Clinical Officers Research Articles

Does nephrolithometry scoring systems predict success and complications in miniPCNL?

Auxiliary nephrolithometric scoring systems (NSSs) have been developed to predict complications and treatment success of conventional percutaneous nephrolithotomy (PCNL). However, to our knowledge, there is no study comparing these NSSs in patients undergoing miniPCNL. This study aimed to compare the NSSs in terms of their ability to predict miniPCNL-related complications and treatment success. The data of patients undergoing PCNL between September 2016 and May 2018 were retrospectively reviewed through the electronic medical record system, and 140 patients were included in our study. Stone-free status was evaluated using non-contrast computed tomography between 1 and 3months after the procedure. PCNL was considered successful if the patient was completely stone free. The postsurgical complications were classified according to the modified Clavien-Dindo classification system. The Clinical Research Office of the Endourological Society (CROES) and STONE NSSs significantly predicted miniPCNL treatment success (p = 0.043, p = 0.018). However, the Guy's NSS did not significantly predict the treatment success (p = 0.415). Guy's, CROES and STONE NSSs were not found to significantly predict postsurgical complications (p = 0.584, p = 0.823, p = 0.189). To the best of our knowledge, our study is the first of its kind to investigate the ability of NSSs to predict treatment success and postsurgical complications in patients undergoing miniPCNL. The study found that STONE and CROES NSSs are independent parameters for predicting stone-free status after miniPCNL. In addition, our study found that none of the NSSs were useful in predicting postsurgical complications in patients undergoing miniPCNL.

Planning neurosurgical interventions in patients with anticoagulant therapy

Clinical practice guideline on anticoagulation is intended to manage patients undergoing neurosurgical procedures for the best possible short and long-term outcomes. In the clinical office practice, anticoagulation is offered to prevent thromboembolism with Warfarin, Heparin, Novel Oral Anticoagulants. The management approach starts with the mitigation plans from a reversal of pre-procedural anticoagulants for impending neurosurgical procedures by estimating procedural bleeding risk on the patients. The haemorrhage criteria and the timing of procedures are best assessed by the proceduralist during and after the intervention, standing on ground situations. Yet, intra- and post-procedure anticoagulant therapy should induct a multidisciplinary consultation paradigm for the best outcome in any emergent scenario. Further, each anticoagulation event should be monitored closely with competence in the optimum reversal process. Different neurosurgical procedures also should be weighed for their inherent hazards along with the probabilities of the bleeding and thromboembolism. The treating team should also concur to suggest a resumption of the pre-procedure anticoagulant therapy which may have been in place for altogether different morbidities. Regarding the anticoagulant agent, there are special conditions and recommendations to bear in mind in the daily medical practice for patient management. In the clinical practice guidelines for neurosurgical procedures, decisions about initiation and continuation of anticoagulants require experience and thorough internalization of the planned procedure, to avoid the risks of inherent risks of bleeding and thromboembolism.

Using an on-site modular training approach to amplify prep service delivery in public health facilities in Kenya.

Delivery of oral PrEP, a potent HIV prevention intervention, has begun within public health systems in many countries in Africa. Training as many health providers as possible expeditiously is necessary to efficiently and rapidly scale up PrEP delivery among at risk populations and thereby realize the greatest impact of PrEP. We designed and implemented an innovative on-site modular training approach delivered in five two-hour modules. The modules could be covered in two consecutive days or be broken across several days enabling flexibility to accommodate health provider work schedules. We assessed knowledge gain comparing pre-and post-training test scores and determined monthly PrEP uptake for six months following the training intervention. We also evaluated the cost of this training approach and conducted key informant interviews to explore acceptability among health providers. Between January 2019 and December 2020, 2111 health providers from 104 health facilities were trained on PrEP. Of 1821 (83%) providers who completed both pre- and post-tests, 505 (28%) were nurses, 333 (18%) were HIV counsellors, 276 (15%) were clinical officers and 255 (14%) were lay providers. The mean score prior to and after training was 58% and 82% respectively (p <0.001). On average, health facilities initiated an average of 2.7 (SD 4.7) people on PrEP each month after the training, a number that did not decline over six months post-training (p = 0.62). Assuming Ministry of Health costs, the costs per provider trained was $16.27. Health providers expressed satisfaction with this training approach because it enabled many providers within a facility receive training. On-site modular training is an effective approach for improving PrEP education for health workers in public health facilities, It is also acceptable and low-cost. This method of training can be scaled up to rapidly amplify the number of health workers able to offer PrEP services.

Implementing Advanced HIV Disease Care for Inpatients in a Referral Hospital in Malawi - Demand, Results and Cost Implications.

Setting:100 bed medical ward in referral hospital, Lilongwe, Malawi.Objective:HIV positive patients admitted to hospital often have advanced HIV disease (AHD) and are at risk for mortality. WHO guidelines suggest a package of care for AHD; these are often not implemented, especially in inpatient settings. We describe an implementation model for AHD care, its outcomes in routine care and provide cost estimates.Design:An “AHD care room” was established staffed by HIV counselor, nurse, and clinical officer allowing Provider Initiated Testing and Counseling, diagnostic testing for AHD and ensuring availability of HIV and TB drugs for rapid treatment initiation.Results:In the observation period from January to December 2020, a total of 1549 medical inpatients were tested for HIV (coverage 77.1%); 69 tested positive (yield 4.5%). The total proportion of HIV positive was 32.3% (638 already on ART and 69 newly diagnosed). CD4+ testing was done in 460 medical inpatients (65.1%); 245 (53.2%) were below 200 cells/ml and thus met definition of AHD. A total of 238 received S-CrAg tests; 39 (16.3%) were positive; 62 (28.3%) of 219 U-LAM tests were positive. The cost per identification of HIV positive patient was US$ 110.8; per AHD diagnosis between US$ 17.1 to 78.9; per positive S-CrAg test US$ 18.5 and per positive U-LAM test US$ 17.5.Conclusion:Our model successfully implemented AHD services according to WHO guidelines and provides basic costing data. Similar services could be implemented in other hospitals in LMICs.

Network characteristics of a referral system for patients with hypertension in Western Kenya: results from the Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) study

BackgroundHealth system approaches to improve hypertension control require an effective referral network. A national referral strategy exists in Kenya; however, a number of barriers to referral completion persist. This paper is a baseline assessment of a hypertension referral network for a cluster-randomized trial to improve hypertension control and reduce cardiovascular disease risk.MethodsWe used sociometric network analysis to understand the relationships between providers within a network of nine geographic clusters in western Kenya, including primary, secondary, and tertiary care facilities. We conducted a survey which asked providers to nominate individuals and facilities to which they refer patients with controlled and uncontrolled hypertension. Degree centrality measures were used to identify providers in prominent positions, while mixed-effect regression models were used to determine provider characteristics related to the likelihood of receiving referrals. We calculated core-periphery correlation scores (CP) for each cluster (ideal CP score = 1.0).ResultsWe surveyed 152 providers (physicians, nurses, medical officers, and clinical officers), range 10–36 per cluster. Median number of hypertensive patients seen per month was 40 (range 1–600). While 97% of providers reported referring patients up to a more specialized health facility, only 55% reported referring down to lower level facilities. Individuals were more likely to receive a referral if they had higher level of training, worked at a higher level facility, were male, or had more job experience. CP scores for provider networks range from 0.335 to 0.693, while the CP scores for the facility networks range from 0.707 to 0.949.ConclusionsThis analysis highlights several points of weakness in this referral network including cluster variability, poor provider linkages, and the lack of down referrals. Facility networks were stronger than provider networks. These shortcomings represent opportunities to focus interventions to improve referral networks for hypertension.Trial registrationTrial Registered on ClinicalTrials.gov NCT03543787, June 1, 2018.

Online interprofessional education for in-service health-care providers improved HIV performance indicators at health facilities in Uganda: a targeted training approach

BackgroundThe Makerere University Education for Interprofessional HIV Service Delivery in Uganda capacity-building programme provides online, in-service interprofessional education to HIV health-care providers through a case-based approach. We used this training to address suboptimal performance among health-care providers. MethodsWe used a multilayered integrated training and impact assessment on HIV health outcomes. In partnership with a Ugandan organisation implementing the US President's Emergency Plan for AIDS Relief, we identified health facilities underperforming on selected HIV programme indicators: pre-exposure retention at 12 months for key populations and viral load suppression and annual retention for key populations, which could be aligned with the training modules. We selected health-care providers committed to completing the interprofessional education training and application of interprofessional practice at their workstations from five health facilities. Selected health-care providers were enrolled for the Makerere University Education for Interprofessional HIV Service Delivery in Uganda online training programme. FindingsOf the health-care providers enrolled (n=55), 32 (58%) were women; 17 (31%) were nurses; 9 (16%) were clinical officers; 8 (15%) were counsellors; 6 (11%) were medical officers; 5 (9%) were data clerks; 4 (7%) were laboratory personnel; and 6 (11%) included social workers, records officers, and dispensers. 45 (82%) health-care providers completed the training, and four of the five health facilities initiated quality improvement projects aligned with baseline indicators. The percentage of pre-exposure retention at 12 months improved from 4% to 80%; the percentage of viral load coverage for key populations improved from 50% to 94%; the percentage of viral load suppression improved from 80% to 96%; and the percentage of annual retention for key populations improved from 63% to 85%. InterpretationIn-service and online interprofessional education training, interprofessional practice mentorship, and continuous quality improvement for HIV care improved HIV programme indicators. A multilevel stakeholder engagement strategy was associated with strengthened training and enhanced potential for sustainability and impact on patient outcomes. FundingHuman Resources Services Administration through award 6U1NHA31422-02-04 to University of California San Francisco and African Forum for Research and Education in Health.

Task shifting for point of care ultrasound in primary healthcare in low- and middle-income countries-a systematic review.

SummaryLow-and middle-income countries (LMIC) are faced with healthcare challenges including lack of specialized healthcare workforce and limited diagnostic infrastructure. Task shifting for point-of-care ultrasound (POCUS) can overcome both shortcomings. This review aimed at identifying benefits and challenges of task shifting for POCUS in primary healthcare settings in LMIC. Medline and Embase were searched up to November 22nd, 2021. Publications reporting original data on POCUS performed by local ultrasound naïve healthcare providers in any medical field at primary healthcare were included. Data were analyzed descriptively. PROSPERO registration number CRD42021223302. Overall, 36 publications were included, most (n = 35) were prospective observational studies. Medical fields of POCUS application included obstetrics, gynecology, emergency medicine, infectious diseases, and cardiac, abdominal, and pulmonary conditions. POCUS was performed by midwives, nurses, clinical officers, physicians, technicians, and community health workers following varying periods of short-term training and using different ultrasound devices. Benefits of POCUS were yields of diagnostic images with adequate interpretation impacting patient management and outcome. High cost of face-to-face training, poor internet connectivity hindering telemedicine components, and unstable electrici'ty were among reported drawbacks for successful implementation of task shifting POCUS. At the primary care level in resource-limited settings task shifting for POCUS has the potential to expand diagnostic imaging capacity and impact patient management leading to meaningful health outcomes.

Perfusion Practice in Kenya.

Standards and guidelines for cardiopulmonary bypass have been established by various professional societies. They serve as an instrument to guide safe and effective patient care. We conducted a survey of practicing perfusionists in Kenya to learn about their background, education, current clinical practice and about their knowledge, and attitude regarding standards and guidelines. Two multiple-choice surveys were distributed to all known practicing perfusionist in Kenya using SurveyMonkey (San Mateo, CA). Multiple-choice questions related to professional background, training, annual procedure volume, staffing models, clinical practices, the use of safety devices, and the use of checklists were included in the questionnaires. The survey also inquired about familiarity with American and European perfusion practice standards and guidelines and opinions on establishing standards in Kenya. Responses were received from 12 perfusionists practicing at 10 centers. Professional backgrounds included anesthesia nursing, clinical officers, and critical care nursing. Sixty-seven percent (8/12) received formal training and 33% (4/12) trained primarily through clinical instruction. Of those that received formal training, 63% (5/8) received 1-2 years of training, 25% (2/8) <1 year but more than 6 months, and 12.5% (1/8) received 6 months of formal training. The median clinical experience was 5 years (range 1-22). The median annual case load was 54 (range 0-100). Use of safety devices was reported as follows: level sensor 75% (9/12), air bubble detector 17% (2/12), one-way vent valves 67% (8/12), continuous venous oxygen saturation monitoring 25% (3/12), and gas supply analyzers 33% (4/12). More than one-third of the respondents had no knowledge of the American and European perfusion practice standards, and nearly two-thirds were aware of or had read them. This survey provides contextual information about perfusion practice in Kenya in 2021. There was consensus among perfusionists to develop standards and practice guidelines for Kenya.

Healthcare worker perspectives on mother\u2019s insufficient milk supply in Malawi

BackgroundHuman milk insufficiency is a significant barrier to implementing breastfeeding, and it is identified as a prevalent concern in 60–90% of mothers in low-and-middle-income countries. Breastmilk insufficiency can lead to hypoglycemia, hypernatremia, nutritional deficiencies, and failure to thrive in newborns and infants. Studies investigating the impact of breastfeeding interventions to improve milk production highlight inconsistencies between healthcare workers and mothers perceived support, as well as gaps in practical knowledge and training. The aim of this study was to determine perceptions surrounding human milk insufficiency from Malawian healthcare workers.MethodsThis study is a secondary analysis of 39 interviews with healthcare workers from one tertiary and three district hospitals in Malawi employing content analysis. Interviewed healthcare workers included nurses, clinical officers, midwives, and medical doctors. An inclusive coding framework was developed to identify themes related to human milk insufficiency, which were analyzed using an iterative process with NVivo12 software. Researchers focused on themes emerging from perceptions and reasons given by healthcare workers for human milk insufficiency.ResultsInability to produce adequate breastmilk was identified as a prevalent obstacle mothers face in the early postpartum period in both district and tertiary facilities in Malawi. The main reasons given by participants for human milk insufficiency were mothers’ perceived normalcy of milk insufficiency, maternal stress, maternal malnutrition, and traditional beliefs around food and eating. Three focused solutions were offered by participants to improve mother’s milk production – improving education for mothers and training for healthcare providers on interventions to improve mother’s milk production, increasing breastfeeding frequency, and ensuring adequate maternal nutrition pre- and post-partum.ConclusionHealth care workers perspectives shed light on the complexity of causes and solutions for human milk insufficiency in Malawi. This research highlights that a respectful professional relationship between health care workers and mothers is an essential bridge to improving communication, detecting human milk insufficiency early, and implementing appropriate interventions. The results of this study may help to inform research, clinical practice, and education in Malawi to improve human milk production.

Antenatal Management Information System (Case Study: China-Uganda Friendship Hospital, Naguru)

To eradicate fetal deaths and stillbirths, the World Health Organization (WHO) set up antenatal care guidelines to help expectant mothers through this period. In Uganda today, it is estimated that at least 90% of the expectant mothers receive antenatal care, and with such a large number of people receiving this service, data is collected manually with pen, which makes it a long process and cumbersome to search specific records during emergencies and analysis of data for proper decision making. Therefore, there is a need for an antenatal management information system. The software is sectioned into registration, triage and consultation. The records officer handles registration of patients, patient visits, viewing and printing patient statistics. The senior clinical officer handles triaging the patient and capturing their vitals, viewing and printing patient statistics. The head midwife handles the monthly progress examination, and views and prints patient statistics. All these processes happen in real time. This system is designed to overcome the problems identified in the current antenatal management information system. The interfaces for the new system were implemented using JSP, Bootstrap and Javascript. PostgreSQL was also used for implementing the system database while Spring was used to create interactivity with the database. After the implementation, the new system was then tested and validated. When developing the system, the focus was on making the whole process of information management in the antenatal department faster, more convenient and efficient.

Visible Light Imaging: Clinical Aspects with an Emphasis on Medical Photography—a HIMSS-SIIM Enterprise Imaging Community Whitepaper

Photodocumentation is a subset of visible light imaging and is an important growing segment of enterprise imaging. Medical videography is another subset of visible light imaging that shares many of the challenges of photodocumentation. Medical photographs are used to document clinical conditions, support diagnosis, guide, and document procedures and to enable collaboration among colleagues. They also play a significant role in patient engagement and are a mechanism for patients to share information with their provider without the need for a clinical office visit. The content of medical photographs raises issues for acquisition, management, storage, and access. Medical photographs may contain protected health information, and these images benefit from the standardized, secure processes inherent in any enterprise imaging program. The ability to securely acquire images on mobile, and sometimes personally owned devices, is a necessity. In addition to containing protected health information, photograph content can be sensitive or gruesome or the images may be used for forensic purposes. These types of images require additional protections. Access to these images should be role-based and auditable. To properly identify photographs and to convey information about their acquisition parameters new metadata requirements and mechanisms for its association with the imaging files are evolving. Institutional policies need to be developed to define the organization’s requirements for medical photography, including consent processes. Existing policies such as those defining the designated record set and legal health record should address the management of medical photography.

A survey on knowledge, attitude, and practice about antibiotic prescribing and resistance among medical practitioners in Kenya

Background Antibiotic resistance is a growing global health threat worldwide and especially in developing countries. Irrational antibiotic prescription as well as lack of the requisite knowledge and awareness of proper antibiotic use are major drivers of antibiotic resistance. In Kenya, although the Ministry of Health has developed antibiotic use guidelines, these guidelines are not widely followed. Antibiotic prescription is, therefore, hugely at the discretion of the clinician. It is thus necessary to understand the knowledge, attitude, and practices (KAP) of antibiotic prescription among medical practitioners in the country. This study aimed to evaluate the knowledge, attitude, and practices (KAP) among antibiotic prescribers in three counties (Kiambu, Nakuru, and Bungoma) in Kenya. Methods This was a cross-sectional study using a self-administered questionnaire. Simple descriptive statistics were used to generate frequencies, percentages, and proportions. Where necessary, univariate analyses such as Pearson’s chi-square were performed to compare proportions for statistical significance. Results From the three counties, 240 respondents recorded their responses: 30% from Kiambu, 34.6% from Nakuru, and 35.4% from Bungoma. The respondents included 19 (7.9%) consultants, 66 (27.4%) medical officers, 135 (56.3%) clinical officers and 20 (8.3%) pharmacists. Of all respondents, more than 90% agreed or strongly agreed that antibiotic resistance (ABR) is a catastrophe worldwide and in Kenya. However, the proportion of the respondents who either agreed or strongly agreed (71.6%) that antibiotic resistance is a problem in their respective health facilities was significantly lower (ρ=0.013). Conclusion This study revealed that most medical practitioners were aware and knowledgeable about antibiotic resistance. However, there was a disconnect with mitigation measures such as active antibiotic stewardship and laboratory analyses to support judicious prescription. There is, therefore, a need for continuous education and stewardship interventions.

Antimicrobial stewardship: Attitudes and practices of healthcare providers in selected health facilities in Uganda.

Though antimicrobial stewardship (AMS) programmes are the cornerstone of Uganda's national action plan (NAP) on antimicrobial resistance, there is limited evidence on AMS attitude and practices among healthcare providers in health facilities in Uganda. We determined healthcare providers' AMS attitudes, practices, and associated factors in selected health facilities in Uganda. We conducted a cross-sectional study among nurses, clinical officers, pharmacy technicians, medical officers, pharmacists, and medical specialists in 32 selected health facilities in Uganda. Data were collected once from each healthcare provider in the period from October 2019 to February 2020. Data were collected using an interview-administered questionnaire. AMS attitude and practice were analysed using descriptive statistics, where scores of AMS attitude and practices for healthcare providers were classified into high, fair, and low using a modified Blooms categorisation. Associations of AMS attitude and practice scores were determined using ordinal logistic regression. This study reported estimates of AMS attitude and practices, and odds ratios with 95% confidence intervals were reported. We adjusted for clustering at the health facility level using clustered robust standard errors. A total of 582 healthcare providers in 32 healthcare facilities were recruited into the study. More than half of the respondents (58%,340/582) had a high AMS attitude. Being a female (aOR: 0.66, 95% CI: 0.47-0.92, P < 0.016), having a bachelor's degree (aOR: 1.81, 95% CI: 1.24-2.63, P < 0.002) or master's (aOR: 2.06, 95% CI: 1.13-3.75, P < 0.018) were significant predictors of high AMS attitude. Most (46%, 261/582) healthcare providers had fair AMS practices. Healthcare providers in the western region's health facilities were less likely to have a high AMS practice (aOR: 0.52, 95% CI 0.34-0.79, P < 0.002). In this study, most healthcare providers in health facilities had a high AMS attitude and fair AMS practice.

Digital auscultation as a novel childhood pneumonia diagnostic tool for community clinics in Sylhet, Bangladesh: protocol for a cross-sectional study

IntroductionThe WHO’s Integrated Management of Childhood Illnesses (IMCI) algorithm for diagnosis of child pneumonia relies on counting respiratory rate and observing respiratory distress to diagnose childhood pneumonia. IMCI case defination...

Clinicians' knowledge and practices in the diagnoses and management of non-malarial fever illnesses among under 5 children in Kisii County, Kenya

Background: Indiscriminate fever management using antimalarial drugs escalates patients' health risk, especially those &lt;5 years old, with the likelihood of accelerating the emergence and spread of drug-resistant malaria parasites. We assessed clinicians' knowledge and practices in diagnosing and managing non-malarial fever illnesses among children &lt;5 years in Kisii County, Kenya.Methods: 193 nurses and clinical officers working in selected public health facilities in Kisii County were recruited into the study. Semi-structured questionnaires and individual interviews were used in collecting data. Chi-square was used in testing associations between categorical variables.Results: 94% (n=181) of the respondents were aware of other infectious illnesses other than malaria, 71% (n=137) were aware of fever as the primary clinical sign of malaria while 61% (n=118) of the respondents were aware of non-infectious sources where fever is the leading symptom. The frequently prescribed antipyretic drugs were paracetamol and Ibuprofen. Under the hematinic and vitamins category, clinicians commonly prescribed multivitamin syrups and iron blood tonics. 91% (n=176) of the study respondents reported that they occasionally-prescribed anti-malaria drugs for malaria negative diagnostic results. Knowledge and practices in diagnosis management of non-malaria illnesses, varied significantly among clinician’s who were in the rural and urban facilities (p=0.025, OR: 1.16, 95% CI: 0.02-0.28). However, there was no association between level of knowledge of the enrolled nurses, registered nurse and clinical officer {(p=0.21, OR: 0.88, 95% CI: -0.32-0.07), (p=0.89, OR: 0.98, 95% CI: -0.26-0.23)}Conclusions: Clinicians in Kisii County reported prescribing anti-malarial drugs for malaria negative diagnostic results, highlighting the need for continuous field training in differentiating malarial and non-malarial fevers.

Respiratory-related death in individuals with incident asthma and COPD: a competing risk analysis

BackgroundDistinguishing between mortality attributed to respiratory causes and other causes among people with asthma, COPD, and asthma-COPD overlap (ACO) is important. This study used electronic health records in England to estimate excess risk of death from respiratory-related causes after accounting for other causes of death.MethodsWe used linked Clinical Practice Research Datalink (CPRD) primary care and Office for National Statistics mortality data to identify adults with asthma and COPD from 2005 to 2015. Causes of death were ascertained using death certificates. Hazard ratios (HR) and excess risk of death were estimated using Fine-Gray competing risk models and adjusting for age, sex, smoking status, body mass index and socioeconomic status.Results65,021 people with asthma and 45,649 with COPD in the CPRD dataset were frequency matched 5:1 with people without the disease on age, sex and general practice. Only 14 in 100,000 people with asthma are predicted to experience a respiratory-related death up to 10 years post-diagnosis, whereas in COPD this is 98 in 100,000. Asthma is associated with an 0.01% excess incidence of respiratory related mortality whereas COPD is associated with an 0.07% excess. Among people with asthma-COPD overlap (N = 22,145) we observed an increased risk of respiratory-related death compared to those with asthma alone (HR = 1.30; 95% CI 1.21–1.40) but not COPD alone (HR = 0.89; 95% CI 0.83–0.94).ConclusionsAsthma and COPD are associated with an increased risk of respiratory-related death after accounting for other causes; however, diagnosis of COPD carries a much higher probability. ACO is associated with a lower risk compared to COPD alone but higher risk compared to asthma alone.

Attitude toward Suicidal Behavior: A Cross-Sectional Study among Health-Care Professionals in Northwest Malaysia

Introduction: The attitude of clinicians will steer the direction of clinical care provided to patients with suicidal behavior. However, there is limited local data to suggest the attitude of health-care workers toward suicidal patients in the health-care settings. Objective: We aimed to assess the attitude of health-care professionals toward suicidal behavior and the factors influencing their attitude. Methods: A cross-sectional survey was conducted in a single tertiary health-care facility in northwest Malaysia, using a validated modified Suicide Opinion Questionnaire, distributed to medical doctors, nurses, and assistant medical officers. Results: A total of 487 health-care workers from 13 clinical departments participated in the study. We found that health-care professionals generally held unfavorable attitudes toward suicidal behavior, with 70.0% of the respondents generated low attitude scores in overall section. Independent factors that were found to be significantly associated with unfavorable attitudes toward suicidal behavior include religion (P = 0.027), education level (P = 0.007), and occupation (P = 0.007). Multivariate analysis with logistic regression showed that medical doctors were found to be 2.11 times more likely to hold unfavorable attitudes toward suicidal behavior as compared to nurses (95% confidence interval: 1.15–4.30, P = 0.009). Conclusion: Our findings highlighted the suicide stigma that is prevalent even among professional health-care workers in Malaysia. The unfavorable attitude toward suicidal behavior contrasted the elements of empathy and care that should be the core practice in health-care services. Therefore, we suggest for the implementation of training workshops incorporating interactive communication skills and reflective thinking to improve understanding and attitude toward suicidal behavior among health-care workers.

A case for implementation of adult pneumococcal vaccine program in Africa: review and expert opinion.

Vaccines are considered as a therapeutic area for children; the scientific community focuses mainly on managing chronic disease when it comes to adults. There currently is an increase in the burden of vaccine preventable illnesses in adults. Adult vaccination has been shown to dramatically increase the health and quality of life of older populations. Therefore, adult vaccinations need to be approached as a public health issue, similar to smoking cessation programs, for example. According to the Kenya Non-Communicable Diseases and injuries poverty commission report, 2018. Kenya has a high percentage of disability adjusted life years (DALYs) from communicable diseases at 63%, while non-communicable diseases (NCDs) contribute 30% of the DALYs. Specific to pneumococcal pneumonia (PP) in adults, the Global burden of disease (GBD) study in 2016 found that 2,377,697 people of all ages died from lower respiratory tract infections (LRTI) in 2016. Of these, more people died from Streptococcus pneumonia(SP) than from all other studied respiratory pathogens combined. While the incidence of LRTIs in children under five years old was reducing, partly as a result of well-established vaccination programs in children, the incidence, morbidity and mortality of PP was increasing in older populations. The expert recommendations included the following; i) all individuals 65 years of age and above, and individuals with a predisposing comorbidity regardless of age, should receive the pneumococcal vaccine; ii) several systemic modules can be emulated from the successful childhood vaccines programs onto an adult vaccine program; iii) formulation of an effective vaccine program will require collaboration from the public, the government, healthcare providers, and the media, to create awareness; iv) stakeholders who need to be involved in vaccine policy development and implementation include medical professional associations, nurses, pharmacists, clinical officers, payers (private and public insurances), government, medical learning institutions and faith-based medical organizations.

The Utility of 24-h Ambulatory Blood Pressure Monitoring for the Diagnosis and Management of White Coat Hypertension in a Primary Care Setting

Objectives:Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is recommended in patients with white coat hypertension (HTN) by national guideline, but was poorly utilized, and is available only in very limited subspecialty clinics. We aim to examine the feasibility and utility of ABPM in a primary care setting in the diagnosis and management of white coat HTN including the implementation and modification of antihypertensive therapy.Methods:Patients who have elevated blood pressure in clinic office but normal blood pressure readings at home are eligible for 24-h ambulatory BP monitoring. We analyzed data from patients who were suspected to have white coat HTN in the last 2 years underwent ABPM in our practice.Results:Among 68 patients, 54 patients met the selection criteria. ABPM showed that 13 patients had normal BP (24%), while 41 patients (76%) had persistent HTN. Among these patients with persistent HTN, 28 patients had intervention including 24 patients prescribed with new anti-hypertensive medication or medication increase, 3 patients prescribed with additional lifestyle modification and one started CPAP.13 patients with slightly elevated BP (133/77 for average daytime BP) didn’t have medication adjustment.Conclusion:ABPM has substantial utility in the diagnosis and management of white coat HTN in a primary care setting.

A Prospective Study of Supine Percutaneous Nephrolithotomy with a Modified Technique: A Safe and Desirable Tool in the Armamentarium of Urologists

Introduction: Supine Percutaneous Nephrolithotomy (PCNL) has failed to gain popularity despite the various advantages, primarily due to a lack of standardised technique. A simple and replicable technique is needed to increase its popularity amongst urologists. Aim: To simplify and standardise the puncture technique of supine PCNL and compare it with the Clinical Research Office of the Endourological Society (CROES) PCNL global study. Materials and Methods: A prospective interventional study was conducted in a tertiary care hospital in Dehradun, Uttarakhand, India, between June-December 2020. A total of 82 consecutive patients underwent the procedure with a modified technique of initial puncture using bony landmarks. The results of present study were compared with the outcomes of the patients who underwent supine PCNL in the CROES PCNL global study which is the largest prospective database regarding the supine and prone positions of PCNL till date. Statistical analysis of various demographic variables, patient characteristics and results was done using Statistical Package for the Social Sciences (SPSS) version 24.0 software. Results: The mean age of patients was 47.52±13.044 years and mean stone burden of 266.146±172.430 mm2 . The mean operative time was 85.59±12.733 minutes. Lower calyceal puncture was done in 97.56% of patients. Stone clearance was achieved by a single puncture in 73 (89.0%) patients while 9 (11.0%) patients required two punctures. Sixteen patients (19.51%) had postnephrostomy drain removal leak which settled within 24 hours. Only in one patient the leak continued beyond 24 hours but was managed conservatively. On comparison, it was observed that mean stone burden was lesser (p-value=0.0001) and the stone free rate was comparatively higher in present study (p-value=0.024). Conclusion: Supine PCNL is an effective and safe procedure in a subset of patients with predominant lower calyceal stone bulk.