Patients In Remote Communities Research Articles

Navigating Uncharted Waters: Challenges in Delivering Intravenous Epoprostenol to Paediatric Patients in Remote Communities—A Complex Case of Portal Hypertension with Secondary Pulmonary Hypertension

Navigating Uncharted Waters: Challenges in Delivering Intravenous Epoprostenol to Paediatric Patients in Remote Communities—A Complex Case of Portal Hypertension with Secondary Pulmonary Hypertension

Assessment of community health workers activities in six districts of Zambézia Province, Mozambique

Mozambique’s Community Health Worker (CHW) or Agentes Polivalentes Elementares in Portuguese (APE) in Mozambique was reinitiated in 2010 after an unsuccessful first attempt decades prior. Two decades after this reinitialization, the Ministry of Health of Mozambique (MoH) and other interested parties sought to understand how the implementation of APEs interventions is progressing. Given its low coverage of many health interventions. A cross-sectional study was carried out in six districts of the Province of Zambézia, namely: Ile, Inhassunge, Milange, Mocubela, Mulevala, and Pebane. A questionnaire was developed based on government plans, APE training material, and best practices for implementing ACS programs found in the literature for individual face-to-face interviews with APEs. A descriptive analysis was carried out to summarize the different components of the APEs program according to the interviewees' responses. A total of 148 APEs were interviewed. Only 48% of APEs replenished their kits every month, and stock-outs of medications ranged from 19 to 92%, with expired medication being found for 5–13% of the medications. Although the quality of supervision appears high with APEs reporting service delivery observation (88%), discussion of work performance (81%) and work-related problems (91%), checking of supplies (90%), review of records (93%), and praise (92%) during their last supervision, only 59% of the sample study reported having had their last meeting with their supervisor less than 1 month ago. APEs are very important in providing care to patients in remote communities. Nonetheless, challenges persist in ensuring the proper performance of the APEs program. More urgently, there is a need to focus more on securing a constant supply of APE kits to provide patient care and on regular and timely delivery of subsidies as an incentive.

Telemedicine and Epilepsy. Experience of the Central Hospital "Dr. Ignacio Morones Prieto" During and Post-pandemic COVID-19

Background: Telemedicine is a real-time interactive communication that enables providers to join with patients and consultants across challenging geographic distances in a cost-effective, accessible manner. Telemedicine is helpful in the treatment of epilepsy and other neurological disorders. This work aims to share the use of telemedicine in the management of patients with epilepsy belonging to suburban communities during the COVID-19 pandemic and its post-pandemic follow-up. Material and Methods: A retrospective, descriptive, and analytical study was conducted. The Telemedicine database in our hospital underwent a retrospective analysis. The inclusion criteria encompassed patients who had an initial consultation during the confinement period (2020-2021) and had at least one videoconference in the post-confinement period (2022-2023). Various parameters, including the number of consultations received, city of origin, treatment, etiology, type of epilepsy, comorbidities, and treatment outcomes, were gathered to facilitate a comparison between the two periods. Statistical analyses were performed using IBM SPSS Statistics V.25 for Mac. Results: Ninety-eight patients with an initial consultation between 2020 and 221 were identified, discarding 41 due to loss of follow-up during post-confinement, resulting in N=57 cases for analysis. Conclusions: During the COVID-19 confinement period in our hospital, Telemedicine emerged as the sole feasible option for providing care to patients in remote communities. It demonstrated remarkable success in monitoring the short and midterm progression of epileptic patients. The decrease in seizure frequency was sustained during the midterm.

Understanding Barriers to Implementing and Managing Therapeutic Diets for People Living with Chronic Kidney Disease in Remote Indigenous Communities.

ABSTRACTIndigenous peoples in Canada, and globally, experience a disproportionate burden of chronic kidney disease (CKD) and end-stage renal disease (ESRD) ESRD patients in remote Indigenous communities might experience significant challenges in adhering to dietary guidelines. Much research has documented the poor quality, high cost, and limited availability of healthy foods in remote, Indigenous communities. Food quality and availability are poor in remote communities, indicating that persons with ESRD and CKD might have limited ability to adhere to dietary guidelines. This article reports on research designed to understand food-access barriers in remote First Nations for persons living with stage 4 and 5 CKD/ESRD. The study involved semi-structured interviews with 38 patients in remote communities. It concludes with some reflections on the significance of this issue in the context of dietetic practice.

1113 ASSESSMENT OF CAPSULE ENDOSCOPY UTILIZING CAPSOCAM PLUS® IN PATIENTS WITH SUSPECTED SMALL BOWEL DISEASE INCLUDING PILOT STUDY WITH REMOTE ACCESS PATIENTS

Capsule endoscopy (CE) has been widely utilized for the assessment of patients with known/suspected small bowel disease. The CapsoCam Plus® capsule is unique in that it utilizes four cameras at sequential 90 degree intervals in its mid-section permitting a 360-degree panoramic perspective with a 15+ hour battery life. A panoramic view has been suggested to improve overall visualization of the small bowel (SB) therefore potentially improving diagnostic yield. Unlike other small bowel capsules, it must be retrieved upon excretion (utilizing a magnetic kit) since the images are stored on the device. To assess the use of CapsoCam Plus in patients referred for suspected small bowel disease, including pilot assessments for patients in remote locations. A retrospective chart review (01/16 – 10/19) assessing consecutive capsule procedures utilizing this device was performed. Information acquired included basic demographics, indication, extent of examination, gastric transit time, small bowel transit time, yield, adverse events, capsule retention, recovery rates and recommendations for follow up. A pilot study was also initiated for patients in rural centers to access capsule testing remotely through mail courier without attendance/travel to the primary dispensing site. Acquired data included 65 patients receiving CapsoCam Plus®. Indications: 86% obscure gastrointestinal bleeding, 5% abdominal pain and 1% for IBD. 92% of studies were completed to cecal visualization. Mean gastric and small bowel transit time were 0:48:03 and 3:53:00. 95% were retrieved using retrieval kits provided to patients. 1.5% retrieved endoscopically from the stomach (retained due to pyloric stenosis), 1.5% retained in terminal ileum (previously undiagnosed stricture) and 1.5% not retrieved due to failure of patient to use retrieval kit. 74% of studies were normal SB, 12% contained SB ulceration/erosive disease and 8% did not demonstrate the entire small bowel. Recommendations for follow up included supportive therapy (52%), more aggressive iron supplementation (1%), repeat capsules (17%), further endoscopic evaluation (11%) and 12% for routine office follow up and discussion. All four capsules mailed to patients in remote communities were completed successfully. CapsoCam Plus® had a high retrieval rate of 95% demonstrating that with appropriate patient selection, recovery rates are very high. Only 3% of patients had retained capsules. Most patients in this study had a normal small bowel, however; images and completion rates were adequate to assess small bowel in the vast majority of patients. Success was obtained with mailing this capsule to remote sites sparing the patient travel to the dispensing site.

A151 ASSESSMENT OF CAPSULE ENDOSCOPY UTILIZING CAPSOCAM PLUS® IN PATIENTS WITH SUSPECTED SMALL BOWEL DISEASE INCLUDING PILOT STUDY WITH REMOTE ACCESS PATIENTS

Abstract Background Capsule endoscopy (CE) has been widely utilized for the assessment of patients with known/suspected small bowel disease. The CapsoCam Plus® capsule is unique in that it utilizes four cameras at sequential 90 degree intervals in its mid-section permitting a 360-degree panoramic perspective with a 15+ hour battery life. A panoramic view has been suggested to improve overall visualization of the small bowel (SB) therefore potentially improving diagnostic yield. Unlike other small bowel capsules, it must be retrieved upon excretion (utilizing a magnetic kit) since the images are stored on the device. Aims To assess the use of CapsoCam Plus in patients referred for suspected small bowel disease, including pilot assessments for patients in remote locations. Methods A retrospective chart review (01/16 – 09/19) assessing consecutive capsule procedures utilizing this device was performed. Information acquired included basic demographics, indication, extent of examination, gastric transit time, small bowel transit time, yield, adverse events, capsule retention, recovery rates and recommendations for follow up. A pilot study was also initiated for patients in rural centers to access capsule testing remotely through mail courier without attendance/travel to the primary dispensing site. Results Acquired data included 63 patients receiving CapsoCam Plus®. Indications: 32% obscure gastrointestinal bleeding, 52% iron deficiency anemia, 2% abdominal pain and 6% for IBD. 92% of studies were completed to cecal visualization. Mean gastric and small bowel transit time were 0:48:17 and 3:54:29. 94% were retrieved using retrieval kits provided to patients. 2% retrieved endoscopically from the stomach (retained due to pyloric stenosis), 2% retained in terminal ileum (previously undiagnosed stricture) and 2% not retrieved due to failure of patient to use retrieval kit. 73% of studies were normal SB, 13% contained SB ulceration/erosive disease and 8% did not demonstrate the entire small bowel. Recommendations for follow up included supportive therapy (47%), more aggressive iron supplementation (1%), repeat capsules (19%) and 14% for routine office follow up and discussion. All three capsules mailed to patients in remote communities were completed successfully. Conclusions CapsoCam Plus® had a high retrieval rate of 97% demonstrating that with appropriate patient selection, recovery rates are very high. Only 3% of patients had retained capsules. Most patients in this study had a normal small bowel, however; images and completion rates were adequate to assess small bowel in the vast majority of patients. Success was obtained with mailing this capsule to remote sites sparing the patient travel to the dispensing site. Funding Agencies None

Role of public-private partnerships in achieving UNAIDS HIV treatment targets

BackgroundDespite progress towards achieving UNAIDS 90–90-90 goals, barriers persist in laboratory systems in sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships (PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated impact in the scale up of VL and EID.MethodsWe queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved associated systems from the point of viral load test request to the use of the test result for patient management were deemed eligible.ResultsWe identified six PPPs collaborations with multiple activities in select countries that are contributing to address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented 94% of specimens to reach national laboratory through improved sample referral network and enabled a cost savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as well as reduced turnaround time of reporting results by 50%.ConclusionsOur review identified the benefits, enabling factors, and associated challenges for public and private sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 90–90-90 treatment targets for HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely untapped.

Cost-effectiveness of stroke care in Aboriginal and non-Aboriginal patients: an observational cohort study in the Northern Territory of Australia

ObjectiveTo assess cost-effectiveness of stroke care for Aboriginal compared with non-Aboriginal patients in the Northern Territory (NT), Australia.DesignCost-effectiveness analysis using data from a cohort-based follow-up study of stroke incidents.SettingPublic hospitals...

Review of 5.5 Years' Experience Using E-mail-Based Telemedicine to Deliver Orthopedic Care to Remote Communities

The use of e-mail-based telemedicine has been demonstrated as an effective and low-cost way of delivering healthcare to patients in remote areas who have limited access to medical services. We established a novel teleorthopedic service for a catchment area encompassing 972,000 km2 using a commercial off-the-shelf e-mail application. Before the implementation of this program, patients with acute orthopedic injuries were required to travel by air up to 1,900 km for evaluation by an orthopedic surgeon. In the present study, we examined the patient demographics and consultation characteristics and calculated the cost savings associated with patient travel for this teleorthopedic service. We retrospectively reviewed 1,000 consecutive e-mail-based consults and radiographic images received for new patients with acute orthopedic injuries from January 2008 to June 2013. Seventy-nine consults were excluded due to incomplete documentation, leaving 921 available for analysis. The service records were examined to identify patient demographics, orthopedic diagnosis, the percentage of patients managed locally, and the medical indications for patients requiring transfer. As the travel costs for patients requiring transport to the university hospital center are borne by governmental health agencies, the savings accrued from treating patients in their home communities were also calculated. For the 921 consultations, the mean age of patients was 27 years (range, 3 months-88 years), with 40.7% of all patients being younger than 18 years. The most common diagnoses were ankle fractures (15.2%), clavicle fractures (11.2%), distal radius fractures (11.2%), and fractures of the foot (10.2%). One hundred ninety patients (20.6%) required transfer, whereas 731 patients (79.4%) were treated in their home communities. Of the patients who were transferred, 123 (64.7%) required surgery, 55 (28.9%) required clinical evaluation by an orthopedic surgeon, and 12 (6.4%) required CT or MRI. Cost savings related to return trip travel expenses were calculated to be $5,538,120 Canadian (CAD) for the review period. Using an e-mail-based teleorthopedic service to manage acutely injured patients in remote communities allowed 79% of patients to be treated locally, with travel-related cost savings of $5,538,120 CAD.

Reasons for delays in treatment of bacterial sexually transmissible infections in remote Aboriginal communities in Australia: a qualitative study of healthcentre staff.

Background Remote Aboriginal communities in Australia experience high rates of bacterial sexually transmissible infections (STIs). To control the transmission and decrease the risk of complications, frequent STI testing combined with timely treatment is required, yet significant delays in treatment have been reported. Perceived barriers to timely treatment for asymptomatic patients in remote communities were explored. A qualitative study was undertaken as part of the STRIVE (STIs in Remote communities, ImproVed and Enhanced primary health care) project; a cluster randomised controlled trial of a sexual health quality improvement program. During 2012, we conducted 36 in-depth interviews with staff in 22 clinics in remote Australia. Participants included registered nurses (72%) and Aboriginal health practitioners (28%). A key barrier to timely treatment was infrequent transportation of specimens to laboratories often hundreds of kilometres away from clinics. Within clinics, there were delays checking and actioning test results, and under-utilisation of systems to recall patients. Participants also described difficulties in physically locating patients due to: (i) high mobility between communities; and (ii) low levels of community knowledge created by high staff turnover. Participants also suggested strategies to overcome some barriers such as dedicated clinical time to follow-up recalls and taking treatment out to patients. Participants identified barriers to timely STI treatment in remote Aboriginal communities, and systems to address some of the barriers. Innovative strategies such as point-of-care testing or increased support for actioning results, coupled with incentives to individual patients to attend for results, may also assist in decreasing the time to treatment.

Decreasing prevalence of Trichuris trichiura (whipworm) in the Northern Territory from 2002 to 2012

To observe the prevalence, disease associations, and temporal trends in Trichuris trichiura (whipworm) infection in the Northern Territory between 2002 and 2012. Retrospective observational analysis of consecutive microbiologically confirmed cases of T. trichiura infection among members of the NT population from whom a faecal sample was obtained for testing by NT Government health care facilities between 1 January 2002 and 31 December 2012. Annual prevalence of T. trichiura infection; age, sex, Indigenous status and place of residence of infected patients; percentage of infected patients with anaemia (haemoglobin level, ≤ 110 g/L) and eosinophilia (eosinophil count, ≥ 0.5 × 10(9)/L). 417 episodes of T. trichiura infection were identified over the 11 years from 63 668 faecal samples. The median age of patients was 8 years (interquartile range [IQR], 3-36 years). Patients were predominantly Indigenous (95.3%; P = 0.001) and from three main geographical areas (Victoria Daly, East Arnhem Land and West Arnhem Land). Infections were associated with anaemia (40.2%) and eosinophilia (51.6%). There was a downward trend in the prevalence of T. trichiura infection diagnosed at NT Government health care facilities, from 123.1 cases (95% CI, 94.8-151.3 cases) per 100,000 Indigenous population in 2002 to 35.8 cases (95% CI, 21.8-49.9 cases) per 100,000 Indigenous population in 2011. T. trichiura is the most frequently identified soil-transmitted helminth infecting patients in NT Government health care facilities. Cases are identified predominantly in Indigenous patients in remote communities. We have observed a declining prevalence of whipworm infection in the NT.

Introduction of Portable Computed Tomography Scanners, in the Treatment of Acute Stroke Patients via Telemedicine in Remote Communities

Thrombolysis is an established treatment in selected patients who present early to hospital after symptoms of acute ischaemic stroke. Treatment can only be offered after the patient has been assessed by highly trained physicians and imaging studies have ruled out a brain haemorrhage. This limits the wider availability of thrombolysis to patients in remote communities, especially in countries with limited resources. There has been considerable success with the use of TeleStroke to overcome such barriers. TeleStroke is feasible in remote hospitals provided there is an available computed tomography scanner, a fundamental prerequisite in the assessment of acute stroke and thrombolysis. This is a luxury not widely available, especially in remote sites. Recently, Neurologica introduced a portable computed tomography scanner that can be operated after minimal training. We report our preliminary experience with the portable computed tomography scanner in a remote community where Telemedicine was successfully used to evaluate and treat patients presenting with symptoms suggestive of an acute ischaemic stroke. The University of Alberta Hospital in Edmonton, Canada was the 'hub' site and Wainwright Community Hospital was the 'spoke' site. Over a 3-month period, 18 patients were evaluated in the emergency department of the remote hospital where the referring physician felt that symptoms indicated potential for thrombolysis. All patients were evaluated remotely by a stroke neurologist in a TeleStroke service situated 207 km from the rural site. After clinical examination, cranial computed tomography scans were obtained with the portable scanner and evaluated by the stroke neurologist. In three patients, thrombolysis was not offered because the computed tomography showed evidence of brain haemorrhage: two intracerebral haemorrhage and one subarachnoid haemorrhage. Three patients meeting the standard criteria received thrombolysis within 4.5 h from onset of symptoms. There was a significant improvement in two patients. One patient did not make a good recovery. Repeat computed tomography scans showed a small haemorrhagic transformation in one patient. In the remaining 12 subjects, symptoms improved rapidly, were outside the window for thrombolysis, or were not consistent with an acute ischaemic stroke. Our preliminary study shows that the portable scanner can be used successfully in the evaluation of patients in remote regions that are not within timely reach of stroke experts or do not have available conventional imaging with computed tomography scans. Telemedicine, in combination with the use of portable scanners, offers hope to a large remote population base that would otherwise not have access to appropriate acute stroke treatment.