A patient-driven clinicogenomic partnership for metastatic prostate cancer.

Molecular profiling studies have enabled discoveries for metastatic prostate cancer (MPC) but have predominantly occurred in academic medical institutions and involved non-representative patient populations. We established the Metastatic Prostate Cancer Project (MPCproject, mpcproject.org), a patient-partnered initiative to involve patients with MPC living anywhere in the US and Canada in molecular research. Here, we present results from our partnership with the first 706 MPCproject participants. While 41% of patient partners live in rural, physician-shortage, or medically underserved areas, the MPCproject has not yet achieved racial diversity, a disparity that demands new initiatives detailed herein. Among molecular data from 333 patient partners (572 samples), exome sequencing of 63 tumor and 19 cell-free DNA (cfDNA) samples recapitulated known findings in MPC, while inexpensive ultra-low-coverage sequencing of 318 cfDNA samples revealed clinically relevant AR amplifications. This study illustrates the power of a growing, longitudinal partnership with patients to generate a more representative understanding of MPC.

If we build it, will they come? Results of a quasi-experimental study assessing the impact of maternity waiting homes on facility-based childbirth and maternity care in Zambia.

INTRODUCTION: Maternity waiting homes (MWHs) aim to increase access to maternity and emergency obstetric care by allowing women to stay near a health centre before delivery. An improved MWH model was developed with community input and included infrastructure, policies and linkages to health centres. We hypothesised this MWH model would increase health facility delivery among remote-living women in Zambia. METHODS: We conducted a quasi-experimental study at 40 rural health centres (RHC) that offer basic emergency obstetric care and had no recent stockouts of oxytocin or magnesium sulfate, located within 2 hours of a referral hospital. Intervention clusters (n=20) received an improved MWH model. Control clusters (n=20) implemented standard of care. Clusters were assigned to study arm using a matched-pair randomisation procedure (n=20) or non-randomly with matching criteria (n=20). We interviewed repeated cross-sectional random samples of women in villages 10+ kilometres from their RHC. The primary outcome was facility delivery; secondary outcomes included postnatal care utilisation, counselling, services received and expenditures. Intention-to-treat analysis was conducted. Generalised estimating equations were used to estimate ORs. RESULTS: We interviewed 2381 women at baseline (March 2016) and 2330 at endline (October 2018). The improved MWH model was associated with increased odds of facility delivery (OR 1.60 (95% CI: 1.13 to 2.27); p<0.001) and MWH utilisation (OR 2.44 (1.62 to 3.67); p<0.001). The intervention was also associated with increased odds of postnatal attendance (OR 1.55 (1.10 to 2.19); p<0.001); counselling for family planning (OR 1.48 (1.15 to 1.91); p=0.002), breast feeding (OR 1.51 (1.20 to 1.90); p<0.001), and kangaroo care (OR 1.44 (1.15, 1.79); p=0.001); and caesarean section (OR 1.71 (1.16 to 2.54); p=0.007). No differences were observed in household expenditures for delivery. CONCLUSION: MWHs near well-equipped RHCs increased access to facility delivery, encouraged use of facilities with emergency care capacity, and improved exposure to counselling. MWHs can be useful in the effort to increase delivery at advanced facilities in areas where substantial numbers of women live remotely. TRIAL REGISTRATION NUMBER: NCT02620436.

Building financial management capacity for community ownership of development initiatives in rural Zambia.

BACKGROUND: Building financial management capacity is increasingly important in low- and middle-income countries to help communities take ownership of development activities. Yet, many community members lack financial knowledge and skills. METHODS: We designed and conducted financial management trainings for 83 members from 10 community groups in rural Zambia. We conducted pre-training and post-training tests and elicited participant feedback. We conducted 28 in-depth interviews over 18 months and reviewed financial records to assess practical application of skills. RESULTS: The training significantly improved knowledge of financial concepts, especially among participants with secondary education. Participants appreciated exercises to contextualize financial concepts within daily life and liked opportunities to learn from peers in small groups. Language barriers were a particular challenge. After trainings, sites successfully adhered to the principles of financial management, discussing the benefits they experienced from practicing accountability, transparency, and accurate recordkeeping. CONCLUSION: Financial management trainings need to be tailored to the background and education level of participants. Trainings should relate financial concepts to more tangible applications and provide time for active learning. On-site mentorship should be considered for a considerable time. This training approach could be used in similar settings to improve community oversight of resources intended to strengthen developmental initiatives.

Epidemiology of Emergency Medical Services (EMS) Utilization in Four Indian Emergency Departments.

Introduction Without a universal Emergency Medical Services (EMS) system in India, data on the epidemiology of patients who utilize EMS are limited. This retrospective chart review aimed to quantify and describe the burden of disease and patient demographics of patients who arrived by EMS to four Indian emergency departments (EDs) in order to inform a national EMS curriculum. METHODS: A retrospective chart review was performed on patients transported by EMS over a three-month period in 2014 to four private EDs in India. A total of 17,541 patient records were sampled from the four sites over the study period. Of these records, 1,723 arrived by EMS and so were included for further review. RESULTS: A range of 1.4%-19.4% of ED patients utilized EMS to get to the ED. The majority of EMS patients were male (59%-64%) and adult or geriatric (93%-99%). The most common chief complaints and ED diagnoses were neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease. CONCLUSIONS: Neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease are the most common problems found in patients transported by EMS in India. Adult and geriatric male patients are the most common EMS utilizers. Emergency Medical Services curricula should emphasize these knowledge areas and skills. Wijesekera O , Reed A , Chastain PS , Biggs S , Clark EG , Kole T , Chakrapani AT , Ashish N , Rajhans P , Breaud AH , Jacquet GA . Epidemiology of Emergency Medical Services (EMS) utilization in four Indian emergency departments. Prehosp Disaster Med. 2016;31(6):675-679.