Musculoskeletal Soft-Tissue Sarcoma: Quality Assessment of Initial MRI Reports Shows Frequent Deviation from ESSR Guidelines

Soft-tissue sarcomas (STS) are a rare subtype of soft-tissue mass and are frequently misinterpreted as benign lesions. Magnetic resonance imaging (MRI) is the primary recommended type of diagnostics. To assess the quality of primary radiology reports, we investigated whether recommended MRI report elements were included in compliance with European Society of Musculoskeletal Radiology (ESSR) guidelines. A total of 1107 patients were evaluated retrospectively, and 126 radiological reports on patients with malignant STS were assessed for ESSR quality criteria. One or more required sequences or planes were missing in 67% of the reports. In all 126 cases, the report recognized the mass as anomalous (100%). Sixty-eight percent of the reports mentioned signs of malignancy. The majority of reports (n = 109, 87%) articulated a suspected diagnosis, 32 of which showed a mismatch with the final diagnosis (25%). Thirty-two percent of the reports had a misinterpretation of the masses as benign. Benign misinterpretations were more common in masses smaller than 5 cm (65% vs. 27%). Thirty percent of the reports suggested tissue biopsy and 6% recommended referral to a sarcoma center. MRI reports showed frequent deviations from ESSR guidelines, and protocol guidelines were not routinely met. Deviations from standard protocol and reporting guidelines could put patients at risk for inadequate therapy.

The role of EEG in patients with suspected epilepsy

Despite the advances in imaging, EEG remains a critical test for the diagnosis of epilepsy. Not only can it confirm the diagnosis, but it can also clarify the type of epilepsy. There are many different types of EEG recordings depending on duration, the presence of video, and inpatient or outpatient setting, each with its pros and cons. Interictal epileptiform abnormalities are very specific to epilepsy, but they can be over-interpreted by inexperienced readers. In addition to diagnosis of epilepsy, EEG also has a role in the decision to discontinue treatment in seizure-free patients, and in assessing critically ill patients for possible status epilepticus and encephalopathies. EEG reports should be relatively standardized and clear to the clinician who requested the EEG.

Recommendations for Reporting Machine Learning Analyses in Clinical Research

Use of machine learning (ML) in clinical research is growing steadily given the increasing availability of complex clinical data sets. ML presents important advantages in terms of predictive performance and identifying undiscovered subpopulations of patients with specific physiology and prognoses. Despite this popularity, many clinicians and researchers are not yet familiar with evaluating and interpreting ML analyses. Consequently, readers and peer-reviewers alike may either overestimate or underestimate the validity and credibility of an ML-based model. Conversely, ML experts without clinical experience may present details of the analysis that are too granular for a clinical readership to assess. Overwhelming evidence has shown poor reproducibility and reporting of ML models in clinical research suggesting the need for ML analyses to be presented in a clear, concise, and comprehensible manner to facilitate understanding and critical evaluation. We present a recommendation for transparent and structured reporting of ML analysis results specifically directed at clinical researchers. Furthermore, we provide a list of key reporting elements with examples that can be used as a template when preparing and submitting ML-based manuscripts for the same audience.

Severe adenomyosis with unexpectedly high CA-125: report of a rare case

A 46-year-old woman presented to the emergency department with abdominal pain and abnormal uterine bleeding over the last year. She had a history of failed cyclic progesterone with tranexamic acid over the last 3 months to control her bleeding attacks. She had a tender pelvi-abdominal mass of 28 weeks’ gestation size. Therapeutic curettage was performed, followed by correction of her iron deficiency anemia with intravenous iron.

The trans-abdominal ultrasound of the pelvi-abdominal mass showed asymmetrical myometrial thickening, predominantly its anterior wall, with myometrial hyperechoic regions surrounded by hypoechoic areas suggestive of adenomyosis uterus for magnetic resonance imaging (MRI) evaluation.

The MRI evaluation confirmed the diagnosis of adenomyosis uterus and showed diffuse asymmetrical uterine adenomyosis, predominantly its anterior myometrial wall, with an ill-defined endo-myometrial junction. Total abdominal hysterectomy with bilateral salpingectomy and bilateral ovarian conservation was performed after departmental approval and the patient’s consent.

The routine pre-operative investigations were completely normal except the cancer antigen (CA-125) which was unexpectedly high (1658 and 1046 IU/ml repeated twice two days apart). The histological examination of the surgical removed uterus confirmed the diagnosis of adenomyosis uterus and the pre-operative high CA-125 decreased to 22 IU/ml (normal range 0-35 IU/ml) one week after surgery.

Automating the Generation of Antimicrobial Resistance Surveillance Reports: Proof-of-Concept Study Involving Seven Hospitals in Seven Countries

BACKGROUND

Reporting cumulative antimicrobial susceptibility testing data on a regular basis is crucial to inform antimicrobial resistance (AMR) action plans at local, national, and global levels. However, analyzing data and generating a report are time consuming and often require trained personnel.

OBJECTIVE

This study aimed to develop and test an application that can support a local hospital to analyze routinely collected electronic data independently and generate AMR surveillance reports rapidly.

METHODS

An offline application to generate standardized AMR surveillance reports from routinely available microbiology and hospital data files was written in the R programming language (R Project for Statistical Computing). The application can be run by double clicking on the application file without any further user input. The data analysis procedure and report content were developed based on the recommendations of the World Health Organization Global Antimicrobial Resistance Surveillance System (WHO GLASS). The application was tested on Microsoft Windows 10 and 7 using open access example data sets. We then independently tested the application in seven hospitals in Cambodia, Lao People's Democratic Republic, Myanmar, Nepal, Thailand, the United Kingdom, and Vietnam.

RESULTS

We developed the AutoMated tool for Antimicrobial resistance Surveillance System (AMASS), which can support clinical microbiology laboratories to analyze their microbiology and hospital data files (in CSV or Excel format) onsite and promptly generate AMR surveillance reports (in PDF and CSV formats). The data files could be those exported from WHONET or other laboratory information systems. The automatically generated reports contain only summary data without patient identifiers. The AMASS application is downloadable from https://www.amass.website/. The participating hospitals tested the application and deposited their AMR surveillance reports in an open access data repository.

CONCLUSIONS

The AMASS is a useful tool to support the generation and sharing of AMR surveillance reports.

The effect of clinical information on radiology reporting: A systematic review

INTRODUCTION

The aim of this study was to investigate the effects of clinical information on the accuracy, timeliness, reporting confidence and clinical relevance of the radiology report.

METHODS

A systematic review of studies that investigated a link between primary communication of clinical information to the radiologist and the resultant report was conducted. Relevant studies were identified by a comprehensive search of electronic databases (PubMed, Scopus and EMBASE). Studies were screened using pre-defined criteria. Methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Quasi-Experimental Studies. Synthesis of findings was narrative. Results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

There were 21 studies which met the inclusion criteria, of which 20 were included in our review following quality assessment. Sixteen studies investigated the effect of clinical information on reporting accuracy, three studies investigated the effect of clinical information on reporting confidence, three studies explored the impact of clinical information on clinical relevance, and two studies investigated the impact of clinical information on reporting timeliness. Some studies explored multiple outcomes. Studies concluded that clinical information improved interpretation accuracy, clinical relevance and reporting confidence; however, reporting time was not substantially affected by the addition of clinical information.

CONCLUSION

The findings of this review suggest clinical information has a positive impact on the radiology report. It is in the best interests of radiologists to communicate the importance of clinical information to reporting via the creation of criteria standards to guide the requesting practices of medical imaging referrers. Further work is recommended to establish these criteria standards.

Do radiologists need to review abdominal ultrasound examinations reported as 'normal' by the sonographer?

INTRODUCTION

Sonographers demonstrate a high standard of diagnostic performance and work with a considerable degree of professional independence. In Australasia, sonographers typically generate a preliminary report which is reviewed by the radiologist who issues a final report. The aim of this study was to determine whether radiologist's review is required in cases reported as normal by the sonographer.

METHODS

This study was a retrospective review of 1000 abdominal US examinations considered normal by sonographers that were subsequently reported by radiologists. Any findings reported by radiologists that were not reported by sonographers were analysed and separated into errors or discrepancies according to commonly accepted definition.

RESULTS

The 1000 abdominal examinations included 244 complete abdominal, 200 hepatobiliary, 506 urinary tract and 50 other abdominal examinations. Patients' age ranged from < 1 to 94 years (mean = 35 years, median = 32 years). US examinations were performed by any one of 14 sonographers with 1-21 years (mean = 6 years, median = 7 years) of clinical experience. Two diagnostic errors were made by sonographers and two errors by radiologists. In no single case did the radiologist uncover a case of an acute or serious illness, illness requiring admission or urgent clinical review, nor did the radiologist identify the cause for the presenting symptoms. Eighteen discrepancies were found, but these were of trivial nature and most were rated by specialist clinicians as irrelevant.

CONCLUSION

Sonographers are accurate in distinguishing normal abdominal US examinations. The involvement of a radiologist in a second reading of normal abdominal US examinations is unnecessary.

C1/C2 osteomyelitis secondary to malignant otitis externa complicated by atlantoaxial subluxation-a case report and review of the literature

We present a case of C1/C2 osteomyelitis secondary to malignant otitis externa complicated by atlantoaxial subluxation. This case is unique because surgical fixation of the spine was delayed, and despite clearance of the infection with antibiotics, the patient developed cervical myelopathy and required instrumented spinal fusion surgery. He presented with 1 month of fever, headache and worsening neck stiffness. An MRI of his cervical spine showed C1/C2 osteomyelitis with atlantoaxial subluxation. He was initially treated non-operatively with prolonged intravenous antibiotics and external immobilisation of his cervical spine. However, the first course of antibiotics failed, and he represented with a progression of his infection to the contralateral ear. He declined surgical intervention and completed a second course of antibiotics. Unfortunately, he eventually progressed to cervical myelopathy and subsequently underwent posterior C1 decompression with occipital to C4 instrumentation. There was no biochemical or bacterial culture evidence of infection at the time of the surgery. This case highlights the potential challenges in the management of cervical osteomyelitis-optimal duration of antibiotics is not supported by strong evidence and the clinician will therefore have to decide each treatment in the context of the patient. Spinal instability may still remain an issue after adequate treatment of the infection.

Full Radiology Report through Patient Web Portal: A Literature Review

The aim of this study discusses the gap between the patient web portal and providing a full radiology report. A literature review was conducted to examine radiologists, physicians, and patients’ opinions and preferences of providing patients with online access radiology reports. The databases searched were Pubmed and Google Scholar and the initial search included 927 studies. After review, 47 studies were included in the study. We identified several themes, including patients’ understanding of radiology reports and radiological images, as well as the need for decreasing the turnaround time for reports availability. The existing radiology reports written for physicians are not suited for patients. Further studies are needed to guide and inform the design of patient friendly radiology reports. One of the ways that can be used to fill the gap between patients and radiology reports is using social media sites.

A decision-making model for pre-sentence evaluations for juveniles

Forensic mental health assessments (FMHAs) are requested by the courts to assist in the sentencing process and can have a major impact upon the life of the person evaluated. Completing these assessments is a core competency for forensic psychologists. However, some FMHAs are undertaken by psychologists who have no forensic training. Despite this, there are no formalised Australian minimum standards to ensure reports are helpful to the courts and reflect sound evaluation methodologies. Drawing upon a critical review of the literature and recent research findings, we propose a 10-step decision-making model for pre-sentence evaluations of juveniles. Our model provides a framework for decision-making and highlights the key elements of an evaluation. The model provides a basis for developing practice guidelines and professional standards. The next step is to test the model in the field to determine its impact on the quality of psychological pre-sentence reports.

Discussing elder abuse and neglect in undergraduate dental education: a commentary

The intra- and extra-oral signs of physical abuse and neglect can appear visible to a dental professional during routine care. Yet, little is known about the existing pedagogies employed to discuss elder abuse and neglect in undergraduate dental education and the level of knowledge undergraduate dental students have about elder abuse and neglect. The purpose of this commentary is to present a literature review exploring how the subject of elder abuse and neglect is taught in dental schools and to discuss the results of a brief knowledge-based questionnaire focused on elder abuse and neglect applied to Canadian undergraduate dental students.

Has the Reporting Quality of Systematic Review Abstracts in Nursing Improved Since the Release of PRISMA for Abstracts? A Survey of High-Profile Nursing Journals

BACKGROUND

The PRISMA for Abstracts (PRISMA-A) was developed to guide authors to present a structured abstract. However, the adherence of abstracts to these guidelines in some areas was of concern.

AIMS

To determine whether the publication of PRISMA-A resulted in an improvement in the abstracts reported with nursing systematic reviews (SRs).

METHODS

This was a cross-sectional study. We searched PubMed for randomized controlled trials-based SRs published in top-tier nursing journals. A PRISMA-A checklist was used to assess abstracts in the SR included. Total score on checklists, comparison of total scores between two periods, and effect factors were analyzed.

RESULTS

Overall, abstract reporting compliance with PRISMA-A has not improved significantly with the time span. Of the 81 SRs, 74.1% were structured. About half reported eligibility criteria, information sources, and description of the effect as recommended. Registration status was reported only in 4.9%. The reporting quality was significantly higher for journals with higher impact factors (p < .001).

LINKING EVIDENCE TO ACTION

Although not inclusive of all SRs in the nursing field, our sample reflects the general trend that there was no significant improvement in the compliance of SR abstracts reported in nursing with the release of PRISMA-A. There is room for improvement, as most items have not been fully reported.

Dermatopathologist assessment of "pathologist-to-dermatologist" communication for dermatopathology services

BACKGROUND

While patients are the ultimate beneficiaries of pathology services, pathologist to clinician communication is an essential component of excellent patient care.

OBJECTIVE

To survey dermatologists on how well pathologists communicate with them and to assess which aspects of pathologists' communication skills are deemed most significant to dermatologists, stratified by practice type.

METHODS

A survey-based instrument was developed and sent to dermatologists through various email listservs. Of the approximately 400 potential Association of Professors of Dermatology respondents, 64 returned the survey questionnaire (response rate 16%). Of the 79 state and regional dermatologic societies, seven agreed to distribute the survey on their listservs (response rate 9%).

RESULTS

Surveyed dermatologists believe that the pathologists with whom they work are meeting expectations in the areas of diagnostic accuracy, communicating pertinent information in a timely fashion, integrating written pathology reports into the electronic medical record, and making a clinically meaningful histopathologic interpretation. Discussion of cost of ancillary testing is an area of improvement. University affiliated dermatologists are more likely to use electronic medical records as their predominant mode of communication compared to community dermatologists with and without academic affiliations. Community dermatologists are more likely to use faxed written pathology reports as their predominant mode of communication.

CONCLUSION

Physician-to-physician communication is a key component of effective patient care. When it comes to dermatopathology services, dermatologists appear overall satisfied with the indicators examined, however, potential opportunities for improvement exist.

OIE Annual Report on Antimicrobial Agents Intended for Use in Animals: Methods Used

For over two decades, the World Organisation for Animal Health (OIE) has engaged in combatting antimicrobial resistance (AMR) through a One Health approach. Monitoring of antimicrobial use (AMU) is an important source of information that together with surveillance of AMR can be used for the assessment and management of risks related to AMR. In the framework of the Global Action Plan on AMR, the OIE has built a global database on antimicrobial agents intended for use in animals, supported by the Tripartite (World Health Organization (WHO), Food and Agriculture Organization of the United Nations (FAO) and OIE) collaboration. The OIE launched its first annual data collection in 2015 and published the Report in 2016. The second Report, published in 2017, introduced a new methodology to report quantitative data in the context of relevant animal populations, and included for the first time an annual analysis of antimicrobial quantities adjusted for animal biomass on a global and regional level. A continuing annual increase of countries participating in the data collection demonstrates the countries engagement for the global development of monitoring and surveillance systems in line with OIE international standards. Where countries are not yet able to contribute their quantitative data, their reports also highlight the barriers that impede them in data collection, analysis and/or reporting. The OIE Reports show annual global and regional estimates of antimicrobial agents intended for use in animals adjusted for animal biomass, as represented by the quantitative data reported by countries to the OIE. The OIE advises caution in interpretation of estimates made in the first few years of reporting recognizing some important limitations faced by countries as they develop their monitoring systems. The OIE remains strongly committed to supporting its Members in developing robust and transparent measurement and reporting mechanisms for AMU.

Malaysian Journal of Medical Sciences' Performance Status in 2018

The Malaysian Journal of Medical Sciences (MJMS) would like to present a brief report of its progress in 2018 with a purpose to provide a clear picture of how it has performed so far. This report may considered as a helpful information, especially, to future authors who wish to submit their articles to MJMS. This report summarised the information of the total of original manuscripts received based on manuscript type, authors’ country of origin and total of original manuscripts received by month. It also reveals the statistics of the final decisions made based on manuscript type, the accept-reject ratio by the editor and the time taken from submission to decision for all manuscripts submitted throughout 2018.

Visualization of the small RNA transcriptome using seqclusterViz

The study of small RNAs provides us with a deeper understanding of the complexity of gene regulation within cells. Of the different types of small RNAs, the most important in mammals are miRNA, tRNA fragments and piRNAs. Using small RNA-seq analysis, we can study all small RNA types simultaneously, with the potential to detect novel small RNA types. We describe SeqclusterViz, an interactive HTML-javascript webpage for visualizing small noncoding RNAs (small RNAs) detected by Seqcluster. The SeqclusterViz tool allows users to visualize known and novel small RNA types in model or non-model organisms, and to select small RNA candidates for further validation. SeqclusterViz is divided into three panels: i) query-ready tables showing detected small RNA clusters and their genomic locations, ii) the expression profile over the precursor for all the samples together with RNA secondary structures, and iii) the mostly highly expressed sequences. Here, we show the capabilities of the visualization tool and its validation using human brain samples from patients with Parkinson’s disease.

The need for standardization of nuclear cardiology reporting and data system (NCAD-RADS): Learning from coronary artery disease (CAD), breast imaging (BI), liver imaging (LI), and prostate imaging (PI) RADS

Newer structured reporting manners, the reporting and data system (RADS), have made vast steps in improving standardized and structured reporting, allowing better communication between radiologists and referring providers. This has been implemented in several fields: breast (BI-RADS), lung (Lung-RADS), liver (LI-RADS), thyroid (TI-RADS), prostate (PI-RADS), and in cardiovascular radiology (CAD-RADS). The field of nuclear cardiology began its efforts of standardization years ago; however, a widespread standardized reporting structure has not yet been adopted. Such an approach in nuclear cardiology, the nuclear cardiology reporting and data system (NCAD-RADS), will assist radiologists and treating clinicians in conveying and understanding reports and determining the appropriate next steps in management. By linking explicit findings to defined recommendations, patients will receive more consistent and appropriate care.

Report of a Hydatid Cyst Case with Biceps Brachii Involvement

Muscular hydatid cyst is a rare condition mainly secondary to the cysts from other organs. We hereby present an uncommon case of primary hydatid cyst found in the right biceps brachii muscle of a 36-year-old male. Magnetic resonance revealed no Echinococcus involvement in any other part of his body. Chest X-ray was normal, and no trace of cyst was found in the lung. In areas where echinococcosis is endemic, any tumor or mass in any part of the patient's body should be evaluated and examined for Echinococcus infestation. This paper is the second case report article on echinococcal biceps brachii infestation existing to this date.

Mini Review on the Use of Clinical Cancer Registers for Prostate Cancer: The National Prostate Cancer Register (NPCR) of Sweden

Given the increasing prevalence of cancer, it is vital to systematically collect data in order to monitor disease trends and quality of cancer care. For this purpose, clinical cancer registries have been developed in some countries. These registers are intended to be used as a basis for quality assurance and quality improvement, but they also constitute a rich resource of real world data for research. The aim of this mini-review was to describe the structure and the organization of the National Prostate Cancer Register (NPCR) with some examples on how data in NPCR have affected prostate cancer care in Sweden.

Frequency, Determinants, and Costs of Recommendations for Additional Imaging in Clinical 18F-FDG PET/CT Reports

Our purpose was to determine the frequency, determinants, and costs of recommendations for additional imaging (RAIs) in clinical ¹⁸F-FDG PET/CT reports. Methods: This retrospective study included a random sample of 2,643 ¹⁸F-FDG PET/CT scans that were performed for various clinical reasons at a tertiary-care academic medical center without financial incentives for self-referral, within a 1.5-y period. Results: Ninety-eight (3.7%) of 2,643 ¹⁸F-FDG PET/CT reports contained an RAI. None of the investigated variables (patient age, hospital status [inpatient or outpatient], indication for ¹⁸F-FDG PET/CT scanning [oncologic, infection/inflammation, or miscellaneous], type of ¹⁸F-FDG PET/CT scan [low-dose ¹⁸F-FDG PET/CT or low-dose ¹⁸F-FDG PET/CT combined with diagnostic CT of any body region], or years of experience of the [most senior] signing author) was univariately associated with the presence of an RAI in the ¹⁸F-FDG PET/CT report. The hypothesis that RAIs more frequently occur when the anatomic area to which the RAI relates is not covered by a diagnostic CT scan (as part of the ¹⁸F-FDG PET/CT examination) was also rejected (P = 0.419). The total costs of all RAIs (regardless of whether they were actually performed by the referring clinicians) were €23,922.21 ($27,065.47), which corresponds to an average of €9.08 ($10.27) RAI costs per ¹⁸F-FDG PET/CT exam. The total costs of all RAIs that were actually performed by the referring clinicians were €16,498.62 ($18,666.46), which corresponds to an average of €6.26 ($7.08) RAI costs per ¹⁸F-FDG PET/CT exam. Conclusion: RAIs in ¹⁸F-FDG PET/CT reports in a European tertiary-care academic medical center without financial incentives for self-referral are infrequent, cannot be anticipated, and result in relatively low overall costs.

Psychological reports for sentencing juveniles in Australian courts

Psychological reports for use in court must be relevant to the legal issues in dispute, meet professional standards, and reflect evidence-based practice. Using the Delphi method, a high degree of consensus was found among Australian experts in the methodology and knowledge required for conducting forensic mental health assessment (FMHAs) and the content needed in pre-sentence reports. Consensus was absent in two areas, if a pre-sentence report should always include a risk-assessment; and the need for a model to guide the FMHA. Without a model it is difficult for practitioners to justify their decision-making process, and judicial officers have no mechanism to determine if the work provided to the court is of an acceptable standard. Future research should focus on developing a model for presentence reports that includes a decision-making process and minimum standards. Researchers also need to determine judicial officers' views on the helpfulness of presentence reports.

Successful management of severe preeclampsia major complications: Case report

Severe preeclampsia (PE) have considerable adverse outcome especially in low-resource countries. A 21-year-old pregnant woman with severe PE and intrauterine fetal death, delivered by cesarean section (CS). The CS complicated by atonic postpartum hemorrhage (PPH). She was transferred by the air ambulance to the tertiary center of West Kazakhstan University-intensive care unit, once she developed anuria. She was carefully monitored after exclusion of maternal sepsis and HELLP (hemolysis, elevated liver enzymes and low platelet) syndrome and she developed postpartum eclampsia and right partial lobe intracranial hemorrhage (ICH). She was managed by multi-disciplinary team with proper and clear management plan and discharged from the hospital on the 20^th postpartum day in good general condition. The complications of severe PE need clear multi-disciplinary team management plan to avoid the adverse outcome of the severe PE.

Barriers of Visceral Leishmaniasis reporting and surveillance in Nepal: comparison of governmental VL-program districts with non-program districts

OBJECTIVES

At the time when Nepal is on the verge of reaching the maintenance phase of the Visceral Leishmaniasis (VL) elimination program, the country is facing new challenges. The disease has expanded to 61 of the country's 75 districts including previously non-endemic areas where there is no control or patient management program in place. This study aimed to assess which elements of the surveillance and reporting systems need strengthening to identify cases at an early stage, prevent further transmission and ensure sustained VL elimination.

METHODS

In a cross-sectional mixed-method study, we collected data from two study populations in VL program and non-program districts. From February to May 2016, structured interviews were conducted with 40 VL patients, and 14 in-depth and semi-structured interviews were conducted with health managers.

RESULTS

The median total delay from onset of symptoms to successful reporting to the Ministry of Health was 68.5 days in the VL-program and 83 days in non-program districts. The difference in patient's delay from the onset of symptoms to seeking health care was 3 days in VL-program and 20 days in non-program districts. The diagnostic delay (38.5 days and 36 days, respectively), treatment delay (1 vs. 1 days) and reporting delay (45 vs. 36 days) were similar in program and non-program districts. The diagnostic delay increased three-fold from 2012, while treatment and reporting delay remained unchanged. The main barriers to surveillance were: (i) lack of access and awareness in non-program districts; (ii) growing private sector not included in and not participating to referral, treatment and reporting; (iii) lack of cooperation and coordination among stakeholders for training and deployment of interventions; (iv) insufficient validation, outreach and process optimisation of the reporting system.

CONCLUSIONS

Corrective measures are needed to maintain the achievements of the VL elimination campaign and prevent resurgence of the disease in Nepal. A clear patient referral structure, reinforcement of report notification and validation and direct relay of data by local hospitals and the private sector to the district health offices are needed to ensure prompt treatment and timely and reliable information to facilitate a responsive system of interventions.