Accuracy of Store-and-Forward Teledermatology for the Diagnosis of Skin Cancer: The Nouvelle-Aquitaine Experience

Background In Nouvelle-Aquitaine (a French region with a population of almost 6 million), the density of dermatologists is less than 3.8/100,000 inhabitants. This lack of dermatological care is delaying diagnosis and management, especially for skin cancer. The SmartDerm Project is a store-and-forward (SAF) teledermatology platform for primary care in Nouvelle-Aquitaine providing dermatological counselling to general practitioners (GPs). Objective The main objective was to determine the concordance between the diagnosis of skin cancer made by dermatologists and the pathologists’ diagnosis. Methods GPs in 3 pilot departments of Nouvelle-Aquitaine (Lot-Et-Garonne, Deux-Sèvres, Creuse) sent their dermatology requests using their smartphone, via an app called PAACO/Globule; dermatologists at the University Hospital of Bordeaux answered within 48-72 hours. Consecutive cases of skin cancer suspected by the referent dermatologists during the intervention were included, if the result of biopsy interpreted by a certified pathologist was available at the time of the study. Results Among the 1727 requests, 163 (9%) concerned a possible diagnosis of skin cancer and were eligible. For 61 cases, the histopathological findings were not available. Eventually, 93 patients with a total of 102 skin lesions were included. Median age was 75 years (range 26-97 years), with 53% women. The skin lesions had progressed for 8 months on average (range 0.5-36 months). The median response time was 1 day (range 0-61 days); 65 days (range 1-667 days) elapsed on average between the SAF opinion and the histological sample. Histopathology diagnosed 83 malignant lesions (57 basal cell carcinomas, 69%; 18 squamous cell carcinomas, 22%; 6 melanomas, 7%; 1 cutaneous lymphoma, 1%; 1 secondary location of a primary cancer, 1%), 1 precancerous lesion, and 18 benign lesions. The concordance between the opinion of the referent dermatologist and the final pathological finding was 83% for nonmelanocytic lesions and 67% for melanocytic lesions. Conclusions This study showed the reliability of SAF teledermatology in the diagnosis of skin cancer, comparable to literature data in the absence of dermatoscopy. The median delay of about two months between request and histology was an improvement compared to the delay of usual appointments in the intervention area. The lack of data for 61 patients showed that SAF telemedicine requires better coordination and follow-up, especially for the management of skin cancer. With this reservation in mind, teledermatology offers an alternative answer for the triage of patients with skin cancer residing in areas with low medical density. Conflicts of Interest None declared.

Accuracy of Store-and-Forward Teledermatology for the Diagnosis of Skin Cancer: The Nouvelle-Aquitaine Experience (Preprint)

BACKGROUND In Nouvelle-Aquitaine (a French region with a population of almost 6 million), the density of dermatologists is less than 3.8/100,000 inhabitants. This lack of dermatological care is delaying diagnosis and management, especially for skin cancer. The SmartDerm Project is a store-and-forward (SAF) teledermatology platform for primary care in Nouvelle-Aquitaine providing dermatological counselling to general practitioners (GPs). OBJECTIVE The main objective was to determine the concordance between the diagnosis of skin cancer made by dermatologists and the pathologists’ diagnosis. METHODS GPs in 3 pilot departments of Nouvelle-Aquitaine (Lot-Et-Garonne, Deux-Sèvres, Creuse) sent their dermatology requests using their smartphone, via an app called PAACO/Globule; dermatologists at the University Hospital of Bordeaux answered within 48-72 hours. Consecutive cases of skin cancer suspected by the referent dermatologists during the intervention were included, if the result of biopsy interpreted by a certified pathologist was available at the time of the study. RESULTS Among the 1727 requests, 163 (9%) concerned a possible diagnosis of skin cancer and were eligible. For 61 cases, the histopathological findings were not available. Eventually, 93 patients with a total of 102 skin lesions were included. Median age was 75 years (range 26-97 years), with 53% women. The skin lesions had progressed for 8 months on average (range 0.5-36 months). The median response time was 1 day (range 0-61 days); 65 days (range 1-667 days) elapsed on average between the SAF opinion and the histological sample. Histopathology diagnosed 83 malignant lesions (57 basal cell carcinomas, 69%; 18 squamous cell carcinomas, 22%; 6 melanomas, 7%; 1 cutaneous lymphoma, 1%; 1 secondary location of a primary cancer, 1%), 1 precancerous lesion, and 18 benign lesions. The concordance between the opinion of the referent dermatologist and the final pathological finding was 83% for nonmelanocytic lesions and 67% for melanocytic lesions. CONCLUSIONS This study showed the reliability of SAF teledermatology in the diagnosis of skin cancer, comparable to literature data in the absence of dermatoscopy. The median delay of about two months between request and histology was an improvement compared to the delay of usual appointments in the intervention area. The lack of data for 61 patients showed that SAF telemedicine requires better coordination and follow-up, especially for the management of skin cancer. With this reservation in mind, teledermatology offers an alternative answer for the triage of patients with skin cancer residing in areas with low medical density.

Impact of investment case on equitable access to maternal and child health services in Nepal: a quasi-experimental study

Background Disparities in the use of maternal, neonatal and child health (MNCH) services remain a concern in Low- and Middle-Income countries such as Nepal. Commonly observed disparities exist in education, income, ethnic groups, administrative regions and province-level in Nepal. In order to improve equitable outcomes for MNCH and to scale-up quality services, an Investment Case (IC) approach was lunched in the Asia Pacific region. The study assessed the impact of the IC intervention package in maternal and child health outcomes in Nepal. Methods The study used a quasi-experimental design extracting data from the Nepal Demographic Health Surveys – 2011 (pre-assessment) and 2016 (post-assessment) for 16 intervention and 24 control districts. A Difference in Difference (DiD) analysis was conducted to assess the impact of the intervention on maternal and child health outcomes. The linear regression method was used to calculate the DiD, adjusting for potential covariates. The final models were arrived by stepwise backward method including the confounding variables significant at p < 0.05. Results The results of the DiD analyses showed at least four antenatal care visits (ANC) decreased in the intervention area (DiD% = − 4.8), while the delivery conducted by skilled birth attendants increased (DiD% = 6.6) compared to control area. However, the adjusted regression coefficient showed that these differences were not significant, indicating a null effect of the intervention. Regarding the child health outcomes, children with underweight (DiD% = 6.3), and wasting (DiD% = 5.4) increased, and stunting (DiD% = − 6.3) decreased in the intervention area compared to control area. The adjusted regression coefficient showed that the difference was significant only for wasting (β = 0.019, p = 0.002), indicating the prevalence of wasting increased in the intervention group compared to the control group. Conclusion The IC approach implemented in Nepal did not show improvements in maternal and child health outcomes compared to control districts. The use of the IC approach to improve MCH in Nepal should be discussed and, if further used, the process of implementation should be strictly monitored and evaluated.

Evaluation of pilot implementation of seasonal malaria chemoprevention on morbidity in young children in Northern Sahelian Ghana

Background In Sahelian Africa, the risk of malaria increases with the arrival of the rains, particularly in young children. Following successful trials, the World Health Organization (WHO) recommended the use of seasonal malaria chemoprevention (SMC) in areas with seasonal peak in malaria cases. This study evaluated the pilot implementation of SMC in Northern Ghana. Methods Fourteen communities each serving as clusters were selected randomly from Lawra District of Upper West Region as intervention area and West Mamprusi District in the Northern Region as the non-intervention area. The intervention was undertaken by the National Malaria Control Programme in collaboration with regional health directorates using sulfadoxine-pyrimethamine plus amodiaquine and standard WHO protocols. Before and after surveys for malaria parasitaemia and haemoglobin levels as well as monitoring for malaria morbidity and mortality were undertaken. Results At the end of the intervention, participant retention was 92.9% (697/731) and 89.5% (634/708) in the intervention and the non-intervention areas, respectively. The proportion of children with asexual parasites reduced by 19% (p = 0.000) in the intervention and increased by 12% (p = 0.000) in the non-intervention area. Incidence rates of severe malaria were 10 and 20 per 1000 person-years follow up in the intervention and comparison areas, respectively with P.E of 45% (p = 0.62). For mild malaria, it was 220 and 170 per 1000 person-years in intervention and comparison area, respectively with PE of - 25% (p = 0.31). The proportion of children with anaemia defined as Hb< 11.0 g/dl reduced from 14.2% (52.8–38.6%) in the intervention area as compared to an increase of 8.1% (54.5% to 62.6) the non-intervention arm, Mean Hb reduced by 0. 24 g/dl (p = 0.000) in the non-intervention area and increased of 0.39 g/dl (p = 000) in the intervention area. Conclusions The feasibility and effectiveness of SMC introduction in Northern Ghana was demonstrated as evidenced by high study retention, reduction in malaria parasitaemia and anaemia during the wet season.

Alone Again: Altered Activation in the Observation Execution System during Synchronization in High Loneliness Individuals

Lonely people evaluate social exchanges and relationships negatively and display difficulties in interpersonal interaction. Interpersonal synchronization is crucial for achieving positive interactions, promoting affinity, closeness, and satisfaction. However, little is known about lonely individuals ability to synchronize and about the activity in the lonely brain while synchronizing. In the present neuroimaging study, 64 participants engaged in interpersonal synchronization, using a novel paradigm involving real dyadic interaction. Results show that high loneliness individuals exhibited a reduced ability to adapt their movement to their partners movement. Intriguingly, during periods in which participants adapted their movement, high loneliness individuals showed increased activation in the observation-execution (OE) system, specifically in the inferior frontal gyrus (IFG) and the inferior parietal lobule (IPL). They did not show increased activation in the dmPFC, which in the context of synchronization was suggested to be related to gap-monitoring. Based on these findings, we propose a model according to which lonely people may require a stronger activation of their OE system for movement alignment to compensate for some deficiency in their ability to synchronize. However, despite this hyper-activation, they still suffer from reduced synchronization capacity. Consequently, synchronization may be a relevant intervention area for the amelioration of chronic loneliness.

Reduction in Malaria Burden Following the Introduction of Indoor Residual Spraying in Areas Protected by Long Lasting Insecticidal Nets in Western Kenya, 2016 – 2018

Background: Long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) are the main malaria vector control measures. Kenya has employed multiple approaches, including free mass net distribution campaigns, for distributing LLINs to the community that resulted in increased household ownership of one or more nets from 44% in 2010 to 63 % in 2015. Migori and Homa Bay Counties are among the malaria endemic counties in Western Kenya that benefitted from three free mass net distribution campaigns between 2012 and 2018.. Widespread pyrethroid resistance among the primary vectors in Western Kenya has necessitated the re-introduction of IRS using an organophosphate insecticide, pirimiphos-methyl (Actellic® 300CS), as part of a strategy to manage insecticide-resistance. Evaluation of the effectiveness of the combined use of non-pyrethroid IRS and LLINs have yielded varied results. We aimed to evaluate malaria indicators before and after the introduction of IRS in a high malaria transmission area compared with an adjacent area where IRS was not introduced until one year later to estimate the effect of the intervention in an area with pyrethroid resistance.Methods: We reviewed records (MoH 405 A, 405 B, and 706) and tallied monthly aggregate of outpatient department (OPD) attendance, suspected malaria cases, those tested for malaria and those testing positive for malaria at two health facilities, one from Nyatike, an intervention sub-county, and one from Suba, a comparison sub-county, both located in Western Kenya, from February 1, 2016, through March 31, 2018. The first round of IRS was conducted in February – March 2017 in Nyatike sub-county and the second round one year later in both Nyatike and Suba sub-counties while the mass distribution of LLINs has been conducted in both locations. We performed a descriptive analysis and estimated the effect of the interventions and temporal changes of malaria indicators using Poisson regression for a period before and after implementation of the first round of IRS.Results: A higher reduction in the intervention area in total OPD, the proportion of OPD visits due to suspected malaria, testing positivity rate and annual malaria incidences except for the total OPD visits among the under 5 children where 59% decrease was observed in the comparison area while 33% decrease was observed in the intervention area (net change -27%, P <0.001). The percentage decline in annual malaria incidence observed in the intervention area was more than twice the observed percentage decline in the comparison area across all the age groups. A marked decline in the monthly testing positivity rate (TPR) was noticed in the intervention area, while no major changes were observed in the comparison area upon introduction of the non-pyrethroid IRS in the intervention area. The monthly TPR reduced from 46% in February 2016 (start of review period) to 11% in February 2018 (end of review period), representing a 76% absolute decrease in TPR among all ages (RR=0.24, 95% CI 0.12–0.46). In the comparison area, TPR was 16% in both February 2016 and February 2018 (RR=1.0, 95% CI 0.52–2.09). A month-by-month comparison revealed that the TPR in Year 2 remained lower than in Year 1 in the intervention area for most of the one year after the introduction of the IRS.Conclusions: Our findings demonstrated a reduced malaria burden among population protected by both non-pyrethroid IRS and LLINs implying a possible additional benefit afforded by the combined intervention in malaria endemic zone.

High efficacy of microbial larvicides for malaria vectors control in the city of Yaounde Cameroon following a cluster randomized trial

The rapid expansion of insecticide resistance and outdoor malaria transmission are affecting the efficacy of current malaria control measures. In urban settings, where malaria transmission is focal and breeding habitats are few, fixed and findable, the addition of anti-larval control measures could be efficient for malaria vector control. But field evidences for this approach remains scarce. Here we provide findings of a randomized-control larviciding trial conducted in the city of Yaoundé that support the efficacy of this approach. A two arms random control trial design including 26 clusters of 2 to 4 km2 each (13 clusters in the intervention area and 13 in the non-intervention area) was used to assess larviciding efficacy. The microbial larvicide VectoMax combining Bacillus thuringiensis var israelensis (Bti) and Bacillus sphaericus in a single granule was applied every 2 weeks in all standing water collection points. The anopheline density collected using CDC light traps was used as the primary outcome, secondary outcomes included the entomological inoculation rate, breeding habitats with anopheline larvae, and larval density. Baseline entomological data collection was conducted for 17 months from March 2017 to July 2018 and the intervention lasted 26 months from September 2018 to November 2020. The intervention was associated with a reduction of 68% of adult anopheline biting density and of 79% of the entomological inoculation rate (OR 0.21; 95% CI 0.14–0.30, P < 0.0001). A reduction of 68.27% was recorded for indoor biting anophelines and 57.74% for outdoor biting anophelines. No impact on the composition of anopheline species was recorded. A reduction of over 35% of adult Culex biting densities was recorded. The study indicated high efficacy of larviciding for reducing malaria transmission intensity in the city of Yaoundé. Larviciding could be part of an integrated control approach for controlling malaria vectors and other mosquito species in the urban environment.

Estimating the impact of Tiny Targets in reducing the incidence of Gambian sleeping sickness in the North-west Uganda focus

Background Riverine species of tsetse (Glossina) transmit Trypanosoma brucei gambiense, which causes Gambian human African trypanosomiasis (gHAT), a neglected tropical disease. Uganda aims to eliminate gHAT as a public health problem through detection and treatment of human cases and vector control. The latter is being achieved through the deployment of ‘Tiny Targets’, insecticide-impregnated panels of material which attract and kill tsetse. We analysed the spatial and temporal distribution of cases of gHAT in Uganda during the period 2010–2019 to assess whether Tiny Targets have had an impact on disease incidence. Methods To quantify the deployment of Tiny Targets, we mapped the rivers and their associated watersheds in the intervention area. We then categorised each of these on a scale of 0–3 according to whether Tiny Targets were absent (0), present only in neighbouring watersheds (1), present in the watersheds but not all neighbours (2), or present in the watershed and all neighbours (3). We overlaid all cases that were diagnosed between 2000 and 2020 and assessed whether the probability of finding cases in a watershed changed following the deployment of targets. We also estimated the number of cases averted through tsetse control. Results We found that following the deployment of Tiny Targets in a watershed, there were fewer cases of HAT, with a sampled error probability of 0.007. We estimate that during the intervention period 2012–2019 we should have expected 48 cases (95% confidence intervals = 40–57) compared to the 36 cases observed. The results are robust to a range of sensitivity analyses. Conclusions Tiny Targets have reduced the incidence of gHAT by 25% in north-western Uganda. Graphical abstract

Effect of Community-Level Intervention on Early Initiation and Optimal Antenatal Care Attendance: A Quasi-Experimental Study Among Post-Partum Women in Eastern Uganda

Background: Initiating antenatal care within the first trimester and making at least four visits during pregnancy are recommended to enable screening and support for healthy lifestyles, well-being, and self-care in pregnancy. Due to glaring evidence on inequalities in access to antenatal care, this study assessed the effect of engaging community health structures on utilization of antenatal care services during pregnancy in resource-constrained rural settings in Uganda. Methods: A quasi-experimental evaluation study was conducted among mothers in Eastern Uganda. The intervention components included community dialogues and empowering community health workers to sensitize expectant mothers on the use of maternal health services, and health facility strengthening. The primary outcomes were early initiation of antenatal care and completion of at least 4 ANC visits. We used Difference in Differences (DiD) analysis and multivariate regression to assess the effect of the intervention on ANC attendance.Results: Early initiation of antenatal care increased from 35.7% to 48.1% in the intervention area and 26.9% to 40.7% in the control area but with a non-significant net change of -1.3% (DID, p = 0.733) in the intervention area with respect to changes in the control area. The DiD results revealed the intervention resulted in a 5.5% net significant improvement in attendance of at least 4 ANC visits (p= 0.037). Higher education level of husband (PR1.19,95%CI 1.02–1.39), higher household size (PR=0.81, 95%CI 0.70–0.95), and higher wealth index (PR1.19,95%CI 1.03–1.37) predicted early initiation. Making at least 4 visits for antenatal care was influenced by post-primary education (PR1.14, 95%CI 1.02–1.30), higher wealth quintile (PR1.17, 95%CI 1.06 – 1.30), early initiation (PR1.58, 95%CI 1.49–1.68), and the community intervention (PR1.16, 95%CI 1.01–1.33). Conclusion: Although the community intervention improved the attendance of at least four antenatal care visits, effect estimates are low hence raising scepticisms on the feasibility of at least 8 visits as per the new WHO recommendations. Women with less education should be prioritized in maternal and child health (MCH) interventions as their families need economic empowerment to reduce financial barriers when access MCH services.

C-Reactive Protein Level Predicts Need For Medical Intervention In Pregnant Women With SARS-CoV2 Infection: A Retrospective Study

BackgroundDuring the Coronavirus disease 2019 (COVID-19) pandemic, many hospitals experienced a shortage of hospital beds. To make effective use of the limited available hospital space during the pandemic, we conducted this study to investigate the laboratory indices that identify pregnant women with SARS-CoV2 infection who require medical intervention.MethodsWe carried out a retrospective analysis of pregnant women positive for COVID-19 who were admitted to Hokkaido University Hospital from September 2020 to June 2021. Medical interventions included oxygen supplementation, systemic corticosteroids, or supplemental liquids to treat infection-related symptoms.ResultsForty-two infected pregnant patients were admitted to the hospital, half of whom required medical intervention (n = 21). Fever, C-reactive protein , and platelet count are all associated with need for medical intervention. Of the 32 patients with a fever of ≥37.5℃ on days 0–3 after onset of syndromes, 22 (69%) continued to have a fever on days 4–6, of which 19 (86.4%) required medical intervention. C-reactive protein level and platelet count on days 4–6 predicted the presence or absence of medical intervention (area under the receiver operating characteristic curve = 0.913, and 0.856, respectively), with a sensitivity of 81% and specificity of 100% at a C-reactive protein cutoff of 1.28 mg/dL, with a sensitivity of 75% and specificity of 87% at a platelet count cutoff of 16.3 × 10⁴/μL.ConclusionsThe need for medical intervention in pregnant patients can be predicted with high accuracy using a C-reactive protein cutoff of 1.28 mg/dL on days 4–6 after onset of syndromes. The presence of fever also may be an easy marker for selecting subjects who need or will need therapeutic intervention. These could be an effective triage method to determine appropriate indications for the hospitalization of pregnant women in future outbreaks.