Barriers and enablers to people-centred viral hepatitis care in Vietnam and the Philippines: Results of a patient journey mapping study.

In Vietnam and the Philippines, viral hepatitis is the leading cause of cirrhosis and liver cancer. This study aims to understand the barriers and enablers of people receiving care for hepatitis B and C to support both countries' efforts to eliminate viral hepatitis as a public health threat by 2030. Retrospective, semi-structured interviews were conducted with a purposive, quota-based sample of 63 people living with hepatitis B or C in one province of Vietnam and one region of the Philippines. A rapid deductive approach to thematic analysis produced key findings among the three phases of care: (1) pre-awareness and testing, (2) linkage and treatment initiation and (3) ongoing treatment and recovery. The research found that participants followed five typical journeys, from a variety of entry points. Barriers during the pre-awareness and testing phase included limited awareness about hepatitis and its management, stigma and psychological impacts. Enablers included being familiar with the health system and/or patients benefiting from social connections within the health systems. During the linkage and treatment initiation phase, barriers included difficult physical access, complex navigation and inadequate counselling. In this phase, family support emerged as a critical enabler. During the ongoing treatment and recovery phase, the cost of care and socially and culturally informed perceptions of the disease and medication use were both barriers and enablers. Exploring peoples' journeys with hepatitis B and C in Vietnam and the Philippines revealed many similarities despite the different cultural and health system contexts. Insights from this study may help generate a contextualized, people-centred evidence base to inform the design and improvement of primary care services for hepatitis in both research sites.

Radioembolization for Treatment of Hepatocellular Carcinoma: Current Evidence and Patterns of Utilization.

Primary liver malignancy, of which hepatocellular carcinoma (HCC) is the most common type, is the second most common cause of death due to cancer worldwide. Given the historically poor prognosis of liver cancer, there has been major research on its treatment options, with significant advancements over the last decade. Transarterial radioembolization (TARE) is a locoregional treatment option for HCC that involves transarterial delivery of the ß-emitter yttrium-90 via resin or glass microspheres to arterialized tumor vasculature, delivering a tumoricidal dose to the tumor. The recent 2022 update of the Barcelona Clinic Liver Cancer (BCLC) treatment algorithm features a more prominent role for locoregional treatment, including the incorporation of radioembolization for very-early-stage (BCLC-0) and early-stage (BCLC-A) diseases. This review provides a contemporary summary of the evolving role of TARE in treatment of HCC in light of recent and upcoming trials.

Knowledge, facilitators and barriers to the practice of person-centred care in aged care workers: a qualitative study.

The current study describes aged care workers' interpretation of the concept of person-centred care; and identifies the barriers that exist to impede its practice, and the facilitators that encourage person-centred care practice. Data were collected from interviews with aged care workers from two residential aged care facilities providing both high and low care for residents with and without physical and psychological issues based in Australia. Data were analysed to identify and explore categories of meaning for barriers and facilitators. Analysis is grounded in Brooker's VIPS framework for person-centred dementia care which is utilised as a comparative tool for analysing participants' understanding of person-centred care. Findings revealed that aged care workers have a reasonable but incomplete understanding of person-centred care. Insufficient time and residents' dementia behaviours acted as barriers to care workers' provision of person-centred care. Teamwork was found to facilitate person-centred care by increasing instrumental and relationship resources.

Social Workers as Workplace-Based Instructors of Alcohol and Drug Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Emergency Medicine Residents.

PROBLEM: Residency education is challenged by a shortage of personnel and time, particularly for teaching behavioral interventions such as screening, brief intervention, and referral to treatment (SBIRT) to reduce hazardous drinking and drug use. However, social workers may be well placed to teach SBIRT in clinical training settings. INTERVENTION: We describe a curriculum with social workers as SBIRT trainers of emergency medicine (EM) residents during actual clinical shifts in an EM residency training program. The curriculum required 1 EM faculty member working with social workers and 1 additional hour of formal residency conference teaching time. CONTEXT: We implemented the curriculum at both a university tertiary care hospital emergency department and a county trauma center. We trained 8 social workers at both sites as SBIRT superusers to teach and assess EM resident SBIRT performance with actual patients. We measured the length and number of sessions to attain SBIRT competence, residents' satisfaction, and resident comments (coded by authors). OUTCOME: Five of the 8 social workers trained residents between June 2013 and May 2014, 31 EM residents trained to a level indicating SBIRT competence with 114 patients. Each patient interaction averaged 8.8 minutes and residents averaged 3.13 patients. Twenty-four (77%) residents gave ratings of 1.58 (SD = .58) for the quality of teaching, 2.33 (SD = .87) for recommending the training to a colleague, 1.38 (SD = .49) for superusers' knowledge, 1.88 (SD = .95) for usefulness of instruction, 1.54 (SD = .72) for workplace learning, and 1.58 (SD = .78) for valuing learning from social workers (on a scale of 1 [very satisfied/strongly agree] to 5 [very dissatisfied/strongly disagree]). Residents preferred learning SBIRT during the 1st and 2nd training years and in the workplace. LESSONS LEARNED: Social work colleagues can be effective in teaching SBIRT to residents in the workplace, and our residents highly valued learning from social workers, who all had prior training in motivational interviewing. In the implementation of this curriculum, the clinical demands of residents must be taken into account when teaching occurs, and having multiple social worker instructors was instrumental.

Medical student perceptions on the instruction of the emergency medicine oral case presentation.

BACKGROUND: The emergency medicine oral case presentation (EM OCP) is the clinician's communication tool to justify whether urgent intervention is required, to argue for ruling out emergent disease states, and to propose safe disposition plans in the context of triaging patients for medical care and prioritization of resources. The EM OCP provides the representation of the practice of emergency medicine, yet we do not know the current level of effectiveness of its instruction. OBJECTIVES: We aimed to document medical student perceptions and expectations of the instruction of the EM OCP. METHODS: We surveyed medical students from five institutions after their emergency medicine clerkship on their instruction of the EM OCP. Analysis included univariate descriptive statistics and chi-squared analyses for interactions. RESULTS: One hundred fifty-five medical students (82%) completed the survey. Most medical students reported the EM OCP to be unique compared to that of other disciplines (86%), integral to their clerkship evaluation (77%), and felt that additional teaching was required beyond their current medical school instruction (78%). A minority report being specifically taught the EM OCP (37%), that their instruction was consistent (29%), or that expectations of the EM OCP were clear (21%). Respondents felt that brief instruction during their orientation (65%) and reading with a portable summary card (45%) would improve their EM OCP skills, whereas other modalities would be less helpful. CONCLUSION: This study identifies a need for additional specific and consistent teaching of the EM OCP to medical students and their preference on how to receive this instruction.

ECHO+: An Innovative Technology-Enabled Collaborative Learning and Quality Improvement Program Strengthening Rural Primary Care in Arkansas, West Virginia, and Oklahoma.

In this paper, we describe the Project Extension for Community Healthcare Outcomes+ (ECHO+) model and evaluation plan for incorporating changes to primary care delivery, improving patient and clinician outcomes, and making long-term system improvements.

Embedding viral hepatitis into primary healthcare: results of a strategic landscape analysis in Vietnam and the Philippines.

Chronic viral hepatitis is a significant public health concern in the Western Pacific, including in Vietnam and the Philippines. To accelerate progress toward meeting the 2030 elimination goals, the World Health Organization (WHO) encourages countries to adopt an integrated, people-centered health sector response to hepatitis, grounded in Primary Health Care (PHC). A review of the academic and grey literature, along with policy documents, was conducted to describe the national health system and PHC response to hepatitis B and C in Vietnam and the Philippines. Information was analyzed against the four strategic levers of the WHO Operational Framework for PHC to identify challenges and opportunities. The findings suggest that both countries have relatively robust policy frameworks, with some room for improvement. Vietnam may have stronger political commitment and funding than the Philippines, while the Philippines appears to be stronger in community engagement. Both countries share challenges and opportunities for learning to actualize viral hepatitis elimination utilizing a PHC approach.

Depressive symptoms and use of perspective taking within a communicative context.

OBJECTIVE: The ability to take the perspective of one's conversational partner is essential for successful communication. We assessed whether individuals who report high levels of depressive symptoms have more difficulty with navigating this interpersonal task. METHOD: Undergraduate students participated in a computerised communication task that, on some trials, required perspective taking (N=125). RESULTS: When participants were grouped according to their self-reported depressive symptoms, the "dysphoric group" (BDI ≥ 16, n=37) showed more errors than a "non-dysphoric group" (BDI ≤ 10, n=56) on trials requiring participants to use the perspective of the speaker, but not on control trials where perspective taking was not required. The dysphoric group demonstrated slower response times overall. CONCLUSIONS: Individuals with moderate to high levels of depressive symptoms are more challenged by using a speaker's perspective to interpret statements.

Does mandatory inpatient alcohol detoxification reduce emergency department recidivism, hospital admissions, and emergency medical services transports for patients with chronic, severe alcohol dependence?

BACKGROUND: In Massachusetts, patients with chronic alcohol dependence can be committed to 30 days of mandatory inpatient alcohol detoxification (MAD). STUDY OBJECTIVES: To examine the effects of MAD on the number of emergency department (ED) visits, hospital admissions, and emergency medical service (EMS) transports. METHODS: This retrospective study identified patients in our urban ED committed to MAD. We compared the number of ED visits and admissions to our hospital and Boston EMS transports to any facility in the 1, 3, and 6 months pre- and post-MAD, excluding the 30-day MAD period. Paired t tests were used for analysis of mean values across time. RESULTS: Ten subjects were enrolled. Comparing pre- and post-MAD, the mean number of ED visits fell 6.5 to 2.7 (p = 0.05) in the first month, 14.2 to 9.3 (p = 0.18) in 3 months, and 25.6 to 17.7 (p = 0.15) in 6 months. Mean number of hospital admissions declined: 1.3 to 0.1 (p = 0.03) in 1 month, 2.3 to 0.9 (p = 0.06) in 3 months, and 3.2 to 1.9 (p = 0.08) in 6 months. Mean number of EMS transports fell 4.6 to 2.3 (p = 0.21) in the first month, 9.2 to 5.6 (p = 0.14) in 3 months, and 13.9 to 10.0 (p = 0.26) in 6 months pre- and post-MAD. CONCLUSIONS: MAD was associated with an immediate reduction in ED visits and hospital admissions that did not remain statistically significant long term, and a non-significant reduction in EMS transports.

Undergraduate Medical Education Reform in Viet Nam for a Primary Health Care Workforce.

Strong primary health care (PHC) systems require a robust PHC workforce. Traditionally, medical education takes place in academic medical centres that favour subspecialty care rather than PHC settings. This may undervalue primary care as a career and contribute to a shortage of PHC workers. However, designing undergraduate medical education curricula that incorporate early experiences in clinical care delivery at PHC sites remains a challenge, including in many low- and middle-income countries (LMICs). This paper describes how a collaboration between Harvard Medical School and five medical schools in Vietnam, and in-country collaborations among the Vietnamese medical schools, facilitated curricular innovation and co-creation of coursework relevant to PHC through the development of a Practice of Medicine (POM) course. The collaboration implemented a technical assistance strategy consisting of in-person workshops, focused virtual consultations, on-site 'office hours', site visits and observations to each of the five medical universities, and immersion trips to support the creation and implementation of the POM course. A pilot program was started at a single site and then scaled nationally using local customisation, experience, and expertise utilising a train-the-trainers approach. As a result, five new POM courses have been developed by five Vietnamese institutions. Fifty Vietnamese faculty received training to lead the POM course development, and 228 community-based preceptors have been trained to teach students at PHC sites. A total of 52 new PHC and community-based clinical training sites have been added, and 3,615 students have completed or are currently going through a POM course. This experience can serve as a model for future academic collaborations to support the development of a robust PHC workforce for the 21st century.

Strengthening national capacities for pandemic preparedness: a cross-country analysis of COVID-19 cases and deaths.

The International Health Regulations-State Party Annual Reporting (IHR-SPAR) index and the Global Health Security Index (GHSI) have been developed to aid in strengthening national capacities for pandemic preparedness. We examined the relationship between country-level rankings on these two indices, along with two additional indices (the Universal Health Coverage Service Coverage Index and World Bank Worldwide Governance Indicator (n = 195)) and compared them to the country-level reported coronavirus disease (COVID-19) cases and deaths (Johns Hopkins University COVID-19 Dashboard) through 17 June 2020. Ordinary least squares regression models were used to compare weekly reported COVID-19 cases and death rates per million in the first 12 weeks of the pandemic between countries classified as low, middle and high ranking on each index while controlling for country socio-demographic information. Countries with higher GHSI and IHR-SPAR index scores experienced fewer reported COVID-19 cases and deaths but only for the first 8 weeks after the country's first case. For the GHSI, this association was further limited to countries with populations below 69.4 million. For both the GHSI and IHR-SPAR, countries with a higher sub-index score in human resources for pandemic preparedness reported fewer COVID-19 cases and deaths in the first 8 weeks after the country's first reported case. The Universal Health Coverage Service Coverage Index and Worldwide Governance Indicator country-level rankings were not associated with COVID-19 outcomes. The associations between GHSI and IHR-SPAR scores and COVID-19 outcomes observed in this study demonstrate that these two indices, although imperfect, may have value, especially in countries with a population under 69.4 million people for the GHSI. Preparedness indices may have value; however, they should continue to be evaluated as policy makers seek to better prepare for future global public health crises.

Complications of tube thoracostomy placement in the emergency department.

BACKGROUND: Emergency medicine residents frequently perform invasive procedures, including tube thoracostomy (TT), that inherently place patients at risk for complications. OBJECTIVES: The purpose of the study was to assess the prevalence and types of complications from TT in an academic emergency department (ED). METHODS: A combined prospective and retrospective, observational study of all patients who had TT between December 2002 and January 2006 was performed. Exclusion criteria included age < 15 years and tube placement at an outside facility. Complications detected in the ED were defined as immediate, whereas those discovered later were defined as delayed. Complications requiring corrective surgical intervention, administration of blood products, or intravenous antibiotics were defined as major. Bivariate and multivariate analyses were used to identify operator and patient factors associated with complications. RESULTS: TTs were placed in 242 patients, and 90 (37%; 95% confidence interval [CI] 31.1-43.3%) experienced a complication. Major complications included one intercostal artery laceration, one retroperitoneal placement, and empyema in 2 patients. In multivariate analysis, blunt injury excluding motor vehicle accidents (odds ratio [OR] 2.57; 95% CI 1.27-5.21) and spontaneous pneumothorax (OR 3.84; 95% CI 1.80-8.18) were associated with all complications. TT size < 36 French and blunt injury excluding motor vehicle accidents were associated with immediate complications and spontaneous pneumothorax was associated with delayed complications. CONCLUSIONS: The vast majority of complications from TT in the ED were minor. The prevalence of complications was consistent with previous reports of TTs placed by non-emergency-medicine-trained physicians outside the ED. The findings can be used to identify avoidable complications and improve residency training.

Association Between Emergency Medicine Clerkship Diversity Scholarships and Residency Diversity.

OBJECTIVE: To improve resident diversity, emergency medicine (EM) residencies across the United States have implemented financial scholarships to attract visiting medical students underrepresented in medicine (URiM). The impact of these scholarships on changes in residency racial and ethnic diversity is currently unknown. In this study, we describe characteristics of these visiting elective scholarships for underrepresented students and evaluate changes in residency racial and ethnic diversity after program implementation. METHODS: From 2018 to 2019, we conducted a cross-sectional survey of EM residency programs with a visiting clerkship rotation scholarship for medical students URiM. Programs were identified for study inclusion using the Society for Academic Emergency Medicine's online directory of Visiting Elective Scholarship Programs for Underrepresented Minorities. Program characteristics were analyzed descriptively. Changes in residency racial and ethnic diversity were evaluated using an interrupted time series analysis. RESULTS: Of 34 programs contacted, 20 responded. While there was some variability in funding sources, scholarship amounts, and application review, most scholarships were similar in implementation practices. Of the 20 program respondents, nine were able to provide complete data on residency race and ethnicity and were included in the time series analysis. After program implementation, the time series analysis showed a significant increase in both underrepresented minority EM residents overall and Black and Latinx EM residents in particular. CONCLUSION: Emergency medicine visiting clerkship scholarship programs for medical students URiM vary in funding type and application review but had similar implementation practices. Residency programs increased their racial and ethnic diversity after program implementation. Future investigations are needed to determine specific factors contributing to the successful implementation of scholarship programs.

Rhabdomyolysis: evidence-based management in the emergency department.

Rhabdomyolysis is a life-threatening pathological process that must be treated as early as possible to avoid potentially life-threatening sequelae. Much of the evidence that informs the management of rhabdomyolysis is retrospective research, often reported from mass disasters, and many practices that have been implemented as standard treatment are based on small studies published more than 30 years ago. This issue reviews the current literature on rhabdomyolysis and provides recommendations for each phase of care, from the prehospital setting through disposition. The evidence is examined regarding the variety of therapies that are used to manage rhabdomyolysis, the potential for recognizing a genetic predisposition for the condition, and therapeutic recommendations that improve patient outcomes.

Annual Primary Care 2030 Convening: Creating an Enabling Ecosystem for Person-Centered Primary Healthcare Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries.

Background: The 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana reaffirm the highest level of political commitment by United Nations Member States to achieve access to health services and primary healthcare for all. Both documents emphasize the importance of person-centered care in both healthcare services and systems design. However, there is limited consensus on how to build a strong primary healthcare system to achieve these goals. Methods: We convened a diverse group of global stakeholders for a high-level dialogue on how to create a person-centered primary healthcare system, using the country examples of the Republic of Kenya and the Socialist Republic of Vietnam. We focused our discussion on four themes to enable the creation of person-centered primary healthcare systems in Kenya and Vietnam: (1) strengthened community, person and patient engagement in subnational and national decision making; (2) improved service delivery; (3) impactful use of innovation and technology; and (4) meaningful and timely use of measurement and data. Findings: Here, we present a summary of our convening's proceedings, with specific insights on how to enable a person-centered primary healthcare system within each of these four domains. Conclusions: Following the 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana, there is high-level commitment and global consensus that a person-centered approach is necessary to achieve high-quality primary healthcare and universal health coverage. We offer our recommendations to the global community to catalyze further discourse and inform policy-making and program development on the path to Universal Health Coverage by 2030.

Primary Care 2030: Creating an Enabling Ecosystem for Disruptive Primary Care Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries.

Background: Forty years after Alma Ata, there is renewed commitment to strengthen primary health care as a foundation for achieving universal health coverage, but there is limited consensus on how to build strong primary health care systems to achieve these goals. Methods: We convened a diverse group of global stakeholders for a high-level dialogue on how to create an enabling ecosystem for disruptive primary care innovation. We focused our discussion on four themes: workforce innovation and strengthening; impactful use of data and technology; private sector engagement; and innovative financing mechanisms. Findings: Here, we present a summary of our convening's proceedings, with specific recommendations for strengthening primary health care systems within each of these four domains. Conclusions: In the wake of the Astana Declaration, there is global consensus that high-quality primary health care must be the foundation for universal health coverage. Significant disruptive innovation will be required to realize this goal. We offer our recommendations to the global community to catalyze further discourse and inform policy-making and program development on the path to Health for All by 2030.

Clinician-performed ultrasound diagnosis of ruptured interstitial pregnancy.

An interstitial pregnancy is a rare type of ectopic pregnancy located within the proximal portion of the fallopian tube in the muscular wall of the uterus. They are more likely to result in significant or fatal hemorrhage because of the increased vascularity. Diagnosis of interstitial pregnancy is challenging but critical to facilitate prompt and appropriate intervention. Ultrasound performed by an emergency physician is commonly used to assess early pregnancy, but little has been published in the emergency medicine literature regarding its use in assessing for presence of interstitial pregnancy. We describe a case of a ruptured interstitial pregnancy diagnosed by emergency ultrasonography in the emergency department and review the literature regarding the sonographic findings of interstitial pregnancies.

Eosinophilic cystitis caused by Candida glabrata: A case report.

Eosinophilic cystitis is a rare disease of the bladder, for which there is no clear cause or standard treatment. We report the case of a 61 year old man who presented with irritative voiding symptoms and gross hematuria. Cystoscopy showed diffuse urothelial erythema and a posterior bladder wall ulcer. Bladder biopsy revealed marked eosinophilic cystitis with ulceration. Urine culture grew Candida glabrata. After treatment with oral fluconazole, his voiding symptoms resolved and subsequent bladder biopsy revealed a complete dearth of eosinophils. This is the first case report linking eosinophilic cystitis to Candida glabrata.

Readiness, Availability and Utilization of Rural Vietnamese Health Facilities for Community Based Primary Care of Non-communicable Diseases: A CrossSectional Survey of 3 Provinces in Northern Vietnam.

BACKGROUND: Vietnam's network of commune health centers (CHCs) have historically managed acute infectious diseases and implemented national disease-specific vertical programs. Vietnam has undergone an epidemiological transition towards non-communicable diseases (NCDs). Limited data exist on Vietnamese CHC capacity to prevent, diagnose, and treat NCDs. In this paper, we assess NCD service readiness, availability, and utilization at rural CHCs in 3 provinces in northern Vietnam. METHODS: Between January 2014 and April 2014, we conducted a cross-sectional survey of a representative sample of 89 rural CHCs from 3 provinces. Our study outcomes included service readiness, availability of equipment and medications, and utilization for five NCD conditions: hypertension, diabetes, chronic pulmonary diseases, cancer, and mental illnesses. RESULTS: NCD service availability was limited, except for mental health. Only 25% of CHCs indicated that they conducted activities focused on NCD prevention. Patient utilization of CHCs was approximately 223 visits per month or 8 visits per day. We found a statistically significant difference (P<.05) for NCD service availability, medication availability and CHC utilization among the 3 provinces studied. CONCLUSION: This is the first multi-site study on NCD service availability in Vietnam and the first study in a mountainous region consisting predominately of ethnic minorities. Despite strong government support for NCD prevention and control, Vietnam's current network of CHCs has limited NCD service capacity.