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Development during the early stage of life i.e. in the first 1000 d is crucial in determining the psychosocial productivity of a child in the future. Frontline workers (FLWs) are not trained to detect of developmental delays (DDs) in children under the national programme of Rashtriya Bal Swasthya Karyakram (RBSK) in India. To train the FLWs and assess the effectiveness of a training strategy in detection of DDs in children less than 6 y of age using a cluster-randomized trial approach. A community-based interventional study was conducted in Khurdha district of Odisha. Training was imparted to FLWs in intervention arm using a training module developed in regional language. Knowledge level of FLWs was assessed before and after the training in both study arms using a structured questionnaire, and data were analyzed in IBM SPSS 22. Outcomes were compared using chi square, Student t (both paired and unpaired) and Man–Whitney U test. After 3 mo of intervention, the investigator examined a sample of children (intervention arm: 870, control arm: 847) for DDs using the Denver Developmental Screening Test II. The mean difference in knowledge scores of FLWs was found to be 7.26 (8.8 to 5.7) and 1.11 (1.38 to 0.84) in intervention and control arm, respectively. Case detection rate by FLWs in intervention and control arm was 61.5% and 9.09%, respectively. Capacity building of the FLWs should be considered by the government for integrating them in the Rashtriya Bal Swasthya Karyakram (RBSK) programme for screening children.

Timely access to dermatology care is poor across the US, especially in underserved geographical areas. Rural regions with fewer practising dermatologists and constrained resources often experience insufficient care access and health outcomes, underscoring the importance of addressing these disparities. However, potential interventions are difficult to compare due to their disruptiveness, time and resource requirements, and institutional resistance, given their uncertain impacts. Queueing and computer simulation models were used to analyse several potential interventions to reduce dermatology appointment delays and gain insights into dynamics and structural inter-relationships. Model logic, candidate interventions, and cost–benefit considerations were developed from mixed-methods analyses of rural access processes and barriers. Sensitivity analyses were conducted. The best of ten investigated interventions reduced internal dermatology access delays from roughly 150 weeks with 95% provider utilisation currently to 0.49 and 72%, respectively. Two other interventions reduced travel for external dermatology care by an estimated 68.1%. Model logic and inputs were developed from the literature and a six-facility rural health system, which may differ in other geographic regions. Model simplifications may not capture all access dynamics, and resources required for some interventions may not be available. Model-based analysis of rural care access disparities can help evaluate and screen potential interventions, develop useful insights, and identify policies worth further evaluating or testing in actual practise. In our rural setting, two interventions appear cost-effective in reducing patient access delays and provider over-utilisation; two others performed too poorly to warrant investing resources to implement or test in practise.

Background: Inguinal hernias are a major cause of morbidity and mortality in the developing world. In resource limited settings in rural Africa the clinical management of inguinal hernias may pose a therapeutic challenge to the surgeon due to the late presentation of this condition and lack of availability and affordability of mesh and laparoscopy. In our environment there is a lack of data and literature regarding the surgical management of inguinal hernias. The purpose of this study was to outline the clinical profile and outcomes among patients undergoing inguinal hernia repairs in our hospital. Methods: A descriptive retrospective study was carried out between 1st April 2008 to the 31st July 2012 on all patients ≥15 years of age that underwent an inguinal hernia repair were eligible in this study. The patients were reviewed on the surgical ward postoperatively and in the surgical out-patients clinic 3 months post-operatively. Data was collected using a pretested questionnaire on the following variables: age, sex, recurrence of hernia, post-operative pain and post-operative complications. Physical examination was used to determine post-operative recurrence and evidence of haematomas, seromas or severe wound sepsis requiring operative intervention. Results: One hundred and fifty eight patients following repair of inguinal hernia using the Modified Bassini technique were analyzed. Mean age was 44.84 years. The male:female ratio was 3.65:1 with male predominance. Emergency inguinal hernia repairs were carried out in 4(2.53%) and the majority of patients, 154(97.47%) were elective inguinal hernia repairs. One(0.63%) mortality and the morbidity included 1(0.63%) seroma, 1(0.63%) haematoma, 1(0.63%) necrotizing fasciitis and 1(0.63%) enterocutaneous fistula. The overall complication rate was 3.16%. Conclusions: In rural Africa patients with inguinal hernias should be encouraged to present early with signs and symptoms of inguinal hernia. Elective hernia repair of inguinal hernias, irrespective of the type of repair, will reduce the morbidity and mortality from this common problem in East Africa.

Introduction Obesity is a known risk factor for gastroesophageal reflux disease (GERD). Morbidly obese patients in rural areas are usually referred to the local surgeon for endoscopic evaluation. This situation poses significant challenges given the increased risk for perioperative complications due to anatomical and metabolic factors. This study aims to evaluate the safety of performing GERD diagnostic workup studies in a rural setting. Methods Institutional review board approval was obtained for a retrospective chart review of patients who presented with GERD symptoms to a rural antireflux clinic between August 2015 and October 2020. Patients were included if their body mass index (BMI) was over 35 with comorbidities or over 40 kg/m2 who underwent upper gastrointestinal endoscopy with or without concomitant placement of wireless pH probe and/or functional luminal imaging probe. Results A total of 117 patients met the inclusion criteria. There were 94 (80.3%) females and 23(19.7%) males. The average age was 56.0 ± 13.4 years. The average BMI was 40.4 (35-66.4). Proton pump inhibitor use was noted in 97/117 (82.9%) with an average duration of 12.0 ± 9.2 years. The average GERD-Health Related Quality of Life, Reflux Symptom Index and GERD Symptom Score (GERSS) were 29.8 ± 20, 24.5 ± 14.2 and 21.3 ± 15.4 respectively. There were no procedural complications. All the endoscopic examinations were successfully completed and patients were discharged. Conclusion Performing diagnostic studies for GERD for morbidly obese patients in critical access hospitals is safe. Patient selection, proper training and adequate preparation are critical prerequisites for good outcomes.

Robotic Roux en Y gastric bypass (R-RYGB) is becoming more common due to the shifting trend toward robotic gastrointestinal surgery. The goal of this study is to determine if R-RYGB can be safely implemented at a robotic bariatric surgery program in a community hospital with similar results to laparoscopic RYGB (L-RYGB) in a cost-effective manner. A total of 50 R-RYGB procedures were performed with the Xi and the X da Vinci systems and compared with 50 L-RYGB cases by a single surgeon from October 2018 to January 2020 at an acute-care community hospital in a rural setting with a high-volume MBSAQIP-accredited program. A retrospective chart review was conducted with IRB approval and statistical analysis of 30-day morbidity, mortality, re-interventions, and resolution of co-morbidities, with financial analysis of cost reduction. Both groups were similar in age, gender, ASA class, co-morbidities, and body mass index (BMI). There was no mortality or anastomotic leak. The 30-day morbidity for R-RYGB was 10.0% with a re-operation rate of 4.0%. There were no conversions to open, and the mean hospital length of stay was 2.22 ± 1.19 days. There were no statistically significant differences between R-RYGB and L-RYGB with respect to any measured outcome, including intraoperative time (121.94 vs. 113.52, respectively; p = 0.1495). However, when incidences and percentages were used, R-RYGB had improved performance for most of the outcomes measuring safety. There was an average cost reduction of $816.90 per case (total saving of $40,845.00 for 50 cases) in the R-RYGB by transitioning from a hybrid approach to a totally robotic approach. R-RYGB appears to be as safe as L-RYGB and can be performed in a rural community hospital while maintaining a low complication rate, achieving a high co-morbidity resolution rate, and saving costs with a totally robotic approach.

Osteoarthritis (OA) represents a major cause of disability in India. For implementation of best practice management, it is important to consider the views of people in India since they might deviate from those expressed in previous studies by people with OA in the Western world.The purpose of this study was to explore and describe approaches toward OA and its management among patients in a rural setting in Central Western India.Conventional content analysis was used to analyze semi-structured interviews with 24 patients diagnosed with OA from the target area of Pravara University Hospital and ten adjacent primary health care centers in Maharashtra, India.Four categories; lack of power, active ambivalence, taking control and a constant struggle were identified as patients' approaches to OA. The categories were further elaborated on in seven subcategories.Daily challenges and efforts, of which some may be unique to patients in a rural setting in India, underlie passive and active approaches to OA and its management. Understanding these may enhance Indian physiotherapists' implementation of evidence-based self-management programs adapted to Indian conditions and reduce the distress of their patients.

Introduction: Knowledge, attitude and practices (KAP) of COVID-19 pandemic play a significant role in reducing the transmission of the virus. There is limited information available about HCWs KAP regarding COVID-19. Therefore, the objective of this study was to investigate the KAP of KCWs from a primary healthcare setting in South Africa. Method: This was a cross-sectional study conducted among all medical and nursing healthcare professionals of KwaDabeka Community Healthcare Center (KCHC) and seven PHC clinics. Selfadministered questionnaire was used to collect data. Student’s t-test and ANOVA test were carried out to compare the overall mean knowledge, attitude and practice scores between two or more groups. Pearson’s correlation test was undertaken to establish correlation between KAP scores. Results: Majority HCWs were female (82.8%), single or unmarried (56.6%) and nurses comprised the most (69.2%). Nearly half (44%) reported to have recognized vulnerable co-morbid illnesses for COVID-19. Only 24% of HCWs had good knowledge (scored > 60%), however, 81% had positive attitude (scored >60%) and 63% had good practice (>60% scores). Nursing practitioners had significantly lower mean knowledge and practice scores than medical officers and allied healthcare workers (p

Primary hyperparathyroidism (PHPT) is a common condition associated with significant morbidity and mortality. Recently Endocrine multidisciplinary team (MDT) has greatly influenced the care of such patient and has helped in improving the outcome and reducing the complications related with surgery. We conducted a review of prospectively collected data of all consecutive parathyroidectomies carried out in our district general hospital between October 2016 and Jan 2020 by a single surgeon. The collected data include patient's characteristics, laboratory results, radiological findings and operative outcomes. There were 53 parathyroidectomies performed during this period for PHPT. Mean age of patients was 75 years. Our results demonstrated a reduction in post-operative PTH in 46 patients (92%). We have identified no cases of vocal cord palsy, significant neck haemorrhage or mortality. 6 patients had temporary hypocalcaemia and 2 patients had hungry bone syndrome. Patient selection and evaluation for parathyroidectomies under endocrine MDT has greatly influenced the outcome for our patients. We had low complication rate and surgery was done at a more convenient location for selected patients. We benefit from dedicated monthly parathyroid clinic and weekly endocrine multidisciplinary team meetings to assist with patient selection and optimisation. A team effort helps in reducing complications and improving outcomes. We feel that surgery can be provided safely and successfully in a district general hospital in rural settings.

Evidence suggests that socio-cultural barriers that limit the ability of women in sub-Saharan Africa to make decisions regarding contraceptive use and childbearing contribute to the slow uptake of contraception in this region. This paper explores factors influencing women’s decisions regarding contraceptive uptake, switching and discontinuation, and the implications of those decisions for family planning programmes. Data were from in-depth interviews that were conducted in 2018 with 42 women who participated in a longitudinal research project implemented in Homa Bay County of Kenya. Participants comprised women who were aged 15–39 years at the time of recruitment into the study and who discontinued using injectables or implants between the first and second rounds of data collection. Data were analysed using an exploratory inductive content analytic approach. The findings show that uptake of contraception was largely driven by concerns about the negative consequences of frequent childbirth on individual health and household socioeconomic well-being. Most women discontinued methods because of dissatisfaction but, instead of abandoning contraception altogether, switched to alternative methods, albeit sometimes less-effective ones. However, some women had difficulties in identifying an appropriate new method after experiencing side-effects, contraceptive failure or stock-out of their current method. Securing the cooperation of sexual partners was an additional problem especially for women whose partners did not support contraception. The findings suggest that concerns about the negative consequences of frequent childbirth outweigh challenges associated with contraceptive use. This presents an opportunity for family planning programmes to improve contraceptive uptake and continuation by addressing the health system challenges related to commodity stock-out and poor quality of care, as well as the concerns of men.

Colorectal cancer screening has been shown to prevent or detect early colorectal cancer and reduce mortality; yet, adherence to screening recommendations remains low, particularly in rural settings.RCT.Adults (n=7,812) aged 50-75 years and due for colorectal cancer screening in a largely rural health system were randomly assigned to either the intervention (n=3,906) or the control (n=3,906) group in September 2016, with analysis following through 2018.A mailed motivational messaging screening reminder letter with an option to call and request a free at-home fecal immunochemical screening test (intervention) or the standard invitation letter detailing that the individual was due for screening (control). Multifaceted motivational messaging emphasized colorectal cancer preventability and the ease and affordability of screening, and communicated a limited supply of test kits.Colorectal cancer screening participation within 6 months after mailed invitation was ascertained from the electronic medical record.Colorectal cancer screening participation was significantly improved in the intervention (30.1%) vs the usual care control group (22.5%; p0.001). Individuals randomized to the intervention group had 49% higher odds of being screened over follow-up than those randomized to the control group (OR=1.49, 95% CI=1.34, 1.65). A total of 13.2 screening invitations were needed to accomplish 1 additional screening over the usual care. Of the 233 fecal immunochemical test kits mailed to participants, 154 (66.1%) were returned, and 18 (11.7%) tested positive.A mailed motivational messaging letter with a low-cost screening alternative increased colorectal cancer screening in this largely rural community with generally poor adherence to screening recommendations. Mailed colorectal cancer screening reminders using motivational messaging may be an effective method for increasing screening and reducing rural colorectal cancer disparities.

There are no large reports of comparative outcomes of transcatheter pulmonic valve implantation (TPVI) and surgical pulmonic valve replacement (SPVR). Prospective studies are unlikely to be feasible in the future also. Thus, we utilized a large adult inpatient database to compare the two with respect to temporal trends, in hospital outcomes and costs. Data from the National Inpatient Sample database from 2003 to 2014 was analyzed to extract patients who underwent TPVI and SPVR using unique ICD 9-CM codes. In-hospital outcomes and charges were then analyzed. All charges were converted to 2018 dollars and a loss of wages analysis was performed using the Bureau of Labor Statistics published median weekly wages. A total of 8,449 and 555 SPVR and TPVI discharges were identified. 5.8% SPVR procedures were done in rural setting versus 1.8% of TPVI. Complications including in-hospital mortality (2.3 vs 0.9%; p = 0.02) were higher in SPVR group. Length of stay was significantly shorter for the TPVI group (1 vs 5 days; p0.001), which also contributed to lower loss of wages ($1028.57 vs $6042.86; p0.001) with similar hospital charges. In conclusion, volumes of both TPVI and SPVR are increasing across adult hospitals in the United States, reflecting an overall increase in the adult congenital heart disease population. TPVI offers improved short-term outcomes and decreased loss of wages through shorter recovery time in this real-world database analysis.

BackgroundPersons with dementia (PwD) need support to remain in their own homes as long as possible. Family caregivers, homecare nurses and general practitioners (GPs) play an important role in providing this support, particularly in rural settings. Assessing caregiver burden is important to prevent adverse health effects among this population. This study analysed perceived burden and needs of family caregivers of PwD in rural areas from the perspectives of healthcare professionals and family caregivers.MethodsThis was a sequential explanatory mixed methods study that used both questionnaires and semi-structured interviews. Questionnaires measuring caregiver burden, quality of life and nursing needs were distributed to the caregivers; health professionals received questionnaires with adjusted items for each group. Additionally, in-depth qualitative interviews were carried out with eight family caregivers.ResultsThe cross-sectional survey population included GPs (n = 50), homecare nurses (n = 140) and family caregivers (n = 113). Healthcare professionals similarly assessed the psychosocial burden and stress caused by behavioural disturbances as most relevant. Psychological stress, social burden and disruptive behaviour (in that order) were regarded as the most important factors from the caregivers’ perspective. It was found that 31% of caregivers reported permanent or frequent caregiver overload. Eight themes related to caregiver burden emerged from the subsequent interviews with caregivers.ConclusionsProfessional support at home on an hourly basis was found to be highly relevant to prevent social isolation and compensate for lack of leisure among caregivers of PwD. Improvement of interprofessional dementia-related education is needed to ensure high-quality primary care.

Whilst there is considerable evidence to support the efficacy of physical activity and dietary interventions in disease and death prevention, translation of knowledge into practice remains inadequate. We aimed to examine the uptake, retention, acceptability and effectiveness on physical activity, physical function, sitting time, diet and health outcomes of a Healthy Eating Activity and Lifestyle program (HEALTM) delivered under real-world conditions. The program was delivered to 430 adults living across rural South Australia. Participants of the program attended weekly 2 h healthy lifestyle education and exercise group-based sessions for 8 weeks. A total of 47 programs were delivered in over 15 communities. In total, 548 referrals were received, resulting in 430 participants receiving the intervention (78% uptake). At baseline, 74.6% of participants were female, the mean age of participants was 53.7 years and 11.1% of participants identified as Aboriginal and/or Torres Strait Islander. Follow-up assessments were obtained for 265 participants. Significant improvements were observed for walking, planned physical activity, incidental physical activity, total physical activity, 30 s chair stand, 30 s arm curl, 6 min walk, fruit consumption and vegetable consumption, sitting time and diastolic blood pressure. Positive satisfaction and favourable feedback were reported. The healthy lifestyle program achieved excellent real-world uptake and effectiveness, reasonable intervention attendance and strong program acceptability amongst rural and vulnerable communities Refereed/Peer-reviewed

Background A direct admission to angiosuite (DAA) strategy in transfer patients with large vessel occlusion (LVO) is considered to decrease stroke time metrics and benefit functional outcomes. However, feasibility and effectiveness of DAA have not been established in rural settings. Fast door‐to‐reperfusion times and high‐quality reperfusion are key predictors of outcome in patients with LVO. To reduce treatment times in transferred patients with suspected LVO, we initiated a DAA triage protocol in 2017. Methods We conducted a nested interventional cohort study of adult patients with anterior LVO from January 2015 to August 2019 transferred to our center from an outside hospital. Patients were divided into DAA for mechanical thrombectomy (MT) and patients directly admitted to the emergency department (DAED). DAED was subdivided into patients undergoing MT and patients who did not. Workflow times and clinical and radiographic outcomes were analyzed. Results Forty‐five DAA patients and 241 DAED patients (DAED patients undergoing MT=134 patients and DAED patients not undergoing MT=107 patients) were identified. DAA patients had significantly shorter median door‐to‐arterial‐puncture times (15 versus 71 minutes) and puncture‐to‐recanalization times (27 versus 42.5 minutes). At discharge, DAA patients had a significant decrease in median admission National Institutes of Health Stroke Scale (NIHSS) score (ΔNIHSS score 10 versus 4; P =0.02), and higher rate of dramatic clinical improvement (ΔNIHSS score >10; 48.9% versus 23.5%; P P =0.52), and mortality at 90 days ( P =0.63). When mortality was excluded, DAA patients showed a significant proportion of excellent functional outcome (mRS 0–1; 50% versus 26%) before ( P =0.04) and after ( P =0.02) adjusting for confounders. Conclusions DAA is feasible and can safely reduce reperfusion times in transferred patients with LVO to MT centers in a rural setting. Reducing workflow times may impact the functional recovery of patients undergoing MT.

IntroductionThe South West Acute Hospital (SWAH) serves the most rural population in Northern Ireland. The British Society of Gastroenterology (BSG) updated guidelines on the treatment and management of Primary Biliary Cholangitis (PBC) in 2018.1 We audited our PBC patients to assess management of patients with PBC, and identify areas for improvement.MethodsPatients were identified by searching PAS and the Northern Ireland Electronic Care Record (NIECR). ICD-10 code K74.3 was used - ‘Chronic nonsupparative destructive cholangitis’ – as primary and secondary diagnosis. We audited the notes of all patients who had a diagnosis of PBC in our hospital catchment area within the last 10 years based on recommendations from the 2018 BSG PBC guidelines.ResultsA total of 51 patients with PBC were identified. Mean age 66 [age range 31 to 92], 11 male and 40 female [78% F;22% M].Of our patients, 84% were on Ursodeoxycholic Acid (UDCA), but only 54% were on the correct dose of 13-15mg/kg/day of UCDA.6 patients considered high risk on their LFT results has not been referred for second line therapy. 3 UDCA intolerant patients had not been referred for second line therapy.98% (50/51) had had baseline TFTs checked;51% (26/51) had had coeliac serology checked. Bone densitometry (DEXA scan) had been performed on 63% of our patients with PBC.14 patients reviewed during our audit had passed away over the last 10 years. Of these 50% (7/14) had died of PBC or a liver related illness.ConclusionsThe majority of patients were on UDCA, but not all were on the correct dose. Of concern were the high risk patients and UDCA-intolerant patients who had not been referred onwards for consideration of second line therapy and consideration of liver transplant. COVID19 lockdown certainly negatively influenced the optimal management of PBC patient over the last 12 months. To improve our care, we have instituted a PBC proforma, to be used during clinics and aim to streamline all PBC patients into one specialist clinic, rather than the current multi-clinic, multi-consultant set up. The recent addition of a Fibroscan service will also benefit patient management.ReferenceHirschfield GM, Dyson JK, Alexander GJM, et al. 2018, Gut, e-publication, 2018, page0-27.

Paraurethral vaginal leiomyoma is the infrequent case to be described. Approximately 300 cases have been described so far. Imaging modalities aid in identifying the morphological, structural characteristics of the mass and its relationship to the surrounding structures. Thirty-six years old married women presented with a vulvar mass of (3x5) cm2. Her associated complaints were left shift of the urinary stream and dyspareunia. Ultrasonography and cystography revealed a mass with no relationship with bladder or uterine structure. Surgical excision was performed. The histopathological report confirmed the diagnosis of paraurethral vaginal leiomyoma. Surgical excision is the treatment of choice and diagnosis is confirmed by histopathological examination.

Hydatid cyst is a zoonosis caused mainly by the larval stage of the cestode worm Echinococcus granulosus, hydatidosis is frequently found in sheep-raising countries such as the Mediterranean countries. The disease usually involves the liver (75%) and lung (15%). We describe a case of hydatid cyst of the psoas muscle; we are reporting this case because of its rarity and its difficulty to diagnose clinically. A 16 –year-old female from rural setting, presented to the department of surgery of our institution, with complaints of right flank pain. On abdominal examination, there was sensitization in the right lower quadrant, and there was no resistance or rebound. On abdominal ultrasonography, a 6 × 6 cm hydatid cyst was detected within the psoas muscle, which was confirmed by positive indirect hemagglutination, no other organ involvement has been detected by CT scan. A pericystectomy was performed; the intact intramuscular cyst was completely excised, Macroscopic and microscopic examination of the specimen confirmed Hydatid cyst. The patient was discharged from hospital on the fifth postoperative day. No local recurrence was detected during postoperative follow up. Hydatidosis should be considered in cases of a symptomatic swelling in musculoskeletal system without history of trauma and irradiation when patients belong to endemic area. Cyst or complex retroperitoneal tumors, cold or pyogenic abscess of psoas muscle are considered in differential diagnosis. In the light of this case and the literature data, we discuss the diagnosis and the therapeutic problems raised by hydatid cyst of the psoas muscle., Highlights • Hydatid cyst is a parasitic common disease in sheep breeding areas, especially in Mediterranean countries. • Hydatid cyst of the psoas muscle is important to know because of its rarity and its difficulty to diagnose clinically, especially in young people. • Hydatid cyst should be considered in the presence of any painless cyst mass of muscle in endemic regions. Unilateral and primitive forms are mainly reported. • Excision of the intact intramuscular cyst completely is required to avoid contamination and recurrence. • Cyst or complex retroperitoneal tumors, cold or pyogenic abscess of psoas muscle are considered in differential diagnosis.

Introduction Patients with inflammatory bowel disease (IBD) require long-term secondary care with periodic specialist follow-up. This can be especially challenging for patients living in remote areas. One possible solution is the implementation of videoconference (VC) clinics as a distance-management tool. Here we assessed the use of VC clinics for IBD in terms of patient safety and economic benefit for patients with IBD living in rural areas in the Scottish Highlands and Islands. Methods Eighty-eight patients participating in the IBD specialist nurses VC clinic administered via Raigmore Hospital, Inverness, Scotland, UK, between January 2016 and June 2017 were included in this study. A total of 229 appointments were assessed. Results We found the use of a VC clinic to be safe and effective as only 0.9% of appointments required urgent medical assessment and 92% of the VC clinic appointments resulted in further VC clinic follow-up. A total travelling distance of 72,245.3 km and a total travelling time of 71,688 minutes were saved in this patient cohort. It was shown that an average of US$36.61 of potential travelling cost could be saved per appointment. Discussion VC clinics represent a patient-centred participatory model of care for IBD patients living in remote areas with enormous time- and cost-saving potential while being safe and effective. Further investigations into patient satisfaction and the combination with other telemedicine tools such as telephone conferencing and mobile phone applications are needed to evaluate the full potential of the concept.

Aim: The aim of this study was to evaluate the prevalence of elder abuse in a rural setting. In addition, the study aimed to evaluate the association of elder abuse with psychiatric morbidity and demographic factors. Methodology: A total of 125 elderly (age ≥55 years) were evaluated for psychiatric diagnosis as per the International Classification of Diseases, 10th revision (ICD-10) criteria by the qualified psychiatrist and were evaluated on Vulnerability to Abuse Screening Scale for elder abuse. Results: More than half (58.4%) of the participants had one psychiatric disorder, with depression being the most common. Elder abuse was seen in more than one-third (41.6%) of the study participants. Those with psychiatric morbidity had significantly higher prevalence of abuse. None of the demographic factors was associated with abuse. Conclusion: Elder abuse is highly prevalent in rural setting, especially among those with psychiatric morbidity. Implications: Considering the high prevalence of elder abuse, there is an urgent need to address the problem. Public awareness, education, and sensitization of people toward the abuse are need of the day.

To assess the nutritional and infection status of rural schoolchildren and to study the relationship of infection status with serum 25(OH)D concentrations. This study was carried out in a primary school, in a rural setting, near Pune (18°N), Maharashtra. Data collected from 387 children included anthropometric, clinical, infection-related data (using a validated questionnaire) and dietary data (by 24-h recall method over 3 non-consecutive days, including a holiday) and serum 25(OH)D estimations (by ELISA). Prevalence of underweight and stunting were 18% and 11% respectively. Upper respiratory tract infection (URTI) related symptoms were commonly reported. Episodes of URTI were found to be significantly and negatively correlated with serum 25(OH)D concentrations (rs = −0.14, p

Purpose To evaluate the status of interventional radiology (IR) staffing, recruitment, and retention in the United States, specifically as they apply to small hospitals and rural communities. Materials and Methods A 22-question survey was created by an ACR intercommission workgroup and circulated via e-mail to ACR members who self-identified as a “group practice leader,” “general radiologist,” “interventional radiologist,” or “abdominal radiologist.” Contingency tables were constructed, and bivariate analyses were performed to assess overall responses and the distribution of responses among specific groups of respondents. Results A total of 1,005 e-mail recipients completed the survey. A statistically significant greater proportion of responders from rural hospitals (versus nonrural hospitals) answered that (1) their group falls short or far short of meeting demand for IR services (29.1% versus 14.3%), (2) they had difficulty recruiting IR physicians to their practice (67% versus 40.6%), and (3) they had difficulty retaining IR physicians (40% versus 29%). The most frequently reported reasons for difficulty recruiting were that IR-trained physicians “do not want to do diagnostic work” (56.2%) and “do not want to practice in a small or rural setting” (48.8%). A greater proportion of respondents from rural hospitals perceived that they had difficulty retaining IR physicians because of perceived inadequate “complexity of case mix” (67.5%) or “number of cases” (66.1%). Conclusion Small hospitals and rural communities experience greater difficulty recruiting and retaining IR physicians and meeting IR service demands compared with their nonrural counterparts.

Introduction: Dyspepsia affects up to 40% of the general population and significantly reduces the quality of life. Dyspeptic symptoms may be associated with endoscopically negative conditions, such as functional dyspepsia, or with organic lesions like peptic ulcer and oesophagitis which are easily detected by endoscopy. On the other hand, such lesions may also be asymptomatic and there is not always a clear cause and effect relationship between endoscopic findings and symptoms. Objective: To determine the prevalence of significant endoscopic lesion and or ultrasonographic findings and their association with dyspeptic symptoms in Bangladeshi rural population. Materials and Methods: This prospective cross sectional study was carried out in Nov 2015 to Dec 2015 in a field mobile hospital of Bangladesh Army, established in Daudkandi, Comilla where total 1094 uninvestigated dyspeptic patients were invited to participate in this cross sectional study and 105 typical dyspeptic patients were finally recruited as per Rome III criteria. Participants underwent clinical assessment through a preformed structured questionnaire and non video upper gastrointestinal endoscopy (UGIE) and ultrasonogram (USG) of hepatobiliary system (HBS). Results: The mean age of 105 participants (male-29; female-76) studied was 36.51±7.26 years with female preponderance (72.38%). Predominant symptoms were epigastric pain (69.52%), flatulence (34.28%), heart burn (28.57%) and diffuse abdominal pain (22.85%). Regarding treatment 48(45.71%) patients took proton pump inhibitors (PPI), 24 patients (22.85%) took H2 receptor blocker and 13 patients (12.38%) were on antacids irregularly. Seventeen patients (16.15%) had no history of medications for dyspepsia. Most of the patients (76.19%) had symptoms of less than 5 years. Organic dyspepsia was found in 68(64.76%) and functional dyspepsia in 37(35.23%) participants. Percentage of functional dyspepsia in male was 24.13% and in female it was 39.47% and the difference was statistically significant (p

Background: Modern contraceptive use among women of reproductive age (15 - 49 years) is a public health priority in Tanzania. The national prevalence remains unacceptably low as 32%. Shinyanga region is one among the regions with lowest contraceptive prevalence rate (21%) and high unmet need for family planning (23%). Understanding factors contributing to its use may help to improve maternal and child health. This study aimed to assess the prevalence and determinants of modern contraceptive use among women of reproductive age. Methods: A community-based cross-sectional study was conducted in Kishapu district of Shinyanga region: A total of 602 women aged 15 - 49 years were interviewed using a standardized questionnaire. Data were analysed using SPSS version 20.0. Odds ratios with 95% confidence intervals for factors associated with use of modern contraceptives were estimated in multivariable logistic regression models. Results: The prevalence of modern contraceptive use was 42.7%. Being employed (OR 2.42, 95% CI: 1.13 - 5.18), formal educational level (OR 2.45, 95% CI: 1.38 - 4.35), couples communication (OR 2.44, 95% CI: 1.74 - 3.42) and availability of modern contraceptives (OR 1.94, 95% CI: 1.17 - 3.20) were significantly associated with current use of modern contraceptives. Husband disapproval was frequently reported as barrier for modern contraceptives in the study area. Conclusions: Numerous factors were associated with use of modern contraceptives. Husband disapproval was frequently reported as barrier for contraceptive use. Strategies to promote the importance of modern contraceptives use in the study area are warranted. District health office and concerned stakeholders should encourage male involvement for family planning.

Purpose The cardiac rehabilitation (CR) program at Dartmouth-Hitchcock Medical Center (DHMC) devotes a nurse to the inpatient units in an attempt to optimize the referral process. This report defines the rates of referral and participation at DHMC and explores potential factors that affect participation. Methods Seven hundred ten consecutive patients who underwent percutaneous coronary intervention, coronary artery bypass grafting, or valve surgery from January 1, 2015 to June 30, 2015 were reviewed to determine whether the patient was referred for CR. Participation rates and the effect of time delay and patient-specific factors on participation were examined. Results Six hundred ninety-eight (98%) of the 710 post-procedural patients were evaluated by the inpatient rehabilitation nurse. One hundred sixty-seven patients were ineligible for outpatient therapy on the basis of established criteria; the remaining 543 patients were referred to DHMC or regional rehabilitation programs. Of those referred to the on-site program at DHMC, 84% participated. Of those referred to regional programs, 60% participated. There was an inverse correlation (r = -0.82; P = .003) between wait times and participation rates for the various programs. Conclusions Despite its rural location with a large geographic catchment area, DHMC achieves high rates of CR referral and participation. The approach used at DHMC, which includes a CR nurse working with the inpatient cardiac services, a strong level of integration with the physician community, and well-developed relationships with regional rehabilitation programs, may be helpful for those programs wishing to improve referral and participation rates. Shorter wait times between hospital discharge and initiation of rehabilitation may improve participation rates.

Helicobacter pylori, is a spiral-shaped pathogenic bacterium which is believed to cause peptic ulcers, chronic gastritis, active ulcers disease and many gastrointestinal diseases. The study aimed to find out the prevalence of H. pylori infection and factors associated with the infection in a rural setting of Nepal. A cross-sectional study was conducted among 804 participants from March 2019 to April 2020 in a rural setting of Province 2, Nepal. A structured questionnaire was administered to obtain information about the socio-demographic condition, food habits, hygienic practices, and family history. Venous blood was collected for laboratory examination of H. pylori antibodies.Serum anti-H. Pylori antibodies were detected; out of 804 participants 375 (46.6%) were positive for H. pylori infection; 411(51.1%) were female and male 393 (48.9%). The minimum age of the participant was 13, the maximum was 85 with a mean age of 43±15.26. A significant association was found with age group Pvalue 0.012, with religion [P-value 0.021 and OR (95% CI) was 2.938 (1.128-7.650)] and place of residence [P value 0.011 OR (95% CI) was 1.438(1.087-1.904)]. A significant association was also observed with marital status, occupation, total family members and total annual income. A significant association was seen with food habits like consumption of vegetables, onion and garlic, milk and meat products, spicy foods, and fried foods.Even though the prevalence of H. pylori is lower than other still has a higher prevalence than developed countries in the rural area and socio-demographic factors and food habit are associated with H. pylori. Awareness campaigns should be focused on rural areas where education is not primary.

OBJECTIVE To assess the status of intestinal schistosomiasis among preschool-aged (PSAC) and school-aged children (SAC) and to compare the efficacy of praziquantel (PZQ) in both groups. METHODS The study was conducted on 400 children; 103 PSAC and 297 SAC. Diagnosis of Schistosoma mansoni was based on triplicate Kato-Katz thick smears from a single stool sample. To identify the missed cases by Kato-Katz, 120 randomly selected negative cases (38 PSAC and 82 SAC) were screened by real-time PCR. All S. mansoni-positive cases by Kato-Katz were treated by crushed PZQ tablets. Four weeks after treatment, the cure rate was assessed by Kato-Katz smears and real-time PCR. RESULTS The prevalence of S. mansoni with Kato-Katz was 7.8% among PSAC and 7.4% among SAC. Most of children (63.3%) had light-intensity infection. The cure rate was 100% among PSAC by both techniques, and 91%, and 77.2% among SAC by Kato-Katz and real-time PCR, respectively. In the 120 stool samples screened by real-time PCR, S. mansoni prevalence was 25%; 15.8% and 29.3% were among PSAC and SAC respectively. Treated cases showed a lower range of Ct values than untreated cases. Two melting temperature ranges (Tm = 83-87°C and 89-93°C) were recognised among uncured cases which may point to S. mansoni genetic variability. CONCLUSION Continuous monitoring and inclusion of PSAC in schistosomiasis control programmes are crucial. Real-time PCR and other molecular tools are recommended for evaluation of the true prevalence, assessment of cure and further studies on genetic diversity.

BackgroundAcceptance of the COVID-19 vaccine will play a major role in combating the pandemic. Healthcare workers (HCWs) are amongst the first group to receive vaccination, so it is important to consider their attitudes about COVID-19 vaccination to better address barriers to widespread vaccination acceptance.MethodsWe conducted a cross sectional study to assess the attitude of HCWs toward COVID-19 vaccination. Data was collected between October 7th and November 9th, 2020. We received 4080 responses out of which 3479 were complete responses and were included in final analysis.Results36% of respondents were willing to take the vaccine as soon as it became available while 56% were not sure or would wait to review more data. Vaccine acceptance increased with increasing age, education, and income level. Lower acceptance was noted in females (31%), Black (10%), Latinx (30%) and Conservative/Republican (21%) HCWs, and those working in a rural setting (26%). Direct medical care providers had higher vaccine acceptance (49%). Safety (69%), effectiveness (69%) and speed of development/approval (74%) were noted as the most common concerns regarding COVID-19 vaccination in our survey.ConclusionImmediate acceptance of a COVID-19 vaccine is low, with the majority of HCWs choosing to wait to review more data before deciding on personal vaccination. Overall attitudes toward vaccination were positive but specific concerns regarding COVID-19 vaccine are prevalent. Differences in vaccine acceptance were noted between individual and group characteristics which should be addressed to avoid exacerbating health inequities.

Background Oral rehydration solution (ORS) is an evidence-based intervention to reduce diarrhoea-related morbidity and mortality, but consistently low rates of ORS use have been documented in Nigeria. Aim To identify barriers to the optimal use of ORS for childhood diarrhoea in Nigeria and recommend appropriate interventions to improve uptake of ORS at community and facility levels. Methods A quantitative cross-sectional survey of 400 mothers with children under 5 years of age was conducted in Nigeria to explore reasons for suboptimal utilization of ORS for childhood diarrhoea. An interviewer-administered questionnaire was used for data collection. Data were analysed using the statistical software SPSS version 21.0®. Results Sixty-one (15.3%) of the respondents were unaware of ORS. Of the 339 that were aware, their source of information was mainly hospital/health workers (81.1%). Among mothers that affirmed they could prepare ORS, only 64 (22.1%) prepared it correctly. Level of education significantly influenced awareness of ORS as well as its correct preparation. Nineteen mothers (5.6%) had difficulty getting ORS when needed, whereas 13 (3.8%) reported that it was difficult for them to remember how to prepare ORS. Four in ten children took ORS reluctantly or refused it outrightly. No cultural taboo concerning the use of ORS was reported. Conclusion There is still a wide gap in the awareness of ORS and many caregivers prepared the solution incorrectly. We recommend that the method of preparation of ORS be clearly indicated on the sachets, and production of commercial 1-L water packages for ORS preparation be encouraged. Lay summary Oral rehydration solution (ORS) is an evidence-based intervention to reduce diarrhoea-related morbidity and mortality, but consistently low rates of ORS use have been documented in Nigeria. A quantitative cross-sectional study was carried out among 400 mothers to identify barriers to the optimal use of ORS for childhood diarrhoea and recommend appropriate interventions. Sixty-one (15.3%) of the respondents were unaware of ORS. Among mothers that affirmed they could prepare ORS, only 64 (22.1%) prepared it correctly. Level of education significantly influenced awareness of ORS as well as its correct preparation. Some mothers had difficulty getting ORS when needed, while some found it difficult to remember how to prepare it. Four in ten children took ORS reluctantly or refused it outrightly. No cultural taboo concerning the use of ORS was reported. The study showed that there is still a wide gap in the awareness of ORS and many caregivers prepared the solution incorrectly. Hence, we recommend that the method of preparation of ORS be clearly indicated on the sachets, and production of commercial 1-L water packages for ORS preparation be encouraged.

Background Trans-oral robotic surgery (TORS) facilitates surgical resection of tumours as an alternative to open surgery and has demonstrated favourable oncological results. Given the novelty of TORS and the paucity of evidence on TORS-specific complications in a rural setting, we report our experience with TORS at an Australian rural head and neck centre. Methods A retrospective review of all robotic cases performed at a regional head and neck centre in Queensland was undertaken from 2014 to 2019. Patient demographics, pre-operative surgical risk, complications and outcomes such as margins and cancer recurrence were recorded. Complications were graded based on the Clavien-Dindo grading system. Descriptive statistics were used to present patient characteristics and statistical analyses were performed using Stata. Results Forty-two TORS surgeries were performed. Twenty-one had histology confirming malignancy. There were no adverse intraoperative effects. Overall, seven patients (16.7%) had at least one complication. Four were recorded as a Clavien-Dindo 3b (post-operative bleed, wound infection and drain dislodgment). Of two cases with residual positive margins, one declined further surgery, and another received chemoradiotherapy. One patient recurred with distant metastatic disease, and another had locoregional nodal recurrence. The distribution of complications was significant across the pre-operative risk categories for both American Society of Anaesthesiologists and surgical risk score (P = 0.02). Conclusion TORS in a rural head and neck centre is a safe and viable treatment option for patients so long as this is undertaken with appropriate training, mentorship and teamwork.

Background: Emergency contraception has been available in pharmacies across England since 2001.There is a paucity of evidence describing those women accessing the service, particularly in rural locations, where pharmacies are integral to improving healthcare accessibility. Methods: Routinely collected data from all pharmacy consultations for emergency contraception in Shropshire, England, were obtained and anonymized for the study period April 1, 2016 to January 31, 2019. Consultations were described by time, age of consultee, rationale for consultation, method dispensed (levonorgestrel or ulipristal acetate), referral for copper intrauterine device fitting, chlamydia screening where appropriate and reason for choosing pharmacy setting. Repeat attenders were also described separately. Results: 3499 consultations occurred during the study period; 39% were aged between 16-20 years, and 52% attended following unprotected sexual intercourse. Levonorgestrel was initially most prescribed, however ulipristal acetate overtook it in 2018. Onward referral for copper intrauterine device and age-appropriate chlamydia screening took place in 3% and 4% of the eligible populations respectively. Women overwhelmingly chose the pharmacy setting owing to its convenience. Repeat attenders tended to be younger than single attenders, but otherwise similar. Conclusion: Pharmacy-based emergency contraception is an important and well-utilized service in this rural location and continued funding and possible service expansion should be considered.

Most studies regarding the use of locking condylar plates in distal femoral fractures have been carried out in tertiary centres. The aim of this case series was to examine outcomes for patients managed in a rural setting and to answer the question: ‘should we be shipping these patients out to a regional trauma centre?’ Recent insertions of condylar locking compression plates (LCPs) at a rural district general hospital were examined. (All used the Synthes LCP Condylar Plate 4.5/5.0 periarticular plating system). Their clinical records and radiology were reviewed to identify failure rates and facilitate discussion of such cases. Of 36 reviewed cases, 4 instances of failure were identified (11%), and their cases are discussed individually herein. This review not only affords the opportunity to discuss cases of failure and to speculate upon their potential causes, but also highlights reassuringly high quality of outcomes for these patients outside of larger teaching hospitals.

BackgroundIn the last decade, (2000–2019), the modern contraceptive prevalence among married women of reproductive age (14–49 years), has increased by only 2.1%. The slow progress was due to limited access to services and myths surrounding methods held by both users and providers. This case report was identified, diagnosed and managed by a midwife working in rural health center in low resource setting. However, literature is scare on the management of missing Intra-Uterine Contraceptive Device (IUCD) thread removal services of confirmed diagnosis using Vscan or limited ultrasound services in rural health centers. The aim of reporting this case report was developed to enhance easy access to intra-uterine contraceptive method removals, which may address myths associated with difficulties of undergoing the services in rural set-up.A 26 year-old married woman, Gravida 1 and Para 1, attended Mekoy Health Center for IUCD removal service after 7 years of protection and internally referred to limited obstetric ultrasound service room due to non- visualization of IUCD thread with Vaginal Speculum examination. An ultrasonography scan however, showed a centrally located copper-T 380A IUCD in the endometrial cavity. As a result, after dilatation of the cervix, a successful removal of the Copper-T 308A was conducted. The client received followed up care for 2 hours post-procedure and was then discharged.ConclusionsThis case highlights the importance of availing diagnostic and removal services in rural set ups to mitigate myths in the community. The availability of limited obstetric ultrasound scanning services can improve the diagnoses and management of conditions in clients. The reported case shows that although, the basic infrastructure was limited, ultrasound scanning and Long Acting Reversible Contraception (LARC) trained midwives can ensure the provision of safe IUCD removal services in rural areas.

This study examined the effects of aural and visual experience on psycho-physiological recovery in simulated environments. Laboratory experiments were conducted with 32 participants. Ten horror videos were used as stressor clips, while five videos depicted urban or rural settings as recovery clips. The videos were presented via VR (head-mounted display) and on a monitor screen. The effect of the audio presentation was tested by presenting the stimuli with or without sound. Psychological recovery was assessed using a set of questions (e.g., perceived preference). Physiological recovery was measured with five physiological responses (e.g., fEMG and HR) monitored throughout the experiment. It was found that the rural setting led to a better psycho-physiological recovery than the urban setting when the stimuli were presented both in the VR and Screen conditions. In particular, the rural setting with water features evoked the greatest recovery. The rural setting presented with water sound showed significant differences in psychological recovery between Audio-Visual and No-Audio conditions. Compared to the Screen condition, stimuli presented in the VR condition did not have any main effect on the psychological recovery; however, it showed main effects on some of the physiological responses. The audio presentation had significant impacts on all psychological recovery ratings but it showed an impact on only one physiological response, fEMG of the zygomatic muscle.

Seizures which occur in the first twenty-eight days of life of a full-term infant or in the forty-four weeks of gestational age in a preterm...

OBJECTIVE:To investigate current speech pathology practice regarding working with friends. METHOD:An online survey was conducted with 68 speech pathologists who worked with TBI across metropolitan and rural settings in Australia. The survey investigated the reasons speech pathologists work with friends, barriers to working with friends and perceptions of successful friendships post TBI. Descriptive statistics and content analysis of open ended responses were used to analyze the data. RESULTS:There were more speech pathologists (40%) who did not include friends compared to those who did. Friends were most commonly included in the rehabilitation process, through the provision of education programs. The primary rationale for working with friends was to prevent negative psychosocial outcomes for the person with TBI. There were numerous barriers to working with friends, most commonly the inability to access friends. CONCLUSIONS:Making and keeping friends are a significant part of most people's lives. Therefore, it is important to consider their role in contributing to improved outcomes for people with TBI. With communication partner training being an integral component to recovery and maintenance of relationships post TBI, the development of targeted education and training materials is warranted, to enable the inclusion of friends in the rehabilitation process.

Introduction:the cancellation of elective surgery is still a worldwide challenge and this is associated with emotional and economical trauma for the patients and their families as well as a decrease in the efficiency of the operating theatre. This study aimed at determining the prevalence and factors associated with cancellation and deferment of elective surgery in a rural private tertiary teaching hospital in Western Uganda. Methods:a cross-sectional study design was conducted. Data was collected from 1stJuly 2019 to 31stDecember 2019. Patients scheduled for elective surgery and either cancelled or deferred on the actual day of surgery were included in the study. Statistical analysis was done using STATA version 15. Results:four hundred patients were scheduled for elective surgery during the study period, among which 90 (22.5%) were cancelled and 310 (78.5%) had their surgeries as scheduled. The highest cancellation of elective surgical operations was observed in general surgery department with 81% elective cases cancelled or deferred, followed by orthopedic department 10% and gynecology department 9%. The most common reasons for cancellation were patient-related (39%) and health worker-related (35%) factors. Other factors included administrative (17%) and anesthesia related factors (9%). Cancellation was mainly due to lack of finances which accounted for 23.3% of the patients, inadequate patient preparation (16.6%) and unavailability of surgeons (15.5%). Major elective surgeries were cancelled 1.7 times more than minor electives surgeries [adjusted prevalence ratio 1.7 (95%CI: 1.07-2.73) and p-value: 0.024]. Conclusion:cancellation and deferment of elective surgeries is still of a major concern in this private rural tertiary hospital with most of the reasons easily preventable through proper scheduling of patients, improved communication between surgical teams and with patients; and effective utilization of available resources and man power.

In this month’s issue of Hospital Pediatrics , Ahuja et al1 examined characteristics of technology-dependent children (TDC) admitted to children’s versus nonchildren’s hospitals. With discharge data from 1408 total hospitals, categorized as 63 children’s hospitals and 1345 nonchildren’s hospitals, they found that the majority of TDC were hospitalized at nonchildren’s hospitals. However, given the proportionately large number of nonchildren’s hospitals, the exposure rate to TDC at nonchildren’s hospitals was lower than at children’s hospitals. Ultimately, these findings highlight several important conclusions. First, TDC are cared for across hospital types; accordingly, all hospitals should know how to assess and stabilize TDC. Second, understanding hospitalization patterns of TDC may help to inform which subpopulations of TDC may benefit from the regionalization of care. Inherent to exploring the latter, however, is the need to have clear and consistent definitions of the terms used to define hospital settings. In the analysis by Ahuja et al1, they dichotomized hospital types using the Healthcare Costs and Utilization Project Kids’ Inpatient Database (KID) from 2012. Within KID, hospitals are stratified by geographic region (ie, northeast, Midwest, west, and south), control (ie, public, private, or proprietary), urban or rural setting, teaching or nonteaching as determined by the American Hospital Association Annual Survey, bed size (ie, small, medium, and large), and “hospital type – freestanding children’s or other hospital.”2 By using an identifier within KID, freestanding children’s hospitals are assigned a unique stratification element that can identify them within the data set. Any children’s hospital that is not freestanding does not possess this specific identifier. Before 2012, children’s hospitals within general hospitals (or nested children’s hospitals) could be selected by using a separate data identifier. Unfortunately, beginning with the 2012 data, that identifier is no longer available; as such, the …

•People with HIV experience cumulative stigma with effects contributing to stress.•Family distancing and discrimination impact the health of people with HIV.•Effects of alcohol use on medication adherence are independent of HIV-stigma.•Cumulative HIV stigma impacts HIV treatment adherence through HIV-related stress.

Background: Nonadherence to prescribed therapy is a significant challenge at the primary healthcare level of South Africa. There are documented evidence of the potential impact of mobile health technology in improving adherence and compliance to treatment. This study assessed the effect of unidirectional text messaging on adherence to dietary and activity regimens among adults living with diabetes in a rural setting of Eastern Cape, South Africa. Methods: This was a 2-arm, multicenter, parallel, randomized controlled trial, involving a total of 216 patients with diabetes with uncontrolled glycemic status randomly assigned into the intervention (n = 108) and the control group (n = 108). Participants in the intervention arm received daily educational text messages on diabetes and reminders for 6 months, while the control arm continued with standard care only. A validated, self-developed adherence scale was used to assess participants’ adherence to diets and physical activity. Descriptive statistics and linear regression were used to assess changes in adherence and the effect of the intervention on adherence to therapy. Results: On a scale of 8, the mean medication adherence level for the intervention group was 6.90 (SD ± 1.34) while that of the control group was 6.87 (SD ± 1.32) with no statistical difference (P = .88). The adjusted mean change in the medication adherence level was 0.02 (−0.33 to 0.43) with no significant difference (P = .79). There was however a low level of adherence to dietary recommendations (1.52 ± 1.62), and physical activity (1.48 ± 1.58) at baseline, and both groups demonstrated a nonsignificant increase in dietary (P = .98) and physical activity adherence (P = .99) from baseline to the follow-up period. Conclusion: There is a moderate level of adherence to medication and a low level of adherence to dietary and physical activity recommendation in this setting. The text messaging intervention did not bring about any significant improvement in medication, dietary and physical activity adherence levels. There is a need to design effective strategies for improving adherence to recommended lifestyle changes in this setting.

Background and Purpose: A stroke may occur without warning and deficits can range from mild deficits to death. Improved outcomes are associated with decreased time to revascularization of cerebral tissue. The time sensitive nature of stroke care contributes to the challenges associated with caring for individuals suffering from stroke who live far from a stroke center. The American Stroke Association (ASA) guidelines include a recommendation for the implementation of telestroke. The technology is preferred over telephone consults and is an effective method to determine eligibility of fibrinolytic therapy. Methods: The project was implemented in a stroke ready facility in a rural area and supported by an urban care center that is recognized as a comprehensive stroke center. Stroke education was provided to the rural site and an algorithm utilizing the telestroke technology was implemented. Times from door to CT (computed topography) scan, door to fibrinolytic therapy, and door to transfer time were tracked for 90 days to compare average times to baseline data using a one-tail t-test. Statistical significant was determined with a p-value Results: There were 27 patients that presented during the collection period, with a baseline comparison of 39 patients over an 11-month period. Overall, each category had a decrease in time, with significant differences noted in door to CT and door to transfer time. The average door to CT time with telestroke decreased on average by 14.1 minutes from baseline data to a new average of 8.6 minutes. Door to transfer time with telestroke decreased by 42.2 minutes from baseline to a new average of 121.4 minutes. Additionally, during the collection period, fibrinolytic therapy initiation doubled, resulting in 48% receiving therapy. Due to the faster times, 35% of patients were able to receive a thrombectomy at the tertiary site. Conclusions: In conclusion, this study demonstrates promising results for the continuation of telestroke use in rural treatment sites for acute cerebrovascular events to decrease time to interventions for optimal outcomes.

India contributes a quarter of the global burden of multidrug-resistant tuberculosis (MDR-TB) and has inadequate diagnostic infrastructure and institutional capacities for drug susceptibility testing. Subsequently, this leads to a large number of undetected and untreated cases of MDR-TB. In this report, we describe a case of a 55-year-old man from rural North India presenting with complaints of continued symptoms of chronic cough, fever and dyspnoea despite being recently diagnosed with recurrent tuberculosis and receiving treatment from the local community health centre. MDR-TB was suspected, but confirmatory diagnostic capabilities were not available in the local setting. The patient was finally diagnosed with MDR-TB. Treatment was coordinated by the district tuberculosis programme officer. Through this case, we describe the various barriers to detecting MDR-TB in the rural regions of India. Prompt identification of patients with presumptive MDR-TB, diagnosis of the disease and initiation of treatment are crucial to preventing disease transmission and reducing morbidity and mortality.

This chapter discusses staffing for medical simulation labs, whether you are affiliated with an academic institution or a standalone facility in a small rural setting. Identifying your needs, availability in budgets for staffing, and choosing what positions meet the needs of your simulation lab are essential in meeting your customers’ needs and the success of your lab. This chapter discusses key roles/personnel of a simulation lab.

Introduction: Sleep is an integral part of human physiology; therefore, disorders of sleep may result in significant derangement in human functionality. Sleep medicine has received little attention in Nigeria. Against this backdrop, this survey seeks to evaluate the quality of sleep among doctors. Methodology: This was a cross-sectional descriptive study involving 59 doctors working with Federal Medical Centre Birnin Kebbi, Kebbi State, Nigeria; it was done between August 2017 and December 2017. Purposive sampling method was adopted. The Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS) were adopted. The questionnaire was self-administered. Results: There were 34 (57.6%) males and 25 (42.4%) females. Their age ranged from 20 to 66 years, with a mean of 34.39 ± 8.00. The Epworth score ranged from 8 to 29, with a mean of 16.1 ± 4.4, while the PSQI score ranged from 5 to 19, with a mean of 9.5 ± 2.7. The mean work hour per week was 90.3 ± 36.2 h, and majority of the respondents worked for >80 h and or >24 h consecutively in the preceding week, and most had high ESS scores; however, this observation was not statistically significant (Fisher's exact test = 4.0904, P = 0.213). All respondents were poor sleepers and majority sleep for