Resource-limited Healthcare Research Articles

Neoadjuvant Capecitabine in Operable HPV-Negative Head and Neck Cancer: Fortuitous Findings in a Resource Constrained Setting.

Limited progress has occurred in treating operable human papillomavirus (HPV)-negative head and neck squamous cell carcinoma (HNSCC). Accessing timely care remains challenging in public health care systems, potentially resulting in disease progression before treatment initiation. A prospective cohort of patients receiving neoadjuvant capecitabine (NC) was compared to stage-matched patients undergoing standard of care (SC). This study was performed at 2 academic centers in Montreal, Canada. To ascertain the effect of 2 cycles of NC in operable HPV-negative HNSCC patients on clinical-to-pathologic stage migration. Comparison to an SC group was performed to site and TNM stage matched patients. Pathologic treatment response was measured using the modified Ryan score. We compared 16 NC patients (11 oral cavity, 3 skin, 2 larynx) with 32 SC patients. Ten NC patients exhibited a pathologic response (1 complete, 3 major, 6 minor). Clinical-to-pathologic stage migration differed significantly between NC and SC groups: downstage (6 vs 1), upstage (3 vs 14), no change (7 vs 17, P = .0047). There was no severe treatment toxicity related to capecitabine. All patients in the NC group underwent surgery. NC followed by surgery demonstrates measurable pathologic response in HPV-negative HNSCC, suggesting potential utility in resource-limited health care settings.

Ensuring Neurosurgical Equity: Setup for Safe Ventricular Endoscopy and Predictors of Clinical Outcome in a Resource-Limited Health Care System

Background/ObjectiveNeuroendoscopic surgeries require specialized equipment, which may not be universally available or equitably distributed in most neurosurgical units of resource-limited healthcare systems. This review reports on the use of locally available resources to perform safe ventricular endoscopic surgeries in patients with hydrocephalus and cystic craniopharyngioma, in a resource-limited health care system. MethodsThis study, described the use of locally available resources to perform intraventricular endoscopic surgeries, and retrospectively reviewed a three-year outcome of these surgeries, The authors, used a 24Fr, 2-way Foley's catheter, that served as an endoscopic working sheet. A transparent 9mm naso-tracheal tube, that served as a retractor and a peel-away sheet. An intravenous fluid (IVF) giving set, was used for irrigation, and a metallic stylet of External ventricular drain(EVD) was used for third ventricular floor or cyst wall fenestration. ResultsTwenty-one intraventricular endoscopic surgeries were performed, consisting; of endoscopic third ventriculostomy (ETV), septostomies, cystostomies, and intraventricular biopsies. Mortality occurred in four patients, with one of the mortality, directly related to intraoperative hemorrhage. Most (3/21) of the complications were post-operative CSF leakage and partial wound dehiscence. Of the 17 surviving patients, the ETV success rate was 82.4% (14/17). Logistic regression analysis revealed that the patient's age, etiology, ETV success score (ETVSS) and procedure performed were not predictive of ETV success or mortality. ConclusionsPatients accessing neurosurgical care in resource-limited healthcare systems can benefit from safe and successful intraventricular endoscopy. However, this may require the innovative use of locally available resources that can be adapted to local neurosurgical needs.

Endocrine syndromes and challenges in resource limited healthcare settings from clinical management point of view

Endocrine syndromes and challenges in resource limited healthcare settings from clinical management point of view

Abstract 6423: KRAS mutation detection by Sanger sequencing using the SeqStudio Flex capillary electrophoresis instrument

Abstract The detection of mutations in the KRAS gene highly associated with cancer is one of the most widely used Sanger sequencing capillary electrophoresis (CE) applications in molecular diagnostics. In addition to their traditional role in cancer diagnostic, KRAS mutations have recently gained additional relevance as pharmacogenomics (PGx) markers for a significant number of new oncology therapeutics. KRAS mutation detection assays are used as companion diagnostics (CDx) for these cancer treatments. Analysis by Sanger Sequencing of KRAS mutations is cost effective and lends itself for use in resource limited healthcare settings. While there are currently no commercial kits for targeted sequencing of the KRAS mutation hotspots available, the online Applied Biosystems Primer Designer™ Tool (thermofisher.com) allows standardization of the PCR primer design between labs and repeat orders of the KRAS assays by using these commercially available assay ID numbers. Here we demonstrate the use of Primer Designer KRAS mutation detections assays for mutation in codon 12, 13 and 61 totaling to 8 allele variants. The data was generated on the SeqStudio Flex CE instrument using reference standard DNA as well as DNA extracted from FFPE solid tumor samples. We show accuracy of variant call (OPA 100% (64/64)) and concordance (OPA 98.3% (59/60)) in a side-by-side comparison of the SeqStudio Flex with the legacy Model 3500 Genetic Analyzer instrument using a set of commercially available (Horizon Discovery) KRAS reference DNA samples. Primary solid tumor samples are processed to Fresh Frozen Paraffin Embedded samples (FFPE) for further disease marker evaluation. These samples are stable for long term at ambient temperatures and provide the opportunity to evaluate prospective biomarkers at large scale to understand their potential utility. Discovery Life Sciences has generated a large-scale biorepository of human biospecimen, including FFPE, plasma/sera, buffy coat, and PBMCs. Archival FFPE samples from oncology indications associated with KRAS mutations, such as non-small cell lung cancer and colorectal cancer, were analyzed and identified samples with KRAS mutations, demonstrating the potential diagnostic utility of these assays. Finally, cell-free (cf) DNA from double spun plasma from relevant indications was also successfully evaluated for KRAS mutations, highlighting the potential for these assays in liquid biopsy studies. The study demonstrates the robustness of the Primer Designer KRAS mutation detection sequencing assays using reference standard DNA as well as DNA derived from FFPE DNA and cfDNA from patient derived tumor samples. For Research Use Only. Not for use in diagnostic procedures. Citation Format: Achim Karger, Ami Patel, Kaylee Tseng, Camila Ornelas, Mary Napier, Rod Beck, Kerri Collwell, Shawn Fahl, Carole Bornarth. KRAS mutation detection by Sanger sequencing using the SeqStudio Flex capillary electrophoresis instrument [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6423.

Early discharge after low-risk ST-eletavation myocardial infarction and risk of adverse clinical ouctomes. validity and applicability of the zwolle risk score in a resource-restricted health system

Abstract Background/Introduction A Low Zwolle Risk Score (ZRS) identifies patients suitable for early hospital discharge after primary percutaneous coronary intervention (PPCI) without subsequent increase in post-discharge major adverse events (MAE).1 Data supporting this approach in resource-limited health care systems is sparse. This is particularly relevant in locales where the primary health care infrastructure is not efficiently geared towards managing patients with cardiovascular diseases and where the risk of MAE approaches 4% in the first-year post discharge.2. Purpose We aim to validate the ZRS in our population and correlate it with MAE. We intend to examine the rates of the individual adverse events at 1-month and 6-months post discharge and identify any potential gaps in management during the short hospital stay. Methods This was a retrospective analysis from the local PCI Registry at our Hospital. It included patients from 2014-2020 who were > 18 years of age who underwent PPCI for ST-elevation myocardial infarction. The rates of MAE were examined at 1-month and 6-months post-discharge. These were compared against patients with high ZRS (>4) from the same registry. Results A total of 570 patients were included in the analysis; 406 (71.2%) had a low ZRS of <4 and the remaining 164 (28.8%) were high risk (ZRS >4). The low ZRS group were younger (52.8 + 11.7 yrs. vs. 64.7 + 12.4 yrs., p<0.001), less likely to have CKD (6.4% vs. 17.7%, p<0.001) and previous CABG (0.5% vs. 2.4%, p=0.03). The median total length of hospital stay was 2 days (IQR 1-3) and significantly shorter than that in the high ZRS group of up to 7 days (p<0.001). The low-risk group were less likely to have an infarct culprit lesion in the LM (0.5% vs. 4.9%, p<0.001) or the LAD (42.6% vs. 68.3%. p<0.001). They were also less likely to have multivessel disease (32.8% vs. 47.6%, p=0.001). When comparing outcomes between the Low ZRS and high ZRS groups, the overall event rate at 1-month was 11.8% vs.37.1% (p<0.001), respectively and 14.0% vs. 45.7% (p<0.001) at 6-months, respectively. Interestingly, 1 in 20 patients at 1-month and 1 in 15 patients at 6-months post-discharge were re-hospitalized for decompensated heart failure. A ZRS of <4 was associated with lower procedural (0.4% vs. 3%, p=0.01), in-hospital (2.4% vs. 14.0%, p<0.001), and 6-month mortality (0.24% vs. 1.8%, p<0.001). A ZRS of >4 was an independent predictor of increased mortality at 6 months (OR 1.37, 95% CI 1.275-1.500, p<0.001] Conclusion(s) Even within a resource-restricted health system, the ZRS can identify patients safe for early discharge with a low event rate at 1- and 6-months post-discharge. Additionally, a low ZRS was associated with low mortality. Our study captured more MAE than previous reports. There is a potential for optimization of medical therapy during the short hospital stay to minimize risk of adverse events, especially re-hospitalizations for heart failure.Baseline CharacteristicsMain Study Outcomes

Types and outcome of Respiratory Diseases among children at a tertiary healthcare facility.

Objective: To find out the types and outcome of respiratory illnesses at a tertiary healthcare facility. Study Design: Cross-sectional study. Setting: Department of Pediatrics, Rai Medical College Teaching Hospital, Sargodha Pakistan. Period: January 2022 to July 2022. Material & Methods: Admitted children of both genders aged between 1 month to 12 years were analyzed. At the time of admission, characteristics like gender, age, body weight, vaccination status and types of respiratory illness were noted. Duration of hospitalization along with outcome was recorded. Results: During the study period, a total 851 children were admitted. Out of these 851 children, 266 (31.3%) children had some kinds of respiratory illnesses and were further analyzed. There were 148 (55.6%) male children while overall mean age was 3.9±2.6 years. Pneumonia was the commonest respiratory illness noted in 92 (34.5%) children while bronchiolitis was the 2nd most common respiratory illness observed in 56 (21.1%). A total of 241 (90.6%) children were discharged, 11 (4.1%) referred to other departments, 7 (2.6%) LAMA while deaths were noted in 7 (2.6%). Vaccination status was found to have significant association with the outcome (n=0.0096). Conclusion: Respiratory illnesses contribute significantly to children admitted to resource limited healthcare facilities. Poor immunization status has significant association with mortality among children with respiratory illnesses.

Comment: Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary Embolism.

Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary EmbolismJournal of the Society for Cardiovascular Angiography & InterventionsVol. 2Issue 1100453PreviewThere is significant debate on whether large-bore thrombectomy (LBT) or catheter-directed thrombolysis (CDT) is superior for the treatment of intermediate- and high-risk pulmonary embolism (PE) while employing an early invasive strategy through endovascular therapies. Full-Text PDF Open Access Feroze et al1Feroze R. Arora S. Tashtish N. et al.Comparison of large-bore thrombectomy with catheter-directed thrombolysis for the treatment of pulmonary embolism.J Soc Cardiovasc Angiogr Interv. 2023; 2100453Google Scholar retrospectively investigated important problem in contemporary pulmonary embolism (PE) practice by demonstrating that there was no difference in mortality and rehospitalization rates in patients with intermediate-to-high-risk (IHR) PE treated with large-bore thrombectomy compared with those in patients treated with catheter-directed thrombolysis (CDT). Furthermore, both treatment approaches for PE were similar concerning safety. Given the scarcity of randomized data in this setting and inconclusive evidence base regarding hard clinical end points,2Harvey J.J. Huang S. Uberoi R. Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism.Cochrane Database Syst Rev. 2022; 2022: CD013083Google Scholar,3Pietrasik A. Gąsecka A. Szarpak Ł. et al.Catheter-based therapies decrease mortality in patients with intermediate and high-risk pulmonary embolism: evidence from meta-analysis of 65,589 patients.Front Cardiovasc Med. 2022; 9861307Crossref Scopus (0) Google Scholar we would wish to complement the authors' findings with our own recently published retrospective data.4Giunio L. Lozo M. Borovac J.A. Bradaric A. Zanchi J. Miric D. Feasibility and safety of catheter-directed thrombolysis via superficial cubital vein for the treatment of acute massive and submassive pulmonary embolism.Postepy Kardiol Interwencyjnej. 2021; 17: 389-397Google Scholar In our cohort of patients presenting with IHR acute PE, we performed CDT through the superficial cubital vein using a standard pigtail catheter and administering alteplase locally. This method had a robust effect on hemodynamics because it significantly reduced SPAP, and mean PAP, and improved mean systemic perfusion pressure at 12 hours after intervention with a concomitant reduction in the Miller score and index, both reflecting the angiographic severity of pulmonary artery obstruction and perfusion. Of importance, the rates of adverse events, particularly bleeding, were low with 2 bleeding events of which only 1 required the transfusion of 1 unit of packed red blood cells. Furthermore, procedural success was 100% with no intracranial hemorrhage, access-site bleeding, or death events. However, no comparator was available in our study. Taken together, data from the study by Feroze et al1Feroze R. Arora S. Tashtish N. et al.Comparison of large-bore thrombectomy with catheter-directed thrombolysis for the treatment of pulmonary embolism.J Soc Cardiovasc Angiogr Interv. 2023; 2100453Google Scholar and our own suggest that CDT in patients with IHR acute PE is complementary to mechanical thrombectomy and is equally safe and effective procedure that can be successfully performed by cannulating either small or large veins by experienced operators. This is exquisitely important from the pharmacoeconomic standpoint. An option to use readily available catheters outside of dedicated thrombolytic or thrombectomy systems may provide significant economical savings, especially in resource-limited health care systems. Finally, both interventional approaches have a great potential to help a large proportion of patients with PE, and a transcubital access is also a feasible option in this scenario. However, as Feroze et al1Feroze R. Arora S. Tashtish N. et al.Comparison of large-bore thrombectomy with catheter-directed thrombolysis for the treatment of pulmonary embolism.J Soc Cardiovasc Angiogr Interv. 2023; 2100453Google Scholar rightly conclude, adequately powered randomized studies that would examine percutaneous thrombectomy versus CDT and OMT are needed to confirm the clear signal of benefit associated with catheter modalities. Finally, these observations should be put in the context with the recently published consensus statement on percutaneous therapies in acute PE, stipulating that CDT-based strategies should be considered in all cases of IHR acute PE in whom systemic thrombolysis is contraindicated or failed or there was a hemodynamic deterioration despite full therapeutic anticoagulation.5Pruszczyk P. Klok F.K. Kucher N. et al.Percutaneous treatment options for acute pulmonary embolism: a clinical consensus statement by the ESC Working Group on Pulmonary Circulation and Right Ventricular Function and the European Association of Percutaneous Cardiovascular Interventions.EuroIntervention. 2022; 18: e623-e638Crossref Scopus (1) Google Scholar

Genomic analysis of extended-spectrum beta-lactamase (ESBL) producing Escherichia coli colonising adults in Blantyre, Malawi reveals previously undescribed diversity.

Escherichia coli is one of the most prevalent Gram-negative species associated with drug resistant infections. Strains that produce extended-spectrum beta-lactamases (ESBLs) or carbapenemases are both particularly problematic and disproportionately impact resource limited healthcare settings where last-line antimicrobials may not be available. A large number of E. coli genomes are now available and have allowed insights into pathogenesis and epidemiology of ESBL E. coli but genomes from sub-Saharan Africa (sSA) are significantly underrepresented. To reduce this gap, we investigated ESBL-producing E. coli colonising adults in Blantyre, Malawi to assess bacterial diversity and AMR determinants and to place these isolates in the context of the wider population structure. We performed short-read whole-genome sequencing of 473 colonising ESBL E. coli isolated from human stool and contextualised the genomes with a previously curated multi-country collection of 10 146 E. coli genomes and sequence type (ST)-specific collections for our three most commonly identified STs. These were the globally successful ST131, ST410 and ST167, and the dominant ESBL genes were bla CTX-M, mirroring global trends. However, 37 % of Malawian isolates did not cluster with any isolates in the curated multicountry collection and phylogenies were consistent with locally spreading monophyletic clades, including within the globally distributed, carbapenemase-associated B4/H24RxC ST410 lineage. A single ST2083 isolate in this collection harboured a carbapenemase gene. Long read sequencing demonstrated the presence of a globally distributed ST410-associated carbapenemase carrying plasmid in this isolate, which was absent from the ST410 strains in our collection. We conclude there is a risk that carbapenem resistance in E. coli could proliferate rapidly in Malawi under increasing selection pressure, and that both ongoing antimicrobial stewardship and genomic surveillance are critical as local carbapenem use increases.

Feasibility & cost effectiveness of day-of-surgery-admission (DOSA) in elective hepato-pancreato-biliary surgery in a resource limited health care setting

Feasibility & cost effectiveness of day-of-surgery-admission (DOSA) in elective hepato-pancreato-biliary surgery in a resource limited health care setting

Outcomes Associated With Colorectal Cancer After Population-Based Colonoscopy Screening: Results From a European Pragmatic Randomized Trial

Bretthauer M, Løberg M, Wieszczy P, et al. Effect of colonoscopy screening on risks of colorectal cancer and related death. N Engl J Med 2022;387:1547–1556. Colorectal cancer (CRC) is an ideal target for both opportunistic and population-based screening. Currently recommended screening strategies rely primarily on stool-based modalities such as fecal immunochemical testing (FIT) and endoscopic modalities such as sigmoidoscopy and colonoscopy. Bretthauer et al performed the first randomized trial to assess the effects of population-based screening colonoscopy on CRC and CRC-associated death. Screening-naïve healthy participants aged 55 to 64 years from 4 European countries were identified from population registries and, in a 1:2 ratio, randomly invited to undergo screening colonoscopy or not invited for screening. Screening colonoscopies were performed from 2009 to 2014. Importantly, no participants received any competing CRC screening modalities outside of the trial during either the screening or follow-up periods. Follow-up data were available for 84,585 patients. Among the invited group, 42.0% of participants accepted their invitation and underwent colonoscopy. The mean adenoma detection rate (ADR) was 30.7%. In intention-to-treat analyses, the 10-year risk ratio (RR) of CRC was 0.82 (95% confidence interval [CI] 0.70–0.93) in the screening arm, although the risk of CRC-related death was not significantly different (RR 0.90, 95% CI 0.64–1.16). In per-protocol analyses, RRs of CRC and CRC-related death with screening were 0.69 (95% CI 0.55–0.83) and 0.50 (95% CI 0.27–0.77), respectively. These results have triggered a broad range of reactions. Given the acceptance rate of 42%, one widely repeated stance is that colonoscopy can be effective only if performed, and that the per-protocol analyses may be a better representation of colonoscopy’s benefits (Dominitz and Robertson, N Engl J Med 2022;387:1609–1611). While perhaps true at the patient level, the aims of this study were to assess the efficacy of colonoscopy as a population-based screening tool. Therefore, barriers to dissemination, acceptability, and uptake are all relevant. Put another way, one might ask whether offering screening colonoscopy as a primary population-based screening modality increases or decreases health equity. Furthermore, existing cohort studies, which likely overestimate colonoscopy’s effectiveness given healthy user bias and inability to adjust for poor uptake, have demonstrated similar results (Nishihara et al, N Engl J Med 2013;369:1095–1105). The issue of justifying the costs (and risks) of colonoscopy as a primary screening modality is therefore also paramount, especially in single-payer resource-limited health care systems, given the established benefits of FIT in reducing CRC incidence and mortality (Chiu et al, Cancer 2015;121:3221–3229). Another debatable point is that the mean ADR was potentially suboptimal at 30.7%. However, given (1) the study period (2009–2014), (2) the screening-naïve non-FIT population, and (3) the upper age limit of 64 years (with established increases in ADR with increasing age [Shaukat et al, Am J Gastroenterol 2021;116:1946–1949]), these results are likely generalizable. Furthermore, inter-endoscopist variations in ADR are well established, with outliers prevalent in most practice settings (Mazurek et al, Clin Gastroenterol Hepatol 2022;20:1931–1946; Bishay et al, Gastrointest Endosc 2020;92:1030–1040.e9). Although the benefits of screening colonoscopy are clear at the patient level, providers and policy makers should carefully consider its role in population-based average-risk screening. Similar studies with long(er) follow-up periods, studies comparing colonoscopy and FIT for population screening, and studies carried out in different populations are all needed. Regardless of the modalities employed, ongoing efforts should be made to provide widespread patient education on CRC screening to improve uptake and optimize health equity.

Fast-Track-Chirurgie in der Neuroonkologie

BackgroundFast-track surgical treatment of neurooncology patients is a multimodal approach aimed at reducing the length of hospital stay, and is gaining more and more importance in a resource-limited health care system.ObjectiveThis study aimed to analyze current evidence on fast-track surgery in neurooncology patients.Materials and methodsA systematic literature review was performed in the PubMed database including the search items “ERAS AND neurosurgery,” “neurooncology AND ERAS,” and “fast-track AND neurosurgery.” Evidence grades were assessed by applying the Oxford evidence classification.ResultsIn total, 19 studies were identified analyzing fast-track surgery in neurooncology. While 6 studies corresponded to literature reviews, 13 included clinical retrospective and prospective studies showing a shortened hospital stay using fast-track protocols.ConclusionFast-track surgery in neurooncology is feasible and presents great opportunities to reduce patients’ hospital stay. However, it requires additional employees to provide perioperative supervision.

Challenges and recommendations to improve implementation of phototherapy among neonates in Malawian hospitals

BackgroundSevere neonatal jaundice can result in long term morbidities and mortality when left untreated. Phototherapy is the main-stay intervention for treating moderate jaundice and for prevention of the development of severe jaundice. However, in resource-limited health care settings, phototherapy has been inconsistently used. The objective of this study is to evaluate barriers and facilitators for phototherapy to treat neonatal jaundice at Malawian hospitals.MethodsWe conducted a convergent mixed-method study comprised of a facility assessment and qualitative interviews with healthcare workers and caregivers in southern Malawi. The facility assessment was conducted at three secondary-level hospitals in rural districts. In-depth interviews following a semi-structured topic guide were conducted at a district hospital and a tertiary-level hospital. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia).ResultsThe facility assessment found critical gaps in initiating and monitoring phototherapy in all facilities. Based on a total of 31 interviews, participants identified key challenges in diagnosing neonatal jaundice, counselling caregivers, and availability of infrastructure. Participants emphasized the need for transcutaneous bilirubinometers to guide treatment decisions. Caregivers were sometimes fearful of potential harmful effects of phototherapy, which required adequate explanation to mothers and family members in non-medical language. Task shifting and engaging peer support for caregivers with concerns about phototherapy was recommended.ConclusionImplementation of a therapeutic intervention is limited if accurate diagnostic tests are unavailable. The scale up of therapeutic interventions, such as phototherapy for neonatal jaundice, requires careful holistic attention to infrastructural needs, supportive services such as laboratory integration as well as trained human resources.

Video Observed Treatment is an Innovative Method of Tuberculosis Treatment Observation in Resource-Limited Health Care Settings

The objective of the study: to analyze the potential use of video observed therapy (VOT) as one of the fields of mobile health care for treatment of patients with tuberculosis, to substantiate prospects of using VOT as an alternative to directly observed therapy including settings with limited health care resources.Subjects and Methods. The relevant studies were searched for in the following bibliographic databases: MEDLINE/PubMed, EMBASE, LILACS, IMEMR and IMSEAR, and clinicaltrials.gov. 40 publications devoted to video observed treatment of tuberculosis abroad and in Russia were selected. The recommendations of the World Health Organization on the use of digital technology in tuberculosis treatment, in particular video observed treatment have been studied.Results. The article highlights the advantages of video observed treatment of tuberculosis, the possibility of implementing this approach in different groups of patients taking into account the inclusion and exclusion criteria, assessing effectiveness of its use (improved treatment adherence, higher number of completed observations, better responsibility of patients for the disease and therapy, economic benefits for the health system and the patient). The study speculates on the potential implementation of video observed therapy of tuberculosis in the Russian Federation.

COMPARISON STUDY OF SEMI-QUANTITATIVE RPR TEST AND TPHA FOR SERODIAGNOSIS OF SYPHILIS AT A TERTIARY CARE HOSPITAL, UDAIPUR, RAJASTHAN

Areactive RPR should always be conrmed with treponemal test like TPHAin suspected syphilis patients to rule out biological false positive cases. It is important to nd an alternative to TPHA as it is frequently not available in resource limited health care facilities of developing nations like India. Aim:Aim of our study is to evaluate semi-quantitative RPR test and TPHAin serological diagnosis of syphilis in resource limited health care facilities. Methodology: A retrospective cross sectional study from January 2020 to December 2021 was conducted on 116 suspected cases of syphilis. All cases were tested for qualitative RPR test, semi-quantitative RPR test ant TPHA test. Serum samples that are positive in qualitative RPR test but negative in TPHAwere referred to as biologic falsepositive (BFP) reactions. Results:We found 32 (27.58%) biological false positive (BFP) cases in dilutions 1:8 or below on semi quantitative RPR test. No BFP case was found in dilutions 1:16 or more. BFP can occur in any age group. We have noted that female 25(21.55%) were showing more BFP cases in our study. Conclusions: No biological false positive reaction has been found in above 1:8 dilution of RPR test. Semi-quantitative RPR test results in 1:16 or more dilution is equivalent to TPHAresults for diagnosis of syphilis.

Inpatient Management of Acute Stroke of Unknown Type in Resource-Limited Settings.

Stroke is the second leading cause of death and disability worldwide, with a disproportionate burden on low- and middle-income countries. Critical elements of guideline-based stroke care developed in high-income countries are not applicable to resource-limited settings, where lack of access to neuroimaging prevents clinicians from distinguishing between ischemic stroke and intracranial hemorrhage, requiring challenging clinical decision-making, particularly in the acute setting. We discuss strategies for acute inpatient management of stroke of unknown type with a focus on blood pressure management and antiplatelet therapy when neuroimaging is unavailable, and review some of the challenges and strategies for successfully implementing stroke unit care in resource-limited health care settings.

Ninety Day Post Discharge Outcome in Acute Exacerbation of Chronic Obstructive Pulmonary Disease Using the PEARL Score.

Chronic obstructive pulmonary disease exacerbation is a leading cause of frequent hospitalizations imposing substantial global health burden. The 90 day post discharge period has been associated with higher readmission rates and substantial risk of death. The aim of this study was to assess post discharge 90 day outcome in patients admitted with acute Chronic obstructive pulmonary disease exacerbation using the PEARL score. A longitudinal study was conducted at Tribhuvan University Teaching hospital from February 2019 to November 2019. Patients admitted in respiratory ward with acute Chronic obstructive pulmonary disease exacerbation were stratified into low, intermediate and high risk groups using PEARL score and post discharge 90 day outcome was assessed. Data entry and analysis was done in SPSS version 20.0. Descriptive and inferential statistics were performed. A total of 102 patients were included for final analysis. Mean age of patients was 70.54 ± 10.85 years. There were 53.9% male. Intermediate and high risk PEARL groups had the highest proportion of readmission within 90 days of discharge which was found to be 23 (52.3%) and 9 (50%) respectively. High risk PEARL group had the highest proportion of death within 90 days (11.1%). The difference in these outcomes among three PEARL groups was found to be statistically significant (p-value < 0.05). PEARL score is a simple tool that can be applied at bedside in assessing 90 dayrisk of readmission or death in acute Chronic obstructive pulmonary disease exacerbation. This can be beneficial in post-discharge planning and early referral especially in resource limited health care setting where advanced facilities are not available.

Bridging Learning in Medicine and Citizenship During the COVID-19 Pandemic: A Telehealth-Based Case Study

Background. COVID-19 presented great challenges for not only those in the field of health care but also those undergoing medical training. The burden on health care services worldwide has limited the educational opportunities available for medical students due to social distancing requirements.Objective. In this paper, we describe a strategy that combines telehealth and medical training to mitigate the adverse effects of the COVID-19 pandemic.Methods. A toll-free telescreening service, Telecoronavirus, began operations in March 2020. This service was operated remotely by supervised medical students and was offered across all 417 municipalities (14.8 million inhabitants) in the Brazilian state of Bahia. Students recorded clinical and sociodemographic data by using a web-based application that was simultaneously accessed by medical volunteers for supervision purposes, as well as by state health authorities who conducted epidemiological surveillance and health management efforts. In parallel, students received up-to-date scientific information about COVID-19 via short educational videos prepared by professors. A continuously updated triage algorithm was conceived to provide consistent service.Results. The program operated for approximately 4 months, engaging 1396 medical students and 133 physicians. In total, 111,965 individuals residing in 343 municipalities used this service. Almost 70,000 individuals were advised to stay at home, and they received guidance to avoid disease transmission, potentially contributing to localized reductions in the spread of COVID-19. Additionally, the program promoted citizenship education for medical students, who were engaged in a real-life opportunity to fight the pandemic within their own communities. The objectives of the education, organization, and assistance domains of the Telecoronavirus program were successfully achieved according to the results of a web-based post-project survey that assessed physicians' and students' perceptions.Conclusions. In a prolonged pandemic scenario, a combination of remote tools and medical supervision via telehealth services may constitute a useful strategy for maintaining social distancing measures while preserving some practical aspects of medical education. A low-cost tool such as the Telecoronavirus program could be especially valuable in resource-limited health care scenarios, in addition to offering support for epidemiological surveillance actions.

Oncoplastic surgery: A suitable alternative to conventional breast conserving surgery in low - Middle income countries; a retrospective cohort study

IntroductionBreast Conserving Surgery (BCS) with whole breast radiation is now standard of care as a safer alternative to Mastectomy in terms of loco-regional recurrence and long-term survival. Despite this, a frequent pitfall of conventional BCS is positive surgical margins and need for second surgery with a reported frequency of 12–59 % in literature. Oncoplastic Surgery can be a safer, more cost effective alternate to conventional BCS owing to its higher rate of negative surgical margins (4–6% vs 12–59 %) and better cosmetic results. We aim to prove utility of Oncoplastic surgery for Low-Middle income countries. ObjectiveThe aim of this study was to determine Oncoplastic Surgery as a more appropriate alternative to Conventional Breast Conserving Surgery for Low-Middle Income countries in terms of its lower positive margins and re-excision rates. MethodologyA retrospective comparative single center study by reviewing patient's medical records from August 2016 to June 2020 was conducted. Rate of positive margins and re-excisions along with mean volume of resection specimen, mean tumor size and quadrant dealt by both surgical procedures were compared. ResultsOut of 421 patients 249 patients underwent oncoplastic surgery and were compared with 173 patients who had conventional breast conserving surgery. Positive margins were seen in 5 patients (2 %) in OPS group whereas in 31 (17.9 %) patients in BCS group (p value < 0.001). Therefore, 2 from OPS group and 17 from BCS group underwent re-excision (p value < 0.002).None in OPS group while 7 out of 17 patients in BCS group underwent mastectomy as second procedure. Mean tumor size in OPS group was 2.26 cm ± SD 1.66 and in BCS group was 1.94 cm ± SD 1.28. Majority of Lobular carcinoma and Ductal carcinoma in-situ, multifocal, upper inner and central quadrant tumors and those unresponsive to neo-adjuvant therapy were treated by Oncoplastic techniques. ConclusionOncoplastic surgery has shown promising results as a safer tool to deal with large, complex tumors, lesions in difficult anatomical locations, multifocal or progressing on neo-adjuvant therapy. With its low Re-excision rates, it is a better alternative to traditional Breast Conserving approach for overburdened and resource limited health care system of Low-Middle Income countries. Multi-center, prospective trials are needed to determine its feasibility.

Technology and Disasters: The Evolution of the National Emergency Tele-Critical Care Network.

Technology and Disasters: The Evolution of the National Emergency Tele-Critical Care Network.

COVID-19-Related Anxiety and Its Association with Dietary Diversity Score Among Health Care Professionals in Ethiopia: A Web-Based Survey.

BackgroundThe outbreak of coronavirus disease 2019 (COVID-19) is a stressful and overwhelming situation for health care professionals (HCP), especially, who are caring for patients in the resource-limited health care settings of low-income countries. Due to the increasing number of COVID-19 cases in Ethiopia, HCPs are at risk for COVID-19-related anxiety and associated inadequate nutrition. However, the magnitude of COVID-19-related anxiety and its association with dietary diversity among HCPs is not well studied.ObjectiveTo assess the magnitude of COVID-19-related anxiety and its association with dietary diversity score among health care professionals in Ethiopia.MethodsA web-based cross-sectional survey was conducted among HCPs working in university hospitals, primary hospitals, and health centers in south and southwest Ethiopia. A structured online survey questionnaire was designed on Google forms and carried out from May 15 to June 14, 2020. COVID-19-related anxiety was assessed using the coronavirus anxiety scale. Dietary diversity was measured using 9 items individual dietary diversity score. Data analysis was done using the Statistical Package for Social Sciences version 24. Multiple logistic regression was computed to identify independent factors associated with COVID-19-related anxiety. Statistical significance was set at p<0.05.ResultsThe prevalence of COVID-19-related anxiety among health care professionals was found to be 20.2%. COVID-19-related anxiety is significantly associated with a low dietary diversity score [AOR=5.93 (1.67, 21.07)]. The other factors which are independently associated with COVID-19-related anxiety are the presence of depression [AOR=6.98 (2.91–16.73)] and diploma educational status [AOR=0.16 (0.04–0.55)].ConclusionOne-fifth of the study participants were found to have probable COVID-19-related anxiety. Designing a screening and intervention strategy for COVID-19-related anxiety among HCPs, particularly to those with low dietary diversity scores and depression, is recommended.