IntroductionThe Dutch Medical Doctor-Global Health (MD-GH) prepares to work in low-resource settings (LRS) by completing a hybrid postgraduate training program of 2 years and 9 months, with clinical and public health exposure in the Netherlands and a Global Health residency in LRS. The objectives of the program include acquiring clinical skills to work as a physician in a setting with different (often more severe) pathology and limited resources. In public health teaching, emphasis is given, among other, to adapting to a culturally different environment. After graduation, MD-GH work in a wide variety of countries and settings for variable time. As part of a curriculum review, this study examines MD-GHs' perception of the quality of the training program and provides recommendations for improvement.MethodsA qualitative study was performed. Thematic analysis was applied to semi-structured interviews with 23 MD-GH who graduated between 2017 and 2021.ResultsMD-GHs predominantly worked as clinicians; several were (also) involved in management or capacity building. The clinical training program adequately addressed general skills, but did not sufficiently prepare for locally encountered, often severe, pathology. During the training, adequate supervision with clear learning goals was found pivotal to a positive learning experience. Gaps included clinical training in Internal Medicine (particularly infectious diseases and non-communicable diseases) and Paediatrics. Public Health teaching as well as cultural awareness should be intensified and introduced earlier in the program. The Global Health residency was considered important, but tasks and learning outcomes varied. Teaching, supervision, and capacity building were considered increasingly important key elements of working in LRS. Consensus favoured the current duration of the training program without extension.DiscussionWhile the generalist nature of the MD-GH training was appreciated, the program would benefit from additional clinical training in infectious diseases, non-communicable diseases, and Paediatrics. Moving forward, emphasis should be placed on structured mentorship, enhanced public health teaching, and standardized residency programs with clearly delineated objectives to better equip MD-GH professionals for their multifaceted roles in LRS. Moreover, future revisions of the training program should incorporate the perspectives of host institutes in LRS and tailor the training needs.
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The sensitivity of tropical forest carbon to climate is a key uncertainty in predicting global climate change. Although short-term drying and warming are known to affect forests, it is unknown if such effects translate into long-term responses. Here, we analyze 590 permanent plots measured across the tropics to derive the equilibrium climate controls on forest carbon. Maximum temperature is the most important predictor of aboveground biomass (−9.1 megagrams of carbon per hectare per degree Celsius), primarily by reducing woody productivity, and has a greater impact per °C in the hottest forests (>32.2°C). Our results nevertheless reveal greater thermal resilience than observations of short-term variation imply. To realize the long-term climate adaptation potential of tropical forests requires both protecting them and stabilizing Earth’s climate.
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Bitter gourd is also called sopropo, balsam-pear, karela or bitter melon and is a member of the cucumber family (Cucurbitaceae). It is a monoecious, annual, fast-growing and herbaceous creeping plant. The wrinkled fruit of the bitter gourd is consumed as a vegetable and medicine in Asia, East Africa, South America and India. The aim of this bitter gourd cultivation manual is to make this cultivation accessible to Dutch growers and in this way be able to meet market demand. In addition, this cultivation manual aims to provide insight into the standardized production of the medicinal ingredients in the fruit.
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Background: The coronavirus disease 2019 (COVID-19) pandemic is rapidly expanding across the world, with more than 100,000 new cases each day as of end-June 2020. Healthcare workers are struggling to provide the best care for COVID-19 patients. Approaches for invasive ventilation vary widely between and within countries and new insights are acquired rapidly. We aim to investigate invasive ventilation practices and outcome in COVID-19 patients in the Netherlands.Methods: PRoVENT-COVID ('study of PRactice of VENTilation in COVID-19') is an investigator-initiated national, multicenter observational study to be undertaken in intensive care units (ICUs) in The Netherlands. Consecutive COVID-19 patients aged 18 years or older, who are receiving invasive ventilation in the participating ICUs, are to be enrolled during a 10-week period, with a daily follow-up of 7 days. The primary outcome is ventilatory management (including tidal volume expressed as mL/kg predicted body weight and positive end-expiratory pressure expressed as cmH2O) during the first 3 days of ventilation. Secondary outcomes include other ventilatory variables, use of rescue therapies for refractory hypoxemia such as prone positioning and extracorporeal membrane oxygenation, use of sedatives, vasopressors and inotropes; daily cumulative fluid balances; acute kidney injury; ventilator-free days and alive at day 28 (VFD-28), duration of ICU and hospital stay, and ICU, hospital and 90-day mortality.Discussion: PRoVENT-COVID will be the largest observational study to date, with high density ventilatory data and major outcomes. There is urgent need for a better understanding of ventilation practices, and the effects of ventilator settings on outcomes in COVID-19 patients. The results of PRoVENT-COVID will be rapidly disseminated through electronic presentations, such as webinars and electronic conferences, and publications in international peer-reviewed journals. Access to source data will be made available through local, regional and national anonymized datasets on request, and after agreement of the PRoVENT-COVID steering committee.Trial Registration: PRoVENT-COVID is registered at clinicaltrials.gov (identifier NCT04346342).
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Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6–12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.
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Objectives: To understand healthcare professionals' experiences and perceptions of nurses' potential or ideal roles in pharmaceutical care (PC). Design: Qualitative study conducted through semi-structured in-depth interviews. Setting: Between December 2018 and October 2019, interviews were conducted with healthcare professionals of 14 European countries in four healthcare settings: hospitals, community care, mental health and long-term residential care. Participants: In each country, pharmacists, physicians and nurses in each of the four settings were interviewed. Participants were selected on the basis that they were key informants with broad knowledge and experience of PC. Data collection and analysis: All interviews were conducted face to face. Each country conducted an initial thematic analysis. Consensus was reached through a face-to-face discussion of all 14 national leads. Results: 340 interviews were completed. Several tasks were described within four potential nursing responsibilities, that came up as the analysis themes, being: 1) monitoring therapeutic/adverse effects of medicines, 2) monitoring medicines adherence, 3) decision making on medicines, including prescribing 4) providing patient education/information. Nurses' autonomy varied across Europe, from none to limited to a few tasks and emergencies to a broad range of tasks and responsibilities. Intended level of autonomy depended on medicine types and level of education. Some changes are needed before nursing roles can be optimised and implemented in practice. Lack of time, shortage of nurses, absence of legal frameworks and limited education and knowledge are main threats to European nurses actualising their ideal role in PC. Conclusions: European nurses have an active role in PC. Respondents reported positive impacts on care quality and patient outcomes when nurses assumed PC responsibilities. Healthcare professionals expect nurses to report observations and assessments. This key patient information should be shared and addressed by the interprofessional team. The study evidences the need of a unique and consensus-based PC framework across Europe.
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BackgroundUnderstanding cultural perceptions of illness is crucial for effective healthcare delivery. This study examines the ethnomedical concept of ikirimi, a culturally recognized illness in Rwanda characterized by perceived uvula abnormalities, and its traditional management through uvulectomy. This study explores the cultural understanding of ikirimi, its perceived causes, symptoms, and treatments, as well as barriers to integrating modern healthcare.MethodsAn exploratory qualitative approach was employed, involving in-depth semi-structured interviews with eight participants: traditional healers, individuals who underwent traditional uvulectomy, and healthcare providers. A grounded theory approach which analyzes data in systematic manner to generate new theories was applied, with coding conducted in English after initial transcription and analysis in Ikinyarwanda to preserve Indigenous concepts.ResultsParticipants described ikirimi as an illness affecting the uvula (named as akamironko or akamirabugari or agashondabugari in Ikinyarwanda), characterized by swelling, elongation, and pus-like discoloration. Reported symptoms included fever, difficulty swallowing, coughing, and weakness, with children identified as the most affected group. Traditional healers diagnosed ikirimi through visual inspection of uvular morphology and movement and treated it by cutting the affected part of uvula and is known as guca Ikirimi ‘traditional uvulectomy’. Barriers to integrating modern healthcare included skepticism about biomedical care, judgmental attitudes from providers, and communication gaps. Despite the prevalence of ikirimi, its biomedical correlates remain unclear, though participants associated it with severe throat illnesses such as tonsillopharyngitis.ConclusionThe findings highlight ikirimi as a socially constructed illness with deep cultural roots, significant health implications, and persistent barriers to modern healthcare. Addressing these barriers requires culturally sensitive approaches that integrate Indigenous knowledge with biomedical practices. Future research should explore the biomedical correlates of ikirimi and foster collaboration between traditional and modern healthcare systems to improve patient outcomes.
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Standard SARS-CoV-2 testing protocols using nasopharyngeal/throat (NP/T) swabs are invasive and require trained medical staff for reliable sampling. In addition, it has been shown that PCR is more sensitive as compared to antigen-based tests. Here we describe the analytical and clinical evaluation of our in-house RNA extraction-free saliva-based molecular assay for the detection of SARS-CoV-2. Analytical sensitivity of the test was equal to the sensitivity obtained in other Dutch diagnostic laboratories that process NP/T swabs. In this study, 955 individuals participated and provided NP/T swabs for routine molecular analysis (with RNA extraction) and saliva for comparison. Our RT-qPCR resulted in a sensitivity of 82,86% and a specificity of 98,94% compared to the gold standard. A false-negative ratio of 1,9% was found. The SARS-CoV-2 detection workflow described here enables easy, economical, and reliable saliva processing, useful for repeated testing of individuals.
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The COVID–19 pandemic led to local oxygen shortages worldwide. To gain a better understanding of oxygen consumption with different respiratory supportive therapies, we conducted an international multicenter observational study to determine the precise amount of oxygen consumption with high-flow nasal oxygen (HFNO) and with mechanical ventilation. A retrospective observational study was conducted in three intensive care units (ICUs) in the Netherlands and Spain. Patients were classified as HFNO patients or ventilated patients, according to the mode of oxygen supplementation with which a patient started. The primary endpoint was actual oxygen consumption; secondary endpoints were hourly and total oxygen consumption during the first two full calendar days. Of 275 patients, 147 started with HFNO and 128 with mechanical ventilation. Actual oxygen use was 4.9-fold higher in patients who started with HFNO than in patients who started with ventilation (median 14.2 [8.4–18.4] versus 2.9 [1.8–4.1] L/minute; mean difference 5 11.3 [95% CI 11.0–11.6] L/minute; P, 0.01). Hourly and total oxygen consumption were 4.8-fold (P, 0.01) and 4.8-fold (P, 0.01) higher. Actual oxygen consumption, hourly oxygen consumption, and total oxygen consumption are substantially higher in patients that start with HFNO compared with patients that start with mechanical ventilation. This information may help hospitals and ICUs predicting oxygen needs during high-demand periods and could guide decisions regarding the source of distribution of medical oxygen.
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BACKGROUND: The SpO2/FiO2 is a useful oxygenation parameter with prognostic capacity in patients with ARDS. We investigated the prognostic capacity of SpO2/FiO2 for mortality in patients with ARDS due to COVID-19.METHODS: This was a post-hoc analysis of a national multicenter cohort study in invasively ventilated patients with ARDS due to COVID-19. The primary endpoint was 28-day mortality.RESULTS: In 869 invasively ventilated patients, 28-day mortality was 30.1%. The SpO2/FiO2 on day 1 had no prognostic value. The SpO2/FiO2 on day 2 and day 3 had prognostic capacity for death, with the best cut-offs being 179 and 199, respectively. Both SpO2/FiO2 on day 2 (OR, 0.66 [95%-CI 0.46-0.96]) and on day 3 (OR, 0.70 [95%-CI 0.51-0.96]) were associated with 28-day mortality in a model corrected for age, pH, lactate levels and kidney dysfunction (AUROC 0.78 [0.76-0.79]). The measured PaO2/FiO2 and the PaO2/FiO2 calculated from SpO2/FiO2 were strongly correlated (Spearman's r = 0.79).CONCLUSIONS: In this cohort of patients with ARDS due to COVID-19, the SpO2/FiO2 on day 2 and day 3 are independently associated with and have prognostic capacity for 28-day mortality. The SpO2/FiO2 is a useful metric for risk stratification in invasively ventilated COVID-19 patients.
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