conclusions: The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3-82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.

Keywords: care continuum, global neurosurgery, Kampala Uganda, LMIC, Mulago, prospective registry, traumatic brain injury

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Authors: Haruka Ando

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Undernutrition of children is a critical issue, especially for people in the remote areas of the Republic of Djibouti, since household food insecurity, inadequate child caring and feeding, unhealthy environment and lack of clean water, as well as insufficient maternal and child healthcare, are underlying causes which affect. Nomadic pastoralists living in the Dikhil region (Dikhil) are socio-economically and geographically more vulnerable due to displacement, which in turn worsens the situation of child stunting. A high prevalence of inappropriate complementary feeding among pastoral mothers might be a significant barrier to child growth. This study aims to identify health promotion intervention strategies that would support an increase in optimal complementary feeding among pastoral mothers of children aged 6-23 months in Dikhil. There are four objectives; to explore and to understand the existing practice of complementary feeding among pastoral mothers in Dikhil; to identify the barriers in appropriate complementary feeding among the mothers; to critically explore and analyse the strategies for an increase in complementary feeding among the mothers; to make pragmatic recommendations to address the barriers in Djibouti. This is an in-depth study utilizing a conceptual framework, the behaviour change wheel, to analyse the determinants of complementary feeding and categorize health promotion interventions for increasing optimal complementary feeding among pastoral mothers living in Dikhil. The analytical tool was utilized to appraise the strategies to mitigate the selected barriers against optimal complementary feeding. The data sources were secondary literature from both published and unpublished sources. The literature was systematically collected. The findings of the determinants including the barriers of optimal complementary feeding were identified: heavy household workload, caring for multiple children under five, lack of education, cultural norms and traditional eating habits, lack of husbands' support, poverty and food insecurity, lack of clean water, low media coverage, insufficient health services on complementary feeding, fear, poor personal hygiene, and mothers' low decision-making ability and lack of motivation for food choice. To mitigate selected barriers of optimal complementary feeding, four intervention strategies based on interpersonal communication at the community-level were chosen: scaling up mothers' support groups, nutrition education, grandmother-inclusive approach, and training for complementary feeding counseling. The strategies were appraised through the criteria of effectiveness and feasibility. Scaling up mothers' support groups could be the best approach. Mid-term and long-term recommendations are suggested based on the situation analysis and appraisal of intervention strategies. Mid-term recommendations include complementary feeding promotion interventions are integrated into the healthcare service providing system in Dikhil, and donor agencies advocate and lobby the Ministry of Health Djibouti (MoHD) to increase budgetary allocation on complementary feeding promotion to implement interventions at a community level. Moreover, the recommendations include a community health management team in Dikhil training healthcare workers and mother support groups by using complementary feeding communication guidelines and monitors behaviour change of pastoral mothers and health outcome of their children. Long-term recommendations are the MoHD develops complementary feeding guidelines to cover sector-wide collaboration for multi-sectoral related barriers.

Keywords: Afar, child food, child nutrition, complementary feeding, complementary food, developing countries, Djibouti, East Africa, hard-to-reach areas, Horn of Africa, nomad, pastoral, rural area, Somali, Sub-Saharan Africa

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Authors: Lolwa Alansari, Hanen Mrabet, Kholoud Khaled, Abdelhamid Azhaghdani, Sufia Athar, Aska Kaima, Zaineb Mhamdia, Zubaria Altaf, Almunzer Zakaria, Tamara Alshadafat

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Introduction: The Obstetrics and Gynecology Emergency Department at Alwakra Hospital has faced significant challenges, which have been further worsened by the impact of the COVID-19 pandemic. These challenges involve issues such as overcrowding, extended wait times, and a notable surge in demand for emergency care services. Moreover, prolonged waiting times have emerged as a primary factor contributing to situations where patients leave without receiving attention, known as left without being seen (LWBS), and unexpectedly abscond. Addressing the issue of insufficient patient mobility in the obstetrics and gynecology emergency department has brought about substantial improvements in patient care, healthcare administration, and overall departmental efficiency. These changes have not only alleviated overcrowding but have also elevated the quality of emergency care, resulting in higher patient satisfaction, better outcomes, and operational rewards. Methodology: The COVID-19 pandemic has served as a catalyst for substantial transformations in the obstetrics and gynecology emergency, aligning seamlessly with the strategic direction of Hamad Medical Corporation (HMC). The fundamental aim of this initiative is to revolutionize the operational efficiency of the OB-GYN ED. To accomplish this mission, a range of transformations has been initiated, focusing on essential areas such as digitizing systems, optimizing resource allocation, enhancing budget efficiency, and reducing overall costs. The project utilized the Plan-Do-Study-Act (PDSA) model, involving a diverse team collecting baseline data and introducing throughput improvements. Post-implementation data and feedback were analysed, leading to the integration of effective interventions into standard procedures. These interventions included optimized space utilization, real-time communication, bedside registration, technology integration, pre-triage screening, enhanced communication and patient education, consultant presence, and a culture of continuous improvement. These strategies significantly reduced waiting times, enhancing both patient care and operational efficiency. Results: Results demonstrated a substantial reduction in overall average waiting time, dropping from 35 to approximately 14 minutes by August 2023. The wait times for priority 1 cases have been reduced from 22 to 0 minutes, and for priority 2 cases, the wait times have been reduced from 32 to approximately 13.6 minutes. The proportion of patients spending less than 8 hours in the OB ED observation beds rose from 74% in January 2022 to over 98% in 2023. Notably, there was a remarkable decrease in LWBS and absconded patient rates from 2020 to 2023. Conclusion: The project initiated a profound change in the department's operational environment. Efficiency became deeply embedded in the unit's culture, promoting teamwork among staff that went beyond the project's original focus and had a positive influence on operations in other departments. This effectiveness not only made processes more efficient but also resulted in significant cost reductions for the hospital. These cost savings were achieved by reducing wait times, which in turn led to fewer prolonged patient stays and reduced the need for additional treatments. These continuous improvement initiatives have now become an integral part of the Obstetrics and Gynecology Division's standard operating procedures, ensuring that the positive changes brought about by the project persist and evolve over time.

Keywords: overcrowding, waiting time, person centered care, quality initiatives

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Authors: Lolwa Alansari, Abdelhamid Azhaghdani, Sufia Athar, Hanen Mrabet, Annaliza Cruz, Tamara Alshadafat, Almunzer Zakaria

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Introduction: Improving the patient experience is a fundamental pillar of healthcare's quadruple aims. Recognizing the importance of patient experiences and perceptions in healthcare interactions is pivotal for driving quality improvement. This abstract centers around the Patient Experience Program, an endeavor crafted with the purpose of comprehending and elevating the experiences of patients in the Obstetrics & Gynecology Emergency Department (OB/GYN ED). Methodology: This comprehensive endeavor unfolded through a structured sequence of phases following Plan-Do-Study-Act (PDSA) model, spanning over 12 months, focused on enhancing patient experiences in the Obstetrics & Gynecology Emergency Department (OB/GYN ED). The study meticulously examined the journeys of patients with acute obstetrics and gynecological conditions, collecting data from over 100 participants monthly. The inclusive approach covered patients of different priority levels (1-5) admitted for acute conditions, with no exclusions. Historical data from March and April 2022 serves as a benchmark for comparison, strengthening causality claims by providing a baseline understanding of OB/GYN ED performance before interventions. Additionally, the methodology includes the incorporation of staff engagement surveys to comprehensively understand the experiences of healthcare professionals with the implemented improvements. Data extraction involved administering open-ended questions and comment sections to gather rich qualitative insights. The survey covered various aspects of the patient journey, including communication, emotional support, timely access to care, care coordination, and patient-centered decision-making. The project's data analysis utilized a mixed-methods approach, combining qualitative techniques to identify recurring themes and extract actionable insights and quantitative methods to assess patient satisfaction scores and relevant metrics over time, facilitating the measurement of intervention impact and longitudinal tracking of changes. From the themes we discovered in both the online and in-person patient experience surveys, several key findings emerged that guided us in initiating improvements, including effective communication and information sharing, providing emotional support and empathy, ensuring timely access to care, fostering care coordination and continuity, and promoting patient-centered decision-making. Results: The project yielded substantial positive outcomes, significantly improving patient experiences in the OB/GYN ED. Patient satisfaction levels rose from 62% to a consistent 98%, with notable improvements in satisfaction with care plan information and physician care. Waiting time satisfaction increased from 68% to a steady 97%. The project positively impacted nurses' and midwives' job satisfaction, increasing from 64% to an impressive 94%. Operational metrics displayed positive trends, including a decrease in the "left without being seen" rate from 3% to 1%, the discharge against medical advice rate dropping from 8% to 1%, and the absconded rate reducing from 3% to 0%. These outcomes underscore the project's effectiveness in enhancing both patient and staff experiences in the healthcare setting. Conclusion: The use of a patient experience questionnaire has been substantiated by evidence-based research as an effective tool for improving the patient experience, guiding interventions, and enhancing overall healthcare quality in the OB/GYN ED. The project's interventions have resulted in a more efficient allocation of resources, reduced hospital stays, and minimized unnecessary resource utilization. This, in turn, contributes to cost savings for the healthcare facility.

Keywords: patient experience, patient survey, person centered care, quality initiatives

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Authors: Manavjit Singh Dhindsa, Ursula Das, Kshirasagar Naik, Marzia Zaman, Richard Purcell, Srinivas Sampalli, Abdul Mutakabbir, Chung-Horng Lung, Thambirajah Ravichandran

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These days, wildland fires, also known as forest fires, are more prevalent than ever. Wildfires have major repercussions that affect ecosystems, communities, and the environment in several ways. Wildfires lead to habitat destruction and biodiversity loss, affecting ecosystems and causing soil erosion. They also contribute to poor air quality by releasing smoke and pollutants that pose health risks, especially for individuals with respiratory conditions. Wildfires can damage infrastructure, disrupt communities, and cause economic losses. The economic impact of firefighting efforts, combined with their direct effects on forestry and agriculture, causes significant financial difficulties for the areas impacted. This research explores different forest fire spread models and presents a comprehensive review of various techniques and methodologies used in the field. A forest fire spread model is a computational or mathematical representation that is used to simulate and predict the behavior of a forest fire. By applying scientific concepts and data from empirical studies, these models attempt to capture the intricate dynamics of how a fire spreads, taking into consideration a variety of factors like weather patterns, topography, fuel types, and environmental conditions. These models assist authorities in understanding and forecasting the potential trajectory and intensity of a wildfire. Emphasizing the need for a comprehensive understanding of wildfire dynamics, this research explores the approaches, assumptions, and findings derived from various models. By using a comparison approach, a critical analysis is provided by identifying patterns, strengths, and weaknesses among these models. The purpose of the survey is to further wildfire research and management techniques. Decision-makers, researchers, and practitioners can benefit from the useful insights that are provided by synthesizing established information. Fire spread models provide insights into potential fire behavior, facilitating authorities to make informed decisions about evacuation activities, allocating resources for fire-fighting efforts, and planning for preventive actions. Wildfire spread models are also useful in post-wildfire mitigation strategies as they help in assessing the fire's severity, determining high-risk regions for post-fire dangers, and forecasting soil erosion trends. The analysis highlights the importance of customized modeling approaches for various circumstances and promotes our understanding of the way forest fires spread. Some of the known models in this field are Rothermel’s wildland fuel model, FARSITE, WRF-SFIRE, FIRETEC, FlamMap, FSPro, cellular automata model, and others. The key characteristics that these models consider include weather (includes factors such as wind speed and direction), topography (includes factors like landscape elevation), and fuel availability (includes factors like types of vegetation) among other factors. The models discussed are physics-based, data-driven, or hybrid models, also utilizing ML techniques like attention-based neural networks to enhance the performance of the model. In order to lessen the destructive effects of forest fires, this initiative aims to promote the development of more precise prediction tools and effective management techniques. The survey expands its scope to address the practical needs of numerous stakeholders. Access to enhanced early warning systems enables decision-makers to take prompt action. Emergency responders benefit from improved resource allocation strategies, strengthening the efficacy of firefighting efforts.

Keywords: artificial intelligence, deep learning, forest fire management, fire risk assessment, fire simulation, machine learning, remote sensing, wildfire modeling

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