Digital clinical support tools to improve child health: development, implementation, and evaluation of ePOCT+ to support healthcare providers in the management of sick children at primary care health facilities in Tanzania

Bacterial antimicrobial resistance due to inappropriate antibiotic use, and poor quality of care are major contributors to the unacceptably high childhood mortality in Tanzania. Electronic Clinical Decision Support Algorithms (CDSAs) are evidence based digital health tools based on clinical guidelines that guide health providers through a consultation to ultimately propose the diagnosis and treatment based on the inputs entered. Such tools have been found to reduce antibiotic prescription and improve quality of care. Nonetheless, there is a lack of pragmatic studies evaluating CDSAs in Tanzania, and there are many remaining challenges with previously developed CDSAs. The aim of this project was to improve quality of care and reduce antibiotic prescription at primary care level health facilities in Tanzania. This was done by first developing the ePOCT+ clinical decision support algorithm, addressing challenges identified in other CDSAs, and secondly evaluating the effect of ePOCT+ on antibiotic prescription in a pragmatic cluster randomized controlled trial (DYNAMIC Tanzania study). To improve uptake, adherence, safety, and potential for antibiotic stewardship, ePOCT+ expanded the clinical scope of the clinical algorithms, expanded the age range of patients it could manage, and assured comprehensive input from clinical and digital experts, as well as health provider end-users. Numerous meetings were conducted, Delphi processes were utilized, and comprehensive piloting was performed to develop ePOCT+. In order to assure safety, a systematic review was conducted to identify the best performing predictors of severe disease to integrate within the algorithm. The DYNAMIC Tanzania study was a pragmatic, open-label, parallel-group, cluster randomized trial in 40 primary health facilities in the Mbeya and Morogoro regions of Tanzania. Randomization of health facilities were stratified by region, council, level of health facility, and attendance rate. The intervention consisted of the ePOCT+ CDSA with supporting IT infrastructure, C-reactive protein rapid test, hemoglobin rapid test, pulse oximeter, training and supportive mentorship. Co-primary outcomes were 1) antibiotic prescription at the time of the initial consultation (superiority analysis), and 2) clinical failure at day 7 defined as “not cured” and “not improved”, or unscheduled hospitalization (non-inferiority analysis). Secondary safety outcomes include unscheduled re-attendance visits, non-referred secondary hospitalization and death by day 7. Analyses were performed using a random effects logistic regression model using the cluster and patient as random effects, with further adjustment using fixed effect terms for randomization stratification factors, and baseline characteristics. The systematic review on predictors of severe disease in febrile children presenting from the community identified 18 studies evaluating 200 prognostic factors and 25 clinical prediction models in 24 530 children. There were few outpatient and primary care studies identified. The most common and best preforming predictors of severe disease were malnutrition, altered consciousness, markers of acidosis, and poor peripheral perfusion. In expanding the age scope of ePOCT+ to manage children 1 day to 15 years, and based on feedback from previous studies and CDSAs, additional illnesses were integrated in the ePOCT+ clinical algorithm. These include trauma, urinary tract infection, and abdominal pain, selected based on 1) incidence, 2) morbidity/mortality, and 3) feasibility at primary care. A Delphi survey among 30 Tanzanian health providers evaluated feasibility, acceptability and reliability of integrating specific predictors within ePOCT+, notably predictors identified within the systematic review. Feasibility tests in over 200 patients in 20 health facilities, and pilots in over 2000 consultations, lead to modifications to ePOCT+ based on user-experience feedback and observations, notably providing option to not measure some clinical signs when not feasible, allow health providers to accept or refuse a proposed diagnosis or treatment, provide alternative medicines in case of stock-outs, and highlighting clinical elements that would result in referral. The DYNAMIC Tanzania cluster randomized trial took place between December 2021 to October 2022. Over 40,000 children under 15 years of age were enrolled in 20 health facilities (clusters) where health providers could use ePOCT+, and 20 health facilities where health providers provided care as usual. The co-primary outcomes found that the use of ePOCT+ resulted in a 3-fold reduction in the likelihood of a sick child receiving an antibiotic prescription compared to children in usual care health facilities. Despite substantially fewer antibiotics prescriptions, the co-primary outcome of clinical failure was non-inferior. There were also no differences in the secondary outcomes of death, secondary hospitalization, and additional medications after the initial consultations between study arms by day 7. In conclusion, the ePOCT+ electronic clinical decision support algorithm if implemented to scale could help address the urgent problem of antimicrobial resistance by safely reducing antibiotic prescribing. Transfer of ownership to the ministry of health of Tanzania and integration within the Tanzanian digital health landscape will be essential in order to achieve wide scale implementation

Readout of the atomtronic quantum interference device

A Bose-Einstein condensate confined in ring shaped lattices interrupted by a weak link and pierced by an effective magnetic flux defines the atomic counterpart of the superconducting quantum interference device: the atomtronic quantum interference device (AQUID). In this paper, we report on the detection of current states in the system through a self-heterodyne protocol. Following the original proposal of the NIST and Paris groups, the ring-condensate many-body wave function interferes with a reference condensate expanding from the center of the ring. We focus on the rf-AQUID which realizes effective qubit dynamics. Both the Bose-Hubbard and Gross-Pitaevskii dynamics are studied. For the Bose-Hubbard dynamics, we demonstrate that the self-heterodyne protocol can be applied, but higher-order correlations in the evolution of the interfering condensates are measured to readout of the current states of the system. We study how states with macroscopic quantum coherence can be told apart analyzing the noise in the time of flight of the ring condensate

Spatial origin analysis on atmospheric bulk deposition of polycyclic aromatic hydrocarbons in Shanghai

Atmospheric deposition of polycyclic aromatic hydrocarbons (PAHs) onto soil threatens terrestrial ecosystem. To locate potential source areas geographically, a total of 139 atmospheric bulk deposition samples were collected during 2012–2019 at eight sites in Shanghai and its surrounding areas. A multisite joint location method was developed for the first time to locate potential source areas of atmospheric PAHs based on an enhanced three dimensional concentration weighted trajectory model. The method considered spatial and temporal variations of atmospheric boundary layer height and homogenized all results over the eight sites via geometric mean. Regional transport was an important contributor of PAH atmospheric deposition while massive local emissions may disturb the identification of potential source areas. Northwesterly winds were associated with elevated deposition fluxes. Potential source areas were identified by the multisite joint location method and included Hebei, Tianjin, Shandong and Jiangsu to the north, and Anhui to the west of Shanghai. PM and SO2 data from the national ground monitoring stations confirmed the identified source areas of deposited PAHs in Shanghai

Vaccine-associated measles in a patient treated with natalizumab: a case report

Safety of live vaccines in patients treated with immunosuppressive therapies is not well known, resulting in contradictory vaccination recommendations. We describe here the first case of vaccine-associated measles in a patient on natalizumab treatment. A young female patient with relapsing-remitting multiple sclerosis on natalizumab treatment received the live attenuated measles, mumps, and rubella vaccine in preparation for a change in her treatment in favour of fingolimod, with established immunosuppressive qualities. Seven days after receiving the vaccine, our patient experienced diffuse muscle pain, fatigue, and thereafter developed a fever and then an erythematous maculopapular rash, compatible with vaccine associated measles. This was later confirmed by a positive measles RT-PCR throat swab. The patient's symptoms resolved without any sequelae. In this case report we review the immunosuppressive qualities of natalizumab and the evidence in favour and against live vaccines in patients on this treatment. Our findings reveal the insufficient understanding of the immunosuppressive effects of new immunomodulators, and thus of the safety of live vaccines in patients on such medications. While this case triggers precaution, there is insufficient evidence to conclude that natalizumab treatment could favor the onset of vaccine-associated measles

Tuning quantum non-local effects in graphene plasmonics

The response of an electron system to electromagnetic fields with sharp spatial variations is strongly dependent on quantum electronic properties, even in ambient conditions, but difficult to access experimentally. We use propagating graphene plasmons, together with an engineered dielectric-metallic environment, to probe the graphene electron liquid and unveil its detailed electronic response at short wavelengths.The near-field imaging experiments reveal a parameter-free match with the full theoretical quantum description of the massless Dirac electron gas, in which we identify three types of quantum effects as keys to understanding the experimental response of graphene to short-ranged terahertz electric fields. The first type is of single-particle nature and is related to shape deformations of the Fermi surface during a plasmon oscillations. The second and third types are a many-body effect controlled by the inertia and compressibility of the interacting electron liquid in graphene. We demonstrate how, in principle, our experimental approach can determine the full spatiotemporal response of an electron system.Comment: 8 pages, 4 figure

Integrierte e-Learning-Services als Grundlage von qualifiziertem e-Learning an Hochschulen: Das Beispiel Hannover - Braunschweig

Die Anforderungen an Lehrende, die auf qualifizierte Weise e-Learning in ihren Lehr­veranstaltungen einsetzen wollen sind erheblich. Um zu technisch, didaktisch und organisatorisch innovativen Lehr-/Lernszenarien zu gelangen, muss nicht nur der einzelne Lehrende Kompetenzen aufbauen. Auch die mit der Lehre befassten Organisationseinheiten müssen hier Entwicklungen vollziehen. Wie können die Lehrenden und deren institutioneller Hintergrund bei diesen Prozessen unterstützt werden? Im Rahmen eines Förderprogramms des Landes Niedersachsen, dem e-Learning Academic Network (ELAN), haben sich die Technische Universität Braun­schweig, die Universität Hannover und die Medizinische Hochschule Hanno­ver zu einem Netzpiloten zusammengeschlossen. Einen Teil dieses Verbundes bildet das e-Learning Service Team (eST). Der Handlungsansatz des eST zielt sowohl auf die individuelle Kompetenzbildung des einzelnen Lehrenden, unter­stützt organisatorische Veränderungsprozesse und versteht sich selbst als Teil eines hochschulübergreifenden Entwicklungsprozesses, in dem Serviceeinheiten wie das eST komplementäre Aufgaben für die Hochschullehre übernehmen. Grundlage dafür bilden integrierte e-Learning-Services, also die Verknüpfung der verschiedenen Handlungsdimensionen des e-Learnings in einem Angebot, sowie ein prozessorientiertes Beratungsmodell, das Projekte und Organisationseinheiten dabei unterstützt ein so genanntes qualifiziertes eTeaching zu gestalten. 25.02.2007 | Rainer ALBRECHT, Uwe FROMMANN & Thanh-Thu PHAN TAN (Braunschweig, Hannover

Time Resolved TDLAS Investigation of Pre-ionization Effect in Dual HiPIMS Discharges

Time-resolved measurements have been performed during dual High Power Impulse Magnetron Sputtering (dual-HiPIMS) with two cathodes in a closed magnetic field configuration. The dual-HiPIMS system, operated at a repetition frequency f = 100 Hz and duty cycle of 1\%, was equipped with two different metallic targets (Ti, Cu). Pre-ionization effect of the Ti pulse on the Cu pulse was investigated through argon excited atom density and temperature by means of tunable diode laser absorption spectroscopy. We observed an enhancement of metastable density due to pre-ionization effect. It is shown that the peak density in the Cu pulse increases about 30\% for the case of 15$\mu$s delay then decrease as the delay was prolonged. The effect displays even stronger in the peak density in the afterglow, as well as in the atom temperature behavior. Although metastable atoms are abundantly available in post-discharge, they play minor role in the ignition of the subsequence pulse