Development and evaluation of a clinical guideline for a paediatric telemedicine service in a low-resource setting

OBJECTIVE

To develop and evaluate a guideline for a paediatric telemedicine and medication delivery service (TMDS).

METHODS

A clinical guideline for paediatric telemedicine was derived from the World Health (WHO) Organization Integrated Management of Childhood Illness (IMCI) Handbook. The guideline was deployed at a TMDS in Haiti and evaluated through a prospective cohort study; children ≤10 years were enrolled. For non-severe cases, paired virtual and in-person examinations were conducted at the call centre and household; severe cases were referred to the hospital. The performance of virtual examination components were evaluated by comparison with the paired in-person examination findings (reference).

RESULTS

A total of 391 cases were enrolled. Among the 320 cases with paired examinations, no general WHO danger signs were identified during in-person examinations; 5 cases (2%) required hospital referral due to problem-specific danger signs or other reasons for escalation. Cohen's kappa for the virtual designation of mild cases was 0.78 (95% CI: 0.69 to 0.87). The sensitivity and specificity of a virtually reported fever were 91% (95% CI: 87% to 96%) and 69% (95% CI: 62% to 76%), respectively; the sensitivity and specificity of virtually reported 'fast breathing' were 47% (95% CI: 21% to 72%) and 89% (95% CI: 85% to 94%), respectively. Kappa for 'no' and 'some' dehydration indicated moderate congruence between virtual and in-person examinations (0.69; 95% CI: 0.41 to 0.98). At 10 days, 273 (95%) of the 287 cases reached by phone were better/recovered.

CONCLUSION

Critical components of the virtual examination (triage, danger signs and dehydration assessment) performed well despite varied performance among the problem-specific components. The study and associated resources represents formative steps towards an evidence-based paediatric telemedicine guideline built on WHO clinical principles. In-person examinations for select cases were important to address limitations with virtual examinations and identify cases for escalation.

TRIAL REGISTRATION NUMBER

NCT03943654.

Population-Based Serologic Survey of Vibrio cholerae Antibody Titers before Cholera Outbreak, Haiti, 2022

A Vibrio cholerae O1 outbreak emerged in Haiti in October 2022 after years of cholera absence. In samples from a 2021 serosurvey, we found lower circulating antibodies against V. cholerae lipopolysaccharide in children <5 years of age and no vibriocidal antibodies, suggesting high susceptibility to cholera, especially among young children.

A population-based serological survey of Vibrio cholerae antibody titers in Ouest Department, Haiti in the year prior to the 2022 cholera outbreak

After three years with no confirmed cholera cases in Haiti, an outbreak of Vibrio cholerae O1 emerged in October 2022. Levels of pre-existing antibodies provide an estimate of prior immunologic exposure, reveal potentially relevant immune responses, and set a baseline for future serosurveillance. We analyzed dried blood spots collected in 2021 from a population-weighted representative cross-sectional serosurvey in two communes in the Ouest Department of Haiti. We found lower levels of circulating IgG and IgA antibodies against V. cholerae lipopolysaccharide (LPS, IgG and IgA p<0.0001) in those below 5 years of age compared to those five years and older. Among a subset of patients with higher titers of antibodies, we were unable to detect any functional (vibriocidal) antibodies. In conclusion, the lack of detectable functional antibodies, and age-discordant levels of V. cholerae LPS IgG, suggest that populations in Haiti may be highly susceptible to cholera disease, especially among young children.

Implementation of a pediatric telemedicine and medication delivery service in a resource-limited setting: A pilot study for clinical safety and feasibility

OBJECTIVE

Determine the clinical safety and feasibility of implementing a telemedicine and medication delivery service (TMDS) to address gaps in nighttime access to healthcare for children in low-resource settings.

STUDY DESIGN

We implemented a TMDS called 'MotoMeds' in Haiti as a prospective cohort study. A parent/guardian of a sick child ≤10 years contacted the call center (6pm-5am). A nurse provider used decision support tools to triage cases (mild, moderate, severe). Severe cases were referred to emergency care. For non-severe cases, providers gathered clinical findings to generate an assessment and plan. For cases within the delivery zone, a provider and driver were dispatched and the provider performed a paired in-person exam as a reference standard for the call center assessment. Families received a follow-up call at 10 days. Data were analyzed for clinical safety and feasibility.

RESULTS

A total of 391 cases were enrolled from September 9, 2019, to January 19, 2021. Most cases were not severe (92%; 361); household visits were completed for 89% (347) of these cases. Among the 30 severe cases, 67% (20) sought referred care. Respiratory problems were most common (63%; 246). At 10-days, 95% (329) of parents reported their child "improved" or "recovered". Overall 99% (344) rated the TMDS as "good" or "great". The median phone consultation time was 20 minutes, time to household arrival was 73 minutes, and total time was 114 minutes/case.

CONCLUSION

The TMDS was a feasible healthcare delivery model. Although many cases were likely self-limiting, the TMDS was associated with high rates of reported improvement in clinical status at 10 days.

A Nighttime Telemedicine and Medication Delivery Service to Avert Pediatric Emergencies in Haiti: An Exploratory Cost-Effectiveness Analysis

We sought to compare the costs of a nighttime pediatric telemedicine and medication delivery service per disability-adjusted life year (DALY) averted to the costs of current hospital emergency care per DALY averted from a societal perspective. We studied a nighttime pediatric telemedicine and medication delivery service and hospital emergency care in a semi-urban and rural region of Haiti. Costs of the two services were enumerated to represent the financial investments of both providers and patients. DALYs averted were calculated to represent the "years lives lost" and "years lost to disability" from diarrheal, respiratory, and skin (bacterial and scabies etiologies) disease among children from 0 to 9 years old. The incremental cost-effectiveness ratio was estimated and compared with the per capita gross domestic product (GDP) of Haiti ($1,177). Cost-effectiveness was defined as an incremental cost-effectiveness ratio less than three times the per capita GDP of Haiti ($3,531). The total costs of the nighttime telemedicine and medication delivery service and hospital emergency care to society were $317,898 per year and $89,392 per year, respectively. The DALYs averted by the service and hospital emergency care were 199.76 and 22.37, respectively. Correspondingly, the incremental cost-effectiveness ratio is estimated at $1,288 signifying that the service costs an additional $1,288 to avert one additional DALY. A scaled nighttime pediatric telemedicine and medication delivery service is likely a cost-effective alternative to hospital emergency care for pre-emergency pediatric conditions in Haiti, and possibly in similar lower-middle-income countries.

Opportunities to catalyse improved healthcare access in pluralistic systems: a cross-sectional study in Haiti

OBJECTIVE

To identify determinants of intended versus actual care-seeking behaviours in a pluralistic healthcare system that is reliant on both conventional and non-conventional providers and discover opportunities to catalyse improved healthcare access.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

In Haiti 568 households (incorporating 2900 members) with children less than 5 years of age were randomly sampled geographically with stratifications for population density. These households identified the healthcare providers they frequented. Among 140 providers, 65 were located and enrolled.

OUTCOME MEASURES

Household questionnaires with standardised cases (intentions) were compared with self-recall of health events (behaviours). The connectedness of households and their providers was determined by network analysis.

RESULTS

Households reported 636 health events in the prior month. Households sought care for 35% (n=220) and treated with home remedies for 44% (n=277). The odds of seeking care increased 217% for severe events (adjusted OR (aOR)=3.17; 95% CI 1.99 to 5.05; p<0.001). The odds of seeking care from a conventional provider increased by 37% with increasing distance (aOR=1.37; 95% CI 1.06 to 1.79; p=0.016). Despite stating an intention to seek care from conventional providers, there was a lack of congruence in practice that favoured non-conventional providers (McNemar's χ² test p<0.001). Care was sought from primary providers for 68% (n=150) of cases within a three-tiered network; 25% (n=38/150) were non-conventional.

CONCLUSION

Addressing geographic barriers, possibly with technology solutions, should be prioritised to meet healthcare seeking intentions while developing approaches to connect non-conventional providers into healthcare networks when geographic barriers cannot be overcome.

Rates of glaucomatous visual field change after trabeculectomy

BACKGROUND

Trabeculectomy is frequently performed in patients with glaucoma who are deteriorating, although its effects on rates of visual field (VF) progression are not fully understood. We studied the rate of VF progression post trabeculectomy comparing with medically treated patients matched for VF loss.

METHODS

Medical records of patients who underwent trabeculectomy alone or combined with cataract extraction were reviewed. Patients with 5 or more 24-2 VF examinations post trabeculectomy were selected. The rate of mean deviation (MD) change after surgery was calculated for each patient. These patients were pairwise matched based on baseline MD with patients with glaucoma who were treated medically and had at least 5 VF tests.

RESULTS

180 surgical patients were identified and matched with 180 medically treated patients (baseline MD of -8.72 (5.24) dB and -8.71 (5.22) dB, respectively). Surgically and medically treated patients were followed for 7.4 (2.9) and 6.8 (3.1) years respectively. The MD slopes were -0.22 (0.55) dB/year and -0.08 (1.10) dB/year in the surgically and medically treated patients, respectively, and not statistically different (p=0.13, 95% CI -0.31 to 0.04). More patients in the surgical group had fast progression (rates worse than -1 dB/year) than in the medical group (17 and 7 patients, respectively, p=0.05).

CONCLUSIONS

Our findings suggest that most patients who undergo trabeculectomy demonstrate relatively slow rates of VF progression postoperatively, similar to patients treated medically, although some patients can continue to progress despite adequate surgical control of intraocular pressure.

Assessing temporal changes in genetic diversity of maize varieties using microsatellite markers

To quantify genetic diversity among modern and earlier maize cultivars, 133 varieties, representative of the maize grown in France during the last five decades, were fingerprinted using 51 SSR. The varieties were grouped into four periods. For each period, allelic richness, genetic diversity and genetic differentiation among periods were computed. A total of 239 alleles were generated. Allelic richness, in terms of number of alleles per locus, for each period was 4.5, 3.6, 3.9 and 3.6 respectively. Genetic diversity corresponding to Nei's unbiased heterozygosity was calculated, based on allelic frequencies. Values ranged from 0.56 to 0.61. Period I presented the highest genetic diversity, whereas the three other periods all presented a similar value. A great proportion of the total genetic diversity (H(T)=0.59) was conserved within all periods (H(S)=0.57), rather than among periods (G(ST)=0.04). The analysis of molecular variance showed that the variation among periods represented only 10% of the total molecular variation. However, the differentiation among periods, although low, was significant, except for the last two periods. Our results showed that the genetic diversity has been reduced by about 10% in the maize cultivars bred before 1976 compared to those bred after 1985. The very low differentiation (G(ST)=0.21%) observed among cultivars of the last two decades should alert French maize breeders to enlarge genetic basis in their variety breeding programmes.

Human cells compromised for p53 function exhibit defective global and transcription-coupled nucleotide excision repair, whereas cells compromised for pRb function are defective only in global repair

After exposure to DNA-damaging agents, the p53 tumor suppressor protects against neoplastic transformation by inducing growth arrest and apoptosis. A series of investigations has also demonstrated that, in UV-exposed cells, p53 regulates the removal of DNA photoproducts from the genome overall (global nucleotide excision repair), but does not participate in an overlapping pathway that removes damage specifically from the transcribed strand of active genes (transcription-coupled nucleotide excision repair). Here, the highly sensitive ligation-mediated PCR was employed to quantify, at nucleotide resolution, the repair of UVB-induced cyclobutane pyrimidine dimers (CPDs) in genetically p53-deficient Li-Fraumeni skin fibroblasts, as well as in human lung fibroblasts expressing the human papillomavirus (HPV) E6 oncoprotein that functionally inactivates p53. Lung fibroblasts expressing the HPV E7 gene product, which similarly inactivates the retinoblastoma tumor-suppressor protein (pRb), were also investigated. pRb acts downstream of p53 to mediate G(1) arrest, but has no demonstrated role in DNA repair. Relative to normal cells, HPV E6-expressing lung fibroblasts and Li-Fraumeni skin fibroblasts each manifested defective CPD repair along both the transcribed and nontranscribed strands of the p53 and/or c-jun loci. HPV E7-expressing lung fibroblasts also exhibited reduced CPD removal, but only along the nontranscribed strand. Our results provide striking evidence that transcription-coupled repair, in addition to global repair, are p53-dependent in UV-exposed human fibroblasts. Moreover, the observed DNA-repair defect in HPV E7-expressing cells reveals a function for this oncoprotein in HPV-mediated carcinogenesis, and may suggest a role for pRb in global nucleotide excision repair.

Fine-scale spatial genetic structure with nonuniform distribution of individuals

This paper presents the first theoretical study of spatial genetic structure within nonuniformly distributed continuous plant populations. A novel individual-based model of isolation by distance was constructed to simulate genetic evolution within such populations. We found larger values of spatial genetic autocorrelations in highly clumped populations than in uniformly distributed populations. Most of this difference was caused by differences in mean dispersal distances, but aggregation probably also produced a slight increase in spatial genetic structure. Using an appropriate level of approximation of the continuous distribution of individuals in space, we assessed the potential effects of density, seed and pollen dispersal, generation overlapping, and overdominance selection at an independent locus, on fine-scale genetic structure, by varying them separately in a few particular cases with extreme clumping. When selfing was allowed, all these input variables influenced both aggregation and spatial genetic structure. Most variations in spatial genetic structure were closely linked to variations in clumping and/or local density. When selfing was not allowed, spatial genetic structure was lower in most cases.

Scattering of the rRNA genes on the physical map of the circular chromosome of Leptospira interrogans serovar icterohaemorrhagiae

Leptospira interrogans is a pathogenic bacterium with a low G+C content (34 to 39%). The restriction enzymes NotI, AscI, and SrfI cut the chromosome of L. interrogans serovar icterohaemorrhagiae into 13, 3, and 5 fragments separable by one- and two-dimensional pulsed-field gel electrophoresis (PFGE). The genome is composed of a circular 4.6-Mbp chromosome and a 0.35-Mbp extrachromosomal element. A physical map of the chromosome was constructed for NotI, AscI, and SrfI by using single and double digests, or partial NotI digests obtained at random or by cross-protection of NotI sites by FnuDII methylase, and linking clones. rRNA genes were found to be widely scattered on the chromosome.

Cloning of dapD, aroD and asd of Leptospira interrogans serovar icterohaemorrhagiae, and nucleotide sequence of the asd gene

Metabolites such as diaminopimelate and some aromatic derivatives, not synthesized in mammalian cells, are essential for growth of bacteria. As a first step towards the design of a new human live vaccine that uses attenuated strains of Leptospira interrogans, the asd, aroD and dapD genes, encoding aspartate beta-semialdehyde dehydrogenase, 3-dehydroquinase and tetrahydrodipicolinate N-succinyltransferase, respectively, were cloned by complementation of Escherichia coli mutants. The complete nucleotide sequence of the asd gene was determined and found to contain an open reading frame capable of encoding a protein of 349 amino acids with a calculated Mr of 38,007. Comparison of this deduced L. interrogans aspartate beta-semialdehyde dehydrogenase amino acid sequence with those of the same enzyme from Saccharomyces cerevisiae and Corynebacterium glutamicum revealed 46% and 36% identity, respectively. By contrast, the identity between the L. interrogans enzyme and the Streptococcus mutans or E. coli enzymes was less than 31%. Highly conserved sequences within aspartate semialdehyde dehydrogenase from the five organisms were observed at the amino and carboxyl termini, and around the cysteine of the active site.

Genome conservation in isolates of Leptospira interrogans

Reference strains for each of the 23 serogroups of Leptospira interrogans yielded different pulsed-field gel electrophoresis patterns of NotI digestion products. This was also the case for the 14 serovars belonging to serogroup Icterohaemorrhagiae (with one exception). The NotI restriction patterns of 45 clinical leptospiral isolates belonging to serovar icterohaemorrhagiae were analyzed and compared with those of type strains. No differences were observed between isolates from countries of different continents, namely, France, French Guiana, New Caledonia, and Tahiti. The pattern was indistinguishable from that of the reference strain of serovar icterohaemorrhagiae.

Sizing of the Leptospira genome by pulsed-field agarose gel electrophoresis

Pulsed-field gel electrophoresis allowed the determination of the size of the genome of Leptospira, a bacterium of the spirochete family. The three restriction enzymes, NotI (5'GC/GGCCGC), NheI (5'G/CTAGC), ApaI (5'-GGGCC/C) generated DNA fragments of suitable size. The results are compatible with a size of 5000 kb for the chromosome of both the pathogenic and the saprophytic species of Leptospira.

Spontaneous hemothorax in a patient with hereditary multiple exostoses

A case of spontaneous hemothorax in a 7-year-old child secondary to erosion of the diaphragm by an exostosis coming from the left sixth rib is reported. This rare case of hemothorax with hereditary multiple exostoses is made even rarer by the concomitant perforation of the diaphragm.

Linear chromosome of Borrelia burgdorferi

The DNA organization of several European and American isolates of Borrelia burgdorferi, the aetiological agent of Lyme disease, was analysed in pulse-field agarose gel electrophoresis. The results of in situ cell lysis in agarose plugs demonstrated a unique arrangement for the DNA of this spirochete. The chromosome of Borrelia behaved as a eukaryotic linear chromosome with a size of around 1,000 kb. The genome also comprised several circular and linear plasmids which varied in size from 15 to 60 kb.

Metamorphic rate in Rana pipiens larvae treated with thyroxine or prolactin at different times in the light/dark cycle

Premetamorphic Rana pipiens tadpoles at Stages V to VIII on a 12L/12D cycle with photoperiod from 0800 to 2000 hr were treated with 30 micrograms/liter thyroxine (T4) by immersion for various daily 8-hr spans, or by daily intraperitoneal injection at different times with 0.1 to 10 micrograms T4 or 10 micrograms prolactin (PRL), in order to see if the rate of metamorphosis varied with the time of hormone treatment. T4 was most effective in promoting tail resorption and hindlimb growth and development if tadpoles were immersed at least partly in the light or if the hormone was injected late in the dark or in the early or mid light phase. T4 was least effective in accelerating metamorphosis when immersion was totally in the dark or injection early in the dark. PRL antagonized metamorphosis just as well at any time of the day except that tail fin growth was faster when PRL was administered early in the dark. The findings show circadian variations in target tissue responsiveness to exogenous T4 that depend on the occurrence of light during T4 immersion or following T4 injection. The data suggest rhythmicity in the secretion of endogenous T4 in the tadpole and a diurnal effect on T4 utilization by target cells.

Basal cell tumour of third eyelid in a horse

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