SMS-based smartphone application for disease surveillance has doubled completeness and timeliness in a limited-resource setting - evaluation of a 15-week pilot program in Central African Republic (CAR)

Background

It is a challenge in low-resource settings to ensure the availability of complete, timely disease surveillance information. Smartphone applications (apps) have the potential to enhance surveillance data transmission.

Methods

The Central African Republic (CAR) Ministry of Health and Médecins Sans Frontières (MSF) conducted a 15-week pilot project to test a disease surveillance app, Argus, for 20 conditions in 21 health centers in Mambéré Kadéi district (MK 2016). Results were compared to the usual paper-based surveillance in MK the year prior (MK 2015) and simultaneously in an adjacent health district, Nana-Mambére (NM 2016). Wilcoxon rank sum and Kaplan-Meier analyses compared report completeness and timeliness; the cost of the app, and users' perceptions of its usability were assessed.

Results

Two hundred seventy-one weekly reports sent by app identified 3403 cases and 63 deaths; 15 alerts identified 28 cases and 4 deaths. Median completeness (IQR) for MK 2016, 81% (81-86%), was significantly higher than in MK 2015 (31% (24-36%)), and NM 2016 (52% (48-57)) (p < 0.01). Median timeliness (IQR) for MK 2016, 50% (39-57%) was also higher than in MK 2015, 19% (19-24%), and NM 2016 29% (24-36%) (p < 0.01). Kaplan-Meier Survival Analysis showed a significant progressive reduction in the time taken to transmit reports over the 15-week period (p < 0.01). Users ranked the app's usability as greater than 4/5 on all dimensions. The total cost of the 15-week pilot project was US$40,575. It is estimated that to maintain the app in the 21 health facilities of MK will cost approximately US$18,800 in communication fees per year.

Conclusions

The app-based data transmission system more than doubled the completeness and timeliness of disease surveillance reports. This simple, low-cost intervention may permit the early detection of disease outbreaks in similar low-resource settings elsewhere.

[Study on the application of dexmedetomidine combined with remifentanil in dressing change of conscious patients with non-intubation in burn intensive care unit]

Objective: To observe the analgesic and sedative effect and safety of application of dexmedetomidine combined with remifentanil in dressing change of conscious patients with non-intubation in burn intensive care unit. Methods: Forty patients conforming to the study criteria hospitalized in our burn intensive care unit from April 2015 to April 2017 were selected. Prospective, randomized, and double-blind method was used for the design. Patients were divided into dexmedetomidine group and dexmedetomidine+ remifentanil group according to the random number table, with 20 cases in each group. Patients in the two groups were respectively given corresponding drugs during dressing change. The frequency and time of dressing change, Verbal Rating Scale (VRS) score of patients during dressing change (at drug administration for 25 minutes) and after dressing change (25 min after dressing change), Ramsay Sedation Score (RSS) during dressing change, satisfaction level for anesthesia of the patients and physicians after dressing change, dosage of remifentanil, and various adverse effects during and after dressing change were recorded. The heart rate, mean arterial blood pressure (MAP), respiratory rate, and pulse oxygen saturation (SpO₂) before drug administration and at 10, 15, and 25 minutes after drug administration were also recorded. Data were processed with analysis of variance for repeated measurement, t test, chi-square test, and Fisher's exact probability test. Results: (1) Totally 38 patients completed the trial. There were no statistically significant differences between patients in two groups in gender, American Association of Anesthesiologist Grading, age, weight, and total burn area (χ²=0.230, 0.146, t=0.224, 0.351, 0.367, P>0.05). (2) The frequency of dressing change of patients in two groups were both 48 times. The time of dressing change and VRS scores during dressing change of patients in two groups were similar (t=0.821, 1.522, P>0.05). The VRS score of patients in dexmedetomidine+ remifentanil group after dressing change was (3.1±0.4) points, obviously lower than (3.8±0.8) points in remifentanil group (t=2.213, P<0.05). The RSS, satisfaction level scores for anesthesia of the patients and physicians after dressing change in dexmedetomidine+ remifentanil group were (3.13±0.32), (3.44±0.41), and (3.13±0.25) points, respectively, obviously better than (1.82±0.24), (2.71±0.23), (2.53±0.41) points in remifentanil group (t=2.226, 2.684, 7.702, P<0.01). The dosage of remifentanil of patients in dexmedetomidine+ remifentanil group was (282±19) μg, obviously less than (340±31) μg in remifentanil group (t=9.896, P<0.01). There were no statistically significant differences between patients in two groups in rates of respiratory inhibition and hypotension (χ²=0.211, 0.154, P>0.05). Compared with those in remifentanil group, the rates of nausea, vomiting, and other gastrointestinal symptoms of patients in dexmedetomidine+ remifentanil group were obviously reduced (P<0.05), but the rate of bradycardia was obviously increased (χ²=6.008, P<0.05). (3) There were no statistically significant differences between patients in two groups in heart rate, MAP, respiratory frequency, and SpO₂ before drug administration (t=0.444, 0.892, 1.059, 1.039, P>0.05). The heart rates of patients in dexmedetomidine+ remifentanil group at 10, 15, and 25 minutes after drug administration were (83±11), (78±10), and (82±14) times per minute, respectively, significantly lower than (95±10), (87±12), and (89±12) times per minute in remifentanil group (t=5.592, 3.992, 2.630, P<0.05 or P<0.01). The MAP of patients in dexmedetomidine+ remifentanil group at 15 and 25 minutes after drug administration were (69.4±3.1) and (73.8±2.2) mmHg (1 mmHg=0.133 kPa), respectively, significantly lower than (75.4±3.0) and (78.1±3.5) mmHg in remifentanil group (t=9.181, 7.206, P<0.01). There were no statistically significant differences between patients in two groups in respiratory frequency at each time point after drug administration (t=1.489, 1.862, 1.963, P>0.05). The SpO₂ of patients in dexmedetomidine+ remifentanil group at 15 minutes after drug administration was 0.972±0.018, obviously lower than 0.979±0.015 in remifentanil group (t=2.070, P<0.05). Conclusions: Application of remifentanil with small dosage has effective analgesia for conscious burn patients with non-intubation during dressing changes, however, adverse effects such as nausea and vomiting are likely to occur. Remifentanil combined with dexmedetomidine not only guarantee the analgesic effect, but also reduce the dosage of analgesics, improve the sedative effect and satisfaction of the patients for anesthesia, and reduce various adverse effects. However, it will increase the incidence of bradycardia and has some inhibition effect on circulation at the same time.

Ex Vivo Generation of Donor Antigen-Specific Immunomodulatory Cells: A Comparison Study of Anti-CD80/86 mAbs and CTLA4-lg Costimulatory Blockade

Adoptive transfer of alloantigen-specific immunomodulatory cells generated ex vivo with anti-CD80/CD86 mAbs (2D10.4/IT2.2) holds promise for operational tolerance after transplantation. However, good manufacturing practice is required to allow widespread clinical application. Belatacept, a clinically approved cytotoxic T-lymphocyte antigen 4-immunoglobulin that also binds CD80/CD86, could be an alternative agent for 2D10.4/IT2.2. With the goal of generating an optimal cell treatment with clinically approved reagents, we evaluated the donor-specific immunomodulatory effects of belatacept- and 2D10.4/IT2.2-generated immunomodulatory cells. Immunomodulatory cells were generated by coculturing responder human peripheral blood mononuclear cells (PBMCs) (50 × 10⁶ cells) with irradiated donor PBMCs (20 × 10⁶ cells) from eight human leukocyte antigen-mismatched responder–donor pairs in the presence of either 2D10.4/IT2.2 (3 μg/10⁶ cells) or belatacept (40 μg/10⁶ cells). After 14 days of coculture, the frequencies of CD4⁺ T cells, CD8⁺ T cells, and natural killer cells as well as interferon gamma (IFN-γ) production in the 2D10.4/IT2.2- and belatacept-treated groups were lower than those in the control group. The percentage of CD19⁺ B cells was higher in the 2D10.4/IT2.2- and belatacept-treated groups than in the control group. The frequency of CD4⁺CD25⁺CD127^lowFOXP3⁺ T cells increased from 4.1±1.0% (preculture) to 7.1±2.6% and 7.3±2.6% (day 14) in the 2D10.4/IT2.2- and belatacept-treated groups, respectively (p<0.05). Concurrently, delta-2 FOXP3 mRNA expression increased significantly. Compared with cells derived from the no-antibody treated control group, cells generated from both the 2D10.4/IT2.2- and belatacept-treated groups produced lower IFN-γ and higher interleukin-10 levels in response to donor-antigens, as detected by enzyme-linked immunospot. Most importantly, 2D10.4/IT2.2- and belatacept-generated cells effectively impeded the proliferative responses of freshly isolated responder PBMCs against donor-antigens. Our results indicate that belatacept-generated donor-specific immunomodulatory cells possess comparable phenotypes and immunomodulatory efficacies to those generated with 2D10.4/IT2.2. We suggest that belatacept could be used for ex vivo generation of clinical grade alloantigen-specific immunomodulatory cells for tolerance induction after transplantation.

[Clinical effects of a combination treatment with narrow-spectrum intense pulsed light and fractional carbon dioxide laser on hypertrophic scar pruritus]

Objective: To observe the effects of a combination treatment with narrow-spectrum intense pulsed light and fractional carbon dioxide laser on hypertrophic scar pruritus in clinic. Methods: A prospective randomized controlled study was conducted. A total of 90 patients with hypertrophic scars conforming to the inclusion criteria who were hospitalized in our ward from March to December 2017 were divided into combination treatment group and control group according to the random number table, with 45 patients in each group. For scar pruritus, patients in control group were treated twice by narrow-spectrum intense pulsed light with a one-month interval, while patients in combination treatment group were firstly treated by narrow-spectrum intense pulsed light combined with fractional carbon dioxide laser once, and with narrow-spectrum intense pulsed light once one month later. Before and 3 months after treatment, scar pruritus was evaluated by the Visual Analogue Scale and the Four-item Itch Questionnaire, and the improvement of scar was assessed by photography. Three months after treatment, the treatment satisfaction of scar pruritus was self-rated by patients. Meanwhile, adverse effects were recorded during the procedures and follow-up periods. Data were processed with Chi-square test, paired t test, Wilcoxon rank-sum test, and Fisher's exact probability test. Results: Before treatment, there was no statistically significant difference in scar pruritus degree evaluated by the Visual Analogue Scale and score distribution of scar pruritus location, extent, frequency, and sleep effect of the Four-item Itch Questionnaire between patients of two groups (Z=-1.08, -0.91, -0.03, -0.69, -1.49, P>0.05). Three months after treatment, there was reducing degree of scar pruritus of patients evaluated by the Visual Analogue Scale in control group or combination treatment group compared with before treatment within the same group (Z=-1.98, -4.65, P<0.05 or P<0.01), while the latter was more obvious than the former (Z=-2.14, P<0.05). There were reducing scores of scar pruritus extent and frequency of patients in control group, along with location, extent, frequency, and sleep effect of patients in combination treatment group compared with those before treatment within the same group (Z=-2.33, -2.34, -3.53, -4.96, -3.32, -4.84, P<0.05 or P<0.01). However, scores of scar pruritus location and sleep effect of patients in control group were similar to those before treatment within the same group (Z=-0.58, -1.34, P>0.05). The scores of scar pruritus location, extent, frequency, and sleep effect of patients were obviously lower in combination treatment group compared with control group (Z=-2.09, -2.69, -1.99, -2.23, P<0.05 or P<0.01). It was much better of scar improvement of patients in combination treatment group compared with control group (Z=-4.00, P<0.01). The percentages of treatment satisfaction of scar pruritus of patients with 0, 1%-25%, 26%-50%, 51%-75%, 76%-100% were 0, 2.2% (1/45), 17.8% (8/45), 48.9% (22/45), and 31.1% (14/45) respectively in combination treatment group, which were obviously better than 0, 11.1% (5/45), 53.3% (24/45), 28.9% (13/45), and 6.7% (3/45) in control group (Z=-4.42, P<0.01). During the treatment and follow-up periods, the adverse effect ratio of patients in control group was 6.7% (3/45), similar to 2.2% (1/45) of combination treatment group (P>0.05). Conclusions: The combination of narrow-spectrum intense pulsed light and fractional carbon dioxide laser can greatly reduce pruritus, improve effect of scar treatment, and bring higher patient satisfaction compared with narrow-spectrum intense pulsed light alone in treating hypertrophic scar pruritus. Clinical trial registration: Chinese Clinical Trial Registry, ChiCTR-ONH-17012350.

Viscoelastic anomaly accompanying anti-crossing behaviour in liquid As2Se3

We investigate the dynamic structure factor of the melt of the well known glass former, As₂Se₃, using inelastic x-ray scattering for temperatures, T, [Formula: see text] K and momentum transfers Q from [Formula: see text] nm^-1. An anomaly was observed at Q  =  2.7 nm^-1 ([Formula: see text] K) with, in the context of a simple model, both an abrupt change in frequency and an increased linewidth reminiscent of an anti-crossing in a solid. Comparison with structural information from reverse Monte Carlo modeling of x-ray diffraction data allows us to associate the disappearance of the anomaly at higher temperatures with a drop in the number of mechanical constraints per atom, n _mc, to [Formula: see text] reminiscent of the threshold applicable for glass formation in rigidity theory. It is inferred that the surprising jump in the dispersion in the liquid may be correlated with a stiffness transition in a network glass.

[Advances in the research of techniques for traumatic scars intervention with photoelectric acoustic therapy]

Traumatic scar is a common complication of skin injury, such as burn, trauma, and surgery. The mechanism for scar formation still remains unclear. Traumatic scar has a negative impact on the quality of patients' life, due to the appearance of scar always causes physical or/and psychological problems to patients. The treatments for scar include surgery, chemotherapy, radiotherapy, and pressure, depending on the kind of scar present. Recently, a great progress in treating scar has been achieved by novel techniques with laser, intense pulsed light, micro-plasma radiofrequency, and ultrasound. The aim of this review is introducing the advances of these techniques for traumatic scars intervention.

[The analysis of the effect of psycho-intervention combined with diazepam on patients with sudden sensorineural hearing loss and anxiety]

Objective: To investigate the therapeutic effect of psychological intervention combined with diazepam on sudden hearing loss patients with anxiety. Method: 108 cases of sudden hearing loss patients with anxiety were randomly divided into two groups(n=54 in each group): The control group received routine treatment of sudden hearing loss, the study group was given psychological intervention combined with diazepam tablets(2.5 mg once, twice a day) based on the routine treatment. The hearing and HAMA and SAS scores were reviewed after 10 days of treatment. Result: After 10 days of treatment, the average hearing threshold of patients in the control group and the study group were respectively increased by （19.65±7.89）dB and （26.93±9.04）dB (t=4.54, P=0.006), the HAMA score of two groups were respectively decreased by 4.68 and 10.75（t=9.949, P=0.000）and the SAS score of two groups were respectively decreased by 15.93 and 23.39 (t=6.773, P=0.000), and the total efficiency of hearing of two groups were 61.11% and 77.78% (χ²=4.441, P=0.035),respectively. the differences were statistically significant. Conclusion: Psychological intervention combined with diazepam can relieve anxiety in patients with sudden hearing loss effectively, and play a positive role in the development and prognosis of patients with sudden sensorineural hearing loss.

[Relationship between C-C chemokine receptor type 2 and P38 mitogen-activated protein kinase signaling pathway in the spinal cord of rats with bone cancer pain]

Objective: To investigate the relationship between C-C chemokine receptor type 2(CCR2) and P38 mitogen-activated protein kinase (P38MAPK) signaling pathway in the spinal cord of rats and further clarify the mechanism of bone cancer pain (BCP). Methods: A total of 92 healthy female SD rats, of which 60 were subjected to behavioral tests using a ciliary mechanical stimulation needle. SD rats were randomly divided into six groups: sham operation group (group S), bone cancer pain group (group B), sham operation + DMSO solvent group (group SD), bone cancer pain + DMSO solvent group (group BD), sham operation + RS102895 CCR2 inhibitor group (group SR), bone cancer pain + RS102895 CCR2 inhibitor group (group BR), and Von Frey was used in the behavioral test. Another 32 SD rats were randomly divided into the following 8 groups (n=4): sham operation group (group S), bone cancer pain 5 d group (group B5), bone cancer pain 9 d group (group B9), bone cancer pain 14 d group (group B14), bone cancer pain + DMSO solvent group (group BD), bone cancer pain + RS102895 CCR2 inhibitor 0.5 h group (group BR0.5 h), bone cancer pain + RS102895 CCR2 inhibitor 4 h group (group BR4 h), bone cancer pain + RS102895 CCR2 inhibitor 12 h group (group BR12 h). Western blot was used to detect the expression of P38, p-P38 and CCR2 in spinal cord of rats. Results: At day 5, 7, 9, 14, 21 post-injection, mechanical withdrawal thresholds of group S were(30.9±1.5), (31.9±1.2), (32.0±1.1), (31.6±1.5), (32.2±1.4)g respectively, the mechanical withdrawal thresholds of group B were( 26.4±0.7), (24.4±0.8), (21.4±0.8), (13.5±0.4), (9.9±0.2)g respectively, the mechanical withdrawal thresholds in group B decreased obviously versus group S, and the differences were statistically significant(t=-13.177, -16.660, -23.778, -35.574, -48.401, all P<0.01). At day 9 post-injection, the mechanical withdrawal thresholds in SD, BD, SR and BR groups were (32.4±1.7), (19.4±1.1), (32.1±1.3), (26.3±1.0) g respectively, the difference was statistically significant (F=224.681, P<0.01), and the mechanical withdrawal thresholds in group BD decreased obviously versus group SD, while the mechanical withdrawal thresholds in group BR increased obviously versus group BD. The expression levels of p-P38 in spinal cord of group S, group B5, group B9 and group B14 were(0.08±0.03), (0.20±0.05), (0.40±0.17), (0.65±0.14)respectively, the expression levels of CCR2 were(0.08±0.04), (0.18±0.05), (0.30±0.09), (0.58±0.07)respectively, the difference was statistically significant(F=19.123, 40.746, all P<0.01), and the expression of p-P38 and CCR2 in group B9 were showed a significant up-regulation versus group S. The expression levels of p-P38 in spinal cord of group BD, group BR0.5 h, group BR4 h and group BR12 h were (0.57±0.06), (0.17±0.11), (0.03±0.01), (0.25±0.11)respectively, and the difference was statistically significant(F=29.582, P<0.01). The expression of p-P38 in group BR0.5 h, BR4 h, BR12 h showed a significant down-regulation versus group BD. Conclusion: CCR2 in the spinal cord may be involved in the development of bone cancer pain by activating P38MAPK signaling pathway in rats.

[Advances in the research of relationship between CD26 and hypertrophic scar and keloid]

In recent years, researchers have found that CD26 (dipeptidyl peptidase 4) is closely related to the formation and development of many fibrotic diseases. Hypertrophic scar, keloid, and other skin fibrosis diseases are major problems nowadays, which may affect the patient's appearance and cause joints deformity and dysfunction due to scar contracture. This article briefly reviews the relationship between CD26 and hypertrophic scar and keloid to provide new insights into the treatment of skin fibrotic diseases.

[Dose-response relationship of ropivacaine for epidural block in early herpes zoster guided by CT]

Objective: To determine the dose-response relationship of ropivacaine for epidural block in early herpes zoster by CT guided. Methods: From January 2015 to February 2017, according to the principle of completely random digital table, 80 patients with early herpes zoster who were prepared for epidural block were divided into 4 groups(each group 20 patients): in group A the concentration of ropivacaine was 0.08%, in group B was 0.10%, in group C was 0.12% and in group D was 0.14%.Under CT guidance, epidural puncture was performed in the relevant section, mixing liquid 5.0 ml (with 10% iodohydrin)were injected into epidural gap.CT scan showed that the mixing liquid covered the relevant spinal nerve segmental.The numeric rating scale(NRS) values before treatment and at 30 minutes, the incidence of adverse reactions were recorded, and the treatment were evaluated. The response to ropivacaine for epidural block in early herpes zoster was defined as positive when the NRS values was less than or equal to one.The ED(50), ED(95) and 95% confidence interval (CI) of ropivacaine for epidural block in early herpes zoster guided by CT were calculated by probit analysis. Results: The NRS values before treatment were 5.00(4.00, 6.00), 5.00(4.25, 6.00), 5.50(5.00, 6.00) and 5.00(4.00, 6.00), the difference was no significant(Z=2.576, P=0.462). The NRS values at 30 minutes decreased and the effective rate of the treatment increased(χ(2)=8.371, P=0.004), following ropivacaine dose gradient increasing, they were 1.50(1.00, 2.00), 1.00(1.00, 2.00), 0.50(0.00, 1.00) and 0.00(0.00, 1.00), the difference was statistically significant (Z=17.421, P=0.001). There was one case in group C and four cases in group D were hypoesthesia, others were no significant adverse reactions occurred. The ED(50) and ED(95) (95%CI) of ropivacaine for epidural block in early herpes zoster guided by CT were 0.078%(0.015%-0.095%)and 0.157%(0.133%-0.271%), respectively. Conclusion: Ropivacaine for epidural block in early herpes zoster guided by CT is effective for neuropathic pain, with no significant adverse reactions.

[Prevention and treatment of Horner syndrome in treatment of head and face hyperhidrosis by thoracic sympathetic nerve modulation]

Objective: By summarize the Prevention and Treatment of Horner Syndrome of CT-guided thoracic sympathetic nerve modulation in the treatment of head and face Hyperhidrosis, reduce the occurrence of the complications. Methods: A retrospective analysis was made on 116 patients of CT-guided thoracic sympathetic nerve modulation in the treatment of head and face Hyperhidrosis in The First Hospital of Jiaxing from January 2010 to December 2016. Analysis the reasons of Horner syndrome and external management to sum up the corresponding prevention and treatment measures. Results: Under the guidance of CT positioning, 116 patients were successfully punctured to the intended target (both sides of the R3 above the rib head), after injection of local anesthetic plus contrast agent, CT scan showed there are 39 sides of the liquid parallel to the outside of pleural (26 sides) or over (13 sides) R1 above the rib head. CT scan again after the injection of anhydrous alcohol, there are 43 sides of the liquid parallel to the outside of pleural (24 sides) or over (19 sides) R1above the rib head.After the operation, 22 sides appeared Horner syndrome, 19 of which immediately give physiological saline 5 ml into the ipsilateral Satellite ganglion.Within 2 hours Horner's syndrome completely disappeared, while 3 cases were not treated, Horner syndrome lasts for 3 months to 2 years. Conclusion: The incidence of Horner syndrome relatively high during the CT-guided thoracic sympathetic nerve modulation to treatment of head and face Hyperhidrosis. Injecting 5 ml physiological saline into the ipsilateral Satellite ganglion immediately can completely eliminate this common complications.