Enabling Rural Telehealth for Older Adults in Underserved Rural Communities: Focus Group Study.

BACKGROUND: Telehealth is often suggested to improve access to health care and has had significant publicity worldwide during the COVID-19 pandemic. However, limited studies have examined the telehealth needs of underserved populations such as rural communities. OBJECTIVE: This study aims to investigate enablers for telehealth use in underserved rural populations to improve access to health care for rural older adults. METHODS: In total, 7 focus group discussions and 13 individual interviews were held across 4 diverse underserved rural communities. A total of 98 adults aged ≥55 years participated. The participants were asked whether they had used telehealth, how they saw their community's health service needs evolving, how telehealth might help provide these services, and how they perceived barriers to and enablers of telehealth for older adults in rural communities. Focus group transcripts were thematically analyzed. RESULTS: The term telehealth was not initially understood by many participants and required an explanation. Those who had used telehealth reported positive experiences (time and cost savings) and were likely to use telehealth again. A total of 2 main themes were identified through an equity lens. The first theme was trust, with 3 subthemes-trust in the telehealth technology, trust in the user (consumer and health provider), and trust in the health system. Having access to reliable and affordable internet connectivity and digital devices was a key enabler for telehealth use. Most rural areas had intermittent and unreliable internet connectivity. Another key enabler is easy access to user support. Trust in the health system focused on waiting times, lack of and/or delayed communication and coordination, and cost. The second theme was choice, with 3 subthemes-health service access, consultation type, and telehealth deployment. Access to health services through telehealth needs to be culturally appropriate and enable access to currently limited or absent services such as mental health and specialist services. Accessing specialist care through telehealth was extremely popular, although some participants preferred to be seen in person. A major enabler for telehealth was telehealth deployment by a fixed community hub or on a mobile bus, with support available, particularly when combined with non-health-related services such as internet banking. CONCLUSIONS: Overall, participants were keen on the idea of telehealth. Several barriers and enablers were identified, particularly trust and choice. The term telehealth is not well understood. The unreliable and expensive connectivity options available to rural communities have limited telehealth experience to phone or patient portal use for those with connectivity. Having the opportunity to try telehealth, particularly by using video, would increase the understanding and acceptance of telehealth. This study highlights that local rural communities need to be involved in designing telehealth services within their communities.

Outcomes of COVID-19 in children with cancer – Report from the Indian Pediatric Oncology Group (InPOG) COVID-19 registry in India

Introduction The clinical outcomes of COVID-19 infection in children with cancer have been variable worldwide. Therefore, we aimed to collect data from all regions in India through a national collaborative study and identify factors that cause mortality directly related to COVID-19 infection. Methods Data was collected prospectively on children across India on cancer therapy and diagnosed with COVID-19 infections from 47 centers from April 2020 to October 2021. Information was recorded on the demographics, the number of children that required intervention, and the outcome of the infection. In addition, we analyzed the impact of the delta variant in 2021. Results A total of 659 children were studied, of whom 64% were male and 36% were female. The data from the eastern region was sparse, and this was a collection bias. COVID-19 infection was predominantly seen in children less than five years. The delta variant had a higher impact in the southern region, and this was statistically significant. Of the 659 children, 30 children died (4.5%), however only 7 of the deaths were directly attributed to COVID-19 infection (1%). Conclusion The study reports the largest nationally representative cohort of children with cancer and COVID-19 to date in India. We identified demographic and clinical factors associated with increased all-cause mortality in patients with cancer. Complete characterization of the cohort has provided further insights into the effects of COVID-19 on cancer outcomes. The low mortality allows us to recommend that specific cancer treatments be continued without delays in therapy.

Survey protocol for exploring video and phone use in Aotearoa New Zealand general practice: considerations for future telehealth.

INTRODUCTION: Telehealth became the most practical option for general practice consultations in Aotearoa New Zealand (NZ) as a result of the national lockdowns in response to the COVID-19 pandemic. What is the consumer experience of access to telehealth and how do consumers and providers perceive this mode of care delivery going forward? METHODS AND ANALYSIS: A national survey of general practice consumers and providers who used telehealth services since the national lockdowns in 2020 will be distributed. It is based on the Unified Theory of Acceptance and Use of Technology framework of technology acceptance and the access to care framework. The data will be statistically analysed to create a foundation for in-depth research on the use of telehealth services in NZ general practice services, with a specific focus on consumer experiences and health outcomes. ETHICS AND DISSEMINATION: Ethics approval was granted by the Auckland Health Research Ethics Committee on 13/11/2020, reference AH2539. The survey will be disseminated online.

Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients.

Severe hypoxemic respiratory failure is frequently managed with invasive mechanical ventilation with or without prone position (PP). We describe 13 cases of nonhypercapnic acute hypoxemic respiratory failure (AHRF) of varied etiology, who were treated successfully in PP without the need for intubation. Noninvasive ventilation (NIV), high-flow oxygen via nasal cannula, supplementary oxygen with venturi face mask, or nasal cannula were used variedly in these patients. Mechanical ventilatory support is offered to patients with AHRF when other methods, such as NIV and oxygen via high-flow nasal cannula, fail. Invasive mechanical ventilation is fraught with complications which could be immediate, ranging from worsening of hypoxemia, worsening hemodynamics, loss of airway, and even death. Late complications could be ventilator-associated pneumonia, biotrauma, tracheal stenosis, etc. Prone position is known to improve oxygenation and outcome in adult respiratory distress syndrome. We postulated that positioning an unintubated patient with AHRF in PP will improve oxygenation and avoid the need for invasive mechanical ventilation and thereby its complications. Here, we describe a series of 13 patients with hypoxemic respiratory of varied etiology, who were successfully treated in the PP without endotracheal intubation. Two patients (15.4%) had mild, nine (69.2%) had moderate, and two (15.4%) had severe hypoxemia. Oxygenation as assessed by PaO2/FiO2 ratio in supine position was 154 ± 52, which improved to 328 ± 65 after PP. Alveolar to arterial (A-a) O2 gradient improved from a median of 170.5 mm Hg interquartile range (IQR) (127.8, 309.7) in supine position to 49.1 mm Hg IQR (45.0, 56.6) after PP. This improvement in oxygenation took a median of 46 hours, IQR (24, 109). Thus, voluntary PP maneuver improved oxygenation and avoided endotracheal intubation in a select group of patients with hypoxemic respiratory failure. This maneuver may be relevant in the ongoing novel coronavirus disease pandemic by potentially reducing endotracheal intubation and the need for ventilator and therefore better utilization of critical care services. HOW TO CITE THIS ARTICLE: Rao SV, Udhayachandar R, Rao VB, Raju NA, Nesaraj JJJ, Kandasamy S, et al. Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients. Indian J Crit Care Med 2020;24(7):557-562.

Ocular oncology practice guidelines during COVID-19 pandemic-An expert consensus.

The outbreak of rapidly spreading COVID-19 pandemic in December 2019 has witnessed a major transformation in the health care system worldwide. This has led to the re-organization of the specialty services for the effective utilization of available resources and ensuring the safety of patients and healthcare workers. Suspension of oncology services will have major implications on cancer care due to delayed diagnosis and treatment leading to irreversible adverse consequences. Therefore various oncology organizations have called for a continuation of cancer care during this crisis with diligence. The COVID-19 pandemic has forced the clinicians to transform the components of care from screening to outpatient care and primary management. The purpose of this article is to establish guidelines and recommendations for ocular oncology in the management of ocular tumors set by a multidisciplinary team of experts including ocular, medical and radiation oncologists, and pathologists. As the pandemic is evolving fast, it will require constant updates and reformation of health strategies and guidelines for safe and quality health care.