Telehealth as a Means of Enabling Health Equity.

OBJECTIVE: The goal of this paper is to provide a consensus review on telehealth delivery prior to and during the COVID-19 pandemic to develop a set of recommendations for designing telehealth services and tools that contribute to system resilience and equitable health. METHODS: The IMIA-Telehealth Working Group (WG) members conducted a two-step approach to understand the role of telehealth in enabling global health equity. We first conducted a consensus review on the topic followed by a modified Delphi process to respond to four questions related to the role telehealth can play in developing a resilient and equitable health system. RESULTS: Fifteen WG members from eight countries participated in the Delphi process to share their views. The experts agreed that while telehealth services before and during COVID-19 pandemic have enhanced the delivery of and access to healthcare services, they were also concerned that global telehealth delivery has not been equal for everyone. The group came to a consensus that health system concepts including technology, financing, access to medical supplies and equipment, and governance capacity can all impact the delivery of telehealth services. CONCLUSION: Telehealth played a significant role in delivering healthcare services during the pandemic. However, telehealth delivery has also led to unintended consequences (UICs) including inequity issues and an increase in the digital divide. Telehealth practitioners, professionals and system designers therefore need to purposely design for equity as part of achieving broader health system goals.

Random mutagenesis of BoNT/E Hc nanobody to construct a secondary phage-display library.

AIMS: To construct secondary mutant phage-display library of recombinant single variable domain (VHH) against botulinum neurotoxin E by error-prone PCR. METHODS AND RESULTS: The gene coding for specific VHH derived from the camel immunized with binding domain of botulinum neurotoxin E (BoNT/E) was amplified by error-prone PCR. Several biopanning rounds were used to screen the phage-displaying BoNT/E Hc nanobodies. The final nanobody, SHMR4, with increased affinity recognized BoNT/E toxin with no cross-reactivity with other antigens especially with related BoNT toxins. CONCLUSIONS: The constructed nanobody could be a suitable candidate for VHH-based biosensor production to detect the Clostridium botulinum type E. SIGNIFICANCE AND IMPACT OF THE STUDY: Diagnosis and treatment of botulinum neurotoxins are important. Generation of high-affinity antibodies based on the construction of secondary libraries using affinity maturation step leads to the development of reagents for precise diagnosis and therapy.

Arterolane maleate plus piperaquine phosphate for treatment of uncomplicated Plasmodium falciparum malaria: a comparative, multicenter, randomized clinical trial.

BACKGROUND: Artemisinin-based combination therapy is the first-line treatment for uncomplicated falciparum malaria. This study assessed the antimalarial efficacy and safety of a combination of 150 mg of arterolane maleate and 750 mg of piperaquine phosphate (AM-PQP) in comparison to Coartem (artemether and lumefantrine) in patients with acute uncomplicated P. falciparum malaria. METHODS: In this open-label, randomized, multicentric, parallel group clinical trial, 240 patients were randomized to receive AM-PQP (160 patients) or Coartem (80 patients). Patients with P. falciparum monoinfection and initial parasite densities ranging from 1000 to 100 000 asexual parasites/µL of blood were followed for 28 days. Polymerase chain reaction-corrected adequate clinical and parasitologic response on day 28, parasite clearance time, and fever clearance time were evaluated. RESULTS: A total of 151 (94.4%) of 160 patients in the AM-PQP group completed the trial, while 77 (96.3%) of 80 patients in the Coartem group completed the trial. No treatment failure was noted in the AM-PQP group, while one patient receiving Coartem failed treatment on day 28. There was no difference in the median parasite clearance time (30 hours in both groups) or median fever clearance time (24 hours in both groups) after administration of the 2 study treatments. CONCLUSIONS: The available data support the evaluation of a drug combination in a larger population as a fixed-dose combination. Clinical Trials Registration. CTRI/2007/091/000031.

Low efficacy of chloroquine: time to switchover to artemisinin-based combination therapy for falciparum malaria in India.

Drug resistance in Plasmodium falciparum poses a major threat to malaria control globally; including India. Chloroquine is still the most widely used drug in the country because of its safety and cost effectiveness. Although chloroquine resistance was first reported in 1973 in North Eastern India, the extent of the problem was realized only after the more intensive 28-day drug efficacy studies were used to monitor drug resistance. In the present study, efficacy of chloroquine in treatment of uncomplicated falciparum malaria was investigated using standard World Health Organization (WHO) procedures in three distinct epidemiological settings. The prevalence of molecular markers of drug resistance, Pfcrt K76T, Pfmdr1 N86Y, was also studied. A total of 374 children and adults with uncomplicated P. falciparum malaria were enrolled at six sites in four states, treated with chloroquine and follow-up was done for 28 days. The cumulative incidence of success of chloroquine at Day 28 by the Kaplan Meier analysis in the state of Orissa (District Sundargarh, CHC Bisra and Kuarmunda) was 57 (95% CI 43-68) and 54 (95% CI 40-66); in the state of Jharkhand (District Ranchi, PHC Angara and District Simdega, PHC Jaldega) it was 72 (95% CI 59-81) and 65 (95% CI 50-76); in the state of Goa (District North-Goa, Panaji Town), it was 20 (95% CI 10-2) and in the state of Rajasthan (District Udaipur, PHC Rishabdev), it was 96 (95% CI 85-99). Treatment failure was related to Pfcrt mutations but not Pfmdr mutations. Early treatment failure was observed only in 15.8% out of total failures, probably due to the semi-immune nature of the population. This type of response may give false perception about efficacy of the failing drug to patients, clinicians and National Authorities. In a large country like India it is not feasible to conduct in vivo studies in all districts and lack of direct correlation between molecular markers, in vitro studies and treatment outcome makes it difficult to predict the areas requiring change of policy. In this scenario, it is a challenge for National Programmes to make evidence-based revisions in the drug policy. However, considering the global, especially Southeast Asian, scenario and interpretation of available in vivo data, trends of mutations, availability of effective drugs and support of international donors, India should consider changing the first line treatment, at least for all diagnosed P. falciparum cases.

Therapeutic efficacy of antimalarial drugs along the eastern Indo-Nepal border: a cross-border collaborative study.

This collaborative cross-border study was performed to determine the therapeutic efficacy of antimalarial drugs used by the National Programmes for falciparum malaria along the eastern Indo-Nepal border where there is unregulated population movement across the border. The study was conducted at sites in Jhapa District, Nepal and Darjeeling District, India. The study was conducted from August 2003 to February 2004, following the WHO 28 day treatment protocol. The efficacy of chloroquine was tested in India among 91 subjects and of sulfadoxine-pyrimethamine in Nepal among 107 subjects with laboratory-confirmed Plasmodium falciparum malaria. Of the 102 subjects who completed the study in Nepal, there were 21 (20.6%) treatment failures comprising 7 (6.9%) early treatment failures (ETF) and 14 (14.7%) late treatment failures (LTF) (5 late clinical failures [LCF] and 9 late parasitological failures [LPF]). Of the 89 subjects who completed the study in India, there were 46 (51.7%) treatment failures comprising 7 (7.9%) ETFs and 39 (43.8%) LTFs (13 LCFs and 26 LPFs). Based on WHO guidelines both countries need to review their drug policy urgently and make appropriate changes, taking into account aspects of cross-border collaboration in the control of drug-resistant malaria.

Medical arthroscopy--emerging era of rheumatological intervention.

OBJECTIVE: To evaluate the safety and diagnostic value of arthroscopy performed by a rheumatologist. METHODS: Decisions for performing arthroscopy were taken when detailed clinical history-and relevant rheumatological investigations failed to arrive at a definite diagnosis. Arthroscopies were performed under local anesthesia as a daycare procedure. Synovial biopsies taken during procedures were subjected to histopathological examination (HPE). RESULTS: Of the 50 patients enrolled, 39 were males while 11 were females with mean age of 35.5 years. In lower limb oligoarthritis group of patients, three had macroscopic picture of crystal arthropathy, rest of the 29 patients revealed gross picture indicative of non-specific synovitis. While in polyarticular group of eight patients, three had macroscopic picture suggestive of crystal arthropathy (probably polyarticlar gout) while five were indicative of rheumatoid arthritis. In monoarticular disease pattern (n= 10) macroscopic picture findings were as follows- crystal arthropathy-two, tubercular-three, synovial chondromatosis-one and non-specific synovitis-two. HPE of synovium did not correlate in many cases. CONCLUSION: Arthroscopy using a 4 mm scope under local anesthesia in the hands of rheumatologists is a safe daycare procedure. In few cases arthroscopy helped in arriving at a final diagnosis but many patients remained undiagnosed. Both the rheumatologists and the pathologists require further experience in this field.

Conscious sedation as an anaesthetic technique in patients undergoing nonthoracotomy placement of automatic implantable cardioverter defibrillator: an initial experience.

Six adult patients with life threatening recurrent ventricular arrhythmias who underwent non- thoracotomy placement of automatic implantable cardioverter defibrillator under conscious sedation are reported. Our clinical experience, patient satisfaction, recovery profile, complications and cardiologist perception about the technique of conscious sedation is presented and discussed.

Exercise-induced ventricular arrhythmias in congestive heart failure and role of ACE inhibitors.

Ventricular arrhythmias are considered to be related to left ventricular (LV) dysfunction. ACE inhibitors though improve LV function their beneficial role on exercise-induced ventricular arrhythmias is not established. To study the effects of ACE inhibitors on exercise capacity vis-a-vis their role on exercise-induced ventricular arrhythmias, 25 patients of congestive heart failure (CHF) of various etiologies in NYHA Class II and III were subjected to a prospective randomised controlled trial. The control group comprising of 12 patients received conventional treatment (digitalis and diuretics) and the test group was given enalapril/captopril in addition as tolerated. They were followed up for 3 months. Exercise testing on treadmill and monitoring of clinical and biochemical parameters were done at the beginning and end of study in all cases. Ventricular arrhythmias observed during exercise and post-exercise for 10 minutes was analysed using Lown's grading for frequency and severity of ventricular arrhythmia. The mean exercise duration showed significant improvement on ACE inhibitor as compared to the control group (p < 0.05) however there was no significant change in the grades of arrhythmia. Serum electrolytes and other bio-chemical parameter were within normal range. It is concluded that effect of ACE inhibitor on improving functional capacity in CHF is independent of it's any effect on exercise-induced ventricular arrhythmias.

QUANTIFICATION OF EXERCISE TOLERANCE IN CONGESTIVE HEART FAILURE AND ROLE OF ACE INHIBITORS.

A prospective randomised controlled trial with captopril/enalapril was carried out on 25 patients with congestive heart failure (CHF) of various aetiologies in NYHA Class II & III to study the effect of Ace inhibitors on exercise tolerance. The control group (Gp-A) comprising of 12 patients received conventional treatment (digitalis and diuretics) and the test group (Gp-B) with 13 patients were in addition given captopril/enalapril as tolerated. They were followed up for a mean period of 101.6+50.6 days (approx 3 months). Ten patients from each group could complete the study. The exercise testing was done on treadmill using a suitable protocol and end-points, at the beginning and end of study. None of the clinical and noninvasive parameters showed significant difference, however the mean exercise duration in Group A improved from 7.84+3.34 to 9.2 +3.16 minute (P <0.05) and in Group B increased from 7.91+4.6 to 10. 92+4.66 minute (p < 0.001). On comparing the benefits of the two groups the difference was statistically significant (P < 0.05). It is concluded that Ace inhibitor improves the exercise tolerance in CHF and the benefit is evident despite any improvement in clinical and noninvasive indices of left ventricular function.

Deltamethrin impregnated bednets against Anopheles minimus transmitted malaria in Assam, India.

Of the 20 Anopheles species caught in villages in Sonapur, Assam, only An. minimus was incriminated as a malaria vector by finding sporozoites in the salivary glands. It was found to be endophagic and endophilic in Assam and because its biting peaked after midnight it was a suitable target for insecticide impregnated bednets. After the withdrawal of DDT spraying and collecting a year's baseline data, deltamethrin impregnated nets were distributed in 3 villages, untreated nets were distributed in 6 villages and 3 were held as untreated controls. The population of each of these groups of villages was about 1700. The nets were well received by the local tribal population. Human landing catches with baits unprotected or under partially lifted nets showed that the nets provided a high degree of personal protection against all the local species of human biting mosquito. In addition, there was evidence for suppression of the An. minimus population in a village with treated nets. Malaria was monitored by weekly active surveillance in all the villages. In the untreated control villages the slide positivity rate and monthly parasite index rose significantly during the trial. In the villages with untreated nets, these parameters showed no significant change, but in the villages with treated nets they declined significantly. On the basis of these results, the widespread distribution of impregnated nets was recommended to the state health authorities.

Long-term Outcome in a Series of Jejunoileal Bypass Patients.

In 65 jejunolleal (JI) bypasses done from 1973-1979, there were nine Scott and 56 Payne (with Y-shaped anastomosis). Preoperative excess body weight (EBW) translated to the 1983 Metropolitan Tables was 112 +/- 30%. Eight patients are lost to follow-up. We reversed seven patients for renal stones (12%) accompanied by a vertical banded gastroplasty (VBG) and one because she demanded a VBG. Five patients were reversed by surgeons elsewhere for minor problems (three with an accompanying gastric reduction operation), and all five regained and requested a JI bypass again, which we now refused to undertake. This leaves 44 JI bypass patients being followed: loss of EBW is 71 +/- 22% at 12-18 years. The eight reversed by us accompanied by a VBG regained some weight (loss of EBW from initial weight is 56 +/- 18%). Liver biopsies were done for 5 years in 31 patients, and showed improvement by 36 months. Patients took predigested collagen capsules plus high protein and multivitamins. Injections of B12 are indicated in 18 patients, given every 3 months. Liver dysfunction has not occurred in the long-term. Low serum carotene levels persist. Migratory arthraigias were controlled by oral metronidazole and did not occur after the fifth year. Oxalate crystals remain on urinalysis. Potassium and magnesium replacement is not required now, and a mean of 2.5 stools per day is not a problem, with infrequent diarrhea after greasy foods. Metronidazole is continued in 33 patients to prevent foul flatus. One patient developed a brain tumor, one myxedema, and one primary hyperparathyroidism, thought to be complications of the bypass until diagnosed. Most patients appear to be doing well.

Foreign bodies in the rectum.

Although infrequent, rectal foreign bodies present a challenge in management. The authors report on their experience with 29 patients who had rectal foreign bodies. Emergency-department procedures included rectal examination, proctoscopy and abdominal radiography. Soft or low-lying objects having an edge could be grasped and removed safely in the emergency department, but grasping hard objects was potentially traumatic and occasionally resulted in upward migration toward the sigmoid. Operating-room procedures included anal dilatation under general anesthesia, transrectal manipulation, bimanual palpation if necessary and withdrawal of the foreign body. In two cases, rectal mucosa was trapped--in an open deodorant bottle in one patient and in a curtain rod in the second patient; operative release of the mucosa enabled safe removal. Two patients presented with peritonitis; both had "broomstick" injuries and required proximal colostomy. Five patients had perianal sepsis due to inadvertently ingested pieces of wood (three) and chicken bones (two). The mean hospital stay was 3 days (range from 6 hours to 6 days). There were no deaths. Because of the potential complications, rectal foreign bodies should be regarded seriously and treated expeditiously.

Morbid obesity: selection of patients for surgery.

Massive obesity is associated with serious co-morbidities. After failure of extensive conservative measures, surgical procedures have developed as the only successful method for sustained weight loss. Criteria for operation are: presence of serious diseases associated with morbid obesity; greater than 45 kg above ideal weight or body mass index greater than 40 kg/m2 for usually greater than 5 years; failure of sustained weight loss on extensive conservative regimens; commitment to lifelong follow-up; and acceptable operative risk. Angina pectoris itself is not a contraindication to these operations. Patients who do not quite meet the weight criteria may still be candidates for an obesity operation in certain instances, e.g., debilitating musculoskeletal pains in weight-bearing joints, diabetes, significant hypertension, reflux esophagitis, urinary stress incontinence. Although current operations result in lasting weight loss of greater than 50% of excess weight in the majority of patients, the surgical candidate must understand and accept the principles of the procedures, the potential for serious complications, the dietary necessities, and occasional failures.

Sleep-related Disorders in the Obese.

Obesity is a well-known cause of upper airway narrowing, respiratory failure and resulting hypoxemia and hypercapnia, and cardiac arrhythmias during sleep. Obese patients are prone to snore loudly and to develop obstructive sleep apnea syndrome and also obesity-hypoventilation syndrome. Repeated nocturnal upper airway obstruction may cause respiratory failure and cor pulmonale and frequent awakenings, and result in nocturnal choking, with daytime drowsiness, somnolence and irritability. The purpose of this article is to review the evidence for these accepted facts and to consider a variety of new information that relates to the pathogenesis, symptomatology and treatment of sleep disorders caused by obesity.

Effect of Weight Loss in the Morbidly Obese Patient with Severe Disability.

An impairment can result in disability which can result in handicap. In Canada, disabilities have been based on 17 activities of daily living (ADL), nine of which may be due to massive obesity. Severe disability (SD) is inability to perform three or more of these ADL. During 1985, all patients with SD who underwent weight loss surgery were surveyed. Of 120 morbidly obese patients, 44 fulfilled the SD criteria. Effect of weight loss was observed over 5 years in 42 SD patients (initial mean body mass index 47.8 final 27.8), two being lost to follow-up. Disability became moderate (unable to do one or two of the ADL) in three, mild (difficult but able to perform) in 17, and disappeared in 22 patients. Two who regained lost weight redeveloped SD.

Radiological Features after Vertical Banded Gastroplasty.

More than 1300 vertical banded gastroplasty operations have been performed at our hospital since November 1982. We describe the radiologic findings based on 159 of these patients, who were referred for radiologic contrast studies. Patients were referred because of abdominal pain, excess vomiting, excess weight loss, inadequate weight loss or regain of weight. The pre-contrast plain film was an important indicator of staple-line abnormalities. The radiographic findings could be divided into: abnormalities of the partition, abnormalities of the banded outlet, and ulcers and extragastric leaks.

An Apparatus for Visualizing and Videotaping Obesity Operations.

A video camera has difficulty in gaining access for obesity operations. A 7-ft aluminum arm (boom) has been mounted on a sturdy tripod. A camera at one end of the boom enables easy direct videotaping, without interfering with the operating table

Microorganisms in the Stomach During Vertical Banded Gastroplasty.

Vertical banded gastroplasty involves the cutting of a stapled window against an Ewald tube Passed perorally, and creation of a vertical staple-line partition. The channel at the window is banded by a polypropylene mesh collar. A study of the gastric rings removed at this operation found that the bacterial colonization rate was 46.8%, so that the potential for infection of the collar exists. The actual significance of this finding is unknown.