Peripheral Centers Research Articles

Clinicopathological feature and patterns of care of breast cancer patients in a peripheral tertiary care teaching institute: A retrospective analysis

Abstract Background: Breast cancer is the second-most common cancer worldwide and it is the most frequent cause of death due to cancer in women in India. Management of breast cancer requires multidisciplinary treatment. There are very limited data on clinicopathological features and patterns of care for breast cancer in resource-constrained area. Objectives: The objective of the study was to describe the clinicopathological feature of breast cancer and patterns of care provided to breast cancer patients in a peripheral tertiary care teaching institute catering to a rural population. Methods: A retrospective cross-sectional study including 252 histologically proven breast cancer patients was done from January 2022 to December 2022. Clinical characteristics, diagnostic, treatment details, and patterns of care of individual patients were reviewed and compiled in a case record form and the data were analyzed. Results: Two hundred and fifty-two patients were included in the study. 90.9% of patient has infiltrating duct carcinoma. The median age of presentation is 46 years. 50.8% were postmenopausal. The left breast was involved in 56.7%. 47.6% had locally advanced disease and 9.5% had metastatic disease at presentation. 2.4% of patients had a positive family history, and only 45.6% of patients had known immunohistochemistry (IHC) status out of which 46.9% were estrogen receptor positive, 40% were progesterone receptor positive, 13% were Her 2 neu positive, and 46.9% were triple-negative breast cancer. 88.9% of patients underwent Modified Radical Mastectomy. Conclusions: Although breast cancer remains a major clinical problem in India, there are wide disparities in patterns of care among urban fully equipped state-of-the-art centers and peripheral centers catering majorly to a rural population. Our audit shows the majority of patients presenting with advanced disease, not having an IHC report and undergoing mastectomy which reflects both lack of screening, awareness as well as resource constraints that can challenge the delivery of optimal care.

Nonlinear and synergistic effects of demographic characteristics on urban polycentric structure using SHAP

Polycentric urban development is promoted by urban planners and policy makers for its perceived benefits of alleviating urban issues. Theoretically, a polycentric urban structure is formed when different demographic groups present a collection of diverse and unique housing location preferences. Yet, only limited empirical studies have fully captured the complex effects of demographic characteristics on urban polycentric structures. Our study utilizes detailed demographic data and employs interpretable machine learning models to elucidate the nonlinear and synergistic relationship between demographic characteristics and the urban polycentric structure in the context of a city of 10 million population in China. When characterizing urban centers, the three most important demographic groups are young females, senior married couples, and middle-aged single individuals with basic education. Each urban center presents distinctive demographic compositions; for instance, middle-aged married individuals exerting a stronger influence in certain contexts, whereas in senior resident groups, married individuals have a more pronounced impact. Spatial heterogeneity is observed in the demographic profiles of urban centers; for instance, primary central cores are predominantly young, single females, whereas peripheral and secondary centers have stronger presence of highly educated residents.

Automated radiofluorination of HER2 single domain antibody: the road towards the clinical translation of [18F]FB-HER2 sdAb

BackgroundWith the next generation of Human Epidermal Growth Factor Receptor 2 (HER2) -targeting therapies, such as antibody–drug conjugates, showing benefit in “HER2 low” and even “HER2 ultralow” patients, the need for novel methods to quantify HER2 expression accurately becomes even more important for clinical decision making. A HER2 PET/CT imaging assessment could evaluate HER2 positive disease locations while improving patient care, reducing the need for invasive biopsies. A single-domain antibody (sdAb)-based PET tracer could combine the high specificity of sdAbs with short-lived radionuclides such as fluorine-18 (18F) and gallium-68 (68Ga). SdAb-based PET tracers have clinically been used via a 68Ga-chelator approach. However, the distribution of 68Ga-labelled pharmaceuticals to peripheral PET centres is more challenging to organize due to the short half-life of 68Ga, most certainly when the available activity is limited by a generator. Cyclotron produced 68Ga has removed this limitation. Distribution of 18F-labelled pharmaceuticals remains less challenging due to its slightly longer half-life, and radiofluorination of sdAbs via N-succinimidyl-4-[18F]fluorobenzoate ([18F]SFB) has shown to be a promising strategy for developing sdAb-based PET tracers. Although [18F]SFB automation has been reported, automating protein conjugation proves challenging. Herein we report the fully automated, cartridge-based production of [18F]FB-HER2 sdAb on a single synthesis module.Results[18F]FB-HER2 sdAb (> 6 GBq) was obtained after a fully automated production (95 min), with a RCP > 95%, apparent molar activity > 20 GBq/µmol and decay-corrected radiochemical yield (RCY d.c.) of 14 ± 2% (n = 4). Further upscaling amounted to production batches of 16 GBq with an apparent molar activity > 40 GBq/µmol and RCY d.c. of 8 ± 1% (n = 4). Ex vivo biodistribution and PET imaging showed specific HER2-positive tumour targeting and low kidney retention.ConclusionThe [18F]FB-HER2 sdAb tracer was produced with clinically relevant activities using a fully automated production method. The automated production method was designed to ease the translation to the clinic and has the potential to be used not only in mono-centre but also multi-centre clinical trials with one central production site. [18F]FB-HER2 sdAb showed a favourable biodistribution pattern and could be a valuable alternative to 68Ga-labelled sdAb-based PET tracers in the clinic.

Decentralization Matters: Association of Adherence to Treatment and Distance for the Management of Non-Communicable Diseases in Rural Tanzania.

Since March 2019, a non-communicable diseases program has been established at hospital level, with enrollment and clinical reassessment every 6 months. Since July 2023, monthly enrollment and visits have also been conducted at health center level. This study aimed at assessing the adherence to scheduled follow-up visits following the decentralization of the integrated NCDs program from Hospital to Health Center level and investigate factors influencing follow-up adherence. The study was performed in a rural district in Iringa Region, Tanzania. Adherence was measured at both levels. Multivariate regression analysis was conducted to describe socio-demographic and clinical factors influencing attendance at the 6-month hospital-level visit. Among 2198 patients enrolled at the hospital level, weighted adherence over 42 months was 40.8% (95% CI 39.0-42.6%) at the 6-month visit. Multivariate analysis revealed that as the distance from the hospital increased, the probability of attendance decreased (OR 0.17; 95% CI: 0.08-0.39). Among 571 patients enrolled at the residence level, adherence over the first 10 months of program implementation was 91.6% (90.4-92.8%). The findings showed that distance was by far the most important barrier to follow-up adherence and suggested that decentralizing the program from the hospital to peripheral health centers may ensure high follow-up rates.

Creation of a unique centrally monitored and operated neonatal transport network in a lower and middle-income country: A first of its kind initiative

BackgroundWith the current growth of many neonatal units in the country, good initial stabilization of sick neonates is possible at peripheral centers. However, poor neonatal transport and retrieval facilities are unfortunately leading to higher preventable mortality and morbidity in neonates arriving at a tertiary care center in poor condition. ObjectiveTo bridge the gap between referring hospital and tertiary care, this quality improvement initiative aimed to create a well-organized ‘network transport system’ for the round-the-clock provision of a city-wide retrieval system. Methods and interventionVarious causes linked to adverse events in the transport and retrieval of sick infants were initially assessed through a ‘fishbone analysis’. A step-wise-driven PDSA cycle was performed. It was realized that a well-organized, centrally controlled network of fully equipped neonatal ambulances with trained personnel for delivering neonatal intensive care on wheels was necessary even in a tier-one city like Bengaluru, India. A network transport and retrieval system for the city of Bengaluru was systematically created, involving 10 partner hospitals in the Manipal group. Training of all personnel involved in transport, creating a good infrastructure of state-of-the-art ambulances, transport incubators with ventilators, remote monitoring systems, and the creation of a centralized helpline with 24/7 response. The facility was named Neonatal Care on Wheels (NOW) and was propagated as a NICU on Wheels. ResultsThis initiative significantly improved the quality of neonatal transport as well as the stabilization of the neonate before transport. ConclusionThis robust network transport has proven to show improvements in the quality of retrieval and survival similar to that seen in Western countries.

Laparoscopic Versus Open Closure of Duodenal Perforations: A Retrospective Comparative Study in a Rural Hospital, Andhra Pradesh, India

Abstract Introduction: Evidence on the outcomes of laparoscopic surgeries, especially in emergency conditions such as peptic ulcer, remains unknown. A retrospective study was conducted in a rural surgical unit in Andhra Pradesh to compare morbidity, mortality, and duration of hospital admission in patients undergoing laparoscopic (Group L) and open (Group O) closure of duodenal perforations. Methods: Retrospective data of adult patients with peptic ulcer perforation treated by surgical approach during January 2012 and December 2017 were scrutinized. Pre- and postoperative records were abstracted for clinical conditions. Mortality was compared between the two groups with appropriate statistical tests. Results: A total of 120 patients, 60 in each group, were recruited for the study. The preoperative clinical characteristics of the two groups were similar. The mean duration of surgery was significantly higher in Group L (212.8 ± 29 min) compared to Group O (107 ± 16 min) (P < 0.001). Wound discharge (n = 3, 5%) and postoperative leak (n = 2, 3.3%) were the only complications noted in the L group. Several complications were noted in the O group including wound discharge (n = 51, 85%), wound dehiscence (n = 12, 20.0%), postoperative leak (n = 8, 13.3%), pneumonia (n = 1, 1.7%), and need for ventilation (n = 6, 10.0%). Three (5%) patients died in the hospital in Group O while none died in Group L. The average duration of hospital admission was 7.1 days (standard deviation [SD] =1.0 days) for Group L and 11.7 days (SD = 2.2 days) for Group O (mean difference: 4.6 days; 95% confidence interval: 4.6–5.2 days). Conclusion: Laparoscopic correction of duodenal ulcer perforation is both feasible and effective in reducing morbidity and mortality and overall treatment duration at peripheral centers.

Usefulness of intralesional contrast injection as a prebiopsy confirmation technique in a case of breast hemangioma

Hemangiomas are uncommon benign vascular lesions of breast. They have nonspecific imaging features and can be isoechoic or hypoechoic or of heterogeneous echotexture in ultrasound (USG). When isoechoic, it may be difficult to identify these lesions with confidence against a fatty background. Here, we report such a case of a high-density lesion detected in screening mammogram, which was not so obvious in USG. We used the technique of intralesional contrast injection into the probable USG correlate for confirmation, before proceeding with the biopsy and establishing the diagnosis of hemangioma. Thus, this simple prebiopsy confirmation technique helps in identifying the definitive USG correlate, thereby facilitating a USG-guided biopsy. This is very useful, especially in the peripheral healthcare centers where stereotactic facility may not be available. Another learning point from this case is that in case of superficially located lesions that are readily visible in mammogram but less conspicuous in USG, the possibility of hemangioma can be considered in the differentials. This observation has been mentioned in other case reports as well and reiterated in our case. However, due to the nonspecific imaging features and low incidence, it is difficult to make diagnosis of hemangioma without tissue sampling. The imaging features of breast hemangioma in mammogram and ultrasound are reviewed and described in this case report with an emphasis on the role of intralesional contrast injection in lesion localization.

Obstructed Labor at a Tertiary Hospital in Nigeria: A Six-Year Review

Introduction: Unlike most developed countries, obstructed labor with a dead fetus is still a reality in many developing countries, and it is a well-known cause of maternal and perinatal morbidity and mortality. Objective: To highlight the characteristics of patients presenting with obstructed labor at a tertiary hospital and determine fetomaternal outcomes. Methodology: A retrospective descriptive study of 45 cases of obstructed labor that were managed in a tertiary hospital from January 2009 to December 2014. Relevant information was extracted from patients’ case files, and the data obtained were analyzed. Results: Obstructed labor constituted 0.75% of all deliveries. All patients were referred in, and thirty (2/3) of them were nulliparous, while 25 (55.6%) were between the ages of 16 and 25. Forty-one (91.1%) of the patients were delivered by emergency caesarean section, while four patients had exploratory laparotomy with uterine repair and bilateral tubal ligation. Thirty-eight (84.5%) of the babies weighed between 2.6-4kg and five (11.1%) weighed more than 4kg. Most of the patients, 91.1%, had prolonged hospital stay with 25% staying over 3 weeks postpartum before being discharged. Eight (17.8%) suffered severe birth asphyxia, and there were five perinatal and two maternal mortalities. The commonest complication was puerperal sepsis. Conclusion: The study showed obstructed labor remains a cause of perinatal and maternal morbidity and mortality. Effective use of partographs in the peripheral centers, where all the women came from, would ensure early referral before labor became obstructed.

Determinants of data use for programmatic evidence-based decision making at peripheral public health care centres in Haryana, India

BackgroundHealth policies and programs in India are put into practice at the local level, where the frontline managers -Medical Officers in Charges (MOICs) use data for evidence-based decision-making (EBDM) and implementing these programs. However, there are various organizational, technical, and individual determinants that can impact data use. The study aims to recognize the determinants of data-driven decision-making at the grassroots level. MethodsThe cross-sectional study collected primary empirical data from 120 MOICs from six identified districts in Haryana, India. Data utilization was the variable of interest and was measured through Data Utilization Score (DUS). Determinants affecting DUS were extracted through Principal Component Analysis (PCA). Hierarchical multiple regression analysis was used to identify predictors of data utilization from the extracted factors. ResultsMOICs used routine data to plan, implement, manage, and monitor health programs, and administrative activities. Actual skill for data usage (65 %) was less than the anticipated skill (82 %). Twenty-seven reliable organizational, technical, and individual factors were generated from the 154 variables explaining 57.7 %–68 % of the total variance. Regression analysis showed that management meetings with superiors/subordinates, data-conducive and promotive culture, perceived data quality, incentivization, basic software knowledge/skills, and training needs were among the most significant predictors of data usage. ConclusionAlthough a disparity exists between the expected and actual data utilization skills of MOICs, still data-based decisions can be enhanced by effective management meetings, fostering a robust data culture, prioritizing skill development, and incentivizing data use.

Barriers to Effective Prehospital and Hyperacute Stroke Care in India: A Physician Perspective.

The incidence of stroke is increasing in India. Prehospital stroke care is crucial for reducing stroke morbidity and mortality, but its implementation in India faces several challenges. Limited original research exists on prehospital stroke care in India, making it essential to identify the problems in implementing effective prehospital stroke care. A web-based survey was conducted among registered medical practitioners in India who treat acute stroke. The survey questionnaire was developed in English and included 26 questions divided into five parts: questions about the physician's practice setup/hospital in India, perception of community awareness, existing prehospital care/systems, in-hospital stroke care availability, and specific issues faced. Eighty-three doctors in India participated in the survey (43% response rate). Most of the respondents worked in private hospitals (68%) and urban areas (76%). While 89% of hospitals had ambulance services, over 33% reported that patients had to pay for ambulance transport. Among respondents, 12% reported a community stroke care network, with infrequent prehospital procedures such as random blood glucose measurement (22%), stroke identification (15.7%), "last seen normal" documentation (14.5%), and low prehospital notification to hospitals (5%). Delays in referral from peripheral centers were reported by 73% of respondents. Most hospitals had standard operating procedures (SOPs) (84%), computed tomography (CT) (94%), magnetic resonance imaging (MRI) (85%), and offered intravenous thrombolysis (IVT) (77%). However, 24 h availability of CT was reported only by 6%, MRI by 19% and IVT by 12%. Nearly half (45%) reported treatment with thrombolysis was not covered by insurance. Mechanical thrombectomy was available in 34% of hospitals and 63% of hospitals conducted in-hospital audits for stroke patients. The capabilities of stroke-catering hospitals in urban settings are encouraging, with many having SOPs, imaging capabilities, and thrombolysis and mechanical thrombectomy services. However, there is much room for improvement, in making the essential stroke care services financially accessible to all and available around the clock.

Injury to Anatomic Structures Due to Fixation Device in Management of Mandibular Fracture.

ORIF is the gold standard for the management of mandibular fractures. The chances of postoperative complications are due to infection, damage of the inferior alveolar nerve canal, or tooth root during the fixation of the fracture fragments. Fixation hardware placed in the vicinity of the vital structures may encroach on the anatomic structures, leading to postoperative complications. The aim of this study is to evaluate the injury to the anatomic structures in the proximity of the fracture line due to the fixation device. This retrospective study was conducted in a tertiary care teaching hospital from July 2021 to June 2023. The cases of maxillofacial trauma reported and referred from peripheral centers were considered duly, applying the inclusion and exclusion criteria. Patients having mandibular fractures from one mandibular foramen to another with or without associated other facial fractures were treated by ORIF under general anesthesia. The patient was followed up at 1 week, 1 month, 3 months, and 6 months. The cases of postoperative complications were further investigated by CBCT. There were 67 patients (56 males and 11 females) with 86 fracture lines in the age group of 18-55 years with an average age of 35.2 years. Postoperatively 7 patients presented with unilateral paresthesia of the lower lip and chin region. CBCT revealed that the mean distance of the screw from the inferior alveolar nerve canal was 3.02mm. None of these cases had injury to the nerve canal or roots of teeth. All the patients recovered from paresthesia within 6 months. Complications like injury to the inferior alveolar nerve (IAN) with sensory disturbances to the lower lip and chin, as well as tooth/tooth root fractures, may occur due to mandibular fracture, surgical manipulation, and fixation devices. The anatomic structures in the vicinity of the fracture line can be damaged during the fixation of the fracture fragments by the bone plates and screws. In the present study, it was found that 7 out of 67 patients presented with unilateral paresthesia of the lower lip and chin. CBCT analysis showed a considerable distance of 3.02mm from the inferior alveolar nerve canal to the screws. There was no evidence of hardware encroachment on the IAN or tooth roots. Selection and placement of appropriate fixation devices, particularly the length of the bone screws, are crucial to avoid injury to the anatomic structures.

An application (ePRO) -based patient reported outcomes of quality of life from an innovative cancer care delivery model.

e23176 Background: With the accessibility of smartphones, it has become possible to develop applications for patient-reported outcomes. Quality of life (QoL) is an important measure in oncology research. We developed a phone application that could use any standardized form to be filled in by the patient. Here, we report using the EORTC questionnaire, QLQ-C30, built into the application as a form for data collection from our ongoing district cancer care program, which offers support at government district hospitals in India using an alternate oncology work force. Methods: An application (ePRO) was created, which allows one doctor administrator to follow the patients. Once the application is downloaded, the patient opens the QoL questionnaire (QLQ-C30), built into the application, and completes it using a smartphone. The researcher downloaded the data in Excel format and analyzed it. The application was attempted at a tertiary cancer center and a public hospital district cancer unit. A cross-sectional study was conducted over six months in 2023.The data were analyzed using SPSS version 24. Results: The application was downloaded and activated on the smartphones of 441 patients. Patients completed the form available through the application. Of all the respondents, 229 (51.9%) were male and 212 (48.1%) were female. The mean QoL of the tertiary hospital was 69.29, with a standard deviation (SD) of 18.98.The QoL scores were 50.94 (SD 23.50) in district hospital 1 and 77.01 (SD 17.35) in district hospital 2. The difference between one district and the other was significant (p < 0.001). The symptom scale scores varied between district hospitals and other hospitals. Conclusions: This presentation serves two purposes: to validate a new patient-reported outcome application and to provide data on QoL from peripheral centers compared with tertiary centers. The use of technology is feasible and can help gather patient-reported outcomes easily. There appears to be a difference in the quality of life of patients from different geographical locations. [Table: see text]

TIME TO SURGERY FOR NECK OF FEMUR FRACTURES IN SOUTHLAND FOR PATIENTS PRESENTING DIRECTLY TO A REFERRAL HOSPITAL VERSUS TRANSFERRAL FROM PERIPHERAL HOSPITAL: A MATCHED COHORT STUDY

IntroductionThe Te Whatu Ora Southern catchment area covers the largest geographical region in New Zealand (over 62,000 km2) creating logistical challenges in providing timely access to emergency neck of femur (NOF) fracture surgery. Current Australian and New Zealand guidelines recommend that NoF surgery be performed within 48 hours of presentation. The purpose of this study was to compare the outcomes for patients with NoF fractures who present directly to a referral hospital (Southland Hospital) compared to those are transferred from rural peripheral centres.MethodsA retrospective cohort study identified 79 patients with NoF who were transferred from rural peripheral centres to a referral hospital for operative management between January 2011 to December 2020. This cohort was matched 1:1 by age and sex to patients with NoF who presently directly to the referral hospital over the same period. The primary outcome was to compare time to surgery between the groups and secondary outcomes were to compare length of hospital stay, complication rates and mortality rates at 30-days and 1-year.ResultsThe mean delay in transfer time from peripheral centres was 11.5 ± 6.4 h. The mean time to surgery was higher, but not significantly different (p=0.155), for patients transferred from peripheral centres compared to patients presenting directly to the referral hospital (30.7 ± 16.5 h vs. 26.8 ± 17.2 h, respectively). However, rates of surgery within 48 h were similar between the patients transferred from peripheral centres and patients presenting directly to the referral hospital (8.8% vs 7.6%, p>0.999). There were no significant differences in complication rates, length of stay or 30-day or 1-year mortality between the groups.Discussion and ConclusionSignificant delays in transfer from peripheral centres to the referral hospital were identified, averaging 11.5 h. There was a strong trend towards increased time to surgery for patients transferred from peripheral centres. Early transfer of patients with NoF to a referral hospital should continue to be made a high priority.

Tele-ICU Management of a Trauma Patient at a Peripheral Center

Methods: A 23-year-old male was admitted to a peripheral center following a fall from a tractor. Examination at admission revealed a conscious, stable patient with significant chest pain. The tele-ICU (intensive care unit) was called, and when they received the patient, he was stabilized and managed immediately. The tele-ICU connection was provided through the Command Center in Apollo Hospitals, Jubilee Hills, Hyderabad, India, which is connected to multiple spoke locations at peripheral centers using audio-visual aids. An intensivist is available 24 h daily to provide critical care services to the peripheral centers through audio-visual aids. The tele-ICU connection is provided to the peripheral centers through commercial audio-visual and bedside data transfer devices. The tele-ICU team supervised the primary survey remotely via a central monitor, viewing the patient’s vitals along with the audio/video calling capabilities of the cameras as a part of the tele-ICU program. Results: Chest X-rays showed bilateral pneumothorax, lung compression, and multiple rib fractures. The team at the peripheral center was immediately advised to institute bilateral intercostal drainage (ICD). High-resolution CT chest (HRCT) reveals extensive right and minor left pneumothorax, bilateral lung contusions, a right clavicle medial end fracture, and multiple rib fractures. Ultrasonography of the abdomen showed altered splenic echo texture and moderate left pleural effusion. Flail chest and paradoxical breathing pattern warranted endotracheal intubation. The patient was ventilated for 4 days. On day 3, the patient experienced an air leak from the left ICD, increased drain output, and decreased hemoglobin. The tele-ICU team consulted the cardiothoracic surgeon regarding the air leak and followed their advice to attach a vacuum bottle to the ICD. The patient’s breathing improved gradually. Mechanical ventilator settings (i.e., tidal volume, respiratory rate, and peak airway pressures) were reviewed daily by the tele-ICU team during the regular morning and evening rounds. In addition, the ventilator and the bedside monitor were continuously monitored from the Command Center through video conferencing, which is integrated with electronic software and regularly captures the patient’s vitals. After 4 days of mechanical ventilation, the patient was extubated and started on oxygen therapy. Oxygen was gradually tapered and stopped. After 8 days of uneventful hospitalization, the patient was discharged. Conclusion: Studies show that telemedicine can provide expert-guided mentoring for life-saving procedures, including pre-hospital assessment and triage for polytrauma, tube thoracotomies, and extended focused assessment with sonography in trauma (eFAST). Technology may help resource-constrained places adopt telemedicine and its benefits.

What may encourage or deter health services utilization by people living with or at the risk of HIV/AIDS in special health centers? Qualitative evidence from a stigmatized community

BackgroundBehavioral Diseases Counseling Centers (BDCCs) and Vulnerable Women’s Counseling Centers (VWCCs) in Iran are the main peripheral centers that offer educational, counseling, diagnostic, preventive, curative and protective services to individuals living with or at high risk of contracting HIV/AIDS and female sex workers respectively. Due to the social stigma surrounding HIV in Iran, this study aims to identify the factors that may hinder or encourage HIV/AIDS patients and women with risky sexual behaviors from visiting these centers.MethodsConducted in 2023, this qualitative study involved individuals visiting BDCCs and VWCCs in two western provinces of Iran, Ilam and Kermanshah. The study participants included 21 health staff members working in BDCCs and VWCCs and 20 HIV/AIDS patients and vulnerable women with unsafe sexual behaviors referring to these centers. Purposive, snowball and maximum variation sampling techniques were applied to interview the participants. Interviews were conducted between January 5th and May 21st, 2023, using a semi-structure guideline. Interviews were transcribed and content analysis approach was applied to analyze data using MAXQDA20 software.ResultsAccording to the findings, the barriers and facilitators of visiting specialized centers for HIV/AIDS patients and vulnerable women were categorized into three main categories, 10 subcategories and 35 sub-subcategories including: Medical and operational processes (4 subcategories and 12 sub-subcategories), mutual interactions between the personnel and visitors (people living with and at the risk of getting HIV/AIDS) (3 subcategory and 13 sub-subcategories), and physical characteristics of the centers (3 subcategories and 10 sub-subcategories).ConclusionsTo improve the performance of BDCCs and VWCCs and encourage people living with and at the risk of contracting HIV/AIDS to visit these centers regularly, health policy makers should consider modifying clinical processes, physical features, personnel behaviors and visitors’ concerns raised by the interviewees and the issues identified in this study.

The Use of Hand-Held Digital Otoscope as a Basic Nasal Endoscopy Tool for Lacrimal Evaluation and Pedagogy Instrument

Purpose To investigate the utility of a hand-held digital otoscope for nasal endoscopy and as a pedagogy tool for residents and fellows in patients undergoing external dacryocystorhinostomy (DCR) surgery Methods A digital otoscope (MS450-NTE, Teslong Inc., USA) comprising a digital screen device and a connectible camera probe was used for performing nasal endoscopy. Inspection of nasal cavities was performed pre-, intra-, and post-operatively in sequential patients with nasolacrimal duct obstruction, who underwent DCR or lacrimal probing. Images (1920 × 1080 pixels) and videos (1280 × 720 pixels) were captured. The device was also used for training residents and fellows in performing nasal endoscopy, and to teach basic concepts. Results The digital otoscope could be used for routine outpatient nasal examination and for performing minor procedures. 53.8% (n = 13) of ophthalmology trainees had never observed nasal endoscopy and 84.6% could not identify more than one major structure correctly prior to the current training. Post-training, all trainees could independently perform nasal endoscopy with the device and 76.9% identified all structures correctly. Conclusion A digital otoscope with a camera probe is a handy tool for nasal endoscopy and pedagogy. Low-cost gadgets such as this device can effectively be used for performing outpatient nasal endoscopy when expensive endoscopes are unavailable and in peripheral healthcare centers.

Vitamin D3 deficiency and smell regions in adolescents: an MRI evaluation

Abstract OBJECTIVES. We investigated the effect of vitamin D3 deficiency on peripheral and central odor centres by using cranial magnetic resonance imaging (MRI). MATERIAL AND METHODS. In this retrospective study, cranial MRI images of 23 adolescents with vitamin D3 deficiency and 18 adolescents with normal vitamin D3 levels (≥ 20 ng/ml) were evaluated. Blood tests for vitamin D3, B12, hemoglobin and calcium levels were also taken from the database of our hospital. Peripheral odor centers, olfactory bulb (OB) volume and olfactory sulcus (OS) depth, and also central odor centers, insular gyrus and corpus amygdala area were measured on cranial MRI. RESULTS. The insular gyrus and corpus amygdala area were not different between the study group with vitamin D3 deficiency and the control group (p>0.05). There was no difference between OB volume of the study and control groups (p>0.05). Although the right insular area was lower in girls than males (p<0.05), there was no correlation between OB volume and gender (p>0.05). Higher hemoglobin levels were related to higher OB volume on the right side (p<0.05). CONCLUSION. In the group with vitamin D3 deficiency, olfactory bulb volume of the left side was asymmetrically larger than the one on the right side. Therefore, the measurements of vitamin D3 should be performed in adolescents, and the patients with the vitamin D3 levels of < 20 ng/ml should be supplemented with medical treatment and reinforcing vitamin D synthesis by the exposure of sunlight more.

Structured Counselling and Regular Telephonic follow up to improve Referral flow and compliance in Nepal for Diabetic Retinopathy(SCREEN-D Study): a randomised controlled trial

BackgroundDiabetic Retinopathy (DR) is an emerging public health issue, leading to severe visual impairment or blindness. Early identification and prompt treatment play a key role in achieving good visual outcomes. The objective of the study was to estimate the effectiveness of SCREEN package on improving referral compliance from peripheral centres to a tertiary eye centre in Nepal.MethodsIn this facility-based cluster-randomized trial, ten out of 19 referring centres of the tertiary eye care centre in Lumbini zone, Nepal were randomized into intervention and control groups. A SCREEN packagewereprovided as intervention for DR patients who require advanced treatment in the tertiary centres and was compared with the current practice of the control arm, where structured counselling and follow-up mechanism are absent. Compliance was estimated by a weekly follow-up between the referring centre and the referred hospital.ResultsWe recruited 302 participantsof whom 153 were in the intervention arm. The mean age of the participants was 57.8 years (Standard deviation [SD]±11.7 years). With implementation of SCREEN package71.2% (n=109) in the intervention group and 42.9% (n=64) in the control group were compliant till three months of follow-up (Difference 28.3%, 95% CI: 17.6- 39.0, p<0.05). Compliance was 43% (n=66) with counselling alone, and 66% (n=103) with first telephonic follow-up in the intervention arm. The mean duration to reach the referral centre was 14.7 days (SD± 9.4 days) and 18.2 days (SD± 9.1 days) in the intervention and the control arm, respectively (Difference 3.5 days, 95% CI: 0.7 to 6.4 days).ConclusionsCounselling& follow-up to patients is the key factor to improve the utilization of the health services by patients with DR. Health systems must be strengthened by optimizing the existing referral structure in Nepal.Trial registrationClinicalTrials.gov Protocol Registration and Results System, ClinicalTrials.gov Identifier: NCT04834648, 08/04/2021.

Treating and caring for migrant populations suffering from infectious diseases: the experience of the hub&spoke network set up by the Civico Benfratelli ARNAS Hospital in Palermo (Sicily Region, Southern Italy)

This paper describes the experience carried out in a general hospital, implemented in collaboration with a city network of associations involved in the care of migrant populations. Considering the vulnerability of these populations, the difficulty of access to healthcare facilities, and the linguistic and cultural barriers, an organisational model was designed characterised by the concentration of highly complex care (hub centre) supported by a network of peripheral reception centres (spoke centres) responsible for selecting patients and sending them to the centre of reference with the aim of offering screening for sexually transmitted infections, tuberculosis, taking charge of pathologies, including non-infectious ones, treatment, and follow-up. The effectiveness of the model was measured in relation to the continuum of care and its effectiveness with reference to the Joint Commission International guidelines.

The Slitscope.

Slit lamp biomicroscope is the right hand of an Ophthalmologist. Even though precise, its bulky design and complex working process are limiting constraints, making it difficult for screening at outreach camps, which are an integral part of this field for the purpose of eliminating needless blindness. The torchlight is the main tool used for screening. Recently, the integration of smartphones with instruments and the digitization of slit lamp has been explored, to provide simple and easy hacks. By bringing the slit of the slit lamp to traditional torchlight, we have created "The Slitscope". It combines the best of both worlds as a simple innovative do-it-yourself novel technique for precise cataract screening. It is especially useful in peripheral centers, vision centers, and outreach camps. We present two prototypes which can also be 3D printed.