Emerging Therapies in Management of Cholangiocarcinoma.

Cholangiocarcinoma is a heterogeneous group of biliary tract cancers that has a poor prognosis and globally increasing incidence and mortality. While surgical resection remains the only curative option for the treatment of cholangiocarcinoma, the majority of cancers are unresectable at the time of diagnosis. Additionally, the prognosis of cholangiocarcinoma remains poor even with the current first-line systemic therapy regimens, highlighting the difficulty of treating locally advanced, metastatic, or unresectable cholangiocarcinoma. Through recent developments, targetable oncogenic driver mutations have been identified in the pathogenesis of cholangiocarcinoma, leading to the utilization of molecular targeted therapeutics. In this review, we comprehensively discuss the latest molecular therapeutics for the treatment of cholangiocarcinoma, including emerging immunotherapies, highlighting promising developments and strategies.

Prevalence of dementia and its association with central nervous system infections among older persons in northern Uganda: cross-sectional community-based study.

BACKGROUND: Dementia is a condition in which there is deterioration in cognitive function beyond what might be expected from the usual consequence of biological aging. Few studies have been conducted on the prevalence of dementia and its association with central nervous system (CNS) infections among older persons in African settings, particularly in Uganda. Therefore, this study assessed the prevalence of dementia and its association with CNS infections among older persons in Lira District, northern Uganda. METHODS: This was a cross-sectional community-based study in Lira district northern Uganda. The study was conducted in March 2022 among 434 older persons aged 50 and above years who were selected by multistage sampling. Data were collected using an interviewer-administered questionnaire supplemented with information from participant's medical records and a brief community screening instrument for dementia. The instrument classifies dementia into unlikely, probable or possible dementia. Data were entered in duplicate into EpiData version 3.0, then transferred to Statistical Package for Social Sciences (SPSS) version 23 for statistical analysis. RESULTS: Our study found almost one in four (23%) of the older persons in Lira district northern Uganda were suffering from probable or possible dementia. Our study further found that older persons in Lira district northern Uganda with a positive history of central nervous system infections (CNS) had nearly five times higher odds of having probable or possible dementia compared to their counterparts (cOR: 4.5; 2.76-7.23; p ≤ 0.001). Being in advanced age of 70 + years (aOR: 2.6; 1.6-4.3; p ≤ 0.001), positive history of CNS infection particularly Herpes simplex virus-1 (aOR: 5.4; 1.4-20.5; p = 0.013), and chronic headache (aOR: 1.9; 1.1-3.1; p = 0.019) were independent predictors of probable or possible dementia among participants in this study. CONCLUSION AND RECOMMENDATIONS: Dementia is a common condition among older persons in Lira district northern Uganda with a prevalence of 23% in our study. Older persons with a positive history of CNS infection had higher odd of developing dementia compared to their counterparts. Having advanced age, cerebral malaria, Herpes simplex virus - 1 (HSV-1) infections, and chronic headache were independent predictors for dementia. These results imply that health assessment for the risk of dementia should include screening for history of CNS conditions particularly cerebral malaria, HSV-1 and chronic headache.

Behavioral and psycho-social impairments among people living with dementia and their management by caregivers in South-Western Uganda: a qualitative study.

OBJECTIVES: This study aimed to explore the behavioral and social impairments among people living with dementia (PLWD) in rural southwestern Uganda. It also explored the burden of caregivers for people living with dementia. METHODS: This was a qualitative study among people living with dementia and their caregivers. We consecutively enrolled 30 people living with dementia with their caregivers from their homes. We conducted in-depth interviews using a semi-structured interview guide. We did a thematic content analysis. RESULTS: The themes under-reported behavioral impairment were; difficulty in personal care, physical inactivity, and impaired judgment. Under the social and cognitive impairment theme, there was the failure to be in social gatherings like church, community groups, and markets. Under the caregivers' role, their burden included managing behavioral, social, and cognitive impairments of PLWD. Although caregivers were committed to caring for PLWDs, this required sacrificing time at the expense of income-generating activities. CONCLUSIONS: Dementia hinders the behavioral and social aspects of the affected people. Caregivers are highly burdened to care for PLWD. Strategies to minimize caregivers' burden while caring for people living with dementia are recommended.

A scoping review of regenerative medicine in medical education.

Stem cell therapeutics and regenerative medicine have taken a strong foothold in biomedicine. However, most physicians are currently not adequately prepared to identify, refer, and deliver safe regenerative therapies. To understand this gap, we sought to characterize published literature on current physician training in regenerative medicine. Our scoping review describes current training strategies to bridge the gap and integrate such education into medical curricula for adequate training.

Caregiver's perspectives on the Central Nervous System infection illness trajectory among older persons with dementia in Northern Uganda-a qualitative community-based study.

BACKGROUND: Few studies have explored the Central Nervous System (CNS) infection illness trajectory among older persons with dementia in sub-Saharan African (SSA) settings. This study explored the Caregiver's perspectives on the Central Nervous System infection illness trajectory among the older persons with dementia in Northern Uganda. METHODS: This was a qualitative study conducted in Lira District northern Uganda in March 2022 amongst purposively selected 20 caregivers of the older persons aged 50 + years with a positive history of CNS infection and later life dementia. Data were collected using an in-depth interview guide. Audio recordings and field notes of the interviews were undertaken. The interviews generated data on the CNS infection illness trajectory from onset to the current demented state of the older persons. The audio-recorded interviews were transcribed verbatim before manual reflective thematic analysis. RESULTS: Older persons with a positive history of CNS infection illness and later life dementia in rural northern Uganda presented with symptoms of early life CNS infection illness ranging from neck pain, back pain, chronic headache, and fatigue. There were also manifestations of comorbidities particularly road traffic accidents involving traumatic injury to the head, neck, and spine, high blood pressure, chronic headache, and or their medications in the older person's trajectory to later life dementia. A plurality of healthcare which included both formal and informal healthcare medicines was sought and utilized for the treatment and care of the CNS infection illness and dementia by the older persons amidst improper diagnosis and mismanagement. CONCLUSIONS AND RECOMMENDATIONS: Older persons with early-life CNS infections illness and later-life dementia were reported to present with symptoms including neck pain, back pain, chronic headache, high blood pressure, and fatigue. The reported symptoms of CNS infection illness may be intertwined with co-morbidities particularly traumatic injury involving the head, neck, and spine, high blood pressure, and chronic headache. Healthcare professionals should integrate routine screening of older persons for the history of CNS infections, chronic headache, high blood pressure, trauma to the head, neck, and spine, and dementia and early treatment.

Retrospective assessment of metabolic syndrome components in early adult life on vegetarian dietary status.

Background: Metabolic syndrome (MetS) encompasses several clinical presentations that include truncal obesity and insulin resistance at its core. MetS afflicts 23% of the adult US population, increasing their risk of diabetes and cardiovascular disease. Many studies have indicated the importance of a vegetarian diet in improving overall health and more specifically MetS components. Unfortunately, these findings have been inconsistent and cannot be extended to examine effects on MetS incidence in the younger adult population. Objective: This study aimed to conduct a retrospective analysis of a vegetarian vs. non-vegetarian dietary status in young adults (age 18-24) based on MetS components in later adulthood (age 20-30). This study focuses on elucidating any relationship between a vegetarian diet and MetS components of central obesity, hypertension, and hyperlipidemia. Methods: Waves 3 and 4 data were acquired from AddHealth. One-to-one propensity score matched vegetarians to non-vegetarians in a cohort of 535 women and 159 men. Logistical regression assessed the relationship between vegetarian status and MetS components, including truncal obesity (cm), hypertension (normal, pre-HT, HT1, and HT2), and hyperlipidemia (high and low). Results MetS components from ages 20 to 30 are not associated with vegetarian dietary status. Truncal obesity [N = 694; M = 92.82 cm; OR 0.999; p = 0.893; 95% CI (0.980, 1.017)]; hypertension [N = 694; OR 0.949; p = 0.638; 95% CI (0.764, 1.179)]; hyperlipidemia [N = 694; OR 0.840; p = 0.581; 95% CI (0.453, 1.559)]. Conclusion: Current study results were consistent with previous findings suggesting that consumption of a vegetarian diet cannot be directly linked to MetS outcomes. However, further investigation should be completed as MetS is a risk factor for several chronic diseases.

Perceptions and Knowledge towards COVID-19 Vaccine Hesitancy among a Subpopulation of Adults in Kenya: An English Survey at Six Healthcare Facilities.

Background: Vaccine hesitancy, as defined by the WHO, is the reluctance or refusal to vaccinate despite the availability of vaccines and is one of the ten threats to global health in 2019. Vaccine hesitancy remains a complex matter influenced by multiple factors, especially in sub-Saharan Africa. Methods: We conducted a cross-sectional study between November 2021 and January 2022 among the general adult public seeking care at six different healthcare facilities in Kenya. The survey, in English, consisted of questions based on demographics, knowledge, and attitudes, including hesitancy towards the COVID-19 vaccine. Results: Of the 3996 surveys collected, 55.1% were from private, 19.5% from faith-based and 25.3% from government facilities., Approximately 81.0% of all the participants reported it was important to get a vaccine to protect other people from COVID-19, 79.9% reported they would take a vaccine to protect against COVID-19, yet 40.5% reported being hesitant to take the vaccine primarily due to side effects. Most of the variables were associated with receiving a vaccine. Only 52.1% of those seeking care from the government facility and 54.5% of those seeking care from the faith-based facility were vaccinated, compared to 81.5% seeking care from the private facilities (p < 0.001). More participants from private facilities felt that vaccines are safe as compared to those at the faith-based and government facilities (p < 0.001). Conclusion: Vaccine hesitancy in Kenya, even though much lower than reported in other countries, remains a dynamic problem. Mitigating strategies specific to Africa need to be developed to help address vaccine hesitancy in this part of the continent.

Lay Health Workers in Community-Based Care and Management of Dementia: A Qualitative 'Pre' and 'Post' Intervention Study in Southwestern Uganda.

Background: The global need for efficient and cost-effective use of healthcare resources in low-income countries has led to the introduction of lay health workers (LHWs) as a link of the community to healthcare services. As such, the LHWs perform a variety of tasks such as education, support for care delivery, and social support across all disease types. However, little is known about their ability to support dementia care and management in the community. Purpose: The goal of the pilot intervention was to evaluate the 5-day training intervention for LHWs in rural southwestern Uganda in community-based care and management of people with dementia, and implementation of the knowledge and skills gained. Methods: This was a "pre" and "post" pilot intervention study which involved a qualitative assessment of LHWs' knowledge on community-based management and care for people with dementia. We focused on four core competency domains in the WHO dementia toolkit. The intervention included a five-day training of the LHWs on dementia care, eight weeks of implementation, and an evaluation of the experiences. Analysis focused on the needs assessment, early detection and management, community engagement, support for people with dementia; and evaluation of the eight weeks implementation. Results: Before the training, the LHWs did not know much about what dementia-related support to provide in the community. Activities were limited to general support, including nutrition, and health education. After the training, LHWs had a basic understanding of dementia and began sensitizing the communities. They felt more comfortable working with people with dementia and reported a notable change in the attitude of family members. However, they reported challenges in differentiating the signs of early dementia from superstitious beliefs. Conclusion: With enhanced capacity, LHWs may be able to support community-based management for people with dementia. A larger study is needed to explore potential roles for LHWs and further assess effectiveness of the LHWs' skills.

Perceptions of Undergraduates and Mentors on the Appropriateness, Acceptability, and Feasibility of the HEPI-TUITAH Micro-Research Approach to HIV Training in Uganda.

Purpose: To evaluate the perceptions of undergraduates and mentors on the appropriateness, acceptability, and feasibility of a mentored seed-grant (micro-research) by Health Professions Education Partnership Initiative - Transforming Ugandan Institutions Training Against HIV/AIDS (HEPI-TUITAH) program on HIV training in Uganda. Methods: We conducted a cross-sectional descriptive qualitative study with focus groups, on HIV micro-research training, with undergraduate health professions students and faculty mentors across three partner institutions in rural Uganda. Results: A total of 24 students and 13 mentors (5-8 per group) took part in the focus group discussions. Most participants stated that the HEPI-TUITAH micro-research program was acceptable, appropriate and feasible for health professions undergraduate students. The interprofessional education approach of bringing together students from different programs and years of study was valuable especially for peer mentorship. There was a need to provide for institution-based training in addition to the centrally organized training for the benefit of all the team members. Participants also noted a need for the program to find a way of providing the students with data collection experience even with the COVID-19 pandemic situation. Conclusion: The HEPI-TUITAH micro-research program was perceived as acceptable, appropriate, and feasible for health professions undergraduate students. It also promoted teamwork and academic collaboration. Provision for institution-based micro-research training activities and data collection experiences for the undergraduate students even during the COVID-19 pandemic would make the program more valuable. The lessons learnt will be applied to future training cohorts to optimize program impact and may be useful for similar programs in other settings.

Mental health disorders among post graduate residents in Kenya during the COVID-19 pandemic.

BACKGROUND: Healthcare workers, including residents, are prone to various mental health disorders especially given the context of the COVID-19 pandemic. Residents, particularly, are already under undue stress due to their respective training program demands. METHODS: This cross-sectional, online survey-based study from August to November 2020 collected demographic and mental health measurements from all residents at the Aga Khan University Hospital, Nairobi. The questionnaire investigated demographic variables, information regarding direct care of COVID-19 patients, prior history of mental health and mental health outcomes using the Patient Health Questionnaire, Generalized Anxiety Disorder scale, Insomnia Severity Index, Impact of Event Scale-Revised Questionnaire and Stanford Professional Fulfillment Index Questionnaire. RESULTS: A total of 100 residents completed the survey (participation rate 77.5%). Participants were about equal in gender (women [53%]), with a median age of 31.28 years, and majority were single (66.7%). A total of 66 participants (66%) were directly engaged in COVID-19 care. Depression: 64.3%, anxiety: 51.5%, insomnia: 40.5%, distress: 35.4%, and burnout: 51.0% were reported in all participants. Statistical significance was found in median depression, professional fulfillment and interpersonal disengagement when comparing frontline resident directly involved in care of COVID-19 patient versus second line residents. CONCLUSION: Residents directly involved with caring for COVID-19 patients had statistically higher incidences of depression and interpersonal disengagement and lower professional fulfillment compared to second line residents. Keeping in mind the limited resources in sub-Saharan Africa, urgent and geographically specific strategies are needed to help combat mental health disorders in this specific population.

Addressing health disparities in hispanic communities through an innovative team-based medical spanish program at the medical school level - a single-institution study.

BACKGROUND: There are insufficient Spanish-speaking physicians to effectively serve a large and rapidly growing Spanish-speaking patient population. METHODS: A team-based hybrid medical Spanish program was designed and implemented at a single medical school in Southern California. This pilot program consisted of a weekly in-person portion where students reviewed Spanish vocabulary and grammar and practiced clinical encounters in teams through active role play. Students supplemented in-class learning with online coursework. Program success was measured through physician-evaluated clinical encounters with Spanish-speaking standardized patients, a 100-question multiple-choice exam, and pre- and post-program surveys. RESULTS: 97% of students in the program (n = 32) received a passing grade at program completion. Student surveys demonstrated enthusiasm and engagement in weekly sessions (95% overall attendance, 97% reported feeling either excited or ready to learn prior to class). In a post-program survey, 100% of students felt better suited and increased desire to treat Hispanic patients. Additionally, all students indicated an interest in the continued use of Spanish in both their schooling and future practice. In a follow-up survey after three months of clinical experience in their 3rd year of medical school, 100% of students reported that medical Spanish is "very beneficial" in patient care and that students with medical Spanish proficiency have advantages over non-speaking students when it comes to patient care opportunities. 100% felt that time spent learning medical Spanish during pre-clinical years was time well spent and that the medical Spanish program enhanced their care of Spanish-speaking students. CONCLUSIONS: The results of the pilot program show a significant increase in the ability of students to engage in clinical interaction in Spanish. The results of our study demonstrate a significant increase in the knowledge, clinical skills, and self-reported confidence of students to treat Hispanic patients. Furthermore, all students not only felt better equipped and more confident to treat Hispanic patients, but they also had an increased desire to do so moving forward in their careers. We conclude that an effective medical Spanish program can be executed simultaneously with a pre-clinical medical school curriculum.

Language diversity and challenges to communication in Indian emergency departments.

BACKGROUND: Communication in emergency departments (ED) in India is complicated by the country's immense language diversity. Prior research has revealed challenges in language and communication as barriers to care. Our objective was to quantify language diversity among clinicians in Indian EDs and better understand issues related to clinician-clinician and clinician-patient communication. METHODOLOGY: A cross-sectional survey of ED clinicians was conducted. Survey participants were recruited in-person and through email at six partner sites in India. ANOVA and binary logistic regression were used for subgroup analysis. Semi-structured interviews were conducted with ED clinicians. Interview data was analyzed using the rapid assessment process to determine predominant themes. RESULTS: 106 clinicians completed the survey. On average, clinicians spoke 3.75 languages. Seventy-one percent used a non-English language to speak to fellow clinicians most of the time, and 53% reported at least one critical incident over the last year where poor communication played a part. Interviews revealed challenges including low health literacy, high patient volume, and workplace hierarchy. CONCLUSIONS: This study is the first to document the impact of language diversity and communication barriers in Indian EDs. The results highlight the need for effective strategies to improve communication between the multiple languages spoken by clinicians and patients.

COVID-19 and mental well-being of nurses in a tertiary facility in Kenya.

BACKGROUND: The 2019 coronavirus disease (COVID-19) epidemic is a global health emergency which has been shown to pose a great challenge to mental health, well-being and resilience of healthcare workers, especially nurses. Little is known on the impact of COVID-19 among nurses in sub-Saharan Africa. METHODS: A cross sectional study was carried out between August and November 2020 among nurses recruited from the Aga Khan University Hospital, Nairobi. The survey questionnaire consisted of six components- demographic and work title characteristics, information regarding care of COVID-19 patients, symptoms of depression, anxiety, insomnia, distress and burnout, measured using standardized questionnaires. Multivariable logistic regression analysis was performed to identify factors associated with mental health disorders. RESULTS: Of 255 nurses, 171 (67.1%) consented to complete the survey. The median age of the participants was 33.47 years, 70.2% were females and 60.8% were married. More than half, 64.9% were frontline workers directly engaged in COVID-19 care. Only 1.8% reported a prior history or diagnosis of any mental health disorder. Depression, anxiety, insomnia, distress, and burnout were reported in 45.9%, 48.2%, 37.0%, 28.8% and 47.9% of all nurses. Frontline nurses reported experiencing more moderate to severe symptoms of depression, distress and burnout. Furthermore, females reported more burnout as compared to males. Multivariate logistic regression analysis showed that after adjustment, working in the frontlines was an independent risk variable for depression and burnout. CONCLUSION: This is one of the few studies looking at mental health outcomes among nurses during the COVID-19 pandemic in Kenya. Similar to other studies from around the world, nurses directly involved with COVID-19 patients reported higher rates of mental health symptoms. Burnout threatens to exacerbate the pre-existing severe nursing workforce shortage in low-resource settings. Cost-effective and feasible mitigating strategies, geared to low-middle income countries, are urgently needed to help cope with mental health symptoms during such a pandemic.

Adherence to clinical guidelines in integration of mental health services into primary health care in Mbarara, southwestern Uganda: a medical records review.

BACKGROUND: The Ugandan Ministry of Health decentralized mental healthcare to the district level; developed the Uganda Clinical Guidelines (UCG); and trained primary health care (PHC) providers in identification, management, and referral of individuals with common mental disorders. This was intended to promote integration of mental health services into PHC in the country. 'Common mental disorders' here refers to mental, neurological and substance use conditions as indicated in the UCG. However, the extent of integration of mental health into general healthcare remains unknown. This study aimed to establish the level of adherence of PHC providers to the UCG in the identification and management of mental disorders. METHODS: This was a prospective medical record review of patient information collected in November and December 2018, and March and April 2019 at two health centers (III and IV) in southwestern Uganda. Data (health facility level; sex and age of the patient; and mental disorder diagnosis, management) was collected using a checklist. Continuous data was analyzed using means and standard deviation while categorical data was analyzed using Chi-square. Multivariable logistic regression analysis was performed to establish predictors of PHC provider adherence to the clinical guidelines on integration of mental health services into PHC. The analysis was conducted at a 95% level of significance. RESULTS: Of the 6093 records of patients at the study health facilities during the study period, 146 (2.4%) had a mental or neurological disorder diagnosis. The commonly diagnosed disorders were epilepsy 91 (1.5%) and bipolar 25 (0.4%). The most prescribed medications were carbamazepine 65 (44.5%), and phenobarbital 26 (17.8%). The medicines inappropriately prescribed at health center III for a mental diagnosis included chlorpromazine for epilepsy 3 (2.1%) and haloperidol for epilepsy 1 (0.7%). Female gender (aOR: 0.52, 95% CI 0.39-0.69) and age 61+ years (aOR: 3.02, 95% CI 1.40-6.49) were predictors of a mental disorder entry into the HMIS register. CONCLUSION: There was a noticeable change of practice by PHC providers in integrating mental health services in routine care as reflected by the rise in the number of mental disorders diagnosed and treated and entered into the modified paper based HMIS registers.

Mental health disorders among healthcare workers during the COVID-19 pandemic: a cross-sectional survey from three major hospitals in Kenya.

BACKGROUND: COVID-19 is an international global health emergency and has posed a great challenge to mental well-being and resilience. Little is known about the mental health impact of COVID-19 among healthcare workers (HCWs) in sub-Saharan Africa or other low-resource settings. METHODS: We conducted a cross-sectional study between August and November 2020 among HCWs recruited from three major hospitals in Kenya. The survey questionnaire consisted of six components: demographic and work title characteristics; information regarding care of patients with COVID-19; and symptoms of depression, anxiety, insomnia, distress and burnout, measured using standardised questionnaires. Multivariable logistic regression analysis was performed to identify factors associated with mental health disorders. RESULTS: A total of 433 (65.2% response rate) individuals participated in the survey. Median age was 32.75 years, 58.4% were females and 68.8% were front-line workers. Depression, anxiety, insomnia, distress and burnout were reported in 53.6%, 44.3%, 41.1%, 31.0% and 45.8% of all participants, respectively. Front-line HCWs, females and doctors were at higher risk of mental health symptoms. Nearly half of participants reported inadequate resources or training to care for patients with COVID-19, and those in the government hospital were more likely to report mental health symptoms. CONCLUSIONS: This is among the first studies examining mental health outcomes among HCWs during the COVID-19 pandemic in Kenya. Similar to other studies from around the world, HCWs directly involved with patients with COVID-19 reported higher rates of mental health symptoms. Mitigating strategies specific to Kenyan HCWs are urgently needed to help them cope with mental health symptoms during the pandemic.

Delivery of Difficult News Among Residents at a Tertiary Hospital In Kenya Using a Short Training Video (UNMASKES).

This article was migrated. The article was marked as recommended. Background Delivery of difficult news (DDN) remains a challenging task for even the most experienced of providers. Little has been studied about delivery of difficult news among resident physicians in sub-Saharan Africa (SSA). We developed a 4-minute, graphic video using the acronym UNMASKES to help improve delivery of difficult news between resident physicians and their patients. Objective To determine the impact of the UNMASKES training video in improving resident communication when delivering difficult news. Methods We conducted a prospective study amongst all residents at the Aga Khan University hospital in Nairobi, Kenya and Dar es Salaam, Tanzania from February to September, 2019. After completing a pretest survey, residents received a one-hour comprehensive training on delivery of difficult news using UNMASKES. A link to the UNMASKES video was provided to the residents for real-time reference. Post-test surveys were completed at 4 and 12 weeks respectively. Results A total of 102 (68%) residents completed the surveys. At 12 weeks, we found that residents improved in 6 key areas; notified their patients before delivering difficult news, ensured a private and quiet room, provided information in small amounts to patients and family members, provided a summary after delivery of difficult news, followed up with patients at 24-48 hours after delivering difficult news, and felt better prepared to deal with patient and family emotions when delivering difficult news. Conclusions UNMASKES, a 4-minutes, easily accessible, graphic video showed promising results in training our residents to foster effective communication while delivering difficult news to their patients.