The development of the Delivery Assessment Tool (DAT) to facilitate quality improvement in burns services in low-middle income countries

Implementation science is a useful tool to consider ways in which we can introduce improvements to burn services in low-and-middle income countries (LMICs), where the majority of the burden of burn injury is now experienced. This paper outlines the development of the Delivery Assessment Tool (DAT), a method for facilitating quality improvement in burn services in LMICs. We used a participatory approach that ensured that local clinicians and experts were fully involved in piloting the tool. The DAT is based on internationally agreed operational standards for burn care service delivery and has undergone an iterative process of improvement and refinement through an initial three-year project in Nepal and Bangladesh. The DAT, a 50-item tool organised into 10 subsections, is used to assess a service through a participatory focus group discussion with a mixed, multidisciplinary team of staff working at the burn service, typically 6-10 participants. This usually lasts 2-3 h. The staff in the unit then select priority areas for quality improvement programmes that are within their control to achieve, which starts a cycle of audit and review. The final version of the tool was used in a further three-year project to evaluate 11 hospitals in Nepal and Bangladesh. Education and training are key components of this work; both were provided by Interburns as part of on-going support for the clinical teams. At the end of the project a>19% improvement in scores was demonstrated using the final version of the DAT in both Nepal and Bangladesh; this achievement is remarkable given the continued difficulties in service provision where patient numbers far outstrip the resources available to care for them. As a result of this work, we have made a digital version of the tool available free of charge.

Staying Connected In The COVID-19 Pandemic: Telehealth At The Largest Safety-Net System In The United States

New York City Health + Hospitals is the largest safety-net health care delivery system in the United States. Before the coronavirus disease 2019 (COVID-19) pandemic, NYC Health + Hospitals served more than one million patients annually, including the most vulnerable New Yorkers, while billing fewer than five hundred telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve our existing patients while treating the surge of new patients. Starting in March 2020, we were able to transform the system using virtual care platforms through which we conducted almost eighty-three thousand billable televisits in one month, as well as more than thirty thousand behavioral health encounters via telephone and video. Telehealth also enabled us to support patient-family communication, postdischarge follow-up, and palliative care for patients with COVID-19. Expanded Medicaid coverage and insurance reimbursement for telehealth played a pivotal role in this transformation. As we move to a new blend of virtual and in-person care, it is vital that the major regulatory and insurance changes undergirding our COVID-19 telehealth response be sustained to protect access for our most vulnerable patients.

Exploration of risk factors for osteoporotic fracture following hematopoietic stem cell transplantation

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Background: The incidence of fractures following hematopoietic stem cell transplantation (HSCT) ranges from 5% to 12% and the rates are up to 10 times greater than in the general population. The risk factors involved in osteoporotic fracture development following HSCT are incompletely understood. Methods: We conducted a retrospective cohort study of patients > 18 years that received a HSCT at MD Anderson Cancer Center, from January 1, 2001 to December 31, 2010. Patients were followed until December 31, 2013 for assessment of osteoporotic fracture occurrence using ICD-9 codes and confirmed by chart review. Cox regression model was used to identify independent risk factors for osteoporotic fractures. Factors included individual risk factors included in the World Health Organization Fracture Risk Assessment Tool FRAX and type of HSCT, type of preparatory regimen and underlying indication for HSCT. Results: A total of 5,170 patients received a HSCT during the 10-year study period, of which 527 (10%) patients developed an osteoporotic fracture. The median time of follow up was 3.2 years. A multivariate Cox regression model considering all clinical and malignancy specific risk factors was fitted. With the control of all other variables, the risk of developing fracture was 1.20 (95% confidence interval (CI):1.02-1.41) times higher for every 20 years increase in age at HSCT; female patients had a 1.24 (95% CI: 1.05-1.48) times higher risk compared to male patients; patients with a fracture prior to HSCT had a 2.01 (95% CI: 1.62-2.51) times higher risk compared to patients without a prior fracture; patients receiving an allogeneic HSCT had a 1.57 (95% CI: 1.20-2.05) times higher risk compared to patients receiving an autologous HSCT; and patients with multiple myeloma had a 2.62 (95% CI: 1.97-3.49) times higher risk compared to patients without multiple myeloma. Conclusions: Age at HSCT, gender, prior fracture status, type of HSCT, and underlying indication were identified to be statistically significantly associated with fracture. This is one of the first large scale studies assessing a comprehensive set of risk factors. To develop a risk model for fracture, we should consider these factors.

Abstract W P19: Large Single Center Experience of Safety of Parenteral Infusion and Maintenance of Antiplatelets in Patients with Acute Ischemic Stroke undergoing Mechanical Thrombectomy and Thrombolysis

Background and Objective: Lack of achieving complete recanalization in acute strokes using only IV thrombolysis has led to the evolution of a multimodal acute ischemic stroke paradigm which includes combination of intra-arterial tPA, mechanical thrombectomy and stenting. There is limited data on safety of administering intra-arterial and intra-venous antiplatelet agents within the acute stroke treatment paradigm to maintain target vessel recanalization.

Methods: Of the total patients with acute ischemic strokes presented between 2010-13 to our university affiliated comprehensive stroke center, patients that received IA and IV Eptifibatide were retrospectively classified into two groups: Group A underwent emergent intracranial stenting with IV and or IA r-tPa and/or mechanical thrombectomy. Group B underwent IV r-tPa/ IA r-tPa /IA Eptifibatide and/or mechanical thrombectomy with no intracranial stenting. Eptifibatide was administered intra-arterially as a 135-μg/kg single-dose bolus, and then continued on intravenous infusion of 0.5-μg/kg/min post-procedurally. Charts were reviewed for all patients to assess for complications including groin hematoma, asymptomatic and symptomatic hemorrhages, epistaxis and gross hematuria.

Results: Of the total of 2016 patients with ischemic strokes, 326 patients received acute stroke treatment and a total of 138 patients received IA and IV Eptifibatide. Group A with acute stenting (82 patients, mean age 68, 49% males [n=40]) and Group B without stenting (56 patients, mean age 73, 54% males [n=30]) received IV Eptifibatide infusion for a mean duration of 19 hours (range 0 to 364 hours). In Group A, 7.3% [n= 6] showed symptomatic ICH, 4.9% [n=4] asymptomatic ICH, 3.7% [n=3] groin hematomas, 2.4% [n=2] nose bleeds. In Group B, 7.1 % [n=4] had asymptomatic hemorrhages and 1.8% [n=1] showed gross hematuria.

Conclusion: The complications of IV and IA Eptifibatide are not significantly higher than those associated with the existing acute ischemic stroke treatment paradigm. Larger, multi-centered prospective trials are warranted to corroborate our findings.

Abstract W P307:

Background and Objective: The International Subarachnoid Aneurysm Trial (ISAT) showed a greater likelihood of survival free 1 year disability in patients undergoing endovascular coiling who were started on antiplatelet agents after SAH compared to ones undergoing neurosurgical clipping. However, data on safety of acute parental antiplatelet agents after aneurysmal coiling is lacking. We report on the safety of IV Eptifibatide (rapidly reversible Glyprotein IIbIIIa inhibitor) on patients presenting with acute subarachnoid hemorrhage undergoing endovascular coiling for aneurysmal embolization.

Methods: All the patients from 2009-13 who presented to our university affiliated comprehensive stroke center with aneurysmal subarachnoid hemorrhage and underwent endovascular coiling were included for the study. Patients that received IV Eptifibatide for various reasons including acute need for stent assist coiling after securing the ruptured aneurysm with endovascular coiling were reviewed. Eptifibatide was administered intra-arterially as a 135-μg/kg single-dose bolus, and then continued on intravenous infusion of 0.5-μg/kg/min post-procedurally. Charts were reviewed for all patients to assess for medical/procedural complications including symptomatic and asymptomatic intra- and extra-cranial hemorrhages, groin hematomas, epistaxis and gross hematuria.

Results: Of the total of 93 patients treated with coil embolization during this period, 5 patients (mean age 56 years, 20% male [n=1]) received acute intra-procedural Eptifibatide followed by IV infusion for a mean duration of 77 hours (range 20-130 hours). Various reasons for use of Eptifibatide included: stent assist coiling [n=2], multiple stents for flow diversion [n=1], partial coil prolapse [n=1] and vascular lumen flow compromise [n=1]. None of the patients demonstrated symptomatic/asymptomatic hemorrhage, groin hematoma, epistaxis or hematuria.

Conclusion: Our results may highlight safety of administering IV Eptifibatide to prevent thrombotic complications after endovascular coil embolization in select patients with aneurysmal subarachnoid hemorrhage. Multicenter prospective trials are warranted to corroborate our findings.

Ultrasound guided fine needle aspiration cytology: a sensitive diagnostic tool for diagnosis of intra-abdominal lesions

Ultrasound guided fine needle aspiration cytology is widely accepted as a safe diagnostic procedure in various neoplastic and non-plastic disorders. This study was conducted to determine the usefulness and diagnostic accuracy of ultrasound guided fine needle aspiration cytology in the diagnosis of intraabdominal lesions. This cross sectional study was conducted in the Department of Radiology and Imaging, Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh during the period of June 2007 to June 2009. A total 78 patients with intra abdominal lesions were included in this study. Fifty nine (75.6%) were males and 19 (24.4%) were females. Out of total aspirates 29 (37.2%) were categorized as benign, 41 (52.6%) were malignant and 8 (10.3%) were non-representative, as it contained only blood. Most of the benign lesions were liver abscess 19 (24.4%). A diagnosis of primary malignancy was established in 26 (33.3%) and that of secondary in 15 (19.2%). The results showed a sensitivity of 89.7%. Ultrasound guided fine needle aspiration cytology is a sensitive diagnostic tool in a wide spectrum of intra-abdominal neoplastic and non-neoplastic disorders. It is a simple, safe, rapidand inexpensive technique.

Interventional radiology for the treatment of hepatic malignancy

Hepatic malignancies are commonly faced clinical problem. Non surgical minimally invasive therapies are current treatment goal. Interventional radiologists are going forwards with such minimally invasive but effective therapies by transarterial chemoembolization, radiofrequency ablation, percutaneous ethanol injection, cryoablation, laser ablation and upcoming promising procedures like focused ultrasound & gene therapy. Response rates of transarterial chemoembolization for primary and most metastatic tumors are 60-80% with survival rates of 70% at 1 year, 40% at 3 years, and 10% at 5 years. Percutaneous ethanol injection ablation is the most accepted minimally invasive method worldwide, for hepatocellular carcinomas less than 5 cm in diameter, the complete ablation rate is about 70-75%; in 5-8 cm diameter, encapsulated hepatocellular carcinomas, the rate is about 60%. RFA is becoming a widely used ablative technique for primary and secondary liver tumors, with a 52-67% complete ablation rate at 1 year and survival rates of 96%, 64%, and 40% at 1, 3 and 5 years, respectively. Meticulous patient selection, careful planning and execution are imperative and should be carried out with the participation of interventional and diagnostic radiologists, nuclear medicine specialists, and medical, surgical, and radiation oncologists. In terms of cost, equipment, technical efficiency, efficacy & repeated applicability percutaneous procedures particularly PEI & RFA can be carried out in Bangladesh.

The cost-effectiveness of health education in improving knowledge and awareness about intestinal parasites in rural Bangladesh

The impact of regular health education in improving knowledge, attitude and practices in the control of intestinal parasites was examined in four rural areas of Bangladesh; two areas received health education and the other two areas were controls. By the end of the 18-month study households receiving health education showed highly significant improvements in knowledge, water and sanitation facilities and personal hygiene compared with households in the control areas. Improving knowledge by 1% cost between US dollars 0.75 and 0.82 per household, while a 1% improvement in personal hygiene cost between US dollars 1.10 and 1.32 per household and water and sanitation between US dollars 1.39 and 1.52 per household.

Longitudinal growth of Bangladeshi infants during the first year of life

The growth in length and weight of 91 poor urban Bangladeshi infants was monitored at monthly intervals from birth to 1 year. At birth 18%, 22% and 8% were below -2.00 standard deviations of the National Center for Health Statistics (NCHS) height-for-age, weight-for-age and weight-for-height, respectively and at 1 year the percentages were 40%, 40% and 7%. Infant weights over the first 6 months associated positively with both mother's BMI and percentage body fat. Higher mean infant weights from 6 to 12 months were associated with both higher educational status of the mother and monthly family income and the latter two variables provided the best model for predicting weight velocity from birth to 12 months. Internal Z-scores, corrected for day of measurement, provided clear evidence of catch-up/catch-down over the first 6 months with heavier and longer babies at birth showing catch-down while lighter and shorter babies demonstrated catch-up. Infants' weights were almost three times more variable than lengths. Monthly incremental variability of both infant weight and length increased sharply from 6 to 12 months with weight showing significantly more variability. The correlations of birth weight and length with subsequent distances and monthly increment revealed that the first 6 months were dominated by catch-up and catch-down but during the latter half of the year the growth phenomena were influenced mainly by earlier intra-uterine or genetic effects.

Mid-arm circumference at birth as predictor of low birth weight and neonatal mortality

In Bangladesh, like other developing countries, most births occur at home or in the community, so logistic problems and taboos prevent the weighing of every newborn child. This study was performed to see whether other simpler measurements could be substituted for weight to identify neonates of low birth weight. A total of 1676 live births at the Chittagong Medical College Hospital constituted the study sample, and this showed a high correlation between mid-arm circumference and birth weight (r=0.792, p<0.000). A mid-arm circumference of <9.0 cm had the best sensitivity and specificity for identifying newborns with a birth weight of less than 2500 g. These neonates were followed up to record neonatal deaths. Neonatal mortality showed an inverse relation with mid-arm circumference. A mid-arm circumference of <9.0 cm and a birth weight of <2500 g were equally useful in predicting neonatal outcome. Mid-arm circumference is a simple, quick and reliable indicator for predicting low birth weight and neonatal outcome, and can be easily measured by medical practitioners and traditional birth attendants (TBAs) in the community of developing countries like Bangladesh.

Tuberculosis and health sector reform in Bangladesh

In 1998 the Government of Bangladesh changed its health and population sector strategy from a project-oriented approach (the Fourth Population and Health Project--FPHP) to sector-wide management (the Fifth Health and Population Sector Programme--HPSP). This article describes the development and achievements of the tuberculosis programme during the FPHP, and discusses the potential opportunities and challenges anticipated by the programme from the reformed health service delivery of the HPSP. 'Further strengthening of tuberculosis and leprosy control services' was one of the 66 projects of the FPHP. As part of the FPHP, the National Tuberculosis Programme policy was revised in 1992 and the project was implemented in phases. By mid 1998, 90% of the population was covered, and more than 200,000 tuberculosis cases had been diagnosed and treated with 80% success. We describe the reasons for this success and analyse the pitfalls of the project. The objective of the reforms in HPSP is to provide cost-effective, sustainable, quality services to those in need through an essential service package that includes control of communicable diseases such as tuberculosis and leprosy. Tuberculosis services will become more accessible as community clinics deliver essential health services for every 6000 population. Non-public health care providers, who contribute significantly to health services in the country, will be involved in service delivery. The main challenge is to maintain the quality of successful projects, such as tuberculosis control, during the transition period.

An update on the prevalence of HIV/AIDS in Bangladesh

The National AIDS Committee was formed in 1985 to develop and support policies that prevent transmission of human immunodeficiency virus (HIV). In 1990, the Institute of Epidemiology, Disease Control and Research in the Ministry of Health began sero-surveillance for AIDS/HIV infection. Convenience sampling was conducted among prisoners, sailors, truckers, antenatal attendees, repatriated Bangladeshi workers, and brothel-based prostitutes in Dhaka. In 1994, commercial sex workers in other high-risk areas were included in surveillance activities. Among over 75,700 HIV tests through 1998, 119 have been confirmed positive for HIV. While the cumulative HIV prevalence rate was only 1.5/1,000 tests, it was significantly higher among men (p < 0.0001) than among women. The rates among men were as high as 28/1,000 tests in 1996 and 21/1,000 tests in 1997. Almost 50% of the reported HIV cases are from cities on the border of India and Myanmar. It is anticipated that HIV transmission will increase further given the high prevalence of risk behaviors, core high-risk groups, and extreme poverty.

A study of the cost effectiveness of selective health interventions for the control of intestinal parasites in rural Bangladesh

The study examined the cost effectiveness of 4 different regimens in reducing the prevalence and intensity of infection of Ascaris lumbricoides, Trichuris trichiura, and hookworm over an 18-mo period in randomized community samples of children aged 2-8 yr living in rural Bangladesh. The household was the unit of randomization in each community. The 4 regimens were (1) only chemotherapy to all household members at the commencement of the study (i.e., at an interval of 18 mo), (2) same as group (1) and regular health education throughout the study period, (3) chemotherapy to all household members at the commencement of the study and subsequent chemotherapy to all children at intervals of 6 mo, and (4) same as group 3 with the addition of regular health education throughout the study period. Health education (through home and school visits and focus group discussions) was aimed at increasing awareness of worm transmission and the disabilities caused by intestinal helminths. Simple ways of improving personal hygiene and sanitation through hand washing, nail trimming, wearing of shoes, and use of a latrine and clean water supplies were encouraged. Because albendazole is a broad spectrum anthelmintic, the cost effectiveness of the 4 interventions were compared by the weighted percentage reduction in prevalence and the weighted percentage reduction in intensities of infection as measured by geometric mean egg loads of all 3 worms combined. The most cost-effective strategy was the single albendazole mass chemotherapy at an interval of 18 mo. The 2 regimens involving health education were the least cost effective.

The association between birthweight, sociodemographic variables and maternal anthropometry in an urban sample from Dhaka, Bangladesh

The relationship between birthweight, sociodemographic variables and maternal anthropometry was examined in a sample from an inner urban area of Dhaka, Bangladesh. About 21% of babies were of low birthweight (LBW) using the World Health Organization cut-off of < 2500 g. LBW was more common in younger (< 20 years) and older (> 30 years) mothers, the low-income group and those with little or no education. The mean birthweights of the higher-educated, higher-income group and male children were on average 290, 260 and 120 g, respectively, higher than uneducated, lower-income groups and female children. The best cut-offs for detecting LBW and normal-weight infants was maternal weight of 50 kg (odds ratio = 4.6), maternal arm circumference of 23 cm (odds ratio = 5.0) and body mass index of 20.5 (odds ratio = 6.5). The sensitivity and specificity were best for maternal weight (69% and 68%, respectively). Logistic regression analyses show that mothers' weight at term was the best single predictor of LBW (31%), while maternal weight along with age, educational level and income group correctly predicted just over 35% of LBW. Regression analyses also confirmed that mothers' weight at term was the best predictor of birthweight, with a correlation coefficient of 0.49.

Evaluation of cleaving agents other than trypsin in direct agglutination test for further improving diagnosis of visceral leishmaniasis

Trypsin treatment of Leishmania promastigote antigen has proved to be indispensible in the direct agglutination test (DAT) for the diagnosis of visceral leishmaniasis (VL) and canine visceral leishmaniasis (CVL). In the present study four antigen batches were prepared with pronase (400 micrograms/ml), lipase (0.45% [wt/vol]), pancreatin (0.3% [wt/vol]), or 2-mercaptoethanol (2-ME) (1.2% [vol/vol]) at a ratio of 20:1 versus promastigote packed cell volume or a density of 10(8)/ml. Batches prepared in this way performed satisfactorily when compared with the performance of the initial trypsinated antigen. Even higher was the sensitivity and specificity of the 2-ME-processed antigen, scoring a minimum DAT titer of 1:102,400 in the VL and CVL group and a maximum of 1:400 in the negative control group. Corresponding titers ranging from 1:6,400 to 1:12,800 and 1:800 to 1:1,600 were obtained with the antigen variants processed with pronase, lipase, pancreatin, or trypsin. By combining the use of indigenous Leishmania donovani subspecies from Sudan, Bangladesh, or Morocco and incorporating 2-ME instead of trypsin in the antigen processing step, a threefold increase in titer was attained in sera from the respective areas where VL is endemic. 2-ME-processed antigen suspensions maintained stability at 4 degrees C for up to 9 months, as evidenced by the absence of autoagglutination and the reproducibility of DAT readings with standard sera. The specificity of DAT was further improved by supplementation of the sample diluent with 0.03 M urea and incubation of the test plates at 37 degrees C for 1 h. Titers ranging from 1:200 to 1:12,800 in the sera of patients and laboratory animals infected with various trypanosoma species were significantly reduce (</=1:200) or were rendered negative dilution of 1:25. Regardless of the infections caused by trypanosoma species, the sensitivity, specificity, and predictive value of a positive or negative test in DAT were 100%. Sera from patients who formerly had VL and who had been treated 6 to 36 months earlier remained reactive (>/=1:51,200) against 2-ME-processed antigen, despite the incorporation of urea into the DAT.

Positive response to sodium antimony gluconate administration in visceral leishmaniasis seropositive patients

In a prospective study conducted in Mymensingh district of Bangladesh, 1, 273 patients were assessed for the presence of visceral leishmaniasis (VL). Sodium antimony gluconate (SAG) was successfully administered to 715 patients with parasitologically confirmed infection. In the remaining 558, although there was clinical indication of VL, Leishmania donovani parasites could not be demonstrated. Administration of SAG in this group was on the grounds of the prevailing symptoms, exclusion of malaria and a positive direct agglutination test (DAT). Significant improvements in the clinical and hematological parameters were observed in 547 (98%) of the unconfirmed VL cases. On the basis of the parasitological findings or positive response to specific anti-Leishmania chemotherapy, the sensitivity and specificity of the DAT were 99.6% and 97.7% respectively. The results supported the reliability of DAT for diagnosis of VL at levels below that of parasitological detection.

Appraisal of modifiable hospitalization risks

Nine prevention experts rated hospitalization risks of 64 hypothetical healthy adults between 20 and 65 years old. There was substantial agreement among seven out of the nine experts. Pairwise correlations between any two of the experts ranged between 0.66 and 0.86. Decision analytic tools were used to model the average of the experts' ratings. The panel of experts provided us with the factors used, the relationship between the factors, and the relative importance of each factor. An index based on this information was highly correlated with the judgments of seven experts. Thus, we concluded that the scoring procedure can simulate the experts' judgments. Next, the index was used in an interactive computer program to assess modifiable health risks of individuals. This program is provided along with the paper to facilitate further research on validity and impact of the program.