Remote consultations in primary care across low-, middle- and high-income countries: Implications for policy and care delivery.

The COVID-19 pandemic mandated a substantial switch in primary health care delivery from an in-person to a mainly remote telephone or video service. As the COVID-19 pandemic approaches its third year, limited progress appears to have been made in terms of policy development around consultation methods for the post-acute phase of the pandemic. In September 2020, the International Primary Care Respiratory Group convened a global panel of primary care clinicians - including family physicians, paediatricians, pharmacists, academics and patients - to consider the policy and health management implications of the move to remote consultations in the primary care setting. The group gave special consideration to how and how far remote consultations should be integrated into routine primary health care delivery. Remote consultations can be a useful alternative to in-person consultations in primary care not only in situations where there is a need for viral infection control but also for the routine delivery of chronic disease management. However, they may not be more time efficient for the clinician, and they can add to the workload and work-related stress for primary care practitioners if they remain the dominant consultation mode. Remote consultations are also less appropriate than in-person consultations for new disease diagnosis, dealing with multiple issues and providing complex care. Ensuring health care professionals have the appropriate skill set to effectively deliver remote consultations, administrative and/or IT support and appropriate reimbursement will be key to achieving optimal integration of remote consultations into routine clinical practice. Addressing digital access and digital literacy issues at a societal level will also be essential to ensure individuals have fair and equitable access to the internet and sufficient security for exchange of personal and health-related data.

Guideline based knowledge and practice of physicians in the management of COPD in a low- to middle-income country.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death, with 80% of the total death occurring in low- to middle-income countries (LMICs). Nepal is one of the LMIC; COPD is a highly prevalent and significant public health issue often underdiagnosed. Medical physicians' good knowledge and practice to diagnose and treat COPD can help reduce the disease burden. OBJECTIVES: To determine the level of knowledge, practice and factors influencing the practice of physicians regarding COPD management based on GOLD guidelines. DESIGN: A cross-sectional descriptive study using a structured questionnaire was conducted among medical physicians working in Bagmati and Gandaki province of Nepal. Out of total scores, physicians knowledge and practice were graded according to Bloom's original cut-off point for good (≥80%), satisfactory (60%-78%) and poor (<60%). RESULT: A total of 152 medical physicians participated in this study. Out of the possible total score 20, the mean score on knowledge was 17.8 ± 2.4, and out of possible total score eight, the mean score on practice was 5.3 ± 1.3. The correlation test between total knowledge and practice scores showed r = 0.18 and p value <0.02. The most selected factors hindering the appropriate management of COPD was lack of patient follow up and lack of professional training in COPD. Other factors included patient unwillingness to discuss smoking quit plan, lack of screening tool, unavailability of spirometry and physician unawareness of available medicine to treat COPD. CONCLUSION: Despite physicians having good knowledge in COPD, the practice in COPD management is below guideline-recommended. There is a significant, very low positive correlation between total knowledge score and practice score. Proper COPD training to physicians, disease awareness among patients, easy availability of diagnostic equipment and medication can help improve physicians' practice and appropriately manage COPD patients.

Alternative Management Systems of Beef Cattle Manure for Reducing Nitrogen Loadings: A Case-Study Approach.

Livestock manure is one of the main sources of agricultural nonpoint source pollution and poses a great threat to the environment and human health. Sustainable management of manure via recycling is an effective means to tackle the problem. Based on field interviews in China, multiple case studies were employed to investigate alternative manure management systems. Four conclusions arose. First, compost-based systems, product-based systems, substrate-based systems, and biogas-based systems were identified as four main types of manure management systems, with each possessing its success factors and risk factors. The adoption of a system was driven by various factors. Second, market-oriented operation was the dominant operation mechanism of all the manure management systems. Third, compared to direct application of manure to croplands, all the four manure management systems could reduce nitrogen loadings from livestock farms and lower their environmental effects. Among the systems, biogas-based systems could reduce nitrogen loadings to the greatest extent, followed by product-based systems and substrate-based systems, and then by compost-based systems. Lastly, integrated management of manure with mixed recycling systems is imperative for reducing its environmental effects, which can benefit from the increasing role of third-party entities in manure recycling. Policy implications were also discussed.

Integrated Crop-Livestock Systems for Nitrogen Management: A Multi-Scale Spatial Analysis.

The size and productivity of the livestock operations have increased over the past several decades, serving the needs of the growing human population. This growth however has come at the expense of broken connection between croplands and livestock operations. As a result, there is a huge disconnect between the nutrient needs of croplands and the availability of nutrients from livestock operations, leading to a range of environmental and public health issues. This study develops a theoretical framework for multi-scale spatial analysis of integrated crop-livestock systems. Using New Mexico, USA as a case study, we quantify the amount of nitrogen produced by dairy farms in the state and examine if the available nitrogen can be assimilated by the croplands and grasslands across spatial scales. The farm-level assessment identifies that all the farms under study do not have adequate onsite croplands to assimilate the nitrogen produced therein. The successive assessments at county and watershed levels suggest that the among-farm integration across operations could be an effective mechanism to assimilate the excess nitrogen. Our study hints towards the multi-spatial characteristic of the problem that can be pivotal in designing successful policy instruments.

Novel Relationship Between Hemoglobin A1c Levels and Foot Ulcer Development Among Patients With Type 2 Diabetes Mellitus Admitted at Tupua Tamasese Meaole Hospital.

BACKGROUND: Diabetes mellitus is one of the leading chronic conditions worldwide. One of its most debilitating complications is diabetic foot ulcers (DFUs), which appear to have an increased incidence in the Pacific Islands. However, this report has not been studied extensively in Samoa. Nevertheless, DFUs may be prevented through strict glycemic control by hemoglobin A1c (HbA1c) level monitoring. OBJECTIVE: This study aimed to identify a specific cutoff point for HbA1C to reduce the occurrence of DFUs in patients with type 2 diabetes mellitus (T2DM) admitted to an internal medicine ward in Samoa. Increased HbA1c levels are hypothesized to be strongly associated with DFU development. METHODS: A retrospective unmatched case-control study examined 100 patients with T2DM (50 patients with DFUs [case] and 50 patients without DFUs [control]) over four months. Participants were selected by convenience sampling. RESULTS: The HbA1c results were available in 32 cases and 29 controls. The receiver operating characteristic curve showed that the area under the curve was 51% (95% CI, 36%-66%; standard error, 0.075; P = 0.8966), and no cutoff point could be established. CONCLUSION: The HbA1c is not an ideal test to readily predict DFUs in patients with T2DM.