A Case for the Non-Neurologist Telestroke Provider

Introduction: Telestroke networks have effectively increased the number of ischemic stroke patients who have access to acute stroke therapy. However, the availability of a dedicated group of stroke subspecialists is not always feasible. We hypothesize that rates of tPA recommendation, sensitivity of final diagnosis, and post-tPA hemorrhagic complications do not differ significantly between neurologists and an emergency-medicine physician during telestroke consultations.Methods: Retrospective review of all telestroke consults performed at a comprehensive stroke center over 1 year. Statistical analysis: Chi squared test.Results: Three hundred and three consults were performed among 6 spoke sites. 16% (48/303) were completed by the emergency medicine physician; 25% (76/303) were performed by non-stroke-trained neurologists, and 59% (179/303) were completed by a board-certified Vascular Neurologist. Overall rate of tPA recommendation was 40% (104/255), 38% (18/48), 41% (73/179), and 41% (31/76) among the all neurology-trained, emergency medicine-trained, stroke neurology-trained and other neurology- trained provider groups, respectively (p = 0.427). Sensitivity of final stroke diagnosis was 77% (14/18) and 72% (75/104) in the emergency-medicine trained and neurology-trained provider groups (p = 0.777) No symptomatic hemorrhagic complications following the administration of tPA via telestroke consultation occurred in any group over this time period. One asymptomatic intracerebral hemorrhage was observed (0.96% or 1/104) in the neurology-trained provider group.Discussion/Conclusion: Our results did not illustrate any statistically significant difference between care provided by an emergency medicine-trained physician and neurologists during telestroke consultation. While our study is limited by its relatively low numbers, it suggests that identifying a non-neurologist provider who has requisite clinical experience with acute stroke patients can safely and appropriately provide telestroke consultation. The lack of formerly trained neurologists, therefore, may not need to serve as an impediment to building an effective telestroke network. Future efforts should be focused on illuminating all strategies that facilitate sustainable telestroke implementation.

Trend of 4+ Antenatal Care Visits by Rural Women in Bangladesh:

Antenatal Care (ANC) is one of the four pillars initiatives of the Safe Motherhood. Since MMR is high in rural areas of Bangladesh so to reduce MMR the uptake of ANC visit from trained provider is important. The objective of this study was to see the trends of 4+ ANC visit and identify the factors associated with the number of antenatal visits in rural areas.This study used the data generated from Bangladesh Demographic and Health Survey (BDHS) 2004-2014 to observe the trends and factors associated of 4+ ANC visit. The results of bivariate and multivariate analyses confirm that divisions, wealth, education and media exposure had strong influence on rural women’s 4 + ANC visit. Result of logistic regression model shows that poor and less educated women of rural areas were less likely to seek 4+ ANC visit than urban areas. This outcome of the paper suggests that rural women economic status and education has significant effect on 4+ ANC visit. The findings will help to design appropriate strategies, programs and policies for the improvement of rural women’s maternal healthcare seeking behaviour.

Meaning Making as a Central Mechanism of Dignity Therapy for Older Adults With Cancer

Nearly 500,000 older Americans die a cancer-related death each year (National Vital Statistics Report, 2018). Following a diagnosis of a serious illness like cancer, maintaining a sense of dignity is central to a patient’s wellbeing. Dignity Therapy (DT) was recently introduced as an intervention to enhance dignity for terminally ill patients (Chochinov et al., 2005). This therapy provides patients opportunities to foster a sense of dignity though making meaning of their lives (Hack et al., 2010). To date, whether meaning-making actually occurs as a central mechanism of effective DT has not been tested. The current study investigates (i) how often and in what forms meaning-making occurs during DT, and (ii) how patients’ baseline feelings of dignity relate to meaning-making during DT. Participants were 25 male and female cancer outpatients (M age = 63.08; SD = 5.72). They completed the Patient Dignity Inventory (Chochinov et al., 2008) and then participated in Dignity Therapy with a trained provider. Sessions were audio recorded, transcribed, and reliably content-analyzed for meaning-making using an established coding scheme (Park & Folkman, 1997). Content-analysis revealed that all patients made meaning of past life events at least once (range: 1-12 occurrences). Multiple forms of meaning-making emerged, with Finding Benefit and Personal Growth most common. Patients reporting more dignity-related distress prior to DT showed greater meaning-making during the DT session (r = .46, p < 0.05). This study provides foundational evidence that meaning-making is a key mechanism of Dignity Therapy, helping older adults with cancer enhance dignity at end-of-life.

Status of the WHO recommended timing and frequency of antenatal care visits in Northern Bangladesh

Objective There is dearth of information on the timeliness of antenatal care (ANC) uptake. This study aimed to determine the timely ANC uptake by a medically trained provider (MTP) as per the World Health Organization (WHO) recommendations and the country guideline. Methods Cross-sectional survey was done with 2,731 women having livebirth outcome in last one year in Dinajpur, Nilphamari and Rajshahi districts, Bangladesh from August-November,2016. Results About 82%(2,232) women received at least one ANC from a MTP. Overall, 78%(2,142) women received 4 or more ANCs by any provider and 43%(1168) from a MTP. Only 14%(378) women received their first ANC at the 1st trimester by a MTP. As per 4 schedule visits by the WHO FANC model and the country guideline 8%(203) and 20%(543) women respectively received the first 2 timely ANC by a MTP; where only 1%(32) and 3%(72) received the first 3 visits timely and 0.6%(17) and 1%(29) received all the four timely visits. Factors significantly associated with the first two timely visits are: 10 or above years of schooling of women [adj. OR 2.13 (CI: 1.05, 4.30)] and their husbands [adj. OR 2.40 (CI: 1.31, 4.38)], women’s employment [adj. OR 2.32 (CI: 1.43, 3.76)], urban residential status [adj. OR 3.49 (CI: 2.46, 4.95)] and exposure to mass media [adj. OR 1.58 (CI: 1.07, 2.34)] at 95% confidence interval. According to the 2016 WHO ANC model, only 1.5%(40) women could comply with the first two ANC contacts timely by a MTP and no one could comply with all the timely 8 contacts. Conclusion Despite high coverage of ANC utilization, timely ANC visit is low as per both the WHO recommendations and the country guideline. For better understanding, further studies on the timeliness of ANC coverage are required to design feasible intervention for improving maternal and child health.

Can social accountability mechanisms using community scorecards improve quality of pediatric care in rural Cambodia?

Objective To determine the effect of social accountability strategies on pediatric quality of care. Design and Setting A non-randomized quasi experimental study was conducted in four districts in Cambodia and all operational public health facilities were included. Participants Five patients under 5 years and their caretakers were randomly selected in each facility. Interventions To determine the effect of maternal and child health interventions integrating citizen voice and action using community scorecards on quality of pediatric care. Outcome Measures Patient observations were conducted to determine quality of screening and counseling, followed by exit interviews with caretakers. Results Results indicated significant differences between intervention and comparison facilities; screening by Integrated Management of Childhood Illness (IMCI) trained providers (100% vs 67%, P < 0.019), screening for danger signs; ability to drink/breastfeed (100% vs 86.7%, P < 0.041), lethargy (86.7% vs 40%, P < 0.004) and convulsions (83.3 vs 46.7%, P < 0.023). Screening was significantly higher for patients in the intervention facilities for edema (56.7% vs 6.7%, P < 0.000), immunization card (90% vs 40%, P < 0.002), child weight (100 vs 86.7, P < 0.041) and checking growth chart (96.7% vs 66.7%, P < 0.035). The IMCI index, constructed from key performance indicators, was significantly higher for patients in the intervention facilities than comparison facilities (screening index 8.8 vs 7.0, P < 0.018, counseling index 2.7 vs 1.5, P < 0.001). Predictors of screening quality were child age, screening by IMCI trained provider, wealthier quintiles and intervention facilities. Conclusion The institution of social accountability mechanisms to engage communities and facility providers showed some improvements in quality of care for common pediatric conditions, but socioeconomic disparities were evident.

Abstract TP241: Neurologists' Role in Telestroke; How Essential Are We?

Background: Telestroke networks have effectively increased the number of ischemic stroke patients who have access to acute stroke therapy. However, the availability of a dedicated group of stroke subspecialists is not always feasible. Hypothesis: Rates of tPA recommendation, accuracy of final diagnosis and post-tPA hemorrhagic complications do not differ significantly between neurologists and an emergency-medicine physician during telestroke consultations. Methods: Retrospective review of all telestroke consults performed at a comprehensive stroke center during one year. Statistical analysis: Chi squared test. Results: 303 consults were performed among 6 spoke sites. 16% (48/303) were completed by the emergency medicine physician; 25% (76/303) were performed by non stroke-trained neurologists, and 60% (179/303) were completed by a board-certified Vascular Neurologist. Overall rate of tPA recommendation was 40% (104/255), 38% (18/48), 41% (73/179), and 41% (31/76) among the all neurology-trained, emergency medicine- trained, stroke neurology-trained and other neurology- trained provider groups respectively (p = .427). Accuracy of final stroke diagnosis was 77% (14/18) and 72% (75/104) in the emergency-medicine trained and neurology-trained provider groups (p = 0.777) No symptomatic hemorrhagic complications following the administration of tPA via telestroke consultation occurred in any group over this time period. One asymptomatic intracerebral hemorrhage was observed (0.96% or 1/104) in the neurology-trained provider group. Conclusion: Our results did not illustrate any statistically significant difference between care provided by an Emergency Medicine-trained physician and neurologists during telestroke consultation. While our study is limited by its relatively low numbers, it suggests that identifying a non-neurologist provider who has requisite clinical experience with acute stroke patients can safely and appropriately provide telestroke consultation. The lack of formerly trained neurologists, therefore may not need to serve as an impediment to building an effective telestroke network. Future efforts should be focused on illuminating all strategies that facilitate sustainable telestroke implementation.

Migration and investments in the health of children left behind: the role of remittances in children’s healthcare utilization in Cambodia

Remittances, financial support from family members who have migrated for work, are an increasingly important source of income for households left behind in many lower- and middle-income countries. While remittances have been shown to affect the health status of children left behind, evidence is very limited as to whether and how they affect children’s healthcare utilization. Yet, this is an important consideration for policymakers seeking to improve equitable access to quality care in settings where migration is common. I examine whether children under age five whose household receives remittances are more likely to utilize higher quality healthcare providers than those without remittances in Cambodia, a country with high rates of migration and a pluralistic health system. The analysis includes 2230 children reporting recent illness in three waves of the Cambodia Socio-Economic Survey with data on migration, remittances and children’s health expenditures. I use mixed-effects and fixed-effects regression analysis to estimate the effect of remittances on children’s likelihood of entering care with a formally trained provider, and among those attending a formally trained provider, likelihood of using a public-sector facility. Treatment expenditures are lower among households with remittances, while transportation expenditures do not vary significantly by remittance status. In mixed-effects and fixed-effect regression models, children who receive remittances have a lower likelihood of utilizing qualified providers (adjusted OR = 0.66, 95% confidence interval 0.44–0.98), though this effect is attenuated in fixed-effects models, and there is no association between remittances and attending a public-sector facility. These findings underscore that remittances alone are not sufficient to increase children’s utilization of qualified providers in migrant-sending areas, and suggest that policymakers should to address barriers to care beyond cost to promote utilization and equity of access to higher quality care where remittances are a common source of income.

Unexpected Lessons from a Mass Casualty Simulation: Strategies for Management of the Minimally Injured Can Increase Efficiency and Decrease Chaos

Introduction:The SALT Triage system has been advocated as an easy-to-use sorting and treatment system for mass casualty incidents (MCI). Minimally injured (GREEN) patients tend to be in the majority and may cause impediments to access and treatment of the most critically injured (RED). By identifying flaws in MCI communications that impair effective patient care, responders can be more effective.Aim:To discover strategies that effectively manage the minimally injured and leverage their help, increasing triage efficiency and treatment of the immediate casualties.Methods:Direct observation, after-action debriefing, and literature search.Results:The literature was vague regarding recommendations on a bystander and trained provider communication best practices. Feedback from standardized patients (actors) and participants during a structured debriefing following a 2018 American Society of Anesthesiology MCI exercise suggested that triaging providers under stress may communicate poorly, contributing to increased patient anxiety, disruptive behavior, and less effective team dynamics during a disaster. Strategies suggested include: eye contact; therapeutic touch (culturally appropriate); using slow, clear, reassuring speech; clearly explaining what is happening and why (sickest (RED and YELLOW) first priority, minimal (GREEN) next, expectant (BLACK) last); acknowledging their emotional state and their grief (not ignoring them); assigning nontechnical tasks to those capable of helping (putting pressure on a wound, moving casualties, or comforting the injured, dying, and the emotionally distraught).Discussion:Bystander engagement has been repeatedly identified as a means to increase the capacity of first responders to provide care to patients during an MCI. Utilization and management of the minimally injured and any uninjured bystanders and responders can become a force multiplier for the triage/treating responders. Developing a best practice dialogue to be used in training first responders could help improve many of these issues and augment current MCI training programs.

Determinants of Postnatal Care Utilization for the Newborns in Urban Slums of Bangladesh: A Study Based on Bangladesh Urban Health Survey Data

Better child health can be guaranteed by ensuring postnatal care for the newborns after birth. Newborns in the slums of Bangladesh are lagging behind to receive postnatal care and the percentage of newborns receiving health check-up from medically trained provider within first two months after birth is very low. The purpose of this study is to find out the potential determinants of receiving postnatal care from medically trained provider for slum newborns in Bangladesh. Data have been extracted from Bangladesh Urban Health Survey (UHS), 2013 to serve the purpose of the study. From regression analysis, it is found that antenatal care during pregnancy from medically trained provider, delivery by skilled birth attendant, economic status of the newborn family, education level and media exposure of mothers are significant factors associated with the uptake of postnatal care from medically trained provider for the newborns in slums. Dhaka Univ. J. Sci. 67(1): 69-72, 2019 (January)