Treatment of Intrahepatic Cholangiocarcinoma—A Multidisciplinary Approach

Intrahepatic cholangiocarcinoma (iCC) is distinguished as an entity from perihilar and distal cholangiocarcinoma and gallbladder carcinoma. Recently, molecular profiling and histopathological features have allowed further classification. Due to the frequent delay in diagnosis, the prognosis for iCC remains poor despite major technical advances and multimodal therapeutic approaches. Liver resection represents the therapeutic backbone and only curative treatment option, with the functional residual capacity of the liver and oncologic radicality being deciding factors for postoperative and long-term oncological outcome. Furthermore, in selected cases and depending on national guidelines, liver transplantation may be a therapeutic option. Given the often advanced tumor stage at diagnosis or the potential for postoperative recurrence, locoregional therapies have become increasingly important. These strategies range from radiofrequency ablation to transarterial chemoembolization to selective internal radiation therapy and can be used in combination with liver resection. In addition, adjuvant and neoadjuvant chemotherapies as well as targeted therapies and immunotherapies based on molecular profiles can be applied. This review discusses multimodal treatment strategies for iCC and their differential use.

Eye health promotion-oriented policy statements in various national and provincial health policy documents in South Africa

Background: There are many fragmented public health policies that give directives towards various aspects of healthcare needs and implementation. However, none of these policies make specific reference to eye health promotion (EHP) as an enabler for individuals to take control of the determinants of their eye health (EH) needs.Aim: The current study sought to identify EHP messages in the various available policy documents at both national and provincial health department levels with a view to assessing awareness on the available gaps for the development of an integrated EHP policy in South Africa.Setting: The study used documents provided by the National Department of Health and those that were available online from various other provincial Departments of Health in the country.Methods: Content analysis of EH policies requested from the Directorate of Chronic Diseases, Disabilities and Geriatrics was conducted. Various other health policies that were enacted post-1994 and endorsed by the National and Provincial Departments of Health were also considered for analysis.Results: Twenty-four documents were considered for content analysis. The national guidelines on eye healthcare made reference to EH activities such as immunisation of children, vision screening of the elderly, vitamin A supplementation and maternal services to detect sexually transmitted diseases, amongst others. Of the 20 national and provincial health documents analysed, only four made reference to EH. None of these documents made any specific reference to EHP.Conclusion: Although four national guidelines contain content related to EHP, the fragmentation and lack of integration with other health policy documents may lead to eye healthcare messages not being prioritised for dissemination even where they are highly required. Also, public eye healthcare services in general will continue to lag behind as is the case in most provinces in South Africa.

Reducing omission of eye drops during hospital admission

Background/aims Chronic ophthalmic conditions, such as glaucoma and dry eye disease, are frequently encountered debilitating eye conditions that can lead to substantial reduction in vision and quality of life. However, there is ongoing evidence to suggest that topical ophthalmic therapy is inappropriately omitted on admission to hospital. The primary aim of this audit was to investigate the trust adherence to the National Institute for Health and Care Excellence guideline on the prescribing standard of eye drops during hospital admission. The secondary aim was to raise awareness and ensure successful compliance with national standards to reduce unintentional omission of eye drops on admission and subsequent complications. Method Electronic medical records of all medical and surgical adult inpatients were studied prospectively on two different occasions. The quality of documentation of eye drops in clerking notes, the length of time taken between the admission and prescription of eye drops, and the accuracy of the prescription were examined. Following the initial audit, interventions focusing on clinician education were implemented. This includes highlighting the importance of eye drops in all departmental mandatory introductory sessions and putting up posters on all the wards as prompts. The same data collection method was used in the reaudit. Results In the initial audit, 64 (mean age 81.8±8.9 years) patients with regular prescriptions for eye drops were identified; 38 (59.4%) patients had eye drops for dry eye disease only, 20 (31.3%) patients had eye drops for glaucoma only, and six (9.4%) patients had eye drops for both. In the reaudit, 57 (mean age 76.7±15.3 years) patients were identified; 42 (73.7%) patients had eye drops for dry eye disease only, 10 (17.5%) patients had eye drops for glaucoma only, and five (8.8%) patients had eye drops for both. Following the intervention, there was a significant improvement in documentation of ocular diagnosis and eye drops on clerking notes from 41% to 65% (P=0.008), and eye drop reconciliation within 24 hours of admission improved from 45% to 75% (P=0.0008). All patients (100%) received the correct eye drop prescription before and after the intervention. Conclusions Education is effective in promoting adherence to national guidelines and reducing the incidence of inappropriate omission of eye drops on admission to hospital.

Protection against discrimination in national dementia guideline recommendations: A systematic review

Background National dementia guidelines provide recommendations about the most effective approaches to diagnosis and interventions. Guidelines can improve care, but some groups such as people with minority characteristics may be disadvantaged if recommended approaches are the same for everyone. It is not known if dementia guidelines address specific needs related to patient characteristics. The objectives of this review are to identify which countries have national guidelines for dementia and synthesise recommendations relating to protected characteristics, as defined in the UK Equality Act 2010: age, disability, gender identity, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. Methods and findings We searched CINAHL, PsycINFO, and Medline databases and the Guideline International Network library from inception to March 4, 2020, for dementia guidelines in any language. We also searched, between April and September 2020, Google and the national health websites of all 196 countries in English and in each country’s official languages. To be included, guidelines had to provide recommendations about dementia, which were expected to be followed by healthcare workers and be approved at a national policy level. We rated quality according to the iCAHE guideline quality checklist. We provide a narrative synthesis of recommendations identified for each protected characteristic, prioritising those from higher-quality guidelines. Forty-six guidelines from 44 countries met our criteria, of which 18 were rated as higher quality. Most guidelines (39/46; 85%) made at least one reference to protected characteristics, and we identified recommendations relating to age, disability, race (or culture, ethnicity, or language), religion, sex, and sexual orientation. Age was the most frequently referenced characteristic (31/46; 67%) followed by race (or culture, ethnicity, or language; 25/46; 54%). Recommendations included specialist investigation and support for younger people affected by dementia and consideration of culture when assessing whether someone had dementia and providing person-centred care. Guidelines recommended considering religion when providing person-centred and end-of-life care. For disability, it was recommended that healthcare workers consider intellectual disability and sensory impairment when assessing for dementia. Most recommendations related to sex recommended not using sex hormones to treat cognitive impairment in men and women. One guideline made one recommendation related to sexual orientation. The main limitation of this study is that we only included national guidelines applicable to a whole country meaning guidelines from countries with differing healthcare systems within the country may have been excluded. Conclusions National guidelines for dementia vary in their consideration of protected characteristics. We found that around a fifth of the world’s countries have guidelines for dementia. We have identified areas of good practice that can be considered for future guidelines and suggest that all guidelines provide specific evidence-based recommendations for minority groups with examples of how to implement them. This will promote equity in the care of people affected by dementia and help to ensure that people with protected characteristics also have high-quality clinical services.

Current Status of Quality Assurance Scheme in Selected Undergraduate Medical Colleges of Bangladesh

This descriptive cross sectional study was carried out to determine the current status of Quality Assurance Scheme in undergraduate medical colleges of Bangladesh. This study was carried out in eight (four Government and four Non- Government) medical colleges in Bangladesh over a period from July 2015 to June 2016. The present study had an interview schedule with open question for college authority and another interview schedule with open question for head of department of medical college. Study revealed that 87.5% of college had Quality Assurance Scheme (QAS) in their college, 75% of college authority had regular meeting of academic coordination committee in their college, 50% of college had active Medical Education Unit in their college, 87.5% of college authority said positively on publication of journal in their college. In the present study researchers interviewed 53 heads of department with open question about distribution, collection of personal review form, submission with recommendation to the academic co-coordinator, and annual review meeting of faculty development. The researchers revealed from the interviews that there is total absence of this practice which is directed in national guidelines and tools for Quality Assurance Scheme (QAS) for medical colleges of Bangladesh. Bangladesh Journal of Medical Education Vol.13(1) January 2022: 33-39

Can open-defecation free (ODF) communities be sustained? A cross-sectional study in rural Ghana

Community-led total sanitation (CLTS) is a widely used approach to reduce open defecation in rural areas of low-income countries. Following CLTS programs, communities are designated as open defecation free (ODF) when household-level toilet coverage reaches the threshold specified by national guidelines (e.g., 80% in Ghana). However, because sanitation conditions are rarely monitored after communities are declared ODF, the ability of CLTS to generate lasting reductions in open defecation is poorly understood. In this study, we examined the extent to which levels of toilet ownership and use were sustained in 109 communities in rural Northern Ghana up to two and a half years after they had obtained ODF status. We found that the majority of communities (75%) did not meet Ghana’s ODF requirements. Over a third of households had either never owned (16%) or no longer owned (24%) a functional toilet, and 25% reported practicing open defecation regularly. Toilet pit and superstructure collapse were the primary causes of reversion to open defecation. Multivariate regression analysis indicated that communities had higher toilet coverage when they were located further from major roads, were not located on rocky soil, reported having a system of fines to punish open defecation, and when less time had elapsed since ODF status achievement. Households were more likely to own a functional toilet if they were larger, wealthier, had a male household head who had not completed primary education, had no children under the age of five, and benefitted from the national Livelihood Empowerment Against Poverty (LEAP) program. Wealthier households were also more likely to use a toilet for defecation and to rebuild their toilet when it collapsed. Our findings suggest that interventions that address toilet collapse and the difficulty of rebuilding, particularly among the poorest and most vulnerable households, will improve the longevity of CLTS-driven sanitation improvements in rural Ghana.

An Investigation of Indoor Air Quality in a Recently Refurbished Educational Building

Young people spend extended periods of time in educational buildings, yet relatively little is known about the air quality in such spaces, or the long-term risks which contaminant exposure places on their health and development. Although standards exist in many countries in relation to indoor air quality in educational buildings, they are rarely subject to detailed post-occupancy evaluation. In this study a novel indoor air quality testing methodology is proposed and demonstrated in the context of assessing the post-occupancy performance of a recently refurbished architecture studio building at Loughborough University, United Kingdom. The approach used provides a monitoring process that was designed to evaluate air quality in accordance with United Kingdom national guidelines (Building Bulletin 101) and international (WELL Building) standards. Additional, scenario-based, testing was incorporated to isolate the presence and source of harmful volatile organic compounds, which were measured using diffusive sampling methods involving analysis by thermal desorption - gas chromatography - mass spectrometry techniques. The findings show that whilst the case-study building appears to perform well in respect to existing national and international standards, these guidelines only assess average CO2 concentrations and total volatile organic compound limits. The results indicate that existing standards, designed to protect the health and wellbeing of students, are likely to be masking potentially serious indoor air quality problems. The presence of numerous harmful VOCs found in this study indicates that an urgent revaluation of educational building procurement and air quality monitoring guidelines is needed.

The Australian living guidelines for the clinical care of people with COVID-19: What worked, what didn’t and why, a mixed methods process evaluation

Introduction The Australian National COVID-19 Clinical Evidence Taskforce is producing living, evidence-based, national guidelines for treatment of people with COVID-19 which are updated each week. To continually improve the process and outputs of the Taskforce, and inform future living guideline development, we undertook a concurrent process evaluation examining Taskforce activities and experience of team members and stakeholders during the first 5 months of the project. Methods The mixed-methods process evaluation consisted of activity and progress audits, an online survey of all Taskforce participants; and semi-structured interviews with key contributors. Data were collected through five, prospective 4-weekly timepoints (beginning first week of May 2020) and three, fortnightly retrospective timepoints (March 23, April 6 and 20). We collected and analysed quantitative and qualitative data. Results An updated version of the guidelines was successfully published every week during the process evaluation. The Taskforce formed in March 2020, with a nominal start date of March 23. The first version of the guideline was published two weeks later and included 10 recommendations. By August 24, in the final round of the process evaluation, the team of 11 staff, working with seven guideline panels and over 200 health decision-makers, had developed 66 recommendations addressing 58 topics. The Taskforce website had received over 200,000 page views. Satisfaction with the work of the Taskforce remained very high (>90% extremely or somewhat satisfied) throughout. Several key strengths, challenges and methods questions for the work of the Taskforce were identified. Conclusions In just over 5 months of activity, the National COVID-19 Clinical Evidence Taskforce published 20 weekly updates to the evidence-based national treatment guidelines for COVID-19. This process evaluation identified several factors that enabled this achievement (e.g. an extant skill base in evidence review and convening), along with challenges that needed to be overcome (e.g. managing workloads, structure and governance) and methods questions (pace of updating, and thresholds for inclusion of evidence) which may be useful considerations for other living guidelines projects. An impact evaluation is also being conducted separately to examine awareness, acceptance and use of the guidelines.

Strategies for Prevention of COVID-19 Transmission in Hospitals: a Nationwide Survey of Controversial Issues Related to Infection Control and Prevention in Korea

Background: Infection-control measures against the coronavirus disease 2019 (COVID-19) within a hospital are often based on expert experience and intuition due to the lack of clear guidelines. This study aimed to survey the current strategies for the prevention of the spread of COVID-19 in medical institutions.Methods: In a systematic review of national-level guidelines, 13 key topics were selected. Six hospitals were provided an open survey between August 11 and 25, 2020, to assess their responses to these topics. Using these data, an online questionnaire was developed and sent to the infection-control teams of 46 hospitals in South Korea. The survey was conducted between January 31, 2021, and February 20, 2021.Results: All 46 hospitals responded to the survey. All hospitals operated screening clinics, while 89.1% (41/46) allowed symptomatic patients without COVID-19-associated symptoms to visit the general outpatient clinics. Most hospitals (87.2%; 34/39) conducted polymerase chain reaction (PCR) tests for all hospitalised patients. Moreover, 35 (76.1%) hospitals had preemptive isolation policies for hospitalised patients, of which 97.1% (34/35) released patients from isolation after a single negative PCR test. Most hospitals (76.9%; 20/26) allowed shared-room accommodation for patients who met the national criteria for release from isolation but showed positive PCR results with cycle threshold values above a certain threshold (34.6%; 9/26) or after a certain period that satisfied the national criteria (26.9%; 7/26). Conclusions: Various guidelines were being applied by each medical institution, but an explicit set of national guidelines to support these guidelines was unavailable.