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Table Of Contents: The Medicine Forum, Volume 26, 2024-2025

The Medicine Forum

Table of Contents: The Medicine Forum, Volume 26, 2024-2025

The Medicine Forum: Volume 26

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 26, 2024-2025

TABLE OF CONTENTS

• Research Studies
• Case Reports
• Humanities & Reflections

The Effect Of Sars-Cov-2 Reinfection On Long-Term Symptoms In The Innovative Support For Patients With Sars-Cov-2 Infections Registry (Inspire), John J. Openshaw, Ji Chen, Robert Rodriguez, Michael Gottlieb, Kalyani Mccullough, Michelle Santangelo, Mandy J. Hill, Kristyn Gatling, Ahamed H. Idris, Samuel Mcdonald, Lauren E. Wisk, Jonathan Dyal, Ralph C. Wang, Kristin L. Rising, Efrat Kean, Kelli N. O'Laughlin, Kari A. Stephens, Caitlin Malicki, Zhenqiu Lin, Erica S. Spatz, Huihui Yu, Robert A. Weinstein, Joann Elmore

Department of Emergency Medicine Faculty Papers

BACKGROUND: The clinical consequences of repeated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are not clear, especially as they relate to long-term symptoms after infection. We analyzed data collected for the Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE) to determine whether reinfection changes the likelihood of symptoms 3-6 months after reinfection compared with the likelihood in individuals experiencing a single infection.

METHODS: Individuals reporting a single SARS-CoV-2 infection or a single reinfection were included in this analysis. A positive SARS-CoV-2 test occurring ≥90 days after a first infection was considered a reinfection. Outcomes included severe fatigue (fatigue …

Cardiovascular Health In Cardiac Rehabilitation: Applying The American Heart Association Life's Simple 7 Framework In A Center-Based Cohort, Audry Chacin-Suarez, Tomoaki Hama, Matthew P. Johnson, Helayna Abraham, Thomas P. Olson, Laprincess C. Brewer

Einstein Health Papers

BACKGROUND: Cardiac rehabilitation (CR) is a comprehensive secondary cardiovascular disease program with structured lifestyle interventions to reduce morbidity and mortality. The American Heart Association cardiovascular health (CVH) framework measures health-promoting behaviors and clinical factors, but it has not been rigorously evaluated in the CR setting.

METHODS: This retrospective cohort study analyzed patients attending CR from January 2018 to September 2020. Patients were evaluated at baseline (pre-CR) and completion (post-CR) using 3 clinical factors (blood pressure, cholesterol, and hemoglobin A1c) and 4 health behaviors (smoking, body mass index, physical activity, and diet). CVH score was computed as a composite of each …

Slow-Growing Lung Mass In A Patient With Multiple Endocrine Neoplasia Type I: Consider Carcinoid Tumor, Ramin Talebi, Charalambos C. Solomides, Nathaniel R. Evans Iii, Gregory C. Kane

Division of Pulmonary, Allergy, and Critical Care Medicine Faculty Papers

A 23-year-old man with multiple endocrine neoplasia type 1 (MEN 1) with pancreatic tail masses and Cushing syndrome (status after transsphenoidal adenomectomy) presented with a slow-growing, asymptomatic right lower lung lobe mass confirmed to be an atypical carcinoid tumor by pathologic staging following successful basilar segmentectomy with mediastinal lymphadenectomy. Pulmonary carcinoid tumor (PCT) is a rare neoplasm in patients with MEN 1, but there is limited data on trends in atypical versus typical carcinoid tumors in these patients. This case emphasizes the need to characterize these trends given the implications for metastatic potential and 5-year survival, which can help guide …

Brivaracetam For Spinal Cord Injury-Related Neuropathic Pain: Results Of A Pilot Double-Blinded, Randomized, Placebo-Controlled Clinical Trial, Leslie R. Morse, Ricardo A. Battaglino, Nguyen Nguyen, Brian Devries, Abigail Welch, Ana Lucia Battaglino, Clas Linnman, Michael Stillman, Robert Wudlick, Joda Glossner, Grant Anderton, Richard Goldstein, Scott P. Falci

Department of Medicine Faculty Papers

OBJECTIVE: Assess feasibility, safety, and tolerability of 3 months of oral brivaracetam for severe (9-10/10) spinal cord injury-related neuropathic pain.

METHODS: We conducted a multisite pilot study where adults were randomized to 3 months of brivaracetam (100 mg BID) or placebo. Pain was assessed via the Brief Pain Inventory, the International Spinal Cord Injury Pain Basic Dataset (version 2.0), and a daily pain diary.

RESULTS: We enrolled 24 participants across 2 sites and 14 participants were included in the final analysis (n = 8 placebo, n = 6 brivaracetam). The drug was tolerated with expected, nonserious side effects (nausea if …

“Are You Worried About Going Into Withdrawal Today?” Retrospective Analysis Of Single-Question, Patient-Centered Screen For Substance Use And Care Linkage, Kory S. London, Beth Hurwitz, Jennifer Davis, Tareva Warrick-Stone, Alan Cherney, Frederick Randolph, Bernice Bradley-O'Toole, Kate Deis, Karen Alexander

Department of Emergency Medicine Faculty Papers

BACKGROUND: Emergency Department (ED) screening for substance use disorder (SUD) is limited by a lack of standardization and challenging clinical environments. Existing tools may be focused on informing clinicians rather than supporting patients. This study assessed a novel single-question screening tool to identify patients at risk of withdrawal and link those with opioid use disorder (OUD) to standardized treatment.

METHODS: A cross-sectional, retrospective study was conducted at two urban EDs in Philadelphia, PA, using electronic health record data between November 8, 2022, and February 28, 2025. Patients were included in the study if they arrived ambulatory to the emergency department, …

Respectful Patient-Provider Communication And Patient Portal Usage In Pregnant People Of Color, Amy H. Goh, Christopher Lee, Chisolum Nkenke, Joyce K. Edmonds

College of Health Professions Faculty Papers

BACKGROUND: Patient-provider communication (PPC) increasingly occurs in online patient portals. Variations in portal usage might worsen communication inequities for pregnant people of color (POC), widening the digital divide. The objective of this study was to examine the relationships between respectful PPC, patient portal usage, and digital health literacy (DHL) in pregnant POC.

METHODS: A multimethod cross-sectional survey design was used. Ordered logistic regression was performed to determine the relationship between PPC and portal use, controlling for trimester prenatal care was initiated, insurance type, age, gestational age, and parity. The moderating effect of Digital Health Literacy Instrument (DHLI) was tested on …

In Vivo Direct Lentiviral Gene Therapy Improves Disease Pathology In A Mucopolysaccharidosis Iva Murine Model, Betul Celik, Estera Rintz, Shaukat Khan, Andrés F. Leal, Fnu Nidhi, Shunji Tomatsu

Department of Pediatrics Faculty Papers

Mucopolysaccharidosis IVA (MPS IVA) is an autosomal recessive disorder that causes the accumulation of keratan sulfate (KS) and chondroitin-6-sulfate in bone and cartilage. This results in progressive skeletal dysplasia, with no effective treatment available. Our study hypothesized that direct lentiviral vector (LV) gene therapy could produce active enzymes from transduced cells, impacting bone and cartilage lesions in MPS IVA. We developed LVs carrying the GALNS gene under three promoters: ubiquitous (CBh), collagen type II (COL2A1), and Mac-1 integrin subunit (CD11b). At the newborn stage and 4 weeks, Galns-knockout mice received intravenous injections at different doses (5 × 10^{9 …}

Management And Optimization Of Chronic Renal Insufficiency In The Setting Of Kidney Cancer A Systematic Review, Jessica K. Cobb, Hiroko Miyagi, Jad Chahoud, Claude Bassil, Philippe E. Spiess

Division of Internal Medicine Faculty Papers & Presentations

PURPOSE: There is a bidirectional relationship between chronic kidney disease and the incidence of renal cell carcinoma. Despite the frequency of patients with both chronic kidney disease and renal cell carcinoma, there are limited systematic reviews detailing the nuanced treatment. This review provides comprehensive insights for clinicians for managing chronic kidney disease, and renal cell carcinoma. Methods and Methods: We reviewed published literature that examined either chronic kidney disease and renal cell carcinoma or an indirect contributor of both.

RESULTS: We compare and contrast renal cell carcinoma treatment with partial and radical nephrectomies, ablative techniques, and radiation and their impact …

Hydropneumopericardium Due To Esophageal-Pericardial Fistula: A Rare Complication Of Esophageal Stenting, Svenja Schneider, Margaret Doyle, Suzanna Talento, Waqas Ullah, Gregary D. Marhefka

Division of Cardiology Faculty Papers

We present a case of a 53-year-old woman with a history of ulcerative esophagitis and esophageal stricture status post esophageal stenting that was complicated by stent migration. She presented with fatigue, melena, and dark output from her percutaneous endoscopic gastrostomy tube. An echocardiogram showed hydropneumopericardium with cardiac tamponade physiology requiring emergent pericardiocentesis. The aspirated fluid was brown and cloudy; pathology of the fluid showed meat and vegetable matter consistent with food. She ultimately required esophagectomy with esophagostomy. This case highlights the importance of early recognition of esophageal-pericardial fistulas, as delay in the management carries a high risk for morbidity and …

Proceedings Of The Seventh Annual Women In Melanoma Conference, Yana G. Najjar, Marlana Orloff, Tara C. Mitchell, Tawnya L. Bowles, Allison Betof Warner, Kathryn Bollin, Sunandana Chandra, Justine V. Cohen, Zeynep Eroglu, Pauline Funchain, Elizabeth Gaughan, Isabella Glitza Oliva, Sherry Hsu, Siwen Hu-Lieskovan, Lucy B. Kennedy, Thach-Giao Truong, Meredith Mckean, Janice Mehnert, Helen Moon, Katy K. Tsai, Melissa Wilson, Thuy Tran, Elizabeth I. Buchbinder, Leslie A. Fecher, Samantha Guild, Sapna P. Patel

Kimmel Cancer Center Faculty Papers

No abstract provided.

Management Of Embedded Unexploded Ordnance In Low-Resource Settings: A Scoping Review, Eric S. Weinstein, David Nitsch, Chris Leboa, S. Yves G. Sanou, Yves Aziz Nacanabo, Serhii Tertyshnyii, Amila Ratnayake, Akul Gupta, David T. Walker, Paul Amoroso, Barclay Stewart, Hannah Wild

College of Health Professions Faculty Papers

OBJECTIVES: When unexploded ordnance (UXO) is embedded in the body, the effect of explosive weapons used in conflict is amplified. Though relatively rare, such events present potentially devastating consequences for the patient and medical providers as routine diagnostic and therapeutic procedures hold potential to initiate detonation of the embedded UXO (eUXO). The objective is to identify and synthesize available literature relating to the management of eUXO in low resource settings.

METHODS: A scoping review was conducted using PRISMA-ScR methodology to evaluate literature in all languages from all date ranges until January 31, 2024, discussing the management of casualties with eUXO, …

Embedding Mental Rehearsal In Surgery: A Comprehensive Review Of The Evidence, Josephine Walshaw, Bright Huo, Paul Barach, Philippa Banks, Adam Mcclean, Florent Lebon, Faisal Mushtaq, David Jayne, Danilo Miskovic, Marina Yiasemidou

College of Population Health Faculty Papers

BACKGROUND: Mental rehearsal (MR), the deliberate practice of skills specific to a procedure, has been successfully used in sports and music training for decades, but has not been adopted in surgery. This narrative review explores MR's role in surgical training and clinical practice, evaluating its effectiveness in motor skill acquisition, technical and non-technical skill development, and real world clinical implementation. Our aim was to assess MR's impact on both surgical education and clinical performance, while identifying the barriers to its routine adoption in surgical training.

METHODS: We searched for relevant studies on the topic and impacts of MR in surgery …

Enhancing Neuronal Viability: The Protective Role Of 10% Human Cerebrospinal Fluid In Primary Neuronal Cultures, Vineet Arora, Alicia Bernhardt, Alessandro Naopli, Mijail Serruya

Farber Institute for Neuroscience Faculty Papers

Human cerebrospinal fluid (hCSF) is a physiologically rich medium containing neurotrophic factors, signaling molecules, and essential metabolites that support neuronal development, survival, and function. While its neuroprotective properties have been demonstrated in organotypic brain slices and human iPSC-derived models, its application in primary rodent cortical neuron cultures-a foundational system for studying synaptic development and neurodegeneration-remains underexplored. In this study, we systematically evaluated the effects of hCSF supplementation on neuronal viability in primary cortical cultures derived from embryonic day 18 (E18) rat embryos. To determine the optimal concentration, we tested a range of media:hCSF ratios and identified 90:10 (i.e., 10% hCSF) …

Clinical Profile Of Patients With Monocular Elevation Deficiency Undergoing Strabismus Surgery, Mohamad Reza Akbari, Babak Masoomian, Elham Azizi, Mohammed Omer Mahmood, Arash Mirmohammadsadeghi, Ali Majdi, Masoud Khorrami-Nejad

Wills Eye Hospital Papers

PURPOSE: To provide a comprehensive evaluation of the visual, refractive, and strabismic characteristics of patients with monocular elevation deficiency (MED) undergoing strabismus surgery.

METHODS: The medical records of patients at a single institution who were diagnosed with and underwent surgery for MED were reviewed retrospectively. Visual acuity, refractive error, angle of deviation, abnormal head posture (AHP), presence of ptosis, prevalence of amblyopia and strabismic patterns were analyzed, with MED eyes compared with fellow eyes.

RESULTS: A total of 105 patients were included. Mean cylindrical refractive error was significantly higher in MED eyes compared with fellow eyes (-1.40 ± 1.70 D …

Supercritical Co2 Technology For Biomass Extraction: Review, Bahare Nozari, Ron Kander

School of Design and Engineering Papers

Supercritical carbon dioxide extraction is increasingly recognized as a green and efficient alternative to conventional solvent-based techniques for valorizing plant biomass. This review provides a comprehensive overview of recent advances in a scCO₂ extraction method, focusing on its advantages in isolating high-value compounds from agricultural feedstocks. The unique physicochemical properties of scCO₂, combining gas-like diffusivity with liquid-like solvating power, enable selective extraction under mild and tunable conditions, which preserves the integrity of thermally sensitive molecules. In addition, scCO₂ reduces energy consumption, eliminates toxic solvent residues, and offers greater extraction precision than traditional methods. These features have …

24-Month Patient-Reported Outcomes For A Novel Lumbar Total Joint Replacement, Ahilan Sivaganesan, Marissa Koscielski, Ashmal Sami, J. Alex Sielatycki, Jeffrey Goldstein, Brady Riesgraf, Craig Humphreys, Scott Hodges

Department of Neurosurgery Faculty Papers

BACKGROUND: Lumbar fusion remains a prevalent treatment for degenerative conditions; however, its limitations have sparked interest in alternative motion-sparing procedures. Our study evaluates 24-month postoperative patient-reported outcomes from an OUS pilot clinical study on a novel lumbar total joint replacement (TJR) for degenerative conditions.

METHODS: Data was collected from 63 patients, of which 56 patients fulfilled the inclusion criteria. Self-reported measures collected for this study are Oswestry Disability Index (ODI), Numeric Rating Scale (NRS), Minimal Symptom State (MSS), Minimal Clinical Important Difference (MCID), Substantial Clinical Benefit (SCB). This retrospective analysis of prospective, IRB-approved collected data reports 24 month patient-reported outcomes …

Evaluation Of Aav Vectors With Tissue-Specific Or Ubiquitous Promoters In A Mouse Model Of Mucopolysaccharidosis Type Iva, Shaukat A. Khan, Jose Victor Álvarez, F. N. U. Nidhi, Eliana Benincore-Florez, Shunji Tomatsu

Department of Pediatrics Faculty Papers

Mucopolysaccharidosis type IVA (MPS IVA) is caused by a deficiency of N-acetyl-galactosamine-6-sulfate sulfatase (GALNS), leading to the accumulation of keratan sulfate and chondroitin-6-sulfate and development of severe skeletal dysplasia. Enzyme replacement therapy and hematopoietic stem cell transplantation are current treatment options but have limited impact on bone lesions. In this study, we investigated adeno-associated virus (AAV)8 or AAV9 vectors with liver-specific thyroxine-binding globulin or liver-specific promoter-a modification of hAAT (LSPX), liver-muscle tandem (LMTP), liver-bone tandem (LBTP), and ubiquitous cytomegalovirus early enhancer/chicken β-actin (CAG) promoters in MPS IVA mice to compare therapeutic efficacy on biochemical markers and bone pathology. All vectors …

Who Seeks Help? A Sociodemographic Analysis Of Cannabis Use Disorder Treatment In New York, Ayodele Atolagbe, Ekenedilichukwu Theresa Emembolu, Stanley Nkemjika

Department of Psychiatry and Human Behavior Faculty Papers

Introduction: Cannabis use disorder (CUD) is being increasingly diagnosed in the United States, but access to treatment remains unequal, particularly in New York. Identifying the factors that contribute to disparities in receiving treatment for CUD among different population groups is essential for ensuring effective and targeted interventions. This study explores the sociodemographic factors influencing treatment utilization for CUD in New York.

Methods: Data for this study were retrieved from the 2018 Treatment Episode Data Set—Discharges (TEDS-D) of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). Sample size for the study is 422,319 people with CUD. Logistic regression analysis …

Plug And Coil Procedure For Management Of Large Postinfarct Ventricular Septal Defect, Hussam Al Hennawi, Sergio Flores, Michael Little, Lacy Harville, Ahmad Almomani, Muhammad Hammadah

Abington Jefferson Health Papers

Acute surgical mortality for postinfarction ventricular septal rupture remains alarmingly high at approximately 50%. In comparison, medical mortality is nearly 100% and likely exceeds historical levels because of the declining frequency of these acute surgeries, with many surgeons now performing fewer than 1 or 2 annually. Percutaneous device closure has become a feasible option for managing postinfarction ventricular septal defects in carefully selected patients. However, this technique may be associated with challenges such as significant residual shunting, delayed endothelialization, hemolysis, and extended hospital stays. Here, we present a novel approach using coil packing to enhance closure and reduce shunting.

The Incidence Of Peripartum Invasive Group A Streptococcal Infections And Association With Illicit Drug Use, Elizabeth Wagman, Elizabeth Wagman, Rupsa Boelig, Sarah Boudova

Department of Obstetrics and Gynecology Faculty Papers

No abstract provided.

Community Perspectives On Cancer And Cancer Research: Findings From Listening Sessions With Diverse Groups In Philadelphia, Karen Glanz, Emma A. Soliva, Krista Scheffey, Yawei Song, Charnita Zeigler-Johnson, Evelyn T. González, Thierry Fortune, Nilsa Graciani, Amy E. Leader

Kimmel Cancer Center Faculty Papers

BACKGROUND: Listening sessions are useful for understanding community perspectives on cancer disparities. The Philadelphia Communities Conquering Cancer (PC3) coalition conducted listening sessions to identify community priorities for cancer prevention and control research among diverse communities in Philadelphia.

METHODS: Guided by a Stakeholder Advisory Committee, PC3 partnered with community-based organizations to conduct 8 listening sessions with diverse communities (including Black, Hispanic, Asian, Russian, LGBTQ + , and veterans) to learn about perceptions of cancer, research priorities, and training and communication preferences. Sessions were facilitated by community members or PC3 members in the primary language of participants. Sessions were audio recorded, transcribed, …

Large Right Subclavian Artery True Aneurysm Treated With Hybrid Surgery, Melissa Xu, Ioannis Tsouknidas, Alec Krosser, Gaurang Joshi, Babak Abai, Michael Nooromid, Paul Dimuzio, Dawn M. Salvatore

Student Papers, Posters & Projects

Introduction

Subclavian artery (SCA) aneurysms are exceedingly rare (~0.13% of peripheral aneurysms).

There are no criteria regarding size cut off for repair.

Surgery is indicated given risk of complications (thrombosis, embolization leading to CVA or UE ischemia, compression of adjacent structures).

• Open surgery (via median sternotomy, hemisternotomy, lateral thoracotomy, supraclavicular or axillary incision),
• Endovascular (stent graft, aneurysm sac coiling, kissing stents or combination)
• Hybrid (endovascular + extra-anatomic bypass).

Best Practices For Creating An Addiction Curriculum Within Family Medicine Residency Programs: A Qualitative Analysis Of Expert Opinion, Gregory A. Jaffe, Barisue Brodsky, Jacob Buckley, Brooke Mauriello, Corey Pasakarnis, Paul Rizzo, Madison Smith, Randi Sokol

Department of Family & Community Medicine Faculty Papers

Background and Objectives: Primary care physicians are well-positioned to be at the forefront of screening for and treating substance use disorders (SUDs). In addition, the Accreditation Council for Graduate Medical Education has deemed addiction training a common program requirement for all residency programs. With less than one-third of family medicine residency programs providing addiction training, understanding best practices for addiction training is important.

Methods: We interviewed 12 faculty at family medicine residency programs across the country who have a strong reputation for addiction training. We analyzed interview transcripts thematically to identify best practices for creating and providing addiction curricula.

Results: …

A Cascading Effects Model Of Early Sensory Development In Autism, Natalie Russo, Carissa J. Cascio, Grace T. Baranek, Tiffany G. Woynaroski, Zachary J. Williams, Shulamite A. Green, Roseann Schaaf

Department of Occupational Therapy Faculty Papers

Autism has historically been defined by the presence of differences in social communication and restricted, repetitive patterns of behavior, interests, or activities (RRBs). Since 2013 when the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders was published, sensory features were added as one of the polythetic restricted and repetitive behavior diagnostic criteria of autism, though it has remained understudied. Here, we summarize theory and research to provide support for the perspective that early sensory functions and experiences play a primary role in autism and have downstream effects on social communication and repetitive behavioral features of autism. The …

Infectious Endophthalmitis: An Overview Of Clinical Features, Microbiology Profile, And Antibiotic Sensitivity Pattern, Seyed Ali Tabatabaei, Ahmad Masoumi, Arash Mirzaei, Reza Mirshahi, Bita Momenaei, Faezeh Moghimpour Bijani, Ali Rashidinia, Mohammadreza Nazari, Mohammad Ahadifard, Zahra Mahdizad, Samer Habeel, Seyed Mahbod Baharnoori, Mohammad Soleimani

Wills Eye Hospital Papers

PURPOSE: To describe the demographic characteristics, etiology, microbiological spectrum, and antibiotic sensitivity patterns in patients with endophthalmitis.

METHODS: This is a retrospective case series spanning from May 2012 to September 2018. All included patients were diagnosed with endophthalmitis and confirmed by laboratory tests. Data were collected on patient demographics, types of endophthalmitis, and microbiologic and medical records.

RESULTS: Nine hundred ninety-two records of patients with endophthalmitis were assessed. Of the total cases, 657 patients (66.2%) were male, whereas 335 (33.8%) were female. The mean age of the patients was 57.2 ± 22.8 years and ranged from 2 to 95 years. …

An Educational Intervention For The Care Of Older Adults, Michele Orzehoski, Dnp, Rn

Thomas Jefferson University Faculty Days

No abstract provided.

Sg-Met: Past To Present Day Evolution, Aiden Echols, Bs, Madison Via, Bs, Audrey L. Zapletal, Otd, Ms, Otr/L, Cla, Chse, Karla A. Bell, Pt, Dpt, Phd, Fnap

Thomas Jefferson University Faculty Days

Background

LGBTQ+ communities experience health care and health disparities; some reasons include:

• barriers in care,
• negative attitudes,
• lack of awareness by healthcare providers.

Studies have found healthcare professionals are not adequately trained in LGBTQ+ care

Educators benefit from professional development related to LGBTQ+ inclusivity in higher education.

Stakeholders' Expectations And Experiences Of Being Involved With A Global Accreditation Process For Midwifery Centres In Lmics: A Rapid Ethnography, Summer M. Aronson, Laura Batinelli, Lucia Rocca-Ihenacho, Jennifer R. Stevens

College of Health Professions Faculty Papers

BACKGROUND: This study explored the expectations and experiences of stakeholders involved in the accreditation of midwifery centres (MCs) in low- and middle-income countries (LMICs). With increasing evidence that MCs provide safe, respectful, and evidence-based care that improves maternal and neonatal outcomes, accreditation may serve as a mechanism to bridge quality gaps in maternal health systems, particularly in regions with high maternal and neonatal mortality.

METHODS: A rapid ethnographic approach, combining participant observation and semi-structured interviews, was conducted in partnership with the GoodBirth Network (GBN), which identified six pilot midwifery centres in Haiti, Uganda, and South Africa. Convenience sampling was applied, …