Initial Immunomodulation and Outcome of Children with Multisystem Inflammatory Syndrome Related to COVID-19: A Multisite Study from India

Objective To determine the outcomes in children with MIS-C receiving diferent immunomodulatory treatment. Methods In this multicentric, retrospective cohort study, data regarding treatment and outcomes of children meeting the WHO case defnition for MIS-C, were collected. The primary composite outcome was the requirement of vasoactive/inotropic support on day 2 or beyond or need of mechanical ventilation on day 2 or beyond after initiation of immunomodulatory treatment or death during hospitalization in the treatment groups. Logistic regression and propensity score matching analyses were used to compare the outcomes in diferent treatment arms based on the initial immunomodulation, i.e., IVIG alone, IVIG plus steroids, and steroids alone. Results The data of 368 children (diagnosed between April 2020 and June 2021) meeting the WHO case defnition for MIS-C, were analyzed. Of the 368 subjects, 28 received IVIG alone, 82 received steroids alone, 237 received IVIG and steroids, and 21 did not receive any immunomodulation. One hundred ffty-six (42.39%) children had the primary outcome. On logistic regression analysis, the treatment group was not associated with the primary outcome; only the children with shock at diagnosis had higher odds for the occurrence of the outcome [OR (95% CI): 11.4 (5.19–25.0), p<0.001]. On propensity score matching analysis, the primary outcome was comparable in steroid (n=45), and IVIG plus steroid (n=84) groups (p=0.515). Conclusion While no signifcant diference was observed in the frequency of occurrence of the primary outcome in diferent treatment groups, data from adequately powered RCTs are required for defnitive recommendations.

Needs assessment of caregivers of children with disabilities in resource-limited settings / Journal of Rural Medicine

Objective: This study aimed to identify and classify the needs of caregivers of children with disabilities living in resource-limited settings and develop a framework for need assessment.Participants and Methods: This study was conducted in the Maha Sarakham Province, Thailand, with 15 caregivers caring for children with disabilities recruited from hospitals, the Association for the Disabled, and primary health centers. Semi-structured interviews were conducted in local dialects, recorded, transcribed, converted into standard Thai, and then into English for thematic analysis. Meaning units corresponding to caregivers’ needs were extracted, interpreted, coded, and hierarchically organized into subcategories by comparing similarities and differences among the extracted codes. The subcategories were further grouped and abstracted into categories, and then domains of caregivers’ needs were formed.Results: Nineteen categories were identified across five domains of caregivers’ needs: health and medical, welfare, educational, social, and informational. Although basic medical treatment was covered, specific support, such as referral to a specialist, rehabilitation, or psychological support, was limited. Financial support and relief from the care burden are the main welfare needs. Educational needs were identified to provide knowledge to children and to offer respite to their caregivers. Social needs revealed ethical problems that arose because of strong rural community ties, making it difficult to maintain privacy. Informational needs were intertwined with the other four domains. In rural areas, where parents of children with disabilities migrate to cities to find work, the special needs of grandparents who were primary caregivers of the children needed to be addressed.Conclusion: This study provides a conceptual framework for comprehensive needs assessment and policy development for caregivers of children with disabilities living in resource-limited settings.

Factors affecting adoption of a telemedicine device by primary care health workers in the Philippines

@#<p style="text-align: justify;"><strong>Background and Introduction.</strong> The RxBox is a telemedicine device that measures and transmits vital signs to remote experts. It has been deployed to primary care health centers (PCHC) in the Philippines serving disadvantaged populations, to decrease morbidity and mortality due to common diseases and poor access to care. Factors affecting its adoption by healthcare workers is unknown.</p><p style="text-align: justify;"><strong>Materials and Methods.</strong> The study determined social and behavioral factors that affect adoption of a telemedicine device into the clinical workflow using the Unified Theory of Acceptance and Use of Technology (UTAUT) framework. This is a mixed methods research using review of records, survey and focused group discussions.</p><p style="text-align: justify;"><strong>Results and Discussion.</strong> RxBox telemedicine devices were installed in 79 primary care health centers (PCHC) and were used a total of 15,705 times within the study period. An ordinary least squares regression analysis using the combined site and individual-level data showed that among the UTAUT parameters, only compatibility, facilitating conditions, and social factors have significant relationships with intent-to-use of the RxBox. The innovation assisted primary care health workers in their clinical responsibilities, improved the stature of their PCHC in the community, and helped in the care for patients. Training and technology support after deployment as well as encouragement by peer and champions (the PCHC physician, local government leaders) reinforced continuous use after training. Users described the experienced improvements in quality of services provided by the PCHC and the consequent benefits to their patients.</p><p style="text-align: justify;"><strong>Conclusions.</strong> These factors should be accounted for in designing strategies to reinforce health workers' attitudes and enhance support towards acceptance and use of novel telemedicine devices into clinical routine in local health centers. Lessons are immediately useful for local leaders in low- and lower middle-income countries that suffer disproportionately from unnecessary maternal deaths and mortality due to non-communicable diseases. This contributes to the body of knowledge and should bolster national-level advocacy to institute an enabling policy on telehealth Information Communication Technology (ICT) and use of Filipino innovations towards health systems strengthening. Results can be used by implementers, evaluators, and regulators of health ICT, especially in resource-poor settings. Likewise, the study can encourage more research in the field to spur more dynamic local health ICT and biomedical device industries.</p>

The outcome of short stay thyroidectomy in rural medical outreach settings in Northern Nigeria

Background: The practice of short stay thyroidectomy is relatively new in developing nations like Nigeria. The primary reason for this is a lack of resources. Furthermore, the prevailing poverty prevents many patients from accessing tertiary health care, as such, ad hoc medical outreaches are usually conducted to bridge the gap. Thyroidectomies have not been routinely performed in these outreach settings due to safety concerns. The study seeks to analyse whether short stay thyroidectomy can be safely practiced under medical outreach settings with limited resources.Methods: The study is a prospective review of all patients that had short stay thyroidectomy at four rural medical outreach settings in Nigeria. Entire study spanned January 2019 to November 2019. Each outreach lasted one week, and patients were followed up for the duration of the outreach. All patients presenting at the outreach locations and diagnosed with goiters who have had no prior neck surgeries, are euthyroid, have no locally advanced malignancies or intrathoracic goiters, have adequate social support, possess a telephone, and have accommodation within the local government area where the outreach is carried out were included in the study. Exclusion criteria included patients who did not satisfy any of the above listed inclusion criteria. Thyroidectomy was done through a standard cervicotomy. Descriptive statistics were applied.Results: A total of 81 patients with non-toxic goiters had thyroid surgery. There were 76 (94%) females and five (6%) males. Average age was 46 years. Sixty-nine (85.2%) patients had no complication, while 12 (14.8%) patients had complications. Seventy-seven (95.1%) patients were discharged within 24 hours of surgery, while four (9.4%) patients were discharged within 48 hours. There was no mortality.Conclusions: The short-stay thyroidectomy model is feasible and safe in our environment, even in the presence of limited resources, and provides an alternative to the traditional 72 hour postoperative hospital stay.

Extracorporeal Shock-Wave Lithotripsy in Renal and Ureteric Calculi: Role in Resource Poor Developing Countries in Modern Era

Introduction: Extracorporeal shock-wave lithotripsy (ESWL)is an established non-invasive treatment modality for renaland ureteric stones. However, treatment outcome and efficacydepends on multiple factors like stone size, location and typeof machine used. We aimed to assess efficacy of ESWL asa primary treatment modality in renal and ureteric stones ina busy hospital setting having significant renal stone diseaseburden.Material and methods:1187 patients who underwent ESWLbetween January 2015 to December 2016 in our departmentwere included in the study. Patients with nephrolithiasis andureterolithiasis having functional kidney, without any absolutecontraindication to ESWL were included. Dornier Med TechCompact Delta 2 machines were used for all the patients.Stone localization was done using both fluoroscopic andultrasound- guided methods by same expert.Results: Out of 1187 patients,887 patients had solitary renalstones,170 had solitary ureteral calculus and 130 patients hadmultiple renal calculi. Stone size ranged from 8mm–20mm.Renal pelvic stones, upper calycial stones and proximalureteric stones had stone free rate of 84%,86% and 82.5%respectively. 89% and 84% of patients were stone free whensize of stone was between 8-12mm, it decreased to 77% and73% when size increased between 13-16mm for kidney andureteric stones respectively.Conclusions: ESWL is an effective primary treatmentmodality for appropriately selected patients with stone sizeless than 2 cm in favorable location with a normal functioningkidney. Use of both fluoroscopic and ultrasound imagingimproves localization of stones thus improving success. Itis an important modality in hands of urologist treating hugevolume of urolithiasis patients in busy hospitals with longwaiting list and with limited resources.

Blind Transthoracic Fine Needle Aspiration Cytology as a Diagnostic Tool in Suspected Lung Cancer in Resource Poor North-Eastern Part of India

Unguided FNAC may be the only option left for accurate diagnosis of malignant lesions in the lung in resource poor settings. The present study was done with the aim of assessing the accuracy and utility of unguided transthoracic fine needle aspiration cytology in the diagnosis of lung cancer. Methods: An interventional study was taken up in the Department of Respiratory Medicine, JN Institute of Medical Sciences, Imphal. All patients admitted in the IPD with suspected malignant lung lesions during the period July 2017-Dec 2018 was included. After obtaining prior informed written consent fine needle aspiration was done from the dullest area on chest wall by using a lumbar puncture needle under local anaesthesia. The slides prepared thereafter were alcohol-fixed and sent to the Department of Pathology, JNIMS for cytological examination. The patients were observed closely after the intervention to detect any complications. Results: Completed data sets could be obtained from 20 study subjects. Unguided fine needle aspiration cytology had a diagnostic yield of 75% for detecting malignant lesions in the lung. Only minor post-procedure complications were encountered in 10% of the patients. Conclusion: The unguided trans-thoracic fine needle aspiration cytology has many merits. It is rapid, safe, accurate and cost-effective for the diagnosis of intra-thoracic peripheral lesions. It can also be used as an outdoor procedure even in peripheral health centres in properly selected cases.

Expected Qualities of a Lecturer: Perceptions of Medical Students in a Remote Setting.

Studies on medical student perceptions of their lecturers, in a resource poor setting is scarce. Lack of basic infrastructure hampers learning. Quality lecturers can compensate this handicap to some extent. In 2009, as a new medical school located in rural Sri Lanka 220 km away from Colombo, the Faculty of Medicine and Allied Sciences at Rajarata University had scarce human resources and lacked sufficient lecture halls, labs, and clinical space. In order to understand qualities students sought in a lecturer, 55 medical students were given a single, self-administered open-ended question, and responses were subjected to direct thematic analysis. Themes of ―Lecturer Qualities,‖ ―Lecture Preparation Procedure,‖ and ―Lecture Delivery Procedure‖ were identified, and then further divided into sub-themes, the most common of which being ―Speaking Style,‖ ―Content Design,‖ and ―Content Organization.‖ While the findings in this study closely mirrored those of similar studies, identified qualities were underpinned by implicit meaning that accurately reflects the emotional stressors among students coping with limited educational resources. Students emphasized the importance of clear communication due to language barriers and a strong desire for lecturer loyalty to their faculty and country. The examination of these real-life perceptions will not only help us better identify how to improve medical education in this medical faculty and may be useful to similar resource poor rural medical colleges around the world.

Pulmonary rehabilitation in resource poor settings.

Pulmonary rehabilitation is an important component in the management of chronic obstructive pulmonary disease (COPD) and other chronic respiratory diseases. The goal of rehabilitation is to evaluate various systems, treat optimally, improve dyspnoea and health-related quality of life. It is a multi-disciplinary approach and involves a physician, a psychiatrist, a dietician and a physiotherapist. However, in a resource-poor setting, even an experienced physician alone may suffice. Exercise training is the backbone of pulmonary rehabilitation, which may be hospital-based or home-based. Though, the previous trials have shown benefit with hospital-based rehabilitation, several recent studies have demonstrated significant improvement in the 6-minute walk test and quality of life even with unsupervised, home-based pulmonary rehabilitation. In the resource-poor settings, the goal of rehabilitation may be achieved by incorporating regular unsupervised exercise in daily routine. This is not only better accepted and more suitable but is also more feasible for the lifelong maintenance of rehabilitation.