The introduction of video-enabled directly observed therapy (video-DOT) for patients with drug-resistant TB disease in Eswatini amid the COVID-19 pandemic - a retrospective cohort study.

BACKGROUND: Video-enabled directly observed therapy (video-DOT) has been proposed as an additional option for treatment provision besides in-person DOT for patients with drug-resistant TB (DRTB) disease. However, evidence and implementation experience mainly originate from well-resourced contexts. This study describes the operationalization of video-DOT in a low-resourced setting in Eswatini facing a high burden of HIV and TB amid the emergence of the COVID-19 pandemic. METHODS: This is a retrospectively established cohort of patients receiving DRTB treatment during the implementation of video-DOT in Shiselweni from May 2020 to March 2022. We described intervention uptake (vs. in-person DOT) and assessed unfavorable DRTB treatment outcome (death, loss to care) using Kaplan-Meier statistics and multivariable Cox-regression models. Video-related statistics were described with frequencies and medians. We calculated the fraction of expected doses observed (FEDO) under video-DOT and assessed associations with missed video uploads using multivariable Poisson regression analysis. RESULTS: Of 71 DRTB patients eligible for video-DOT, the median age was 39 (IQR 30-54) years, 31.0% (n = 22) were women, 67.1% (n = 47/70) were HIV-positive, and 42.3% (n = 30) were already receiving DRTB treatment when video-DOT became available. About half of the patients (n = 37; 52.1%) chose video-DOT, mostly during the time when COVID-19 appeared in Eswatini. Video-DOT initiations were lower in new DRTB patients (aHR 0.24, 95% CI 0.12-0.48) and those aged ≥ 60 years (aHR 0.27, 95% CI 0.08-0.89). Overall, 20,634 videos were uploaded with a median number of 553 (IQR 309-748) videos per patient and a median FEDO of 92% (IQR 84-97%). Patients aged ≥ 60 years were less likely to miss video uploads (aIRR 0.07, 95% CI 0.01-0.51). The cumulative Kaplan-Meier estimate of an unfavorable treatment outcome among all patients was 0.08 (95% CI 0.03-0.19), with no differences detected by DOT approach and other baseline factors in multivariable analysis. CONCLUSIONS: Implementing video-DOT for monitoring of DRTB care provision amid the intersection of the HIV and COVID-19 pandemics seemed feasible. Digital health technologies provide additional options for patients to choose their preferred way to support treatment taking, thus possibly increasing patient-centered health care while sustaining favorable treatment outcomes.

Correction: The impact of computed radiography and teleradiology on patients' diagnosis and treatment in Mweso, the Democratic Republic of Congo.

[This corrects the article DOI: 10.1371/journal.pone.0227773.].

The impact of computed radiography and teleradiology on patients' diagnosis and treatment in Mweso, the Democratic Republic of Congo.

INTRODUCTION: High quality diagnostic imaging can provide increased diagnostic accuracy and help guide medical decision-making and management, however challenges for radiology in resource-limited settings are numerous. Diagnostic imaging and teleradiology have financial and logistical implications, so evidence of impact is crucial. We sought to test the hypothesis that the implementation of computed radiography with teleradiology consultation support will significantly change diagnoses and treatment plans in a resource limited setting. METHOD: Paired before-after study to determine the therapeutic impact of an add-on diagnostic test. 'Preliminary Plan' and 'Final Plan' forms allowed direct comparison of diagnosis and treatment plans at initial consultation and following radiography and teleradiology. Consecutive consenting patients were included until the sample size (600) was reached. Changes in both diagnosis and treatment plan were analysed in the whole cohort, with sub-analyses of children aged <5 years, and cases of chest radiography. RESULTS: Final analysis included 536 cases. Diagnosis changed following radiography and teleradiology in 62% of cases, and treatment plans changed in 61%. In chest radiography cases, 70% of diagnoses and 62% of treatment plans changed, while in children <5 years 66% of diagnoses and 58% of treatment plans changed. Reduced final treatment plans were most common for exploratory surgery (72% decrease), surgical orthopaedic intervention (62% decrease), and TB treatment (52% decrease), allowing more conservative medical or surgical management in 61 cases. Increased final treatment plans were highest in the orthopaedic and interventional surgery and referral categories. Of 42 cases requiring interventional surgery in the final plan, 26 (62%) were identified only after radiography and teleradiology. 16 additional cases were indicated for orthopaedic surgery, 10 cases required patient transfer, and TB treatment was indicated in 45 cases. A change in the original prescription plan occurred in 41% of 536 cases, with one or more prescriptions stopped in 28% of all cases. CONCLUSION: We found that computed radiography with teleradiology had significant clinical value in this resource-limited setting, with the potential to affect both patient outcomes and treatment costs through providing improved diagnostics and avoiding unnecessary treatments and medications.

What do emergency medicine and burns specialists from resource constrained settings expect from mHealth-based diagnostic support? A qualitative study examining the case of acute burn care.

BACKGROUND: Traumatic injury is a serious global health burden, particularly in low- and middle-income countries where medical care often lacks resources and expertise. In these contexts, diagnostic telemedicine could prove a cost effective tool, yet it remains largely underused here, and knowledge on its potential impact is limited. Particularly scarce is the view of the expert user physicians, and how they themselves relate to this technology. METHODS: This qualitative study investigated tele-experts' (n = 15) views on the potential for image based teleconsultation to be integrated in trauma and emergency care services. A semi-structured interview guide was used to gather data concerning an mHealth app for burns diagnostics in the acute care setting, in the Western Cape, South Africa. Questions examined challenges and opportunities in user acceptance and outcomes, in specific case management and in the wider healthcare system. Resulting data were subject to qualitative content analysis. RESULTS: Experts perceived remote diagnostic support through mHealth as linking directly to several key ideas in medicine, including barriers to care, medical culture and hierarchy, and medical ethics within a society. Ideas running through the data pertained to the widening and narrowing of inherent gaps in the healthcare system, and the formalisation of processes, practices and relationships, effected by the introduction of an app. Wide consensus was stated on positive outcomes such as increased education opportunities, improved professional relationships and a better ability to advise and diagnose, all further facilitated through greater ease of access. The belief was that these could achieve a narrowing of systemic divides within healthcare, although it was acknowledged that the possibility to induce the opposite effect also arose. Differing opinions were voiced relating to the involvement of allied health professionals and feedback. CONCLUSION: Experts see several aspects to an mHealth app for remote diagnostic support which could enhance provision of trauma and emergency care in a resource poor setting, relating to reduced delays, streamlined care and improved outcomes. Attention is also drawn, however, to specifics of the environment which would demand further and careful consideration for success - time pressure, intensity and the wide range of subspecialties to be considered.

Guidelines for the use of chest radiographs in community-acquired pneumonia in children and adolescents.

National guidance from the United Kingdom and the United States on community-acquired pneumonia in children states that chest radiographs are not recommended routinely in uncomplicated cases. The main reason in the ambulatory setting is that there is no evidence of a substantial impact on clinical outcomes. However clinical practice and adherence to guidance is multifactorial and includes the clinical context (developed vs. developing world), the confidence of the attending physician, the changing incidence of complications (according to the success of immunisation programs), the availability of alternative imaging (and its relationship to perceived risks of radiation) and the reliability of the interpretation of imaging. In practice, chest radiographs are performed frequently for suspected pneumonia in children. Time pressures facing clinicians at the front line, difficulties in distinguishing which children require admission, restricted bed numbers for admissions, imaging-resource limitations, perceptions regarding risk from procedures, novel imaging modalities and the probability of other causes for the child's presentation all need to be factored into a guideline. Other drivers that often weigh in, depending on the setting, include cost-effectiveness and the fear of litigation. Not all guidelines designed for the developed world can therefore be applied to the developing world, and practice guidelines require regular review in the context of new information. In addition, radiologists must improve radiographic diagnosis of pneumonia, reach consensus on the interpretive terminology that clarifies their confidence regarding the presence of pneumonia and act to replace one imaging technique with another whenever there is proof of improved accuracy or reliability.