Ilir Hoxha

Introduction Antimicrobial resistance poses a major challenge to both public health and economic stability in many countries. In response, antimicrobial stewardship programmes are essential for optimising antibiotic use and reducing antimicrobial resistance, particularly in primary care settings where most antibiotics are prescribed. Kosovo, like many countries, is increasingly affected by the growing threat of antimicrobial resistance and must strengthen its strategies to address this problem. Although national action plans on antimicrobial resistance and stewardship have been completed, there is limited evidence on the economic impact of antimicrobial stewardship interventions in Kosovo, as is the case in many low- and middle-income country contexts. This study thus aims to evaluate the cost-effectiveness of antimicrobial stewardship programme in Kosovo, and the cost of implementing this programme in primary care settings in Kosovo. Methods and analysis First, for the cost-effectiveness component of the study, we will use a quasi-experimental interrupted time series design focusing on patients ≥18 years old diagnosed with upper respiratory tract infections at intervention and control sites in Kosovo’s primary care system, to analyse changes in antibiotic consumption measured in defined daily doses, and estimate the corresponding monetary value to determine cost-effectiveness. Second, we will use a bottom-up costing method to estimate the costs associated with implementing the antimicrobial stewardship programme, including resources required across intervention and control sites. Cost data for both components will be collected from the implementing institutions and the main family medicine centres, serving as the intervention and control sites. Ethics and dissemination The Ethical Committee of the Kosovo Chamber of Medical Doctors approved the protocol of our study (Number: 122/2024). Moreover, the results from this study will be published and disseminated as a peer-reviewed publication.

PURPOSE: Gastric cancer (GC) is the fourth most common cancer in Rwanda, but access to endoscopy remains limited. Delays in diagnosis contribute to the poor prognosis. The aim of this study was to assess the feasibility of the point-of-care (POC) isoenzyme type M2 pyruvate kinase stool test to facilitate earlier triage of patients with suspected GC who require esophagogastroduodenoscopy. METHODS: We enrolled patients with gastrointestinal symptoms scheduled for endoscopy during the Annual Rwanda Endoscopy Week, sponsored by the Rwanda Society for Endoscopy from 2022 to 2024. Participants provided informed consent and a stool sample before endoscopy. Using the M2 pyruvate kinase test, we collected data on test results, baseline demographics, endoscopic findings, and gastric biopsy results. RESULTS: A total of 82 patients consented before the study was discontinued because of the Marburg virus epidemic. Forty-six participants had incomplete data because of the absence of a gastric biopsy or a stool sample, and three did not meet the eligibility criteria. Thirty-six participants (43.9%) had both M2 pyruvate kinase and esophagogastroduodenoscopy results. Pathology was available in 19 of 82 patients (23%). CONCLUSION: Screening with a POC stool test is feasible and acceptable among Rwandan patients with gastrointestinal symptoms. However, there are many limitations, including low biopsy rates as a result of the cost of pathology services, expired test kits, and early closures. POC testing may be a feasible, opportunistic strategy to implement cancer control programs in low-income countries, but further research is needed for better quantification of sensitivity, specificity, and impact on the prevention of adverse outcomes.

Background: Group Care (GC) is an antenatal/postnatal care model comprised of a stable group of pregnant people or parent–child dyads receiving care in two-hour group sessions that combine clinical care with interactive discussion and learning. Integrating GC into healthcare systems organised for individual care poses challenges at both site and system levels. This study identified scheduling-related modifications across contexts to understand modification processes. Methods: We used an explanatory sequential design with mixed qualitative methods across seven GC implementation sites in Belgium, Kosovo, and the United Kingdom. A qualitative survey based on the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) was completed at each site by multiple stakeholders. Subsequently, in-depth interviews were conducted to further explore modification processes and examine whether changes were sustained or discontinued up to three years post-implementation initiation. Results: Two modifications were identified across countries: (1) combining GC sessions with individual consultations, and (2) integrating GC into digital booking and medical record systems. Guided by FRAME, we identified similarities and differences in the goals, drivers, and impact of these modifications. The dominant one-to-one antenatal care model strongly influenced modifications, making it more difficult to implement GC as a stand-alone model in obstetrician-led systems (Belgium and Kosovo) compared to a midwifery-led system (UK). In both contexts, the dominant model negatively influenced the perceived value of GC, with GC sessions viewed only as education and individual consultations seen as the actual care. Integration in the booking system appeared essential for payment and scheduling arrangements. Conclusions: Integrating GC scheduling into existing care pathways is challenging in systems where one-to-one care is the predominant model. Sustainable integration of GC requires early coordination and shared ownership across areas, including clinical, administrative, and IT.

Antimicrobial resistance is a growing global health crisis, with primary care settings being a major contributor due to inappropriate antibiotic prescribin

Background/Objectives: Malignant pleural effusion is a common and distressing complication of advanced cancer, often resulting in severe symptoms such as dyspnoea, which significantly impacts patients’ quality of life. This study evaluates the effectiveness and safety of talc slurry pleurodesis as a palliative treatment for recurrent malignant pleural effusion and examines predictive factors for pleurodesis success and survival. Methods: A single-centre cohort study was conducted at the Thoracic Surgery Department of the University Clinical Centre of Kosovo between April 2022 and March 2024. The study included adult patients with recurrent and symptomatic malignant pleural effusion who met specific inclusion criteria for performing pleurodesis. Patients were followed prospectively with routine clinical evaluations until the conclusion of the study on 9 September 2024. Descriptive and inferential statistics were employed to evaluate the success of pleurodesis and its associated outcomes. Results: The study shows a success rate of 84.6% at 30 days post-procedure, with 57.6% achieving complete success and 42.4% partial success. Talc slurry pleurodesis was associated with minimal complications, with chest pain and fever being the most common adverse effects. The most significant predictors of survival post-pleurodesis identified were the Karnofsky Performance Status score and serum neutrophil-to-lymphocyte ratio. Patients with higher Karnofsky Performance Status scores and lower neutrophil-to-lymphocyte ratios had improved survival outcomes. Conclusions: This study suggests that talc slurry pleurodesis is an effective and safe option for managing malignant pleural effusions in patients with low-performance status, offering symptom relief and potentially extending survival in certain patients. Further research is required to refine predictive models for treatment success.

Introduction Upper respiratory tract infections (URTIs) are one of the most common reasons for primary care visits, yet often do not require treatment with antibiotics. Antibiotic use is associated with side effects and the development of antibiotic resistance. Antimicrobial stewardship (AMS) programmes are essential to mitigate this issue. Many countries, including Kosovo, an upper-middle-income country, have not yet implemented AMS programmes. The implementation of AMS in Kosovo is shaped by economic, social, technological and legal factors. However, it is the structural weaknesses within the health system that pose the most significant barriers. This study will examine the barriers and enablers for AMS programmes for URTIs in the primary care setting. Methods and analysis We plan to employ a qualitative case study approach, comprising interviews and focus groups conducted at six primary care sites within Kosovo, as well as central health institutions. We will include diverse stakeholders involved or affected by AMS implementation, such as healthcare workers, patients and their representatives, and policymakers from the Ministry of Health. The Consolidated Framework for Implementation Research will guide the design of the study, data collection and analysis. We will use framework analysis to examine key themes within the domains of intervention characteristics, outer setting, inner setting, characteristics of individuals involved, the implementation process and other insights. Ethics and dissemination Ethical approval was obtained from the Kosovo Doctors Chamber (Reference No 122/2024), and we will adhere to good practice in terms of informed consent and data protection. Findings will be disseminated primarily through peer-reviewed publications.

Background: The global crisis of COVID-19 (Coronavirus disease 2019) has prompted comprehensive research into its impact, with studies uncovering varied occurrence and mortality rates. This study seeks to determine the prevalence of COVID-19 amongst the overall population based on self-reported symptoms and testing while also examining the association of prevalence with demographic, health, and epidemiological factors. Methods: A cross-sectional survey was carried out with citizens of Prishtina, the capital city of Kosovo from May to June 2021. We calculated the prevalence of self-reported COVID-19 symptoms and positive tests among the citizens, as well as crude and adjusted ORs examining the association of COVID-19 infection with explanatory factors, including the protection and exposure coefficient. Results: A total of 654 (52.1%) out of 1255 respondents reported having experienced COVID-19 symptoms. Six hundred (47.8%) households reported having an infected family member and 44 (7.3%) households reported having a dead family member due to COVID-19. In addition, 47.2% of 3,068 household members were infected with COVID-19, and 1.5% died due to COVID-19. A total of 689 respondents underwent testing for COVID-19 and 184 (26.7%) reported positive results. For individuals who reported COVID-19 symptoms, higher odds for infection were found among urban residents (adjusted OR, 1.53; 95%CI, 1.13-2.07; p=0.006), individuals with infected household members (adjusted OR, 2.53; 95%CI, 2.00-3.20; p<0.001), higher exposure coefficient (adjusted OR, 2.20; 95%CI, 1.42-3.41; p<0.001), and existing health conditions (adjusted OR, 2.22; 95%CI, 1.50-3.27; p<0.001). For individuals who underwent COVID-19 testing, higher odds for infection were found among individuals with infected household members (adjusted OR, 3.51; 95% CI, 2.29-5.39; p<0.001). Conclusion: This study highlights the prevalence of COVID-19 in Prishtina and the significance of factors like existing health conditions, household size, epidemiologic behaviour, and the number of infected members as important determinants of COVID-19 incidence.

Background: The increasing number of unnecessary cesarean births is a cause for concern and may be addressed by increasing access to midwifery care. The objective of this review was to assess the effect of midwifery care on the likelihood of cesarean births.Methods: We searched five databases from the beginning of records through May 2020. We included observational studies that reported odds ratios or data allowing the calculation of odds ratios of cesarean birth for births with and without midwife involvement in care or presence at the institution. Standard inverse‐variance random‐effects meta‐analysis was used to generate overall odds ratios (ORs).Results: We observed a significantly lower likelihood of cesarean birth in midwife‐led care, midwife‐attended births, among those who received instruction pre‐birth from midwives, and within institutions with a midwifery presence.Conclusions: Care from midwives reduces the likelihood of cesarean birth in all the analyses, perhaps due to their greater preference and skill for physiologic births. Increased use of midwives in maternal care can reduce cesarean births and should be further researched and implemented broadly, potentially as the default modality in maternal care.