A web-based telemedicine system for low-resource settings 13 years on: insights from referrers and specialists

Background: One way to tackle health inequalities in resource-poor settings is to establish links between doctors and health professionals there and specialists elsewhere using web-based telemedicine. One such system run by the Swinfen Charitable Trust has been in existence for 13 years which is an unusually long time for such systems. Objective: We wanted to gain some insights into whether and how this system might be improved. Methods: We carried out a survey by questionnaire of referrers and specialists over a six months period. Results: During the study period, a total of 111 cases were referred from 35 different practitioners, of whom 24% were not doctors. Survey replies were received concerning 67 cases, a response rate of 61 per cent. Eighty-seven per cent of the responding referrers found the telemedicine advice useful, and 78% were able to follow the advice provided. As a result of the advice received, the diagnosis was changed in 22% of all cases and confirmed in a further 18 per cent. Patient management was changed in 33 per cent. There was no substantial difference between doctors and non-doctors. During the study period, the 111 cases were responded to by 148 specialists, from whom 108 replies to the questionnaire were received, a response rate of 73 per cent. About half of the specialists (47%) felt that their advice had improved the management of the patients. There were 62 cases where it was possible to match up the opinions of the referrer and the consultants about the value of a specific teleconsultation. In 34 cases (55%) the referrers and specialists agreed about the value. However, in 28 cases (45%) they did not: specialists markedly underestimated the value of a consultation compared to referrers. Both referrers and specialist were extremely positive about the system which appears to be working well. Minor changes such as a clearer referral template and an improved web interface for specialists may improve it

Internet-delivered eye movement desensitization and reprocessing (iEMDR): An open trial

© 2013 Spence J et al. Recent research indicates internet-delivered cognitive behavioural therapy (iCBT) can reduce symptoms of post traumatic stress disorder (PTSD). This study examined the efficacy of an internet-delivered treatment protocol that combined iCBT and internet-delivered eye movement desensitization and reprocessing (iEMDR), in an uncontrolled trial. Eleven of the 15 participants completed post-treatment questionnaires. Large effect sizes were found from pre-treatment to 3-month follow-up ( d = 1.03 - 1.61) on clinician-assessed and self-reported measures of PTSD, anxiety and distress, with moderate effect sizes ( d = 0.59 - 0.70) found on measures of depression and disability. At post-treatment, 55% of the participants no longer met criteria for PTSD and this was sustained at follow-up. Symptom worsening occurred in 3 of 15 (20%) of the sample from pre- to post-treatment; however, these participants reported overall symptom improvement by follow-up. Future research directions for iEMDR are discussed

Ticarcillin hypersusceptibility in pseudomonas aeruginosa in cystic fibrosis

Background: A subpopulation of Pseudomonas aeruginosa (PsA) exists in cysticfibrosis (CF) patients that&nbsp; is&nbsp; hypersusceptible&nbsp; to&nbsp; ticarcillin,&nbsp; a&nbsp; carboxypenicillin,&nbsp; in&nbsp; vitro (Tichs strain)&nbsp; defined&nbsp; as&nbsp; a minimum inhibitory concentration (MIC) ≤4μg/ml. Methods: In a retrospective cohort study, isolates of PsA from CF (23),&nbsp; non-cystic fibrosis bronchiectasis (NCFB) (17) and control (18) patients were analysed. MICs for each isolate were determined using agar dilution against six antibiotics and interpreted using EUCAST breakpoints. Prevalence of Tichs in&nbsp; each&nbsp; cohort&nbsp; was&nbsp; calculated.&nbsp; A&nbsp; point&nbsp; prevalence&nbsp; survey&nbsp; was&nbsp; conducted&nbsp; in&nbsp; CF&nbsp; to&nbsp; review&nbsp; the&nbsp; patients’ clinical progress following PsA isolation. Results: Prevalence of the Tichs strain in PsA was 48%, 76% and 0% in the CF, NCFB and control cohorts respectively. A statistically significant difference in geometric mean MIC was seen between the Tichs and non-Tichs&nbsp; cohorts in CF for ticarcillin (as expected) and temocillin (p=0.041and p=0.036 respectively). A similar trend was observed in NCFB for ticarcillin (p=0.038) and temocillin (p=0.067), although statistical significance was not reached for the latter.In&nbsp; CF,&nbsp; the&nbsp; Tichs&nbsp; strain&nbsp; demonstrated&nbsp; lower&nbsp; MICs&nbsp; to&nbsp; all antibiotics&nbsp; tested&nbsp; apart&nbsp; from&nbsp; gentamicin compared&nbsp; to&nbsp; their&nbsp; non-Tichs counterparts. Those&nbsp; who&nbsp; had the Tichs strain&nbsp; in&nbsp; CF&nbsp; had&nbsp; fewer&nbsp; antibiotics (13.9&nbsp; days&nbsp; versus&nbsp; 23.5&nbsp; days,&nbsp; Tichs&nbsp; and&nbsp; non-Tichs respectively)&nbsp; although&nbsp; this&nbsp; result&nbsp; was&nbsp; not&nbsp; statistically significant p=0.202. Conclusion: Our&nbsp; data&nbsp; supports&nbsp; the&nbsp; existence&nbsp; of&nbsp; a&nbsp; Tichs strain&nbsp; of&nbsp; PsA&nbsp; in&nbsp; our&nbsp; CF&nbsp; and&nbsp; NCFB&nbsp; patient populations. This strain correlated with reduced MICs to temocillin in CF, to which PsA would normally be resistant, which may be of clinical relevance.</p

A Comparison of Esomeprazole and Lansoprazole for Control of Intragastric pH in Patients With Symptoms of Gastro-Oesophageal Reflux Disease

Background: Intragastric acid suppression is the most direct measure of the pharmacodynamic efficacy of proton pump inhibitors, which are the most effective drugs for acid-related diseases. Aim: To compare the effectiveness of once and twice daily dosing of lansoprazole and esomeprazole in controlling intragastric acidity ( target gastric pH \u3e 4.0) over a 24-hour period. Methods: In an open-label, two-way crossover study, 45 Helicobacter pylori-negative patients with gastro-oesophageal reflux disease were randomized to receive one of two regimens: 30 mg lansoprazole or esomeprazole 40 mg once daily. Intragastric pH was assessed by 24-hour pH monitoring on day 5 of each regimen. Dosing was increased to twice daily and pH was re-assessed on day 10. Following a 14-day washout, patients were crossed over to the other medication and the dosage regimens and pH assessments were repeated. Results: Data were analysed from 35 patients who completed all scheduled assessments and had 24-hour monitoring for each end-point. Mean time pH \u3e 4.0 and mean 24-hour pH were highest for esomeprazole 40 mg twice daily, followed by lansoprazole 30 mg twice daily, esomeprazole 40 mg once daily and lansoprazole 30 mg once daily. Esomeprazole 40 mg twice daily provided superior control of intragastric pH compared with either once or twice daily dosing of lansoprazole and once daily dosing of esomeprazole (P \u3c 0.01). Esomeprazole 40 mg once daily was comparable with lansoprazole 30 mg twice daily and both were superior to lansoprazole 30 mg once daily (P \u3c 0.01). Conclusions: Response to acid suppression treatment depends on the treatment selected. Esomeprazole 40 mg twice daily provided better control of intragastric pH than all other regimens evaluated. Esomeprazole 40 mg daily, however, was comparable with lansoprazole 30 mg twice daily and superior to lansoprazole 30 mg once daily

Characterization of heterogeneous vancomycin-intermediate resistance, MIC and accessory gene regulator (agr) dysfunction among clinical bloodstream isolates of staphyloccocus aureus

<p>Abstract</p> <p>Background</p> <p>The development of hVISA has been associated with vancomycin clinical failures and is commonly misidentified in clinical microbiology laboratories. Therefore, the objectives of this present study was to improve the reliability of methodologies and criteria for identifying hVISA, evaluate the prevalence of hVISA among clinical bloodstream isolates of <it>S. aureus </it>and determine if there exists a relationship between accessory gene regulator (<it>agr) </it>dysfunction and the hVISA phenotype.</p> <p>Methods</p> <p>The presence of hVISA in 220 clinical <it>S. aureus </it>isolates (121 MSSA, 99 MRSA) from bloodstream infections was examined by CLSI broth microdilution, Macro & Standard Etest. Isolates which were classified as hVISA by Macro Etest, were additionally evaluated using a modified PAP-AUC method using a modified starting inoculum of 10¹⁰CFU/mL, and growth on brain heart infusion agar with 4 mg/L vancomycin (BHIV4) at 10⁸and 10¹⁰CFU/mL, and <it>agr </it>function was assessed by delta-hemolysin production.</p> <p>Results</p> <p>Broth microdilution MIC_50/90of <it>S.aureus </it>and hVISA was 1.0/2.0 and 1.5/2.0 mg/L (<it>p</it>= 0.02), respectively. Macro Etest identified 12 (5.5%) hVISA isolates; higher among MRSA (9.1%) versus MSSA (2.5%) (<it>p </it>= 0.03). The mean modified PAP-AUC ratios (> 0.8) of 7 MRSA strains and 3 MSSA strains were significantly different (<it>p </it>= 0.001). 58% of hVISA strains were found to be <it>agr </it>dysfunctional when 21% of MRSA strains were <it>agr </it>dysfunctional. hVISA was detected among <it>S. aureus </it>bloodstream isolates, which were classified as susceptible among clinical microbiology laboratories.</p> <p>Conclusions</p> <p>Evaluating the correlation between Etest MICs and modified PAP-AUC ratio values will add further improvement of discriminating hVISA, and <it>agr </it>dysfunction may be predictive of strains which display a greater predilection to display the hVISA phenotype.</p

Barriers to healthcare access and experiences of stigma: Findings from a coproduced Long Covid case-finding study

Background and Aim Long Covid is often stigmatised, particularly in people who are disadvantaged within society. This may prevent them from seeking help and could lead to widening health inequalities. This coproduced study with a Community Advisory Board (CAB) of people with Long Covid aimed to understand healthcare and wider barriers and stigma experienced by people with probable Long Covid. Methods An active case finding approach was employed to find adults with probable, but not yet clinically diagnosed, Long Covid in two localities in London (Camden and Merton) and Derbyshire, England. Interviews explored the barriers to care and the stigma faced by participants and were analysed thematically. This study forms part of the STIMULATE-ICP Collaboration. Findings Twenty-three interviews were completed. Participants reported limited awareness of what Long Covid is and the available pathways to management. There was considerable self-doubt among participants, sometimes reinforced by interactions with healthcare professionals (HCPs). Participants questioned their deservedness in seeking healthcare support for their symptoms. Hesitancy to engage with healthcare services was motivated by fear of needing more investigation and concerns regarding judgement about the ability to carry out caregiving responsibilities. It was also motivated by the complexity of the clinical presentation and fear of all symptoms being attributed to poor mental health. Participants also reported trying to avoid overburdening the health system. These difficulties were compounded by experiences of stigma and discrimination. The emerging themes reaffirmed a framework of epistemic injustice in relation to Long Covid, where creating, interpreting and conveying knowledge has varied credibility based on the teller's identity characteristics and/or the level of their interpretive resources. Conclusion We have codeveloped recommendations based on the findings. These include early signposting to services, dedicating protected time to listening to people with Long Covid, providing a holistic approach in care pathways, and working to mitigate stigma. Regardless of the diagnosis, people experiencing new symptoms must be encouraged to seek timely medical help. Clear public health messaging is needed among communities already disadvantaged by epistemic injustice to raise awareness of Long Covid, and to share stories that encourage seeking care and to illustrate the adverse effects of stigma

Controlling chaotic transport in a Hamiltonian model of interest to magnetized plasmas

We present a technique to control chaos in Hamiltonian systems which are close to integrable. By adding a small and simple control term to the perturbation, the system becomes more regular than the original one. We apply this technique to a model that reproduces turbulent ExB drift and show numerically that the control is able to drastically reduce chaotic transport

Modelling long-distance route choice using mobile phone call detail record data: A case study of Senegal

The growing mobile phone penetration rates have led to the emergence of large-scale call detail records (CDRs) that could serve as a low-cost data source for travel behaviour modelling. However, to the best of our knowledge, there is no previous study evaluating the potential of CDR data in the context of route choice behaviour modelling. Being event-driven, the data are discontinuous and only able to yield partial trajectories, thus presenting serious challenges for route identification. This paper proposes techniques for inferring the users' chosen routes or subsets of their likely routes from partial CDR trajectories, as well as data fusion with external sources of information such as route costs, and then adapts the broad choice framework to the current modelling scenario. The model results show that CDR data can capture the expected travel behaviour and the derived values of travel time are found to be realistic for the study area

Application of semantic control to a class of pursuer-evader problems

AbstractIn this article, we describe our work in developing a comprehensive software system for tactical decision aiding for an evader faced with multiple pursuers. The objective is to provide the evader with defensive maneuver decisions that maximize its chances of survival.We have developed a hierarchical semantic controller consisting of a System Identifier, a Goal Selector and an Adapter. This system is implemented on a 386DX personal computer via object-oriented programming, knowledge-based systems, Analytical Hierarchy Process, optimal control, and differential game methodologies.The viability of our Semantic Control approach to the evasive action selection problem has been shown and its operation has been tested against pursuers which follow either pure pursuit or proportional guidance strategies. The user is included in the decision process via approval of setpoints. Displays of the engagement and effect of coverage by countermeasures provide a visual reinforcement of the recommendation made. Use of semantic controllers as TDA support systems for man-in-the-loop, pursuer-evader problems on a PC with current software and hardware technology is feasible. The ability to deploy the system on a portable PC permits the use of the technology in a wide variety of applications

MRI radiomic features are independently associated with overall survival in soft tissue sarcoma

Purpose: Soft tissue sarcomas (STS) represent a heterogeneous group of diseases, and selection of individualized treatments remains a challenge. The goal of this study was to determine whether radiomic features extracted from magnetic resonance (MR) images are independently associated with overall survival (OS) in STS. Methods and Materials: This study analyzed 2 independent cohorts of adult patients with stage II-III STS treated at center 1 (N = 165) and center 2 (N = 61). Thirty radiomic features were extracted from pretreatment T1-weighted contrast-enhanced MR images. Prognostic models for OS were derived on the center 1 cohort and validated on the center 2 cohort. Clinical-only (C), radiomics-only (R), and clinical and radiomics (C+R) penalized Cox models were constructed. Model performance was assessed using Harrell\u27s concordance index. Results: In the R model, tumor volume (hazard ratio [HR], 1.5) and 4 texture features (HR, 1.1-1.5) were selected. In the C+R model, both age (HR, 1.4) and grade (HR, 1.7) were selected along with 5 radiomic features. The adjusted c-indices of the 3 models ranged from 0.68 (C) to 0.74 (C+R) in the derivation cohort and 0.68 (R) to 0.78 (C+R) in the validation cohort. The radiomic features were independently associated with OS in the validation cohort after accounting for age and grade (HR, 2.4; Conclusions: This study found that radiomic features extracted from MR images are independently associated with OS when accounting for age and tumor grade. The overall predictive performance of 3-year OS using a model based on clinical and radiomic features was replicated in an independent cohort. Optimal models using clinical and radiomic features could improve personalized selection of therapy in patients with STS