Self-administered at-home lung ultrasound with remote guidance in patients without clinical training.

BACKGROUND: Access to timely and accurate diagnostic imaging is essential for high-quality healthcare. Point-of-care ultrasound has been shown to be accessible and effective in many aspects of healthcare, including assessing changes in lung pathology. However, few studies have examined self-administered at-home lung ultrasound (SAAH-LUS), in particular performed by non-clinical patients (NCPs). RESEARCH QUESTION: Are NCPs able to perform SAAH-LUS using remote teleguidance and produce interpretable images? STUDY DESIGN: Patients were enrolled to the study in a mix of in-person and virtual recruitment, and shipped a smartphone as well as a point of care ultrasound device. Tele-guidance was provided by a remote physician using software integrated with the point of care ultrasound device, allowing real-time remote visualization and guidance of a patient scanning their own chest. A post-intervention survey was conducted to assess patient satisfaction, feasibility, and acceptability of SAAH-LUS. Two POCUS expert reviewers reviewed the scans for interpretability, and inter-rater agreement between the two reviewers was also computed. RESULTS: Eighteen patients successfully underwent 7-14 days of daily telemedicine in parallel to daily SAAH-LUS. Across 1339 scans obtained from ten different lung zones, the average proportion of interpretability was 96% with a chance-corrected agreement, or Cohen's kappa, reported as κ = 0.67 (significant agreement). 100% of NCPs surveyed found SAAH-LUS to be a positive experience, particularly for its ease of operation and ability to increase access to healthcare services. INTERPRETATION: This study demonstrates that NCPs can obtain interpretable LUS images at home, highlighting the potential for SAAH-LUS to increase diagnostic capacity, particularly for rural and remote regions where complex imaging and healthcare providers are difficult to obtain. Trial registration The clinical trials has been registered (clinicaltrials.gov). REGISTRATION NUMBER: NCT04967729.

Improving pathology and laboratory medicine in low-income and middle-income countries: roadmap to solutions.

Insufficient awareness of the centrality of pathology and laboratory medicine (PALM) to a functioning health-care system at policy and governmental level, with the resultant inadequate investment, has meant that efforts to enhance PALM in low-income and middle-income countries have been local, fragmented, and mostly unsustainable. Responding to the four major barriers in PALM service delivery that were identified in the first paper of this Series (workforce, infrastructure, education and training, and quality assurance), this second paper identifies potential solutions that can be applied in low-income and middle-income countries (LMICs). Increasing and retaining a quality PALM workforce requires access to mentorship and continuing professional development, task sharing, and the development of short-term visitor programmes. Opportunities to enhance the training of pathologists and allied PALM personnel by increasing and improving education provision must be explored and implemented. PALM infrastructure must be strengthened by addressing supply chain barriers, and ensuring laboratory information systems are in place. New technologies, including telepathology and point-of-care testing, can have a substantial role in PALM service delivery, if used appropriately. We emphasise the crucial importance of maintaining PALM quality and posit that all laboratories in LMICs should participate in quality assurance and accreditation programmes. A potential role for public-private partnerships in filling PALM services gaps should also be investigated. Finally, to deliver these solutions and ensure equitable access to essential services in LMICs, we propose a PALM package focused on these countries, integrated within a nationally tiered laboratory system, as part of an overarching national laboratory strategic plan.

Images in clinical medicine: Syphilitic gumma.

A 45-year-old woman presented to a clinic in rural Uganda with a 1-year history of a progressively enlarging ulcerated mass on the hard palate. The mass had initially been painless but recently had become painful and was causing difficulty in speaking and swallowing.

Short term global health experiences and local partnership models: a framework.

Contemporary interest in in short-term experiences in global health (STEGH) has led to important questions of ethics, responsibility, and potential harms to receiving communities. In addressing these issues, the role of local engagement through partnerships between external STEGH facilitating organization(s) and internal community organization(s) has been identified as crucial to mitigating potential pitfalls. This perspective piece offers a framework to categorize different models of local engagement in STEGH based on professional experiences and a review of the existing literature. This framework will encourage STEGH stakeholders to consider partnership models in the development and evaluation of new or existing programs.The proposed framework examines the community context in which STEGH may occur, and considers three broad categories: number of visiting external groups conducting STEGH (single/multiple), number of host entities that interact with the STEGH (none/single/multiple), and frequency of STEGH (continuous/intermittent). These factors culminate in a specific model that provides a description of opportunities and challenges presented by each model. Considering different models, single visiting partners, working without a local partner on an intermittent (or even one-time) basis provided the greatest flexibility to the STEGH participants, but represented the least integration locally and subsequently the greatest potential harm for the receiving community. Other models, such as multiple visiting teams continuously working with a single local partner, provided an opportunity for centralization of efforts and local input, but required investment in consensus-building and streamlining of processes across different groups. We conclude that involving host partners in the design, implementation, and evaluation of STEGH requires more effort on the part of visiting STEGH groups and facilitators, but has the greatest potential benefit for meaningful, locally-relevant improvements from STEGH for the receiving community. There are four key themes that underpin the application of the framework: 1. Meaningful impact to host communities requires some form of local engagement and measurement. 2. Single STEGH without local partner engagement is rarely ethically justified. 3. Models should be tailored to the health and resource context in which the STEGH occurs. 4. Sending institutions should employ a model that ultimately benefits local receiving communities first and STEGH participants second. Accounting for these themes in program planning for STEGH will lead to more equitable outcomes for both receiving communities and their sending partners.

Predictors of treatment with mastectomy, use of sentinel lymph node biopsy and upstaging to invasive cancer in patients diagnosed with breast ductal carcinoma in situ (DCIS) on core biopsy.

BACKGROUND: There are few established indications for sentinel lymph node biopsy (SLNB) in breast ductal carcinoma in situ (DCIS). This study examines factors contributing to the high rate of SLNB in DCIS in Alberta, Canada. METHODS: Patients who underwent definitive surgery from January 2009 to July 2011 for DCIS diagnosed on preoperative core-needle biopsy were identified using a provincial synoptic operative report database (WebSMR). The relationship between baseline patient and tumor characteristics and treatment with total mastectomy (TM), use of SLNB, and upstaging were examined. RESULTS: There were 394 patients identified in the study cohort. Mean age was 57 years, and average preoperative tumor size was 3 cm. Overall, 148 patients (37.6 %) underwent TM; predictors were preoperative tumor size [odds ratio (OR), 1.92 per 1-cm increase in size; 95 % CI 1.65-2.24] and surgeon. Upstaging to invasive cancer at surgery occurred in 23 %, predicted only by preoperative tumor size (OR 1.14 per 1 cm; 95 % CI 1.03-1.27). SLNB was performed in 306 patients overall (77 %) and 140 of those treated with BCS (61 %). Predictors of SLNB were larger preoperative tumor size (OR 1.55 per 1 cm; 95 % CI 1.18-2.04) and the surgeon. In patients treated with BCS, 3 patients who were upstaged had positive SLNs (>0.2 mm), and no patients with DCIS had a positive SLN. CONCLUSIONS: SLNB use is high in patients undergoing BCS for DCIS. Tumor size and the operating surgeon predicted SLNB use. Despite a 23 % upstaging rate, the rate of clinically significant positive SLNs in patients treated with BCS is low, supporting omission of upfront SLNB.

Reliability of the Service Trip Audit Tool to assess the quality of short-term medical missions.

BACKGROUND: We aimed to assess the adherence of short-term medical missions (STMMs) operating in Latin America and the Caribbean (LAC) to key best practices using the Service Trip Audit Tool (STAT) and to calculate the inter-rater reliability of the data points. This tool was based on a previously published inventory of 18 STMM best practices. METHODS: Programme administrators and recent volunteers from 335 North American organizations offering STMMs in LAC were invited to complete the STAT anonymously online. Adherence to each of 18 best practices was reported as either 'yes', 'no' or 'not sure'. Fleiss' κ was used to assess inter-rater agreement of the responses. RESULTS: A total of 194 individuals from 102 organizations completed the STAT (response rate 30.4%; 102/335 organizations) between 12 July and 7 August 2017. Reported adherence was >80% for 9 of 18 best practices. For 37 non-governmental organizations (NGOs) with multiple raters, inter-rater agreement was moderate to substantial (κ>0.4) for 12 of 18 best practices. CONCLUSIONS: This is the first study to evaluate adherence to STMM best practices. Such an objective evaluation will be valuable to governments, volunteers and NGO donors who have an interest in identifying high-quality partners. Assessment and monitoring of STMMs through self-audit may be foundational steps towards quality improvement.

Global health training in Canadian family medicine residency programmes.

Objective: Canadian family medicine (FM) residency programmes are responding to the growing demand to provide global health (GH) education to their trainees; herein, we describe the various GH activities (GHAs) offered within Canadian FM programmes. Design: A bilingual online survey was sent out to all 17 Canadian FM program directors (PDs) and/or an appointed GH representative. Setting: Online survey via Qualtrics. Participants: All 17 Canadian FM PDs and/or an appointed GH representative. Results: The response rate was 100% and represented 3250 first-year and second-year FM residents across English and French Canada. All schools stated that they participate in some form of GHAs. There was variation in the level of organisation, participation and types of GHAs offered. Overall, most GHAs are optional, and there is a large amount of variation in terms of resident participation. Approximately one third of programmes receive dedicated funding for their GHAs, and two thirds wish to increase the scope/variety of GHAs. Conclusion: These results suggest nationwide interest in developing a workforce trained in GH, but show great discrepancies in training, implementation and education.

Development of a theoretical framework for assessment of quality of primary care medical service trips in Latin America.

OBJECTIVES: Short-term medical service trips (MSTs) are a controversial modality for addressing the health of marginalized populations. Despite their prevalence, there are no routinely used evaluative frameworks. This study used stakeholder consensus to validate a literature-based framework for MST best practices. METHODS: A recent systematic review was used to construct a preliminary list of best practices for short-term MSTs. We then recruited a multidisciplinary panel of academics, medical professionals, program coordinators, and non-medical volunteers for a three-round e-Delphi consensus-building exercise to review the list. A 7-point Likert scale was used, with mean scores 4-7 representing rejection, scores < 2 representing acceptance, and elements scoring in between being redistributed for discussion. RESULTS: The literature review identified 30 best practices. Twenty-six stakeholders were recruited for the e-Delphi panel, with 73.1% responding to all three rounds. Eighteen elements were accepted into the final framework. CONCLUSIONS: This framework identifies essential MST best practices and enables volunteers to compare organizations. Future research should translate this framework into an assessment tool and initiate dialogue between host communities, local clinicians, and sending organizations.

Employment Opportunities and Experiences among Recent Master's-Level Global Health Graduates.

OBJECTIVES: To examine the job search, employment experiences, and job availability of recent global health-focused master's level graduates. METHODS: An online survey was conducted from October to December 2016 based out of Washington, DC. The study sample includes students graduating with master's degrees in global health, public health with a global health concentration or global medicine from eight U.S. universities. RESULTS: Out of 256 potential respondents, 152 (59%) completed the survey, with 102/152 (67%) employed. Of unemployed graduates, 38% were currently in another educational training program. Out of 91 employed respondents, 62 (68%) reported they had limitations or gaps in their academic training. The average salary of those employed was between $40,000 and $59,000 annually. The majority of respondents reported they currently work in North America (83.5%.); however, only 31% reported the desire to work in North America following graduation. CONCLUSIONS: Discrepancies exist between graduates' expectations of employment in global public health and the eventual job market. Communication between universities, students and employers may assist in curriculum development and job satisfaction for the global public health workforce.

From potential to practice: how accelerating access to HPV tests and screen and treat programmes can help eliminate cervical cancer.

Human papillomavirus (HPV) vaccination campaigns to prevent cervical cancer are being considered and implemented in countries around the world. While vaccination will protect future generations, it will not help the millions of women currently infected, leading to an estimated 311 000 deaths per year globally. This paper examines a selection of strategies that when applied to both existing and new technologies, could accelerate access to HPV testing. Authors from the US Agency for International Development, the National Institutes of Health, and the Bridge to Health Medical and Dental, a non-governmental organisation, joined forces to propose a scalable and country-directed solution for preventing cervical cancer using an end-to-end approach. Collectively, the authors offer seven evidence-based strategies, that when used alone or in combination have the ability to reduce HPV-caused cervical cancer deaths and disability. These strategies include (1) consistent HPV test intervals to decrease HPV DNA test costs; (2) exploring market shaping opportunities; (3) employing iterative user research methodologies like human-centred design; (4) target product profiles for new HPV tests; (5) encouraging innovation around cervical cancer screen and treat programmes; (6) developing national cancer control plans; and (7) integrating cervical cancer screen and treat services into existing infrastructure. By using the strategies outlined here, in combination with HPV vaccination campaigns, national governments will be able to scale and expand cervical cancer screening programmes and provide evidence-based treatment programmes for HPV-infected women.

Ablative Therapies for Cervical Intraepithelial Neoplasia in Low-Resource Settings: Findings and Key Questions.

Barriers to access for cervical precancer care in low-resource settings go beyond cost. Gas-based cryotherapy has emerged as the standard treatment in these areas, but there are barriers to this technology that have necessitated the development and implementation of affordable and portable alternatives. This review identifies knowledge gaps with regard to technologies primarily used in low-resource settings, including standard cryotherapy, nongas-based cryotherapy, and thermoablation. These gaps are addressed using evidence-based guidelines, patient and provider acceptability, long-term obstetric outcomes, and treatment of women with HIV infection. This review highlights the need for prospective studies that compare ablative methods, especially given the increasing use of thermoablation.

Effectiveness of advertising availability of prenatal ultrasound on uptake of antenatal care in rural Uganda: A cluster randomized trial.

In rural Uganda pregnant women often lack access to health services, do not attend antenatal care, and tend to utilize traditional healers/birth attendants. We hypothesized that receiving a message advertising that "you will be able to see your baby by ultrasound" would motivate rural Ugandan women who otherwise might use a traditional birth attendant to attend antenatal care, and that those women would subsequently be more satisfied with care. A cluster randomized trial was conducted across eight rural sub-counties in southwestern Uganda. Sub-counties were randomized to a control arm, with advertisement of antenatal care with no mention of portable obstetric ultrasound (four communities, n = 59), or an intervention arm, with advertisement of portable obstetric ultrasound. Advertisement of portable obstetric ultrasound was further divided into intervention A) word of mouth advertisement of portable obstetric ultrasound and antenatal care (one communitity, n = 16), B) radio advertisement of only antenatal care and word of mouth advertisement of antenatal care and portable obstetric ultrasound (one community, n = 7), or C) word of mouth + radio advertisement of both antenatal care and portable obstetric ultrasound (two communities, n = 75). The primary outcome was attendance to antenatal care. 159 women presented to antenatal care across eight sub-counties. The rate of attendance was 65.1 (per 1000 pregnant women, 95% CI 38.3-110.4) where portable obstetric ultrasound was advertised by radio and word of mouth, as compared to a rate of 11.1 (95% CI 6.1-20.1) in control communities (rate ratio 5.9, 95% CI 2.6-13.0, p<0.0001). Attendance was also improved in women who had previously seen a traditional healer (13.0, 95% CI 5.4-31.2) compared to control (1.5, 95% CI 0.5-5.0, rate ratio 8.7, 95% CI 2.0-38.1, p = 0.004). By advertising antenatal care and portable obstetric ultrasound by radio attendance was significantly improved. This study suggests that women can be motivated to attend antenatal care when offered the concrete incentive of seeing their baby.

Visiting Trainees in Global Settings: Host and Partner Perspectives on Desirable Competencies.

BACKGROUND: Current competencies in global health education largely reflect perspectives from high-income countries (HICs). Consequently, there has been underrepresentation of the voices and perspectives of partners in low- and middle-income countries (LMICs) who supervise and mentor trainees engaged in short-term experiences in global health (STEGH). OBJECTIVE: The objective of this study was to better understand the competencies and learning objectives that are considered a priority from the perspective of partners in LMICs. METHODS: A review of current interprofessional global health competencies was performed to design a web-based survey instrument in English and Spanish. Survey data were collected from a global convenience sample. Data underwent descriptive statistical analysis and logistic regression. FINDINGS: The survey was completed by 170 individuals; 132 in English and 38 in Spanish. More than 85% of respondents rated cultural awareness and respectful conduct while on a STEGH as important. None of the respondents said trainees arrive as independent practitioners to fill health care gaps. Of 109 respondents, 65 (60%) reported that trainees gaining fluency in the local language was not important. CONCLUSIONS: This study found different levels of agreement between partners across economic regions of the world when compared with existing global health competencies. By gaining insight into host partners' perceptions of desired competencies, global health education programs in LMICs can be more collaboratively and ethically designed to meet the priorities, needs, and expectations of those stakeholders. This study begins to shift the paradigm of global health education program design by encouraging North-South/East-West shared agenda setting, mutual respect, empowerment, and true collaboration.

A Protocol to Develop Practice Guidelines for Primary Care Medical Service Trips.

BACKGROUND: North American clinicians are increasingly participating in medical service trips (MSTs) that provide primary healthcare in Latin America and the Caribbean. Literature reviews have shown that the existence and use of evidence-based guidelines by these groups are limited, which presents potential for harm. OBJECTIVE: This paper proposes a 5-step methodology to develop protocols for diagnosis and treatment of conditions encountered by MST clinicians. METHODS: We reviewed the 2010 American College of Physicians guidance statement on guidelines development and developed our own adaptation. Ancestry search of the American College of Physicians statement identified specific publications that provided additional detail on key steps in the guideline development process, with additional focus given to evidence, equity, and local adaptation considerations. FINDINGS: Our adaptation produced a 5-step process for developing locally optimized protocols for diagnosis and treatment of common conditions seen in MSTs. For specified conditions, this process includes: 1) a focused environmental scan of current practices based on grey literature protocols from MST sending organizations; 2) a review of relevant practice guidelines; 3) a literature review assessing the epidemiology, diagnosis, and treatment of the specified condition; 4) an eDelphi process with experts representing MST and Latin American and the Caribbean partner organizations assessing identified guidelines; and 5) external peer review and summary. CONCLUSIONS: This protocol will enable the creation of practice guidelines that are based on best available evidence, local knowledge, and equitable considerations. The development of guidelines using this process could optimize the conduct of MSTs, while prioritizing input from local community partners.

Educational objectives for international medical electives: a literature review.

PURPOSE: Although most medical schools and residency programs offer international medical electives (IMEs), little guidance on the educational objectives for these rotations exists; thus, the authors reviewed the literature to compile and categorize a comprehensive set of educational objectives for IMEs. METHOD: In February and July 2012, the authors searched SciVerse Scopus online, which includes the Embase and MEDLINE databases, using specified terms. From the articles that met their inclusion criteria, they extracted the educational objectives of IMEs and sorted them into preelective, intraelective, and postelective objectives. RESULTS: The authors identified and reviewed 255 articles, 11 (4%) of which described 22 educational objectives. Among those 22 objectives, 5 (23%), 15 (68%), and 2 (9%) were, respectively, preelective, intraelective, and postelective objectives. Among preelective objectives, only cultural awareness appeared in more than 2 articles (3/11; 27%). Among intraelective objectives, the most commonly defined were enhancing clinical skills and understanding different health care systems (9/11; 82%). Learning to manage diseases rarely seen at home and increasing cultural awareness appeared in nearly half (5/11; 45%) of all articles. Among postelective objectives, reflecting on experiences through a written project was most common (9/11; 82%). CONCLUSIONS: The authors identified 22 educational objectives for IMEs in the published literature, some of which were consistent across institutions. These consistencies, in conjunction with future research, can be used as a framework on which institutions can build their own IME curricula, ultimately helping to ensure that their medical trainees have a meaningful learning experience while abroad.