Feasibility of implementing Integrated Management of Childhood Illnesses through Mobile Technology

Background

The Integrated Management of Childhood Illnesses (IMCI) strategy was launched by WHO and partners in 1995 to reduce child mortality by enhancing frontline health workers' (FHWs) ability to diagnose and manage childhood illnesses, and strengthen overall health systems. However, although IMCI is associated with decreased child mortality, numerous studies have shown its impact has been limited due to persistent barriers to implementation.

Methods

We developed a digitized version of IMCI (eIMCI) using Android technology to overcome implementation problems, including poor protocol compliance, lengthy trainings, paper-based data collection, and gaps in the referral system. The feasibility and efficacy of eIMCI was assessed through a mixed-methods pilot study encompassing baseline and end-line surveys, interviews, and Focus Group Discussions, in a low-resource rural district of Punjab, Pakistan. During the 8 weeks of deployment, a total of 1,978 children were enrolled in the eIMCI application by 10 participating FHWs, and 47 electronic referrals were generated.

Results

Preliminary outcomes showed reduced disease occurrence (for example, diarrhea decreased from 48% at baseline to 29% at endline), increased adherence to IMCI protocol, and strengthened health system linkages (facility referrals increased from 5% at baseline to 45% at endline). FHWs reported enhanced performance, as well as an improved community response to their services.

Discussion

Indicating the feasibility and efficacy of eIMCI deployment in a low-resource setting, evidence from the pilot demonstrates the benefit of digitizing the IMCI protocol. eIMCI is a digital health solution with the potential to significantly reduce child mortality and improve service delivery and performance of FHWs.

Key messages

eIMCI is a feasible solution for the implementation of IMCI strategy in developing countries and demonstrates increased compliance and enhanced performance by the frontline health workers. Implementation of eIMCI can result in a significant reduction in child morbidity and mortality via timely referrals of patients and reduced disease occurrence.

Real-time immunization trends in under-2 children in Pakistan: insights from big data analysis

Background

Despite the provision of free-of-cost vaccines in Pakistan, fully immunized child (FIC) coverage in Sindh province remains low at 49%. In 2012, we developed and piloted the Zindagi Mehfooz (Safe Life; ZM) Digital Immunization Registry, an Android-based platform that enables vaccinators to enroll and track child level immunization data of children in the catchment population. In 2017, ZM was scaled-up across Sindh province and is currently being used by 2,284 vaccinators across 1,526 facilities serving >48 million (m) population.

Methods

All children under-2 years of age visiting EPI centers are enrolled. At enrollment, caregiver and child bio-data and child immunization history are recorded, and the child is provided with a unique Quick Response (QR) code for identification. For follow-up immunization visits, 3 SMS reminders are sent to caregivers, and upon immunization, child history is retrieved by scanning the QR code and vaccination record updated. ZM allows real-time access to data and generation of monitoring reports. Data from ZM was used to calculate coverage rates, timeliness, and trends for immunization coverage in Sindh.

Results

From Oct'17 to Dec'19, more than 2.4m children and 0.8m women were enrolled in the Registry, while >17m immunizations were administered. The FIC coverage in 12-23 months old children has increased from 49% (at baseline) to 57% for children enrolled in ZM. Additionally, pentavalent-3 coverage increased from 59% to 68%.

Discussion

ZM demonstrates the potential of DIRs to improve immunization outcomes within low-resource settings by enabling better child tracking and a higher retention rate. Additionally, the big dataset provides the opportunity to identify real-time trends and provides actionable data for evidence-based decision making.

Key messages

ZM Immunization Registry has strengthened the current EPI program through increased FIC coverage and timeliness through better tracking of children and increased retention. Big Data from ZM can be used to analyze immunization trends of global relevance, and guide strategic policy decisions for improving immunization coverage and equity, based on actionable data insights.

Guideline-based flexible cystoscopy safely improves capacity, avoiding unnecessary intervention with cost savings

Introduction:

Flexible cystoscopy (FC) is a common and useful diagnostic tool. Because of its broader applications, availability and simplicity, there has been criticism of its overuse with accompanying financial burden to the health system and unnecessary invasive intervention to the patient. Therefore, we reviewed our local practice against current guidelines to evaluate compliance, enhance patient safety and capacity utilisation.

Patients and methodology:

Data were collected retrospectively on all patients having FC over two months. The indications and findings of FC were gathered from the hospital electronic patient record system.

Results:

A total of 413 FCs were carried out over the study period. The most common indications were cancer surveillance 116 (28%) and visible haematuria 76 (18.4%). A total of 152 (37%) FCs were performed for non-recommended indications. The most common conditions that deviated from guidelines were lower urinary tract symptoms (LUTS) (72, 17.4%), urinary tract infection (UTI) (41, 9.9%) and asymptomatic non-visible haematuria (35, 8.5%). In all non-visible haematuria cases, 65 (90%) of LUTS and 39 (95%) of UTI patients, FC was non-contributory. Adherence to guidelines would have yielded 37% of FC slots. Based on current UK National Tariffs, cost savings would have been £352,032 annually in this trust.

Conclusions:

FC is a frequent investigation within urology departments for which referral guidelines exist. Protocol-driven practice enables appropriate use, ensures patient safety and leads to efficient utilisation of capacity with substantial cost savings.

Level of evidence:

Not applicable for this multicentre audit.

Effectiveness of Pressurized Normal Saline Irrigation of Subcutaneous Tissue Following Appendicectomy in Decreasing Wound Infection: A Quasi Experimental Study

Acute appendicitis is the commonest cause of acute abdomen necessitating surgical intervention and wound infection is the most frequently encountered complication following appendicectomy. To assess the effectiveness of pressurized normal saline irrigation of subcutaneous tissue following appendicectomy in decreasing wound infection this quasi experimental study was done in Surgery Unit III, Mymensingh Medical College Hospital from January 2018 to December 2018. In this study total 200 patients of acute appendicitis were enrolled according to inclusion and exclusion criteria and assigned equally into two groups by non-equivalent control group design. In control group all the standard protocol of wound closure following appendicectomy was followed and in experimental group along with the standard protocol the subcutaneous tissue was irrigated by pressure with normal saline and all the data were recorded in individual case record form. Among the sample most of the patients were between 10-19 years of ages and the male female ratio was 1.38:1. In control group 30% patients developed wound infection while 12% patients developed wound infection in experimental group with a P value of 0.027. Mean hospital stay of experimental group was less than the control group (P value less than 0.05). Overall postoperative outcome in context of wound infection and hospital stay is better following pressurized normal saline irrigation of subcutaneous tissue during closure.

Efficacy of Intra-peritoneal Tramadol Instillation for Postoperative Pain Management after Laparoscopic Cholecystectomy

Gall stone disease is one of the most common conditions encountered in general surgical practices in adult population. The gold standard treatment for symptomatic gall stone disease is laparoscopic cholecystectomy. It results in less post-operative pain as compared to open cholecystectomy but post-operative pain may be mild, moderate or even severe in some patients. This Randomized control trail was conducted to In-patient department of Surgery, Mymensingh Medical College & Hospital (MMCH), Mymensingh, Bangladesh from April 2018 to September 2018. It was undertaken to evaluate the analgesic effect of intra-peritoneal tramadol instillation in patients undergoing laparoscopic cholecystectomy. Total 70 patients with symptomatic gallstone disease undergoing laparoscopic cholecystectomy were randomized equally in two groups. Then patients were selected in according to the inclusion and exclusion criteria. In first group (Group A), patients were received intra-peritoneal tramadol 100mg (diluted in 20.0ml distilled water). Sprayed 10.0ml diluted tramadol into the sub diaphragmatic area, 5.0ml into the area of gall bladder bed and 5.0ml into the space between the liver and kidney under direct vision just before removal of trocars. In second group (Group B) the conventional operative procedure was followed. Postoperatively, patient was extubated and shifted to recovery room. Data recorded and analyzed, such as post-operative pain score at 1, 4, 8, and 24 hour; cumulative 1, 8 and 24 hour analgesic consumption. In addition that postoperative hospital period monitoring of heart rate, blood pressure, respiratory rate, temperature at 0, 4, 8, 24 hours was also analyzed. Intensity of pain was assessed by Visual Analogue Scale (VAS) scoring system. Patients showed a VAS ≥3 or patients who requested for analgesia was administrated a supplemental dose of analgesic. In the present study the mean pain scores in Group A were found to be low at1hourpost-operative was 0.60±0.56 and there was a gradual increase in score in respect of time interval with peak of 2.07±0.91 at 24 hours. Whereas, in Group B the mean pain scores immediate post-operative period were at its peak was, 2.50±0.82 which decreased to 1.30±0.84 at 1 hour and further there was rise at 4 hours (2.10±0.71) and 24 hours (2.33±0.0.71). But at any point of time the mean VAS remained significantly low (p<0.050) in patients with Group A compared to Group B except at 1st 24 hours (p=0.210). Intra-peritoneal instillation of tramadol for postoperative pain control in laparoscopic cholecystectomy has beneficial effect in terms of postoperative pain relief following laparoscopic cholecystectomy.

[Hookworm-related folliculitis in a woman performing skin bleaching in Benin]

Hookworm-related cutaneous larva migrans is caused by the subcutaneous migration of hookworm larvae. The characteristic sign is a serpiginous cutaneous track. Folliculitis is an uncommon clinical manifestation. We report a case of hookworm-related folliculitis in a woman performing skin bleaching. A 33-year-old woman presented with a widespread cutaneous eruption made of erythematous and itchy follicular papulo-nodules, with erythematous serpiginous tracks, about 5-10cm long and numerous streaks of scratching, located on the limbs, buttocks and trunk. The cutaneous lesions occurred two days after contact with the floor of a warehouse contamined by faeces of cats. The lesions have been evolving for a week and have been treated with antibiotics without success. Clinical examination found cutaneous atrophy, purple stretch marks and hyperpigmentation of dorsal parts of fingers joints. The patient reported having been using bleaching cosmetics containing topical steroids and hydroquinone for twelve years. She was cured within 4 weeks with oral albendazole 400mg per day during 7 consecutive days.

Post-traumatic growth in (ex-) military personnel: review and qualitative synthesis

BACKGROUND

Military service can be a traumatic experience and cause mental health problems in a minority of personnel, such as post-traumatic stress disorder (PTSD), which is linked to negative long-term outcomes. As a result, PTSD has received significant research attention. However, post-traumatic growth (PTG) is a newer construct, with comparatively little known about its presentation and development.

AIMS

To qualitatively examine the experience of (PTG) in military and ex-military personnel.

METHODS

A qualitative systematic search of electronic databases was conducted, with studies assessed for methodological quality and data analysed using thematic analysis. Nine qualitative studies, carried out between 2011 and 2016, met the inclusion criteria with 195 participants in total, including both military and ex-military personnel.

RESULTS

Six themes were identified: appreciation for life, re-evaluating sense of purpose, improvement of personal human traits, bonding and connecting with others, integrating into society, and being proud of heritage and feeling valuable to society.

CONCLUSIONS

The results of this review illustrate that military personnel may experience PTG due to deployment-related trauma exposure, and the presentation of PTG in this population is not dissimilar to that of civilians. This study highlights the need for additional research to quantify the long-term psychological impact of PTG and whether a focus on PTG may be helpful in psychological treatment for (ex-) military personnel.

Connectivity of diagnostic technologies: improving surveillance and accelerating tuberculosis elimination

In regard to tuberculosis (TB) and other major global epidemics, the use of new diagnostic tests is increasing dramatically, including in resource-limited countries. Although there has never been as much digital information generated, this data source has not been exploited to its full potential. In this opinion paper, we discuss lessons learned from the global scale-up of these laboratory devices and the pathway to tapping the potential of laboratory-generated information in the field of TB by using connectivity. Responding to the demand for connectivity, innovative third-party players have proposed solutions that have been widely adopted by field users of the Xpert(®) MTB/RIF assay. The experience associated with the utilisation of these systems, which facilitate the monitoring of wide laboratory networks, stressed the need for a more global and comprehensive approach to diagnostic connectivity. In addition to facilitating the reporting of test results, the mobility of digital information allows the sharing of information generated in programme settings. When they become easily accessible, these data can be used to improve patient care, disease surveillance and drug discovery. They should therefore be considered as a public health good. We list several examples of concrete initiatives that should allow data sources to be combined to improve the understanding of the epidemic, support the operational response and, finally, accelerate TB elimination. With the many opportunities that the pooling of data associated with the TB epidemic can provide, pooling of this information at an international level has become an absolute priority.

Biochemical and molecular characteristics of Malaysian patients with lysinuric protein intolerance

Lysinuric protein intolerance (LPI) is an inborn error of dibasic amino acid transport due to a defect in the dibasic amino acid transporter in the renal and intestine and has a heterogenous presentation. Three Malaysian patients with LPI were studied and their biochemical and molecular findings compared. There were differences and similarities in the biochemical and molecular findings. Molecular analysis of SLC7A7 gene revealed a novel mutation c.235G>A; p.(Gly79Arg) in exon three in Patient 1 and a mutation c.1417C>T; p.(Arg473*) in exon 10 in patient 2 and 3. The degree of concentration of dibasic amino acids may determine the type of disease of the cell membrane transport, however, a positive molecular confirmation will secure the diagnosis.

Serum Fragments of Tau for the Differential Diagnosis of Alzheimer's Disease

Differential diagnosis of AD is still a challenge due to overlapping features with other types of dementia. Biomarkers for the differential diagnosis of AD can improve the diagnostic value of the disease and ensure an appropriate treatment of patients. The aim of this study was to evaluate the potential of two neo-epitope fragments of Tau as serum biomarkers for differential diagnosis of AD. The neo-epitope fragments of Tau were assessed in a cross-sectional cohort of subjects with AD, MCI, other dementias or subjects with non-dementia related memory complaints. The two Tau neo-epitope fragments were an ADAM10-generated fragment (Tau-A) and a caspase-3-generated fragment (Tau-C). The serum levels of the fragments were measured by two competitive ELISAs detecting Tau-A and Tau-C, respectively. Tau-A and Tau-C were able to separate subjects with AD and MCI from those with other dementias (p<0.0042 and p<0.05), and Tau-A could also discriminate between AD and MCI patients and subjects with non-dementia related memory complaints (p<0.05). Tau-A showed a significantly greater discrimination between AD and MCI subjects and patients with other dementias when compared to CSF biomarkers t-Tau and p-Tau. The ability of Tau-A to differentiate between AD and MCI from other dementias was comparable with CSF Aβ1-42, t-Tau/Aβ1-42 and p-Tau/Aβ1-42. The separation between the diagnostic groups was significantly improved when the CSF biomarkers as well as age and BMI were used in combination with Tau-A (AUC=0.87, 95% CI: 0.75-0.94) (p<0.0001). In conclusion, this study shows that a neoepitope fragment of Tau detected in serum can provide guidance on the differential diagnosis of AD.

Urban and rural comparison of vitamin D status in Pakistani pregnant women and neonates

We undertook a cross-sectional study in rural Jehlum and urban Karachi to evaluate the prevalence of vitamin D deficiency in Pakistani pregnant women and neonates and to assess any association of serum 25(OH) vitamin D [25(OH)D] concentration with vitamin D binding protein (Gc) genotypes. Altogether, 390 women and 266 neonates were recruited from urban and rural sites, respectively. Serum 25(OH)D was measured by an immunoassay, while Gc genotypes were identified using polymerase chain reaction followed by restriction fragment length polymorphism or PCR-RFLP. One-way analysis of variance or ANOVA and linear regression were used for statistical analysis. In urban Karachi, 99.5% of women and 97.3% of neonates were vitamin D deficient (< 50 nmol/L), while 89% of women and 82% of neonates were deficient in rural Jehlum. Gc genotypes were not associated with serum 25(OH)D concentrations in both women and their neonates. We conclude that vitamin D deficiency is highly prevalent in Pakistani women and their neonates, and Gc genotypes are not associated with serum 25(OH)D concentrations.

Comparative Study of Clinical and Sonographic Estimation of Foetal Weight at Term

A cross sectional comparative study was conducted at Dhaka National Medical College, Dhaka from January to June 2012, to observe the accuracy of clinical and ultrasonographic estimation of foetal weight at term in our environment. Seventy five pregnant women who fulfilled the inclusion criteria had their foetal weight estimated independently using clinical and ultrasonographic methods. Accuracy was determined by percentage error, absolute percentage error and proportion of estimates within 10% of actual birth weight (birth weight fetus of +10%). Statistical analysis was done using the paired t-test, the Wilcoxon signed-rank test, and the chi-square test. The study sample had an actual average birth weight of 2989.60 ± 408.76 (range 2310-4000 gm). Overall, the clinical method overestimated birth-weight, while ultrasound underestimated it. The mean absolute percentage error of the clinical method was more than that of the sonographic method, and the number of estimates within 10% of actual birth weight for the clinical method (41.3%) was less than for the sonographic method (57.3%); the difference was not statistically significant. In the low birth-weight (<2,500 gm) group, the mean absolute percentage error of sonographic estimates were significantly smaller. Significantly more sonographic estimates (75%) were within 10% of actual birth-weight than those of the clinical method (0%). No statistically significant difference was observed in all the measures of accuracy for the normal birth-weight range of 2,500-<4,000 gm and in the macrosomic group (≥ 4,000 gm). Clinical estimation of birth-weight is as accurate as routine ultrasonographic estimation, except in low-birth-weight babies.