Identifying the Causes of Unexplained Dyspnea at High Altitude Using Normobaric Hypoxia with Echocardiography.

Exposure to high altitude results in hypobaric hypoxia, leading to physiological changes in the cardiovascular system that may result in limiting symptoms, including dyspnea, fatigue, and exercise intolerance. However, it is still unclear why some patients are more susceptible to high-altitude symptoms than others. Hypoxic simulation testing (HST) simulates changes in physiology that occur at a specific altitude by asking the patients to breathe a mixture of gases with decreased oxygen content. This study aimed to determine whether the use of transthoracic echocardiography (TTE) during HST can detect the rise in right-sided pressures and the impact of hypoxia on right ventricle (RV) hemodynamics and right to left shunts, thus revealing the underlying causes of high-altitude signs and symptoms. A retrospective study was performed including consecutive patients with unexplained dyspnea at high altitude. HSTs were performed by administrating reduced FiO2 to simulate altitude levels specific to patients' history. Echocardiography images were obtained at baseline and during hypoxia. The study included 27 patients, with a mean age of 65 years, 14 patients (51.9%) were female. RV systolic pressure increased at peak hypoxia, while RV systolic function declined as shown by a significant decrease in the tricuspid annular plane systolic excursion (TAPSE), the maximum velocity achieved by the lateral tricuspid annulus during systole (S' wave), and the RV free wall longitudinal strain. Additionally, right-to-left shunt was present in 19 (70.4%) patients as identified by bubble contrast injections. Among these, the severity of the shunt increased at peak hypoxia in eight cases (42.1%), and the shunt was only evident during hypoxia in seven patients (36.8%). In conclusion, the use of TTE during HST provides valuable information by revealing the presence of symptomatic, sustained shunts and confirming the decline in RV hemodynamics, thus potentially explaining dyspnea at high altitude. Further studies are needed to establish the optimal clinical role of this physiologic method.

Turned away and sleeping apart: A qualitative study on women's perspectives and experiences with family planning denial in Malawi.

INTRODUCTION: Barriers to family planning for potential clients have been explored in the literature, but rarely from the perspective of the women themselves in a low-income setting. This research aimed to understand clients' perspectives on being turned away from receiving a method of family planning at a facility on the day it was sought. METHODS: Three focus group discussions were held in two districts of Malawi in 2019 with clients who had been turned away approximately three to six months prior. RESULTS: The reasons for turnaway participants mentioned fell into eight categories: no proof of not being pregnant, method and/or supply stock-outs, arriving late, provider unavailable, provider refusal, needing to wait longer after delivery of a child, financial constraints, and medical reasons. Participants were often turned away more than once before finally being able to initiate a method, in some cases returning to the same facility and in others finding it through community health workers, traditional healers, or private facilities. Clients often resorted to sleeping apart from their husbands until they could initiate a method and reported stress and worry resulting from being turned away. CONCLUSIONS: Clients are turned away without a method of FP on the day they seek one for multiple reasons, nearly all of which are preventable. Many examples given by the participants showed a lack of knowledge and respect for clients on the part of the providers. Changing attitudes and behaviour, however, may be difficult and will require additional steps. Increasing the availability and use of pregnancy tests, having a more reliable supply of methods and materials, increasing the number of providers-including those trained well in all methods-and providing daily FP services would all help reduce turnaway. Improved access to family planning will help counties achieve their Sustainable Development Goals.

Casting a Wide Net: HIV Drug Resistance Monitoring in Pre-Exposure Prophylaxis Seroconverters in the Global Evaluation of Microbicide Sensitivity Project.

BACKGROUND: Evidence of HIV drug resistance (HIVDR) in individuals using oral pre-exposure prophylaxis (PrEP) who acquire HIV is limited to clinical trials and case studies. More data are needed to understand the risk of HIVDR with oral PrEP during PrEP rollout. Mechanisms to collect these data vary, and are dependent on cost, scale of PrEP distribution, and in-country infrastructure for the identification, collection, and testing of samples from PrEP seroconverters. METHODS: The Global Evaluation of Microbicide Sensitivity (GEMS) project, in collaboration with country stakeholders, initiated HIVDR monitoring among new HIV seroconverters with prior PrEP use in Eswatini, Kenya, South Africa, and Zimbabwe. Standalone protocols were developed to assess HIVDR among a national sample of PrEP users. In addition, HIVDR testing was incorporated into existing demonstration projects for key populations. LESSONS LEARNED: Countries are supportive of conducting a time-limited evaluation of HIVDR during the early stages of PrEP rollout. As PrEP rollout expands, the need for long-term HIVDR monitoring with PrEP will need to be balanced with maintaining national HIV drug resistance surveillance for pretreatment and acquired drug resistance. Laboratory capacity is a common obstacle to setting up a monitoring system. CONCLUSIONS: Establishing HIV resistance monitoring within PrEP programs is feasible. Approaches to drug resistance monitoring may evolve as the PrEP programs mature and expand. The methods and implementation support offered by GEMS assisted countries in developing methods to monitor for drug resistance that best fit their PrEP program needs and resources.

Turned Away and at Risk: Denial of Family Planning Services to Women in Malawi.

Family planning (FP) has been a development priority since the mid-1990s, yet barriers to access persist globally, including women being turned away from facilities without a method. This study aimed to assess the extent of, and reasons for, FP turnaway in three districts of Malawi. In 2019, data collectors screened women exiting 30 health facilities and surveyed those who had been denied a method. Follow-up surveys were conducted via telephone with turned away clients at six and 12 weeks postvisit. Of the 2,246 women who were screened, 562 were new or restarting users. Of these, 15% (83/562) reported having been turned away from the health facility without an FP method. Women cited 14 different reasons for turnaway; the top three were unavailability of method (34%), unavailability of a provider (17%), or a requirement to return on the scheduled FP day (15%). The multiple reasons cited for leaving the health facility without an FP method indicate that reducing turnaway will not be achieved easily. The top reasons for turnaway are related to health systems or management issues within health facilities. Facilities need additional support for staffing, training on long-acting and permanent methods, and a consistent supply of methods.

The Provider Role and Perspective in the Denial of Family Planning Services to Women in Malawi: A Mixed-Methods Study.

Family planning (FP) has been a global health priority for decades, yet barriers persist, including women being turned away from facilities without receiving services. This study assessed the provider role and perspective in client turnaway in three districts of Malawi. In 2019, data collectors surveyed 57 FP providers from 30 health facilities. All reported being comfortable providing FP to married women with children and married adolescents under 18 years old with children, whereas 12% of the providers expressed discomfort providing such services to married adolescents under 18 without children. Sixty percent of the providers required clients desiring FP and wishing to initiate oral contraceptives or injectables to be currently menstruating. Data collectors later conducted in-depth interviews (IDIs) with 8 of the 57 providers about client turnaway. During IDIs, providers' most frequently mentioned reasons for turnaway was client pregnancy or suspicion of pregnancy. Providers expressed fears that initiating FP with a pregnant woman could cause community mistrust in the efficacy of modern contraception. Provider support for FP waned for nulliparous clients, regardless of age or marital status. To improve FP services in Malawi, providers need continuous education on all available methods of FP, a reduction in stockouts and programs to further sensitize the community to how contraception works. Understanding how Malawi has helped providers overcome social and cultural norms regarding provision of FP to adolescents might help other countries to make improvements.

Choosing Daily Labs Wisely in the Hospital: A Novel Tool for Assessing Laboratory Testing Appropriateness.

BACKGROUND: The Minnesota Lab Appropriateness (MLAB) criteria were developed for assessing appropriateness of complete blood counts (CBCs) and serum electrolyte panels (SEPs) ordered for adult inpatients. METHODS: Two independent raters used the MLAB criteria to rate appropriateness of labs ordered during 50 hospitalizations through retrospective medical record review. RESULTS: Evaluation of 208 CBCs and 253 SEPs on a 2-category scale (appropriate/inappropriate) resulted in an inappropriate lab rate of 24% and 25% for CBCs and SEPs, respectively. Using a 3-category Likert scale that included an "equivocal" rating to allow for clinical uncertainty, 17% of CBCs and 20% of SEPs were considered inappropriate. Interrater reliability was "substantial" using the dichotomous scale for both CBCs and SEPs. Using the 3-category Likert scale, reliability was "substantial" for CBCs and "moderate" for SEPs. CONCLUSION: The MLAB criteria identified inappropriate labs at a rate consistent with published figures, with good interrater reliability.

Indicators for Monitoring and Evaluation of Community-Based Injectable Contraception: Multisourced Process and New Global Guidance.

For many women, convenient access to family planning in their communities provides the impetus they need to start and maintain use of a family planning method. The benefits of family planning task shifting, which allows community health workers (CHWs) to provide methods such as oral contraceptive pills and injectables within communities, were publicly recognized by the World Health Organization (WHO) in 2009. WHO's 2012 global guidelines on task sharing recommended CHW provision of injectable contraception, accompanied by targeted monitoring and evaluation (M&E); however, the term "targeted" was not defined. To fill this gap, we undertook a literature review, technical consultation, and case studies in Malawi, Senegal, and Uganda to inform our development of a list of M&E indicators, supporting guidance, and job aids to help strengthen community-based access to injectable contraception programs and their ability to follow WHO recommendations. We identified 4 essential indicators: there are enough CHWs certified to provide injectables to meet project goals, CHWs are being appropriately supervised to ensure client safety, the stock of injectables is reliable and can meet project goals, and clients are receiving injections.

Interactive value-based curriculum: a pilot study.

BACKGROUND: Current health care costs are unsustainable, with a large percentage of waste attributed to doctor practices. Medical educators are developing curricula to address value-based care (VBC) in education. There is, however, a paucity of curricula and assessments addressing levels higher than 'knows' at the base of Miller's pyramid of assessment. Our objective was to: (1) teach residents the principles of VBC using active learning strategies; and (2) develop and pilot a tool to assess residents' ability to apply principles of VBC at the higher level of 'knows how' on Miller's pyramid. METHODS: Residents in medicine, medicine-paediatrics and medicine-dermatology participated in a 5-week VBC morning report curriculum using active learning techniques. Early sessions targeted knowledge and later sessions emphasised the application of VBC principles. Medical educators are developing curricula to address value-based care in education RESULTS: Thirty residents attended at least one session and completed both pre- and post-intervention tests, using a newly developed case-based assessment tool featuring a 'waste score' balanced with 'standard of care'. Residents, on average, reduced their waste score from pre-intervention to post-intervention [mean 8.8 (SD 6.3) versus mean 4.7 (SD 4.6), p = 0.001]. For those who reduced their waste score, most maintained or improved their standard of care. DISCUSSION: Our results suggest that residents may be able to decrease health care waste, with the majority maintaining or improving their management of care in a case-based assessment after participation in the curriculum. We are working to further incorporate VBC principles into more morning reports, and to develop further interventions and assessments to evaluate our residents at higher levels on Miller's pyramid of assessment.