Remote Consulting in Primary Health Care in Low- and Middle-Income Countries: Feasibility Study of an Online Training Program to Support Care Delivery During the COVID-19 Pandemic.

BACKGROUND: Despite acceleration of remote consulting throughout the COVID-19 pandemic, many health care professionals are practicing without training to offer teleconsultation to their patients. This is especially challenging in resource-poor countries, where the telephone has not previously been widely used for health care. OBJECTIVE: As the COVID-19 pandemic dawned, we designed a modular online training program for REmote Consulting in primary Health care (REaCH). To optimize upscaling of knowledge and skills, we employed a train-the-trainer approach, training health workers (tier 1) to cascade the training to others (tier 2) in their locality. We aimed to determine whether REaCH training was acceptable and feasible to health workers in rural Tanzania to support their health care delivery during the pandemic. METHODS: We developed and pretested the REaCH training program in July 2020 and created 8 key modules. The program was then taught remotely via Moodle and WhatsApp (Meta Platforms) to 12 tier 1 trainees and cascaded to 63 tier 2 trainees working in Tanzania's rural Ulanga District (August-September 2020). We evaluated the program using a survey (informed by Kirkpatrick's model of evaluation) to capture trainee satisfaction with REaCH, the knowledge gained, and perceived behavior change; qualitative interviews to explore training experiences and views of remote consulting; and documentary analysis of emails, WhatsApp texts, and training reports generated through the program. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed thematically. Findings were triangulated and integrated during interpretation. RESULTS: Of the 12 tier 1 trainees enrolled in the program, all completed the training; however, 2 (17%) encountered internet difficulties and failed to complete the evaluation. In addition, 1 (8%) opted out of the cascading process. Of the 63 tier 2 trainees, 61 (97%) completed the cascaded training. Of the 10 (83%) tier 1 trainees who completed the survey, 9 (90%) would recommend the program to others, reported receiving relevant skills and applying their learning to their daily work, demonstrating satisfaction, learning, and perceived behavior change. In qualitative interviews, tier 1 and 2 trainees identified several barriers to implementation of remote consulting, including lacking digital infrastructure, few resources, inflexible billing and record-keeping systems, and limited community awareness. The costs of data or airtime emerged as the greatest immediate barrier to supporting both the upscaling of REaCH training and subsequently the delivery of safe and trustworthy remote health care. CONCLUSIONS: The REaCH training program is feasible, acceptable, and effective in changing trainees' behavior. However, government and organizational support is required to facilitate the expansion of the program and remote consulting in Tanzania and other low-resource settings.

A randomized comparison of retention balloon and standard tip rectal catheters in preventing incontinence during double-contrast barium enema.

OBJECTIVE: The objective of this comparison was to determine if retention balloon catheters are more effective than standard tip catheters in preventing barium incontinence during double-contrast barium enemas. SUBJECTS AND METHODS: A prospective randomized study was conducted over a 1-year period after institutional review board approval. Two hundred twenty-three patients (102 men, 121 women; median age, 68 years; age range, 50-94 years) were randomized to retention balloon or standard tip catheter after giving informed consent. Barium incontinence was graded A (did not lead to examination failure) or B (led to examination failure). RESULTS: One hundred thirteen patients (51%) were examined with retention balloon catheters and 110 patients (49%) with standard tip catheters. In the retention balloon catheter group, 26 patients (23%) were incontinent (22 [19.5%] grade A, four [3.5%] grade B). In the standard tip catheter group, 31 patients (28%) were incontinent (24 [21.8%] grade A, seven [6.4%] grade B). No significant difference was seen in incontinence rates between the two catheter groups (p = 0.54, chi-square test). Sixteen patients (7.2%) gave a prior history of fecal incontinence. Of these, 15 (94%) developed incontinence, and in seven (44%), grade-B incontinence led to examination failure. CONCLUSION: Retention balloon catheters have no advantage over standard tip catheters at preventing barium incontinence. Given the possible higher rates of rectal trauma associated with retention balloon catheters, their use may not be justified. A prior history of fecal incontinence is a strong predictor of examination failure.

Transcriptomics and proteomics: tools for optimising phytoremediation activities.

Negligent industrial development has greatly contributed to environmental pollution through the contamination of water and soil by xenobiotic organic chemicals Remedial strategies to deal with chemical pollution require reliable methods to identify and monitor contamination, as well as effective procedures to attenuate or to eliminate the pollutant. In the food chain, plants are ideally placed as early bio-indicators of environmental pollution as they experience and respond to environmental toxicants sooner than organisms at higher trophic levels. Furthermore, some plants are capable of detoxifying anthropogenic chemicals by metabolic transformation and could prove useful for the remediation of contaminated water and soil: so-called phytoremediation. So far research technologies aimed at developing plants for bio-indication/bio-monitoring and for remediation have largely relied on standardised chemical and biochemical procedures to evaluate phytotoxicity, metabolic fate and persistence of organic pollutants in plants. The next stage in the evolution of these plant-based technologies is the improvement and optimisation of any innate phytoremediation activities identified in selected plants. In general, uptake followed by metabolism and compartmentation is responsible for the detoxification of organic xenobiotics in plants. These are complex cellular systems that may be organised in well-defined pathways and are often controlled by large families of genes. In order to elucidate complex traits such as detoxification, an emerging idea is to make use of global approaches such as the new "omic" technologies to identify molecular changes in plant tissues exposed to specific organic xenobiotics. From expression profiles at the messenger RNA level, transcriptomics permit the identification of function-related gene clusters and at the protein level proteomics provide information on where, when and at what level specific proteins accumulate. We conclude that these global approaches may be a useful way of widening screening capability to identify appropriate molecular markers that can be used to improve detoxification activity.

Expression profiling of the response of Arabidopsis thaliana to methanol stimulation.

In order to obtain information about the metabolism of methanol in plants, gene expression in response to methanol stimulation was analysed in leaves of Arabidopsis thaliana through the use of a 26,090 element oligonucleotide microarray. Following confirmation of data and the application of selection criteria, a total of 484 (1.9%) transcripts were shown to be regulated in response to a 10% methanol application. Samples were taken at 1, 24 and 72 h. Of the total identified transcripts, only 20 were shared between all three time points of which only two were down-regulated. Based on functional category analysis of these genes, at 1 h, the largest categories were metabolism, cell communication/signal transduction processes, defence genes associated with transcription and aspects of RNA processing; a few related to cell division and growth; but none were associated with photosynthesis. At 24 and 72 h, the number and overall proportion of regulated transcripts associated with metabolism increased further. Direct measurement of anthocyanin and flavonoid content confirmed that methanol-regulated transcripts corresponded to flavonoid pathways. Within the functional class metabolism, genes encoding detoxification proteins represented by far the most strongly regulated group. These included, cytochrome P450's, glucosyl transferases and members of the ABC transporter family. It is concluded that exposure to methanol affects the expression of hundreds of genes and that multiple detoxification and signalling pathways are activated.

Arteriojugular endothelin-1 gradients in aneurysmal subarachnoid haemorrhage.

Plasma endothelin (ET) is elevated in patients with vasospasm following subarachnoid haemorrhage (SAH). However, systemic levels provide no indication regarding local production in the brain, and late elevation may be a consequence rather than a cause of vasospasm. We measured arteriojugular (AJ) gradients of ET-1 in 17 patients over the first week after SAH, and related these to the subsequent development of vasospasm. Daily, paired arterial and jugular bulb blood samples were obtained up to seven days post SAH, and assayed for ET-1 using radioimmunoassay. Systemic levels and AJ gradients were compared in patients with and without vasospasm. Significant AJ gradients were observed for ET-1 (P<0.01). These differences remained significant in the subgroup of patients who developed vasospasm (0.12+/-0.05 pmol/l; P<0.05), in whom AJ gradients represented 25+/-7% of systemic levels (0.84+/-0.05 pmol/l). AJ gradients did not reach significance in patients who did not develop vasospasm (0.09+/-0.07 pmol/l; P=0.2). Systemic ET-1 levels and AJ gradients were unrelated to SAH grade, surgical or endovascular interventions, or extracranial complications. AJ gradients in the first week following SAH suggest early production of ET-1 in the cerebrovascular bed. However, early systemic ET-1 levels did not discriminate between patients with and without vasospasm. Larger AJ differences may predict vasospasm, but further work is needed to confirm this observation. AJ gradient measurement may provide a useful technique for investigating the role of other peptides in acute brain injury.