Accuracy of periocular lesion assessment using telemedicine.

OBJECTIVES: To assess the agreement in diagnosis and management plans reached between clinicians reviewing eyelid lesions remotely and in face-to-face clinics. METHODS: In this single-centre observational case series, data were prospectively collected on 50 consecutive adults referred with eyelid lesions suitable to be seen by a nurse. A proforma was completed to gather salient information. A nurse specialist saw patients in face-to-face clinics and collected information using the proforma, devising a diagnosis and management plan. Photographs of the eyelid lesions were taken by a medical photographer. A subsequent remote review was completed by an oculoplastic consultant using the proforma information and photographs in the absence of the patient. The diagnosis and management plan constructed by the nurse specialist were compared with those reached by the consultant. RESULTS: Complete data were available for 44 consecutive cases. There was an overall 91% agreement (40 cases out of 44) between the diagnoses reached by the nurse specialist, and the remote reviewer; kappa coefficient 0.88 (95% CI 0.76 to 0.99). There was an overall 82% agreement (36 out of 44 cases) in the management plans devised by the nurse-led clinic and remote reviewer; kappa coefficient 0.74 (95% CI 0.58 to 0.90). The average time taken for a remote reviewer to reach a diagnosis and management plan was 1 min and 20 s. CONCLUSIONS: This study evaluated the feasibility of assessing eyelid lesions using asynchronous telemedicine. There was overall a high rate of concordance in the diagnosis reached, and management devised between the clinic and remote review.

External validation of the EULAR/ACR idiopathic inflammatory myopathies classification criteria with a Japanese paediatric cohort.

OBJECTIVES: To assess the performance of the EULAR/ACR idiopathic inflammatory myopathies (IIMs) classification criteria to classify juvenile IIMs (JIIMs) in an Asian paediatric population. METHODS: Sixty-eight JIIM patients and 49 non-JIIM patients diagnosed at seven major paediatric rheumatology centres in Japan between 2008 and 2015 were enrolled. Retrospective data were collected, and each patient's data form was submitted. The expert group reviewed the forms and re-examined the diagnoses. The EULAR/ACR criteria were then applied and the probability of having JIIM was determined for each case. The sensitivity and specificity of the EULAR/ACR criteria were compared with those of other existing criteria. RESULTS: The sensitivity/specificity of the EULAR/ACR classification criteria were 92.1/100% with muscle biopsy data (n = 38); 86.7/100% without muscle biopsy data (n = 30) and 89.7/100% in our total cohort (n = 68). The sensitivity of Bohan and Peter's criteria and Tanimoto's criteria were 80.9 and 64.7% in our total cohort, respectively. Among 68 physician-diagnosed JIIM patients, seven cases (three JDM and four overlap myositis) were not classified as JIIM because the probability did not reach the cut-off point (55%). The three JDM patients all presented with only one of the three skin manifestations that are listed in the criteria: Gottron's sign. CONCLUSION: Our validation study with Japanese JIIM cases indicates that the EULAR/ACR classification criteria for IIM generally perform better than existing diagnostic criteria for myositis.

Evaluation of continuous quality improvement of tuberculosis and HIV diagnostic services in Amhara Public Health Institute, Ethiopia.

BACKGROUND: Unreliable laboratory results lead to unnecessary tests, procedures or treatments which may harm the patient. Continuous quality improvement (CQI) is a useful objective tool to improve processes and services. The use of quality indicators that meet requirements for effectiveness is an important quality improvement tool. However, the quality of critical aspects of pre-examination, examination, and post-examination processes have not been evaluated in Ethiopia including our setting. Hence, this study aimed to assess the performance of continuous quality improvement of TB and HIV laboratory tests in the Amhara Public Health Institute (APHI). METHODS: A cross-sectional study was conducted to evaluate the quality indicators of advanced TB and HIV related laboratory tests in APHI from 01 January to 30 September 2019. HIV viral load, exposed infant diagnosis (EID), GeneXpert and TB culture quality indicators data were used as a quality improvement tool and evaluated in comparison to established targets. Data were extracted from excel database and record review of patient information, and entered and analyzed using SPSS V20 software. RESULTS: A total of 26,487 samples were received from 01 January to 30 September 2019. The overall specimen rejection rate was 0.43% (115/26,487). Specifically, viral load and TB culture had 0.43% and 1.14% rejection rates, respectively. The highest monthly rejection was documented for TB culture (5.3%) and viral load (2.4%) in September 2019. Centrifugation problems (46.1% [53/115]) and the use of the wrong container (40.9% [47/115]) were the main reasons for the rejections. Moreover, EID test was interrupted for a total of 54 days and 22 days due to reagent stock out and equipment down time, respectively. Similarly, about 82% of viral load and 100% of the EID tests had long turnaround time (TAT) with an average of 24.1 and 29.3 days respectively in September 2019. CONCLUSIONS: There were high rates of TB culture and viral load specimen rejection, and EID test interruptions. The TAT of viral load and EID tests were longer than the targeted goal (10 days) average TAT. Hence, training of sample collectors, functional equipment maintenance systems and supply chain management are recommended for continuous quality improvement.

Compliance of clinical microbiology laboratories with recommendations for the diagnosis of bloodstream infections: Data from a nationwide survey in Italy.

In 2014, the Italian Working Group for Infections in Critically Ill Patient of the Italian Association of Clinical Microbiologists updated the recommendations for the diagnostic workflow for bloodstream infections (BSI). Two years after publication, a nationwide survey was conducted to assess the compliance with the updated recommendations by clinical microbiology laboratories. A total of 168 microbiologists from 168 laboratories, serving 204 acute care hospitals and postacute care facilities, were interviewed during the period January-October 2016 using a questionnaire consisting of nineteen questions which assessed the level of adherence to various recommendations. The most critical issues were as follows: (a) The number of sets of blood cultures (BC) per 1,000 hospitalization days was acceptable in only 11% of laboratories; (b) the minority of laboratories (42%) was able to monitor whether BCs were over or under-inoculated; (c) among the laboratories monitoring BC contamination (80%), the rate of contaminated samples was acceptable in only 12% of cases;(d) the Gram-staining results were reported within 1 hr since BC positivity in less than 50% of laboratories. By contrast, most laboratories received vials within 2-4 hr from withdrawal (65%) and incubated vials as soon as they were received in the laboratory (95%). The study revealed that compliance with the recommendations is still partial. Further surveys will be needed to monitor the situation in the future.

The quality of the sickness certificate. A case control study of patients with symptom and disease specific diagnoses in primary health care in Sweden.

Objective: To compare information in sickness certificates and rehabilitation activities for patients with symptom diagnoses vs patients with disease specific diagnoses. Design: Retrospective case control study 2013-2014. Setting: Primary health care, Sweden. Subjects. Patients with new onset sickness certificates with symptom diagnoses n = 222, and disease specific diagnoses (controls), n = 222. Main outcome measures: Main parameters assessed were: information about body function and activity limitation in certificates, duration of sick leave, certificate renewals by telephone, diagnostic investigations, health care utilisation, contacts between patients, rehabilitation coordinators, social insurance officers, employers and occurrence of rehabilitation plans. Results: Information about body function and activity limitation was sufficient according to guidelines in half of all certificates, less in patients with symptom diagnoses compared to controls (44% vs. 56%, p = 0.008). Patients with symptom diagnoses had shorter sick leave than controls (116 vs. 151 days p = 0.018) and more certificates issued by telephone (23% vs. 15% p = 0.038). Furthermore, they underwent more diagnostic investigations (32% vs. 18%, p < 0.001) and the year preceding sick leave they had more visits to health care (82% vs. 68%, p < 0.001), but less follow-up (16% vs. 26%, p < 0.008). In both groups contacts related to rehabilitation and with employers were scarce. Conclusion: Certificates with symptom diagnoses compared to disease specific diagnoses could be used as markers for insufficient certificate quality and for patients with higher health care utilisation. Overall, the information in half of the certificates was insufficient and early contacts with employers and rehabilitation activities were in practice missing. KEY POINTS Symptom diagnoses are proposed as markers of sickness certification quality. We investigated this by comparing certificates with and without symptom diagnoses. Certificates with symptom diagnoses lacked information to a higher degree compared to certificates with disease specific diagnoses. Regardless of diagnoses, early contacts between patients, rehabilitation coordinators and social insurance officers were rare and contacts with employers were absent.

A fetal alcohol spectrum disorder diagnostic service and beyond: Outcomes for families.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is of significant concern for Australians for many reasons, one being Australia's drinking culture which increases the potential for FASD to occur. AIMS: The current study aimed to explore the lived experiences of Australian caregivers who received a FASD diagnosis for a child in their care, usingthe Australian Guide to the Diagnosis of FASD. METHODS AND PROCEDURES: Semi-structured interviews were conducted with seven caregivers whose children were assessed for FASD by a multidisciplinary team. Interviews explored how families experienced the FASD diagnostic process, and sought insight into outcomes for families following diagnosis, particularly in relation to accessing supports and services. OUTCOMES AND RESULTS: Through thematic analysis, five overarching themes were identified: (1) receiving a FASD diagnosis had a positive impact; (2) caregivers' evaluation of assessment process; (3) positive support services relative to FASD; (4) ongoing difficulties regardless of diagnosis; and (5) need for societal knowledge of FASD. CONCLUSIONS AND IMPLICATIONS: Given the global need for standardised FASD diagnostic procedures and accurate reporting of prevalence rates, the current study provides a contribution to the emerging diagnostic FASD literature, and insight into families' experiences who have children diagnosed with FASD. WHAT THIS PAPER ADDS: This study provides additional information to the developing pool of literature attempting to create a typical profile of FASD. Most importantly, this paper highlights the implementation of the Australian Guide to the Diagnosis of FASD, and evaluates caregivers' experiences of their child's FASD assessment process, within a public FASD diagnostic service, using the revised guidelines.

Optimizing testing for Clostridium difficile infection: A quality improvement project.

Overtesting for Clostridium difficile may result in increased health care facility-onset C difficile infection LabID events. Our quality improvement project optimized testing through standardization of laboratory processes, electronic health record clinical decision support, and real-time monitoring. Our intervention resulted in a 59% reduction in health care facility-onset C difficile infection LabID events.

Mind the gap: Improving the performance of the reference laboratory to end-tuberculosis in Armenia.

INTRODUCTION: A one of the step towards achieving TB related targets is to ensure early and quality diagnosis of TB in national laboratories. WHO recommends that all national reference laboratories in TB burden countries strive to reach accreditation by 2025, based on ISO15189:2012 quality management system standard. To identify gaps, progress and evaluated the evolution in implementation QMS we performed a formal assessment of the national TB reference laboratory of Armenia, as well as estimates the specific quality indicators of NRL activity. METHODOLOGY: This is retrospective study cross-sectional study using laboratory data from the National TB Reference Laboratory in Armenia. Quality Management System assessments was conducted twice a year, using TB SLMTA assessment checklist. The sputum rejection and culture rates for quality indicators are calculated and assessed monthly. RESULTS: Compared to the baseline in 2016, there was a quality improvement reflecting the progress from zero to a "one star" in 2018. Areas that reached half of the target score included document and records, management review and responsibilities, evaluation and audits. Sections as "client management and customer service" and "evaluation and audits" stagnated in terms of progress. In terms of NRL performace, all indicators improved except for culture positivity in smear negative tuberculosis. CONCLUSION: Although a quality management system was introduced in the NRL there is now an urgent need to develop and implement an adapted roadmap for Armenia. This will be vital to hasten the much-needed pace towards accreditation.

[Assessment of ability of professionals in parasitic disease control and prevention techniques in China, 2017].

OBJECTIVE: To understand the professional theory, prevention and control practice, experimental diagnosis and other technical skills of parasitic diseases among technicians of all levels of disease control and prevention institutions, so as to provide the evidence for strengthening the capacity building of Chinese professional personnel. METHODS: According to the method of recommendation at all levels, the subjects from disease control and prevention institutions at province, prefecture or county levels were chosen to assess the theory of parasitic diseases and test operation skills by using the method of answering the questions together with on-site operations in China. A database was built consisting of subjects' basic information and assessment scores. By using the method of hierarchical classification, the scores by gender, age, professional title, institutions and places of participants were analyzed. RESULTS: A total of 124 professions in prevention and treatment of parasitic diseases in 31 provinces (cities and regions) were evaluated in China. The average total score of all the subjects was 125.0 ± 35.2, with a passing rate of 54.8%. The average scores of male subjects and female subjects were 120.8 ± 34.2 and 126.6 ± 35.4 respectively; the average scores of the subjects aged under 30 years, between 30 and 40 years, and above 40 years were 125.6 ± 33.6, 124.9 ± 35.8, and 119.3 ± 45.9 respectively; the average scores of persons with junior, intermediate and senior professional titles were 119.8 ± 35.8, 136.0 ± 32.5 and 127.1 ± 40.9 respectively. The average theoretical assessment score of all the subjects was 67.4 ± 15.6, with a passing rate of 68.5%. The average practical skill assessment score of all the subjects was 57.6 ± 21.8, with a passing rate of 46.0%. The average detection rates of Plasmodium falciparum, P. vivax, P. ovale and P. malariae in endemic and non-endemic areas were 64.1%, 72.8%, 57.0%, 58.3% and 35.9%, 46.9%, 33.3%, 43.8%, respectively. The detection ability of professionals in endemic areas was significantly higher than that in non-endemic areas (χ2 = 767.10, 462.12, 134.97 and 360.80, respectively, all P < 0.01). The total detection rate of schistosome eggs was 48.7%, and the detection rates of schistosome eggs were 67.4% and 36.8% in endemic and non-endemic areas, respectively. The detection ability of professionals in endemic areas was significantly higher than that in non-endemic areas (χ2 = 817.74, P < 0.01). The detection rates of Ascaris lumbricoides, Trichuris trichiura, and Enterobius vermicularis were 85.7%, 78.6%, 91.7%, and 61.8%, 23.5% and 74.4% in the technicians in southern region and northern region of China, showing significant differences (χ2 = 622.58, 301.70 and 588.71, respectively, all P < 0.01). CONCLUSIONS: The overall results of the subjects are good, but the technical operation capability of them is relatively low. Therefore, the specific training based on daily work needs should be enhanced. In addition, we should attach importance to talent cultivation and technical reserve, and strengthen the construction of the team, so as to meet the needs of the prevention and control of parasitic diseases.

Task Sharing and Shifting to Provide Pathology Diagnostic Services: The Kenya Fine-Needle Aspiration Biopsy Cytology and Bone Marrow Aspiration and Trephine Biopsy Training Program.

PURPOSE: Fine-needle aspiration biopsy (FNAB) cytology is a simple, inexpensive, and accurate diagnostic test for benign, infectious, and malignant lesions of the breast, thyroid, lymph nodes, and other organs. Similarly, bone marrow aspiration and trephine (BMAT) biopsy procedures are relatively simple and inexpensive techniques that are important for diagnosing and monitoring many hematologic diseases including leukemias and lymphomas. However, the scarcity of pathologists in Kenya limits patient access to these simple diagnostic tests. We describe a task sharing and shifting program that sought to improve the provision of FNABs and BMAT biopsies in tertiary public hospitals in Kenya. METHODS: Between January 2016 and February 2017, we trained pathologists, pathology residents, and technologists from the University of Nairobi and Aga Khan University Hospital, Nairobi, in FNAB and BMAT biopsies, who in turn trained pathologists, medical officers (MO), clinical officers (CO), and technologists at five tertiary public hospitals. The program involved curriculum development, training workshops, the establishment of new and strengthening existing FNAB and BMAT biopsy clinics, interim site visits, audits, and stakeholder workshops. RESULTS: Fifty-one medical personnel at the tertiary hospitals were trained. The FNAB numbers increased by 41% to 1,681, with 139 malignant diagnoses (7.1%). BMAT biopsy numbers increased by 268% to 140, with 34 malignant cases. Between 60% and 100% of the FNAB and BMAT biopsy procedures were performed by MO and CO over the project period. One new FNAB and two new BMAT biopsy clinics were established. CONCLUSION: This project demonstrates a successful model of task sharing and shifting from specialist pathologists to MO and CO that improved access to important FNAB and BMAT biopsy services in a low-resource setting.

Analysis and Economic Implication of X-Ray Film Reject in Diagnostic Radiology Department of Jimma University Specialized Hospital, Southwest Ethiopia.

BACKGROUND: Patients usually undergo repeated X-ray examinations after their initial X-ray radiographs are rejected due to poor image quality. This subjects the patients to excess radiation exposure and extra cost.It is therefore investigating the magnitude and causes of reject is mandatory. This study aimed to assess the reject rate of X-ray films and its economic implication in order to obtain information for further recommendations on image quality, cost and radiation exposure. METHOD: A cross-sectional study approaches was employed. Reject rate was measured for two x-rays in the department across all plain x-ray films examinations using a structured format on which relevant data for reject were recorded by investigators. The results were then collected and entered into a database for analysis. RESULT: Reject rate and cause of reject were measured across all plane x-ray examinations for the hospital. From a total of 6563 exposed films, 16.85% were rejected. This leads to economic waste of 24,721.99 ETB, or 17.8% of a total cost in 4month period and increase in radiation dose to both patients and staff. CONCLUSION: The findings from this study show that both the overall reject rate and individual reject rate were higher than the accepted range which could be due to machine fault, operator's technical limitations, or absence of quality control program in the department. We recommend that regular quality assurance and quality control procedure which are well documented should be established in the department.

The strategic defense of physician autonomy: State public health agencies as countervailing powers.

Advances in genetic testing and the aggressive marketing of genetic tests by commercial diagnostic laboratories have driven both consumer demand and the need for unbiased information about how tests should guide healthcare delivery. This paper uses the countervailing powers framework to explore the role of state public health agencies as arbiters of quality and safety, specifically through their efforts to encourage physicians to follow evidence-based recommendations for screening for hereditary cancers. Social scientists have often viewed actions by the state to regulate cost, quality, or safety as a threat to physician autonomy. This paper draws on case studies from two US states-Michigan and Connecticut-to better understand the specific role of state public health agencies, and especially whether their activities to encourage adherence to evidence-based recommendations bolster or subvert the interests of other parties in the healthcare arena. We find that lacking authority to compel provider to follow evidence-based recommendations, they improvised ways to foster compliance voluntarily, for example, by emphasizing the role of the physician as gatekeeper, thus affirming the importance of physician autonomy and clinical judgment. Both states also used public health surveillance data to make rare diseases visible and illustrate gaps between recommendations and practice. Finally, they both showed that following evidence-based recommendations could align the professional and market interests of healthcare stakeholders. Both states employed similar strategies with similar effects, despite substantial differences in the regulatory climate and organizational capacity. Taken as a whole, their activities orchestrated a countervailing response that checked the profit-seeking motives of commercial laboratories. Our findings demonstrate that rather than eroding physician autonomy, state action to monitor healthcare quality and encourage adherence to evidence-based recommendations can actually reinforce physician authority.

Performance of health laboratories in provision of HIV diagnostic and supportive services in selected districts of Tanzania.

BACKGROUND: Roll-out and implementation of antiretroviral therapy (ART) necessitated many countries in Sub-Saharan Africa to strengthen their national health laboratory systems (NHLSs) to provide high quality HIV diagnostic and supportive services. This study was conducted to assess the performance of health laboratories in provision of HIV diagnostic and supportive services in eight districts (from four regions of Iringa, Mtwara, Tabora and Tanga), after nine years of implementation of HIV/AIDS care and treatment plan in Tanzania. METHODS: In this cross-sectional study, checklists and observations were utilized to collect information from health facilities (HFs) with care and treatment centres (CTCs) for HIV/AIDS patients; on availability of laboratories, CTCs, laboratory personnel, equipment and reagents. A checklist was also used to collect information on implementation of quality assurance (QA) systems at all levels of the NHLS in the study areas. RESULTS: The four regions had 354 HFs (13 hospitals, 41 Health Centres (HCs) and 300 dispensaries); whereby all hospitals had laboratories and 11 had CTCs while 97.5 and 61.0% of HCs had both laboratories and CTCs, respectively. Of the dispensaries, 36.0 and 15.0% had laboratories and CTCs (mainly in urban areas). Thirty nine HFs (12 hospitals, 21 HCs and six dispensaries) were assessed and 56.4% were located in urban areas. The assessed HFs had 199 laboratory staff of different cadres (laboratory assistants = 35.7%; technicians =32.7%; attendants = 22.6%; and others = 9.1%); with >61% of the staff and 72.3% of the technicians working in urban areas. All laboratories were using rapid diagnostic tests for HIV testing. Over 74% of the laboratories were performing internal quality control and 51.4% were participating in external QA programmes. Regional and district laboratories had all key equipment and harmonization was maintained for Fluorescence-Activated Cell Sorting (FACS) machines. Most of the biochemical (58.0%) and haematological analysers (74.1%) were available in urban areas. Although >81% of the equipment were functional with no mechanical faulty, 62.6% had not been serviced in the past three years. CONCLUSION: Diagnostic and supportive services for HIV were available in most of the HCs and hospitals while few dispensaries were providing the services. Due to limitations such as shortage of staff, serving of equipment and participation in QA programmes, the NHLS should be strengthened to ensure adequate human resource, implementation of QA and sustainable preventive maintenance services of equipment.

Tele-cytology: An innovative approach for cervical cancer screening in resource-poor settings.

Carcinoma cervix remains a leading cause of cancer mortality among women in countries lacking any screening program. The existing screening policy and approach via conventional cytology centered mainly in Tertiary Care Center, is totally unaffordable to Indian women, especially in the remote areas. This suggests the need of depolarizing the resources via generating the near real time modalities which could be used at the door step of the needy ones. For any screening modality to be effective it should be adequately sensitive, specific, reproducible, cheap, simple, affordable, and the most important is should be real time to ensure wide coverage and curtail loss to follow-up. Incorporating telecytology as a screening tool could make the dream come true. Telecytology is the interpretation of cytology material at a distance using digital images. Use of mobile telecytology unit housed in a van carrying satellite equipment and the automated image capturing systems is the central theme behind this idea. The imaging equipment would be carrying out the imaging of Papanicolaou smears prepared at the screening site and sending the images to the central laboratories situated at some tertiary care level. This concept could overcome the hindrance of trained cytology infrastructure in the resource poor settings and could provide an efficient and economical way of screening patients. There is possibility that the designed approach may not detect the entire women positive for the disease but if the desired objective was to diagnose as many cases as possible in resource poor setting, then this process offers an advantage over no screening at all.