Local Physicians Research Articles

Water, Sanitation, and Hygiene Conditions and Health Outcomes: A Comparative Study Between Rohingya Refugees and Local People in Southeastern Bangladesh

Bangladesh is now the home to 1.3 million Rohingya refugees living in the southeastern part of the country, specially following the massive violence in Rakhine state, Myanmar since August 2017. Water, sanitation, and an unhygienic situation have left the entire region the worst affected and most vulnerable, ultimately placing pressure on the health sector. This study assessed water, sanitation, and hygiene (WASH) conditions; and explored associated health outcomes, drawing empirical data from Kutupalong-Balukhali Rohingya refugee camp and its surrounding areas in south-eastern Bangladesh. To determine the WASH condition and associated health outcomes, we conducted 200 structured interviews (with both refugees and local residents), three focus group discussions, and two informal interviews with local physicians. The values of drinking water, sanitation, and hand washing ladders indicate that WASH conditions in both refugee camps and surrounding localities were basic to limited. Respondents believed that due to increasing heat and basic to limited WASH conditions, people suffer from many diseases such as diarrhea, heat rash, dehydration, dysentery, and pneumonia. As reported diseases are related to WASH, it is important to increase awareness among people about the significance of WASH. The Dhaka University Journal of Earth and Environmental Sciences, Vol. 13(1), 2024, P 47-58

"Don't give up, advocate for yourself": A pilot study examining healthcare experiences of people with Mayer Rokitansky Küster Hauser syndrome (MRKH).

Mayer Rokitansky Küster Hauser syndrome (MRKH) is characterized by the underdevelopment or absence of the uterus and upper vagina. Navigating healthcare interactions may present unique challenges for those with MRKH as there appears to be sparse clinical education and research available to healthcare providers. Additionally, limited research exists on the healthcare experiences of people with MRKH. This pilot study investigated the diagnostic journeys, post-diagnosis experiences, current healthcare interactions, and attitudes toward the healthcare system among individuals with MRKH. Participants with MRKH residing in the United States or Canada took part in semi-structured interviews on their MRKH-related healthcare experiences. Interview transcripts were thematically analyzed. People with MRKH conveyed that: 1) MRKH was not well known by healthcare providers and they were seldom provided with information and resources about MRKH, 2) they often needed to advocate for themselves in the healthcare system to receive adequate care, 3) sensitivity, inclusion, and knowledge from healthcare providers was invaluable, and 4) healthcare-system level barriers prohibited access to adequate care. Information and resources for MRKH patients should be age appropriate, patient-centered, trauma informed, and locally based. Providers should have access to evidence-based information and resources about MRKH, which includes knowledge of local specialist physicians, mental health specialists, pelvic health physical therapists, and other allied health professionals. Providers should also limit assumptions and use sensitive and inclusive language when communicating with patients around MRKH diagnosis, education, and development of treatment plans. Lastly, strategies for mitigating healthcare barriers should consider those with MRKH.

Pioneering sustainable treatment delivery in childhood leukemia through synchronous telemedicine-A pilot study.

Cancer care places a heavy economic burden on families and health systems, driven by high treatment costs, lengthy hospital stays, and the necessity for extensive travel to specialized facilities. To address this challenge, an integrated health care network (IHCN) was implemented for maintenance treatment in acute leukemia. The IHCN encompassed outpatient services provided by local physicians and synchronous telemedicine consultation with pediatric oncologists. This study included twenty-two pediatric patients (eleven [50.0%] females; twenty [90.9%] with B-ALL and two [9.1%] with AML). The IHCN was offered to all rural patients (n = 17) with a one-way driving distance more than 30 km, while urban patients (n = 5) received regular cancer care. Throughout the study, rural patients had a total of 510 routine clinical visits, with 367 (72%) conducted through the IHCN. Physical examinations revealed similar frequency of new abnormal findings for urban and rural patients (22.4% vs. 17.8%; p = .31). Laboratory tests indicated no significant difference in the frequency of abnormal values for various parameters between both groups. Similarly, there was no discrepancy of drug modifications or interruption in maintenance therapy between the two settings (p = .85). Moreover, patients' health-related quality of life remained within the normative range, and user satisfaction with the IHCN was notably high. The implementation of the IHCN resulted in savings of 70,158 km, 950 h of travel, and 12,277 kg CO2 emissions. This pilot study underscores the efficacy of a telemedicine-based IHCN, ensuring safety, quality of care, cost reduction, and satisfaction for both families and health care providers in pediatric leukemia management.

Infectious disease prevention among internally displaced people: Perspectives from Lviv, Ukraine

Abstract Background The ongoing war in Ukraine has increased the risk of infection spikes, especially among internally displaced people. The healthcare challenges in the war context necessitate teaching the population of preventative measures, which have become the primary vector of the activities of the Ukrainian Regional Centers for Disease Control and Prevention. Objectives The research aimed to highlight the activities of the Lviv Regional Center for Disease Control and Prevention (CDC) in relation to internally displaced people. Methods The research project analyzed the incidence rate of infectious diseases and vaccination coverage data among the population and internally displaced people in the region. The data were collected from monthly reports of CDC’s departments and alert messages sent by primary care institutions to the CDC. Results According to the Single register of internally displaced people (IDP), 13% of internally displaced people were permanently staying in the Lviv region (the second place was Zakarpattia region - 9% of IDP, and the third was Kyiv - 7% of IDP). In the Lviv region, 237,000 people registered as forcibly displaced. Total, over 700, 000 people are in the area, including the unregistered and 68,000 children. In 2022-2023, the morbidity rates among IDPs did not exceed the rates among the general population in the area. Each IDP residence place had its physician; 11 thousand IDPs were vaccinated, and 3,235 of those were children. In general, 46 mobile medical brigades worked on-site in the Lviv region. Only one spike of gastrointestinal infection was registered. CDC employees provided lectures and workshops on hygiene and food storage in 56 IDP residence places. Conclusions The review results show that coordination between CDCs, local physicians, and mobile medical brigades in the IDP residence areas prevents outbreaks of infectious diseases and swiftly responds to emerging threats. Key messages • The tragic events in Ukraine resulted in healthcare access issues. Lviv CDC, fighting at its own forefront, quickly assessed the risks and efficiently managed the potential hazards. • The Lviv region remains one of the biggest hubs in Ukraine for the temporary residence of internally displaced people, with CDC employees ensuring that preventive measures are effectively carried out.

Variations in access to acute care services by immigrant background and sociodemographic factors

Abstract Background The Emergency Medical Communication Center (EMCC) plays a vital role in the medical emergency response system by triaging contacts, notifying local physicians, and providing medical advice. The utilization of acute care services and the subsequent care pathway by individuals with immigrant background remains unclear in the Norwegian context. This study aims to investigate whether disparities exist in the acute care pathway for patients with different sociodemographic background who use ambulance services. Methods We examined all code red ambulance dispatches for life-threatening emergencies in 2021 in Norway. These ambulance dispatches were linked to primary health care and specialist health care contacts to trace patient pathways and outcomes. Statistical analyses were conducted using linear regression models, adjusted for patient characteristics, such as immigrant background, age, sex, municipality of residence, living condition, socioeconomic status, comorbidity and cause of emergency contact. Results Preliminary crude findings indicate that patients with immigrant background are overrepresented in the groups receiving acute primary care only and underrepresented in the groups transferred directly to specialist health care, within 8 hours after ambulance arrival at the patients’ location. Conclusions The preliminary results suggest challenges for the EMCC in triaging patients with immigrant background, but further research is needed to explore potential systematic differences. This study aims to improve understanding of disparities in access to acute care and inform targeted interventions to optimize resource allocation in emergency departments. Key messages • This study may improve understanding of disparities in access to acute care in Norway. • This study can inform targeted interventions to improve resource allocation in emergency departments.

A study of implementation factors for a novel approach to clinical trials: constructs for consideration in the coordination of direct-to-patient online-based medical research

BackgroundTraditional medical research infrastructures relying on the Centers of Excellence (CoE) model (an infrastructure or shared facility providing high standards of research excellence and resources to advance scientific knowledge) are often limited by geographic reach regarding patient accessibility, presenting challenges for study recruitment and accrual. Thus, the development of novel, patient-centered (PC) strategies (e.g., the use of online technologies) to support recruitment and streamline study procedures are necessary. This research focused on an implementation evaluation of a design innovation with implementation outcomes as communicated by study staff and patients for CoE and PC approaches for a randomized controlled trial (RCT) for patients with vasculitis.MethodsIn-depth qualitative interviews were conducted with 32 individuals (17 study team members, 15 patients). Transcripts were coded using the Consolidated Framework for Implementation Research (CFIR).ResultsThe following CFIR elements emerged: characteristics of the intervention, inner setting, characteristics of individuals, and process. From the staff perspective, the communication of the PC approach was a major challenge, but should have been used as an opportunity to identify one “point person” in charge of all communicative elements among the study team. Study staff from both arms were highly supportive of the PC approach and saw its promise, particularly regarding online consent procedures. Patients reported high self-efficacy in reference to the PC approach and utilization of online technologies. Local physicians were integral for making patients feel comfortable about participation in research studies.ConclusionsThe complexity of replicating the interpersonal nature of the CoE model in the virtual setting is substantial, meaning the PC approach should be viewed as a hybrid strategy that integrates online and face-to-face practices.Trial registrations1) Name: The Assessment of Prednisone In Remission Trial – Centers of Excellence Approach (TAPIR).Trial registration number: ClinicalTrials.gov NCT01940094.Date of registration: September 10, 2013.2) Name: The Assessment of Prednisone In Remission Trial – Patient Centric Approach (TAPIR).Trial registration number: Clinical Trials.gov NCT01933724.Date of registration: September 2, 2013.

Perspectives of non-physician partners on barriers and facilitators to AYA cancer care in Latin America.

Cancer is the fourth leading cause of death in adolescents and young adults (AYA) worldwide. Although successful treatment of cancer in AYA has increased in recent years in most of the world, this is not true for many low- and middle-income countries (LMIC) where over 80% of all AYA live. This study investigated the needs of AYA with cancer in parts of Latin America (LATAM) through the perspectives of non-physician health care providers and partners. Semi-structured interviews (in Spanish) were conducted with non-physician partners from Mexico, Peru, Central America, and the Caribbean over Zoom. Participants were recruited through previously identified local physicians and international non-physician professionals working in these countries. Transcripts were coded and key themes identified until thematic saturation was reached (Atlas.ti). Thirty participants representing eight countries were interviewed, providing 1202 min of transcript data. Data were organized into barriers, facilitators, and strategies to improve the delivery of health care for AYA with cancer in LATAM at the patient- (e.g., financial barriers, continued schooling), parent- (e.g., limited medical literacy, advocacy), and hospital-level (e.g., structural barriers, increasing funding). There are many similarities in the barriers and facilitators to AYA care between LATAM and high-income countries (HIC); however, some characteristics are more unique to LATAM, for example, strict age restrictions for pediatric care and abandonment of therapy. As LATAM countries continue to build cancer control programs, there is an opportunity to consider our identified barriers, facilitators, and strategies to address the unique needs of AYA with cancer.

Multidisciplinary Educational Program to Standardize Education and Management of Immune-related Adverse Events: Review and Outcomes of a Single-institution Initiative.

The use of immune checkpoint inhibitors (ICIs) as anticancer therapy across a variety of malignancies has led to durable efficacy in a subset of patients. However, associated side effects denoted immune-related adverse events (irAEs) have emerged and can result in substantial morbidity and mortality. Particularly early in the experience of using these agents, a lack of standardized education regarding irAEs among patients and clinical providers may have contributed to poor outcomes. Optimal management of these emerging toxicities depends on a coordinated institutional approach. We hypothesized that centralized educational programs and electronic health record (EHR)-based interventions, targeted both toward ICI-treated patients as well as patient-interfacing providers, would improve patient outcomes. We created a multidisciplinary team of clinicians and associated staff to direct a coordinated approach to the education and management of patients receiving ICIs across our institution. A 3-tiered approach was designed: patient-centered, internally centered, and externally centered. Multimedia educational products were produced for patients to improve knowledge and awareness of ICIs and associated irAEs. An EHR-based banner was deployed to improve identification of patients receiving ICIs across disciplines. Tailored educational seminars were provided to clinicians who interact with ICI-treated patients at all levels. Educational seminars were also offered to local physicians and institutions. We assessed patient uptake of educational products and surrogate patient outcomes to measure the potential impact of our interventions. Fox Chase Cancer Center (FCCC)-specific ICI identification cards were created and distributed to patients. By the end of the investigational period, 98.6% of ICI-treated patients reported receiving a card. An ICI-focused on-line portal was created accessible only to ICI-treated patients, with 9.4% of these patients accessing the portal in the first 6 months without marketing promotion. Deidentified surrogate clinical endpoints of corticosteroid use, direct referral unit (DRU) visits, and hospital admissions all improved during the study period. Institutionally directed educational initiatives are feasible at a free-standing academic cancer center and may lead to improved outcomes in patients developing irAEs from ICIs. More granular patient-specific data and studies at other types of institutions are necessary to determine the applicability of similar approaches on a broader scale.

Vaccine practices, literacy, and hesitancy among parents in the United Arab Emirates.

Immunisation is one of public health's greatest success stories, yet, annually, 20 million children miss out entirely or partially on routine immunisation. National immunisation estimates have the United Arab Emirates (UAE) lagging behind with 4% of children under the age of 1 not having received any vaccines. Vaccine hesitancy is considered one of the biggest barriers to vaccination. This study aims to evaluate the UAE's parents' vaccination attitudes and practices as well as estimate vaccine hesitancy's prevalence and determinants. This cross-sectional, descriptive study collected data from parents across the UAE during the months of March and April 2024. The 60-item questionnaire included the Parental Attitudes towards Childhood Vaccines scale (PACV), the Vaccine Hesitancy Scale, and the Digital Vaccine Literacy (DVL) scale. Univariate, bivariate (chi-squared test), and multivariate (logistic regression) analyses were conducted. A total of 550 responses were retained. 84.55% of participants were female (n = 465/550), half were middle-aged (31-45 years old), and 21.09% (n = 116/550) were healthcare workers. 94.36% (n = 519/550) had their child/children receive all mandated vaccines. Only 39.82% (n = 219/550) found their level of knowledge about childhood vaccinations to be good/excellent. 70.11% (n = 386/550) of participants had high digital vaccine literacy. More than 95% had positive attitudes towards measles, meningitis, and pertussis vaccines. 14.00% (n = 77/550) were identified as vaccine-hesitant according to the PACV. Overall, using general practitioner/ paediatrician as a knowledge source, digital vaccine literacy, perceived children's vaccine knowledge, and nationality were associated with lower vaccine hesitancy status. Vaccine hesitancy exists and is prevalent in the UAE; however, the majority of participants reported high trust in vaccines, the local healthcare systems and physicians. Vaccine hesitancy can be tackled but will require tailored solutions and proactive healthcare workers.

A multicenter, prospective, non-interventional real-world study to assess the effectiveness of mecapegfilgrastim in preventing neutropenia in patients with gastrointestinal cancer.

Mecapegfilgrastim, a long-actinggranulocyte-colony stimulating factor has been approved for reducing the incidence of infection, particularly febrile neutropenia (FN), in China. We conducted a multicenter prospective observational study to examine the safety and effectiveness of mecapegfilgrastim in preventing neutropenia in gastrointestinal patients receiving the chemotherapy, including S-1/capecitabine-based regimens or thefluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI)/fluorouracil, leucovorin, and oxaliplatin (FOLFOX)/fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX) regimens. Five hundred and sixty-one gastrointestinal patients from 40 sites across China, between May 2019 and November 2021, were included. The administration of mecapegfilgrastim was prescribed at the discretion of local physicians. The most common adverse drug reactions (ADRs) of any grade for all patients was increased white blood cells (2.9%). Grade 3/4 ADRs were observed for anemia (0.2%), decreased white blood cells (0.2%), and decreased neutrophil count (0.2%). Among the 116 patients who received S-1/capecitabine-based chemotherapy throughout all cycles, ADRs of any grade included anemia (1.7%), myalgia (0.9%), and increased alanine aminotransferase (0.9%). No grade 3/4 ADRs were observed. In 414 cycles of patients who underwent S-1/capecitabine-based regimens, only one (0.2%) cycle experienced grade 4 neutropenia. In the FOLFIRINOX, FOLFOXIRI, and FOLFOX chemotherapy regimens, grade 4 neutropenia occurred in one (2.7%) of 37 cycles, four (4.7%) of 85 cycles, and two (1.2%) of 167 cycles, respectively. In a real-world setting, mecapegfilgrastim has proven effective in preventing severe neutropenia in gastrointestinal patients following chemotherapy. This includes commonly used moderate or high-risk FN regimens or regimens containing S1/capecitabine, all of which have demonstrated favorable efficacy and safety profiles.

Case Report: Multidisciplinary management of severe blast-related craniofacial and ocular injuries at artisanal gold mining sites in Niger: An unusual case report and comprehensive literature review

Blast-related craniofacial and ocular injuries have traditionally been associated with battlefields. In civilian populations, these injuries were infrequent, primarily arising from accidental explosions or terrorism incidents. Explosions can inflict severe damage to the neurological, ocular, and auditory systems through blast waves, high-velocity foreign bodies, and thermal radiation. The pathophysiology of blast-related craniofacial injuries is specific and complex, with severe cases often involving both penetrating and blunt trauma, leading to high mortality and morbidity rates. These injuries necessitate multidisciplinary management and can be defined as intracranial polytrauma. Recently, Niger has seen a surge in blast injuries, predominantly due to the increase in clandestine artisanal gold mining. Managing these injuries in resource-limited settings poses significant challenge. Comprehensive national data on these injuries are sparse due to high pre-hospital mortality rates and their infrequent occurrence, resulting in limited experience among our local physicians in their management. We present a rare case involving an artisanal gold miner with a history of smoking and previous concussions from explosion exposures. The patient was transferred to our hospital following severe craniofacial and ocular injuries caused by an accidental dynamite explosion at a mining site. On admission, the patient presented altered consciousness, agitation, unstable vital signs, multiple craniofacial wounds, including a large frontal wound with brain substance extrusion, diffuse facial burns, left globe rupture, and rhinorrhagia. After resuscitation and stabilization, brain imaging revealed multiple complex craniofacial fractures with foreign bodies. The patient underwent multidisciplinary surgical management. However, the postoperative course was complicated by post-concussive syndrome, and infection of the surgical wounds, necessitating surgical revision. Following the second surgery, the postoperative course was uneventful, although the patient experienced reduced visual acuity. This case highlights the management challenges in Niger and underscores the urgent need for clinical studies and training for gold miners to enhance safety practices in their activities.

Assessment of Breast Pathology Reporting Needs and Development of Tumor Synoptic Templates in Sub-Saharan Africa.

Breast pathology reports include many important details to guide clinical management. Reports with missing critical data elements are commonly seen in non-subspecialized pathology practices. The use of synoptic templates has been shown to improve pathology reports. Although synoptic templates are readily available by professional societies, many are not tailored to low-resource settings. To perform an assessment of current breast pathology reporting at 3 referral hospitals in sub-Saharan Africa and design a locally adapted breast cancer synoptic template. We conducted semi-structured interviews with key stakeholders involved in breast cancer care including pathologists, radiologists, oncologists, and surgeons from Nigeria, Tanzania, and Mozambique. Moreover, each stakeholder reviewed a preliminary synoptic template that was compiled by using templates from the College of American Pathologists, Royal College of Pathologists, and International Collaboration on Cancer Reporting, and was asked to score each data element as essential, optional, or exclude. A locally adapted synoptic template was then designed from the needs assessment. Using the adapted templates, a retrospective review of breast cancer pathology reports from 2020 to 2022 was conducted to determine the completeness of reports at the 3 institutions. A total of 17 physicians were interviewed. Review of pathology reports revealed that none of the reports across all 3 sites contained all data elements considered essential by local physicians. There is an urgent need to improve breast pathology reporting in sub-Saharan Africa. Development and implementation of synoptic templates in collaboration with key stakeholders has the potential to improve pathology reporting practices in low-resource settings.

Reducing Wait Times for Children's Developmental Disorders Consultations Via Simplified Primary Care Assessments

The number of children diagnosed with developmental disorders in Japan is increasing annually, primarily assessed byspecialized physicians in pediatrics, pediatric neurology, and child psychiatry. However, medical institutions for children withdevelopmental disorders often have fully booked schedules, forcing long waiting periods until initial consultations can be obtained. Onereason for this is the shortage of specialized medical institutions and specialists. Prolonged waiting periods may not only delayintervention and support but also exacerbate the child's symptoms and cause psychological distress to the caregivers. Therefore,reducing the waiting period for initial consultations from the perspective of early detection and early support is an urgent issue.However, there is insufficient research on how to shorten the waiting period. Therefore, we focused on local primary care physicians,who are familiar with shortening the waiting time for initial consultations at specialist medical institutions. This aimed to investigatewhether there was a change in the waiting time for initial consultations at specialist medical institutions when local primary carephysicians used a simplified assessment sheet supervised by pediatric specialists, and referrals were made to specialist medical institutionsafter assessment. The participants consisted of 15 individuals referred from primary care physicians to specialist medical institutions and15 who directly visited medical institutions, totaling 30 participants for evaluation. As a result, the group that made appointments andvisited specialist medical institutions directly showed significantly longer waiting periods than those assessed by primary care physiciansand referred to specialist medical institutions (p < 0.05). Assessment and treatment of developmental disorders in early childhood haveprimarily been conducted at specialized medical institutions. Still, using a simplified assessment sheet by primary care physicians suggestsa potential reduction in the waiting time for initial consultations with specialists.

DEI-02. DIRECT PATIENT OUTREACH IN PEDIATRIC NEURO-ONCOLOGY TO IMPROVE ACCESS TO GENOMIC PROFILING – THE MAKE-AN-IMPACT PROGRAM

Abstract BACKGROUND Genomic profiling and precision medicine have revolutionized cancer care but are not accessible to all due to high costs, insurance issues, limited access to testing facilities or qualified personnel. We established a program providing free clinical genomic testing worldwide (Make-An-IMPACT) and report findings from the pediatric CNS tumor cohort. METHODS Following a referral from: (1) a physician, (2) a disease-specific advocacy group, or (3) submission of contact information through program website, patients were enrolled on an IRB-approved protocol (NCT01775072). CSF cell free DNA (cfDNA) and matched normal samples were analyzed using MSK-IMPACTTM, a New York State Department of Health authorized hybridization capture-based next-generation panel DNA sequencing clinical assay. If a driver mutation wasn’t reported, raw genomic data was reviewed. OncoKBTM was used to determine the level of evidence supporting the clinical actionability of genomic aberrations. RESULTS 24 patients (median age 7.5; range 0.1-20 years) were enrolled; 9 (38%) from 5 non-US countries and 6 (25%) from non-NYC US sites. African American and Hispanics constituted 8% and 13% of the cohort. Potentially actionable alterations were identified in 4/24 (17%) cases; 2/24 (8%) subsequently received matched therapy. In unbiopsied or non-diagnostic cases, a disease defining alteration was identified in 8/15 (53.3%). BRAF-KIAA1549 fusions were identified in 2/3 DLGNT patients and 1p loss in all 3. Both patients with BRAF fused DLGNT started targeted therapy with Trametinib, one of whom achieved a durable treatment response for 2.5 years. 3/8 patients with unbiopsied brainstem lesions had a H3.3K27M mutation, while 2 had non-H3.3K27M mutations detected (1 SMARCB1 deletion, 1 IDHR172G mutation) leading to treatment regimen changes. CONCLUSIONS This study captured a broad range of pediatric CNS malignancies with a diverse patient representation across geographic regions. CSF cfDNA profiling provided important diagnostic and therapeutic information reported in real time to patients and local physicians.

Associations of clinical personnel characteristics and telemedicine practices

Abstract Context The use of telemedicine strategies has been increasing in the United States for more than a decade, with physicians taking advantage of this new tool to reach more patients. Determining the specific demographics of physicians utilizing telemedicine most in their practice can inform recommendations for expanded telemedicine use among all physicians and aid in mitigating the need for local physicians in urban and rural populations. Objectives This study aims to assess the use of telemedicine by physicians in 2021, based on four demographics utilizing the National Electronic Health Record Survey (NEHRS): physician age, sex, specialty, and training. Methods We performed a cross-sectional study of the 2021 NEHRS to determine the relationship between physician characteristics and telemedicine practices. Differences between groups were measured through design-based chi-square tests. Results Compared to male physicians, female physicians were more likely to utilize telemedicine services (X 2=8.0; p=0.005). Compared to younger physicians, those over the age of 50 were less likely to utilize telemedicine services (X 2=4.1; p=0.04). Compared to primary care physicians, medical and surgical specialty physicians were less likely to utilize telemedicine services, with surgical specialty physicians being the least likely overall (X 2=11.5; p<0.001). We found no significant differences in telemedicine use based on degree (Osteopathic and Allopathic). Conclusions Our results showed a statistically significant difference between physician’s age, sex, and specialty on telemedicine use in practice during 2021. Efforts to increase telemedicine use among physicians may be needed to provide more accessible care to patients. Thus, by increasing physician education on the importance of telemedicine for modern patients, more physicians may decide to utilize telemedicine services in practice.

Antibody Seroprevalence to Spotted Fever Group Rickettsiae in Miraflores, Colombia: A Cross-Sectional Study in Humans and Dogs.

Tick-borne disease burdens are increasing globally, impacting mostly rural and vulnerable communities. Among the most important emerging tick-borne pathogens are the Rickettsia species within the spotted fever group (SFGR) because of their genetic diversity and high lethality rate. Colombia is highly affected by SFGR despite not being reportable diseases; thus, research and clinical management are neglected. Although some departments have demonstrated high seroprevalence rates, in others, such as Boyacá Department, seroprevalence is unknown. Rickettsioses have not been described in Boyacá since 1943, and conversations with local physicians raised suspicions of recent undiagnosed disease compatible with rickettsiosis in some rural areas of the department, warranting epidemiological investigation. Using biobanked human and canine samples from a previous 2021 vector-borne disease study in Miraflores municipality, Boyacá, we had an opportunity to unearth SFGR's exposure in the region. Samples were evaluated using IgG indirect fluorescent assays against SFGR and complemented by survey questionnaires evaluating associated factors. Findings yielded first-time SFGR serological evidence in Boyacá with a 26.5% seroprevalence among dogs and a 20.4% among humans. Human and dog seroprevalences were positively associated, suggesting the presence of domestic transmission. Owning a greater number of domestic animals (prevalence ratio adjusted for all measured factors [aPR], 1.52) and living near crop fields (aPR, 7.77) were associated with an increased likelihood of household seropositivity. Our findings are consistent with the literature in Colombia, uncovering a suspected region where the disease is endemic. Future studies are warranted to continue defining high-risk areas to determine public health intervention plans.

On the right TRACK: Providing comprehensive genomic profiling (CGP) and molecular tumor board (MTB) for patients (pts) with rare cancers.

3127 Background: Patients (pts) with rare cancers are under-represented in precision medicine trials despite making up ~22% of cancer incidence. We created the TCF-001 TRACK (Target RAre Cancer Knowledge, NCT04504604) study to provide a home-based, patient-centered trial utilizing comprehensive genomic profiling (CGP) at enrollment and progression with review by a molecular tumor board (MTB). Methods: Pts with rare cancers (incidence<6/100,000) were enrolled and consented remotely (WCG IRB 1287011). Liquid (blood via mobile phlebotomy) and tissue biopsy samples were sent for CGP at Foundation Medicine. A fully remote MTB was convened following availability of each test. MTB notes and therapy recommendations were returned to patients and local physicians. Results: TRACK activated on 1 Oct 2020. The MTB included medical/surgical oncologists, genomics experts, molecular pathologists, a basic scientist, a pharmacist, a genetic counselor, regulatory staff, a scribe, an oncology fellow (“mentern”), and a medication acquisition specialist. MTB members were from 8 states. 132 eligible pts with evaluable results were enrolled from 41 states. Tissue and liquid biopsy results were available in 89 pts; tissue only in 5; liquid only in 38. 128 pts had an MTB before the 30 June2023 cut-off date (mean age 54.1 y; female 61.7%). There were >40 rare/ultra-rare cancers, including cholangiocarcinoma (62) and soft tissue tumors (24). No pts had identical molecular alterations. The median number of pathogenic alterations per tissue sample was 3 (range: 0-14) and blood was 2 (range: 0-40). 3 patients had no pathogenic alterations on tissue or liquid CGP. The most commonly altered genes found by tissue biopsy CGP on study (n=68) were TP53(33.8%), CDKN2A (25.0%), KRAS (23.5%), CDKN2B (17.6%), IDH1 (17.6%), and MTAP (14.7%); by liquid biopsy (n=126), they were TP53 (31.7%), KRAS (11.9%), and IDH1 (8.7%), as well as genes often associated with clonal hematopoiesis: DNMT3A (22.2%), ATM (12.7%), and CHEK2 (8.7%). The sensitivity of liquid biopsy for pathogenic alterations found in tissue was 89.3% for pts with ctDNA tumor fraction (TF) ≥1% and 28.1% for TF <1%. 1 pt had microsatellite instability. Median tumor mutational burden (TMB) by tissue was 2.5 mutations/megabase and by blood was 1.3. 3 pts had TMB≥10. Liquid biopsy results were available more quickly than tissue (median processing time, 9.1 vs 13.3 days); time from submission to processing was shorter for blood than tissue (2.4 vs 4.9 weeks). TRACK staff encountered 0.94 queries/sample. MTB recommendations based on CGP were generated for 87.5% of the 128 pts presented. Conclusions: A fully remote, advocacy driven, national precision genomics trial is feasible for managing rare cancers. CGP with expert MTB review can identify potentially targetable alterations and inform therapeutic options. Clinical trial information: NCT04504604 .

Pediatric anesthesia outreach in low and middle-income countries: Models, motives, and moral misalignments.

A lack of anesthesia and surgical capacity leaves approximately 1.7 billion children per annum without access to surgical and anesthetic care. Over the past 50 years, the predominant strategy to address this lack of access has been to provide surgical capacity primarily from high-income countries (HICs) to low and middle-income countries (LMICs) in the form of short-term surgical missions. More recently, the international medical community has recognized the need to build sustainable surgical capacity in resource-constrained settings. This article reviews three models of surgical aid: the vertical model (short-term surgical missions); the horizontal model (system-wide capacity building); and the diagonal model, which is a hybrid of the first two. At their core, medical aid interventions exist on a spectrum ranging from providing surgical capacity to building surgical capacity. The skills, attitudes, and behaviors that drive success in providing medical capacity are fundamentally different from those that drive success in building medical capacity. The root cause of this difference is a shift in the moral duty of the visiting physician from a duty solely to the patient in front of them (based on the primacy of the doctor-patient relationship) to include a duty to the local physicians and the local medical system, and by extension to the next 10 000 patients in need of care. Failure to address the conflicts engendered by this fundamental moral shift risks undermining capacity-building efforts in all models of medical aid.

PREDICTIVITY OF ESTIMATED PULSE WAVE VELOCITY FOR FATAL AND NONFATAL OUTCOMES IN RURAL POPULATION

Objective: Our study assesses the predictive value of arterial stiffness measured by estimated pulse wave velocity (ePWV) for fatal and nonfatal outcomes in general rural adult population. Design and method: This was a prospective observational study (1175 adult subjects) from the ENAH rural project in Croatia. Subjects were followed up for an average of 11.3 (8.3-13.65) years. Mortality data were collected from the National Institute for Public Health, and data for morbidity from the medical records of local physicians. ePWV was calculated using a validated equation. Results: In total, there were 264 deaths (22.5%), and 171 (14.5%) subjects experienced one of the non-fatal outcomes (myocardial infarction, atrial fibrilation, heart failure, stroke, TIA, dialysis). Kaplan Meier analysis (KMa) showed that survival is lower in group with ePWV>10m/s compared with group with ePWV<10m/s (HR=12.8, 95%CI 9.9-16.6, p<0.001) (Figure 1A). Similarly, KMa showed that survival to non-fatal outcome is lower in group with ePWV>10m/s compared to group with ePWV<10m/s (HR=1.50, 95%CI 1.0-2.1, p=0.008), Figure 1B. In the multivariate analysis of predictors for fatal outcome, male gender and ePWV maintained statistical significance in predicting increased risk for death (HR 1.75, 95%CI 1.18-2.61, p=0.006 and HR 1.81, 95%CI 1.08-3.04, p=0.030, respectively). In the multivariate analysis, significance was not confirmed for any predictor for non-fatal outcomes, however, in the multivariate analysis for composite fatal and non-fatal outcome results showed that men were exposed to a greater risk compared to women (HR=1.54; 95%CI 1.14-2.08, p=0.006), and ePWV showed to be a risk factor (HR=1.94, 95%CI 1.50-2.51, p<0.001). Conclusions: ePWV was found to be significant independent predictor for cardiovascular deaths and composite fatal and non-fatal outcomes suggesting that this simple and reliable measure of arterials stiffness could be recommended for clinical work at least in remote rural areas where measurements of arterial stiffness is not feasible.

Stop stunting-A misguided campaign by well-meaning nutritionists.

"Stop stunting" is the central focus of the national Indonesian campaign to improve child health. We provide an autoethnographic statement on the currently practiced strategy that commits 23 ministries and an estimated $3.9 billion per year to coordinating nutrition interventions that are supposed to address the underlying causes of stunting. We visited six community health posts (posyandus) in West Timor and in Java and participated in routine child health examinations. We documented our impressions and discussed them with Indonesian colleagues, health officials, and local physicians. Routine health checks for children include anthropometry (height, weight, head, and mid-upper arm circumference), immunizations, and documentation in the children's health records. The examinations do not include a physical examination, vision and hearing tests of the child, health questionnaires, or information on nutrition. No specific information or recommendations are given to the mothers. Stunting is highly prevalent in Indonesia and "Stop-stunting" campaigns have become a national issue. Yet, their impact is disillusioning. Stunting is associated with a way of life that differs from that in developed Western countries today and was prevalent in feudal and other nondemocratic societies. We do not want to throw away policies that try to improve growth in children, but instead of spending money for dubious interventions as we have encountered in Indonesia, we rather suggest spending thoughts on the political and emotional causes of poor growth in otherwise healthy Indonesian children.