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We reveal the enigmatic origin of one of the earliest surviving botanical collections. The 16th-century Italian En Tibi herbarium is a large, luxurious book with c. 500 dried plants, made in the Renaissance scholarly circles that developed botany as a distinct discipline. Its Latin inscription, translated as “Here for you a smiling garden of everlasting flowers”, suggests that this herbarium was a gift for a patron of the emerging botanical science. We follow an integrative approach that includes a botanical similarity estimation of the En Tibi with contemporary herbaria (Aldrovandi, Cesalpino, “Cibo”, Merini, Estense) and analysis of the book’s watermark, paper, binding, handwriting, Latin inscription and the morphology and DNA of hairs mounted under specimens. Rejecting the previous origin hypothesis (Ferrara, 1542–1544), we show that the En Tibi was made in Bologna around 1558. We attribute the En Tibi herbarium to Francesco Petrollini, a neglected 16th-century botanist, to whom also belongs, as clarified herein, the controversial “Erbario Cibo” kept in Rome. The En Tibi was probably a work on commission for Petrollini, who provided the plant material for the book. Other people were apparently involved in the compilation and offering of this precious gift to a yet unknown person, possibly the Habsburg Emperor Ferdinand I. The En Tibi herbarium is a Renaissance masterpiece of art and science, representing the quest for truth in herbal medicine and botany. Our multidisciplinary approach can serve as a guideline for deciphering other anonymous herbaria, kept safely “hidden” in treasure rooms of universities, libraries and museums. [ABSTRACT FROM AUTHOR]

Background: Due to the disease’s progressive nature, advance care planning (ACP) is recommended for people with early stage dementia. General practitioners (GPs) should initiate ACP because of their longstanding relationships with their patients and their early involvement with the disease, however ACP is seldom applied. Aim: To determine the barriers and facilitators faced by GPs related to ACP with people with dementia. Data sources: We systematically searched the relevant databases for papers published between January 1995 and December 2016, using the terms: primary healthcare, GP, dementia, and ACP. We conducted a systematic integrative review following Whittemore and Knafl’s method. Papers containing empirical data about GP barriers and/or facilitators regarding ACP for people with dementia were included. We evaluated quality using the Mixed-Method-Appraisal-Tool and analyzed data using qualitative content analysis. Results: Ten qualitative, five quantitative, and one mixed-method paper revealed four themes: timely initiation of ACP, stakeholder engagement, important aspects of ACP the conversation, and prerequisites for ACP. Important barriers were: uncertainty about the timing of ACP, how to plan for an uncertain future, lack of knowledge about dementia, difficulties assessing people with dementia’s decisional capacities, and changing preferences. Facilitators for ACP were: an early start when cognitive decline is still mild, inclusion of all stakeholders, and discussing social and medical issues aimed at maintaining normal life. Conclusion: Discussing future care is difficult due to uncertainties about the future and the decisional capacities of people with dementia. Based on the facilitators, we recommend that GPs use a timely and goal-oriented approach and involve all stakeholders. ACP discussions should focus on the ability of people with dementia to maintain normal daily function as well as on their quality of life, instead of end-of-life-discussions only. GPs need training to acquire knowledge and skills to timely initiate collaborative ACP discussions. [ABSTRACT FROM AUTHOR]

Background: Partnerships in global health and development governance have been firmly established as a tool to achieve effective outcomes. Botswana implements Safe Male Circumcision (SMC) for HIV prevention through a North-South partnership comprising the local Ministry of Health, US Centers for Disease Control and Prevention (funded by PEPFAR) and Africa Comprehensive HIV/AIDS Partnership (funded by the Bill and Melinda Gates Foundation). The SMC partnership experienced significant antagony and the aim of this paper is to illuminate the actions and processes in the SMC program that contributed to that antagony. Methods: Methods used to gather data include observation of the partners’ planning and strategic meeting in 2012, in-depth interviews with lead officers at national level, focus group discussions with district officers and implementers, younger male officers and old community members as recipients of the service. Results: The findings reveal that the partnership experienced antagony during operational processes and as the ultimate outcome. Target setting, financial power of the North, superficial ownership given to the South, ignoring local traditional realities results in antagony. Three roots of antagony have been identified: 1. therapeutic domination–medical expertise given with arrogance; 2.iatrogenic violence–good intentions that cause unintended harm; 3. the Trojan horse–Reckless acceptance of the gift as well as deceptive power positioned under the pretext of benevolence. Conclusion: The three roots of antagony; therapeutic domination, iatrogenic violence and the Trojan horse, constitute attitudes, hidden intentions and unintended consequences that influence program implementation and cause harm at different levels. Examples of therapeutic domination and the Trojan horse have highlighted the need for vigilance at the stage of establishing a partnership, to prevent more powerful partners from developing and applying hidden agendas and to strengthen accountability from the local partner. Iatrogenic violence has highlighted the need for partnership interventions to prevent good partner intentions accidentally producing bad outcomes. [ABSTRACT FROM AUTHOR]

Objective: Gestural interfaces allow accessing and manipulating Electronic Medical Records (EMR) in hospitals while keeping a complete sterile environment. Particularly, in the Operating Room (OR), these interfaces enable surgeons to browse Picture Archiving and Communication System (PACS) without the need of delegating functions to the surgical staff. Existing gesture based medical interfaces rely on a suboptimal and an arbitrary small set of gestures that are mapped to a few commands available in PACS software. The objective of this work is to discuss a method to determine the most suitable set of gestures based on surgeon’s acceptability. To achieve this goal, the paper introduces two key innovations: (a) a novel methodology to incorporate gestures’ semantic properties into the agreement analysis, and (b) a new agreement metric to determine the most suitable gesture set for a PACS. Materials and methods: Three neurosurgical diagnostic tasks were conducted by nine neurosurgeons. The set of commands and gesture lexicons were determined using a Wizard of Oz paradigm. The gestures were decomposed into a set of 55 semantic properties based on the motion trajectory, orientation and pose of the surgeons’ hands and their ground truth values were manually annotated. Finally, a new agreement metric was developed, using the known Jaccard similarity to measure consensus between users over a gesture set. Results: A set of 34 PACS commands were found to be a sufficient number of actions for PACS manipulation. In addition, it was found that there is a level of agreement of 0.29 among the surgeons over the gestures found. Two statistical tests including paired t-test and Mann Whitney Wilcoxon test were conducted between the proposed metric and the traditional agreement metric. It was found that the agreement values computed using the former metric are significantly higher (p < 0.001) for both tests. Conclusions: This study reveals that the level of agreement among surgeons over the best gestures for PACS operation is higher than the previously reported metric (0.29 vs 0.13). This observation is based on the fact that the agreement focuses on main features of the gestures rather than the gestures themselves. The level of agreement is not very high, yet indicates a majority preference, and is better than using gestures based on authoritarian or arbitrary approaches. The methods described in this paper provide a guiding framework for the design of future gesture based PACS systems for the OR. [ABSTRACT FROM AUTHOR]

With recent aging demographic trends, the needs for enhancing geo-spatial analysis capabilities and monitoring the status of accessibilities of its citizens with healthcare services have increased. The accessibility to healthcare is determined not only by geographic distances to service locations, but also includes travel time, available modes of transportation, and departure time. Having access to the latest and accurate information regarding the healthcare accessibility allows the municipal government to plan for improvements, including expansion of healthcare infrastructure, effective labor distribution, alternative healthcare options for the regions with low accessibilities, and redesigning the public transportation routes and schedules. This paper proposes a new method named, Seoul Enhanced 2-Step Floating Catchment Area (SE2SFCA), which is customized for the city of Seoul, where population density is higher and the average distance between healthcare-service locations tends to be shorter than the typical North American or European cities. The proposed method of SE2SFCA is found to be realistic and effective in determining the weak accessibility regions. It resolves the over-estimation issues of the past, arising from the assignment of high healthcare accessibility for the regions with large hospitals and high density of population and hospitals. [ABSTRACT FROM AUTHOR]

Primary health care has been recognized as a critical strategy for improving population health in developing countries. This paper investigates the effect of primary care physicians on the infant mortality rate in Brazil using a dynamic panel data approach. This method accounts for the endogeneity problem and the persistence of infant mortality over time. The empirical analysis uses an eight-year panel of municipalities between 2005 and 2012. The results indicate that primary care physician supply contributed to the decline of infant mortality in Brazil. An increase of one primary care physician per 10,000 population was associated with 7.08 fewer infant deaths per 10,000 live births. This suggests that, in addition to other determinants, primary care physicians can play an important role in accounting for the reduction of infant mortality rates. [ABSTRACT FROM AUTHOR]

Background: BMI is a feasible and recommended measure for overweight and obesity screening in children and adolescents. The study aimed to determine how often physicians correctly identified obesity/ overweight status in children and adolescents by using BMI percentile charts. Methods: This retrospective cross-sectional study reviewed the paper medical records of children and adolescents (6–14 years) who visited family medicine and pediatric outpatient clinics (Jan-June 2012) in a medical city in Riyadh. Investigators calculated BMI percentiles (using height, weight, age and gender data retrieved from the records) in order to identify patient weight status. Physician documentation of obesity/overweight diagnoses in patient problem lists were cross checked against their BMI percentile to assess the accuracy of physicians’ identification of weight status. The recommended management plan for identified patients was also recorded. Results: A total of 481 charts were reviewed, 213 (44%) children were seen by family medicine physicians and 268 (56%) by pediatricians. The sample was equally distributed by gender. Height was undocumented for 13% (71) of visiting patients. Eighteen percent of patients (86) were classified as overweight (35)/obese (51) according to age and sex adjusted BMI percentile. Physicians’ correctly identified and documented weight status in 20% of overweight/obese patients: 17 out of 86 subjects. Weight status identification was higher among pediatricians—25% as compared to family medicine physicians—10% [p = 0.08]. Dietary referral was the most common management plan for the identified children. Physicians were more likely to identify obese children {≥95th} compared to overweight {≥85th - 95th} children. Subjects whose BMI for age classified them into the highest BMI percentile category {≥95th} were more likely to be correctly identified (29%) compared to those classified within {≥85th - 95th} category—6% [p = 0.007]. Conclusion: Physician identification of obesity/ overweight status for children and adolescents was low, irrespective of their specialty, and despite the condition being prevalent in the sample. Future research that concentrates on interventions that may improve documentation of obesity/overweight diagnoses and parameters needed for BMI indices would be beneficial. [ABSTRACT FROM AUTHOR]

Computer-aided polyp detection in gastric gastroscopy has been the subject of research over the past few decades. However, despite significant advances, automatic polyp detection in real time is still an unsolved problem. In this paper, we report on a convolutional neural network (CNN) for polyp detection that is constructed based on Single Shot MultiBox Detector (SSD) architecture and which we call SSD for Gastric Polyps (SSD-GPNet). To take full advantages of feature maps’ information from the feature pyramid and to acquire higher accuracy, we re-use information that is abandoned by Max-Pooling layers. In other words, we reuse the lost data from the pooling layers and concatenate that data as extra feature maps to contribute to classification and detection. Meanwhile, in the feature pyramid, we concatenate feature maps of the lower layers and feature maps that are deconvolved from upper layers to make explicit relationships between layers and to effectively increase the number of channels. The results show that our enhanced SSD for gastric polyp detection can realize real-time polyp detection with 50 frames per second (FPS) and can improve the mean average precision (mAP) from 88.5% to 90.4%, with only a little loss in time-performance. And the further experiment shows that SSD-GPNet has excellent performance in improving polyp detection recalls over 10% (p = 0.00053), especially in small polyp detection. This can help endoscopic physicians more easily find missed polyps and decrease the gastric polyp miss rate. It may be applicable in daily clinical practice to reduce the burden on physicians. [ABSTRACT FROM AUTHOR]

Poor intra-facility maternity care is a major contributor to maternal mortality in low- and middle-income countries. Close to 830 women die each day due to preventable maternal complications, partly due to the increasing number of women giving birth in health facilities that are not adequately resourced to manage growing patient populations. Barriers to adequate care during the ‘last mile’ of healthcare delivery are attributable to deficiencies at multiple levels: education, staff, medication, facilities, and delays in receiving care. Moreover, the scope and multi-scale interdependence of these factors make individual contributions of each challenging to analyze, particularly in settings where basic data registration is often lacking. To address this need, we have designed and implemented a novel systems-level and dynamic mathematical model that simulates the impact of hospital resource allocations on maternal mortality rates at Mnazi Mmoja Hospital (MMH), a referral hospital in Zanzibar, Tanzania. The purpose of this model is to provide a rigorous and flexible tool that enables hospital administrators and public health officials to quantitatively analyze the impact of resource constraints on patient outcomes within the maternity ward, and prioritize key areas for further human or capital investment. Currently, no such tool exists to assist administrators and policy makers with effective resource allocation and planning. This paper describes the structure and construct of the model, provides validation of the assumptions made with anonymized patient data and discusses the predictive capacity of our model. Application of the model to specific resource allocations, maternal treatment plans, and hospital loads at MMH indicates through quantitative results that medicine stocking schedules and staff allocations are key areas that can be addressed to reduce mortality by up to 5-fold. With data-driven evidence provided by the model, hospital staff, administration, and the local ministries of health can enact policy changes and implement targeted interventions to improve maternal health outcomes at MMH. While our model is able to determine specific gaps in resources and health care delivery specifically at MMH, the model should be viewed as an additional tool that may be used by other facilities seeking to analyze and improve maternal health outcomes in resource constrained environments. [ABSTRACT FROM AUTHOR]

In 2010, the UK embarked on a self-imposed programme of contractionary measures signalling the beginning of a so-called “age of austerity” for the country. It was argued that budgetary cuts were the most appropriate means of eliminating deficits and decreasing national debt as percentage of General Domestic Product (GDP). Although the budget for the National Health Service (NHS) was not reduced, a below-the-average increase in funding, and cuts in other areas of public spending, particularly in social care and welfare spending, impacted significantly on the NHS. One of the areas where the impact of austerity was most dramatically felt was in Accidents and Emergency Departments (A&E). A number of economic and statistical reports and quantitative studies have explored and documented the effects of austerity in healthcare in the UK, but there is a paucity of research looking at the effects of austerity from the standpoint of the healthcare professionals. In this paper, we report findings from a qualitative study with healthcare professionals working in A&E departments in England. The study findings are presented thematically in three sections. The main theme that runs through all three sections is the perceptions of austerity as shaping the functioning of A&E departments, of healthcare professions and of professionals themselves. The first section discusses the rising demand for services and resources, and the changed demographic of A&E patients—altering the meaning of A&E from ‘Accidents and Emergencies’ to the Department for ‘Anything and Everything’. The second section in this study’s findings, explores how austerity policies are perceived to affect the character of healthcare in A&E. It discusses how an increased focus on the procedures, time-keeping and the operationalisation of healthcare is considered to detract from values such as empathy in interactions with patients. In the third section, the effects of austerity on the morale and motivations of healthcare professionals themselves are presented. Here, the concepts of moral distress and burnout are used in the analysis of the experiences and feelings of being devalued. From these accounts and insights, we analyse austerity as a catalyst or mechanism for a significant shift in the practice and function of the NHS–in particular, a shift in what is counted, measured and valued at departmental, professional and personal levels in A&E. [ABSTRACT FROM AUTHOR]

Background: Although empirical evidence suggests that the adherence club model is more effective in retaining people living with HIV in antiretroviral treatment care and sustaining medication adherence compared to standard clinic care, it is poorly understood exactly how and why this works. In this paper, we examined and made explicit how, why and for whom the adherence club model works at a public health facility in South Africa. Methods: We applied an explanatory theory-building case study approach to examine the validity of an initial programme theory developed a priori. We collected data using a retrospective cohort quantitative design to describe the suppressive adherence and retention in care behaviours of patients on ART using Kaplan-Meier methods. In conjunction, we employed an explanatory qualitative study design using non-participant observations and realist interviews to gain insights into the important mechanisms activated by the adherence club intervention and the relevant contextual conditions that trigger the different mechanisms to cause the observed behaviours. We applied the retroduction logic to configure the intervention-context-actor-mechanism-outcome map to formulate generative theories. Results: A modified programme theory involving targeted care for clinically stable adult patients (18 years+) receiving antiretroviral therapy was obtained. Targeted care involved receiving quick, uninterrupted supply of antiretroviral medication (with reduced clinic visit frequencies), health talks and counselling, immediate access to a clinician when required and guided by club rules and regulations within the context of adequate resources, and convenient (size and position) space and proper preparation by the club team. When grouped for targeted care, patients feel nudged, their self-efficacy is improved and they become motivated to adhere to their medication and remain in continuous care. Conclusion: This finding has implications for understanding how, why and under what health system conditions the adherence club intervention works to improve its rollout in other contexts. [ABSTRACT FROM AUTHOR]

Background: Health literacy (HL), defined as the ability to access, understand, appraise and apply health information, offers a promising approach to reduce the development of cardiovascular diseases (CVD) and to improve the management of CVD in populations. Design: We used data from nationwide cross-sectional German Health Update (GEDA2014/2015-EHIS) survey. 13,577 adults ≥ 40 years completed a comprehensive standardized paper or online questionnaire including the short form of the European Health Literacy Survey Questionnaire (HLS-EU-Q16). Methods: We compared participants with and without CVD with regard to their HL. We also analyzed the association between HL level and health care outcomes among individuals with CVD, i.e. frequency of general practitioner or specialist consultations, hospitalization and treatment delay. Results: The percentage of “problematic” or “inadequate” HL, defined as “not sufficient” HL, was significantly higher in individuals with CVD compared to without CVD (men 41.8% vs. 33.6%, women 46.7% vs. 33.4%). Having CVD was independently associated with “not sufficient” HL after adjusting for age, education, income, health consciousness and social support (adjusted OR: men 1.36, women 1.64). Among participants with CVD, individuals with “inadequate” HL were more likely to have more than 6 general practitioner consultations (49.3% vs. 28.7%), hospitalization (46.6% vs. 36.0%) in the last 12 months and to experience delay in getting health care because of long waiting lists for an appointment (30.7% vs. 18.5%) compared to participants with “sufficient” HL. Conclusion: “Problematic” or “inadequate” HL is independently associated with CVD and health care use. This is a challenge and an opportunity for both CVD prevention and treatment. [ABSTRACT FROM AUTHOR]

Maternal mortality remains very high in Mozambique, with estimates from 2015 showing a maternal mortality ratio of 489 deaths per 100,000 live births, even though the rates tend to decrease since 1990. Pregnancy related hemorrhage, gestational hypertension and diseases such as malaria and HIV/AIDS are amongst the leading causes of maternal death in Mozambique, and a significant number of these deaths occur within health facilities. Often, the analysis of data on maternal mortality involves the use of counts of maternal deaths as outcome variable. Previously we showed that a class of hierarchical zero-inflated models were very successful in dealing with overdispersion and clustered counts when analyzing data on maternal deaths and related risk factors within health facilities in Mozambique. This paper aims at providing additional insights over previous analyses and presents an extension of such models to account for spatial variation in a disease mapping framework of facility-based maternal mortality in Mozambique. [ABSTRACT FROM AUTHOR]

Background: HIV pre-exposure prophylaxis (PrEP) has likely contributed to large decreases in HIV incidence among men who have sex with men (MSM) in several major cities. Berlin has seen a smaller decline, and affordable PrEP has been accessible through formal channels in Germany only since autumn 2017. We aimed to investigate knowledge and use of PrEP among MSM in Berlin, and factors predictive of a desire to use PrEP and history of PrEP use. Methods: Multicentre, paper-based, self-administered survey of adult MSM whose HIV status was negative or unknown at time of participation. Data were collected from 1 October 2017 to 2 April 2018. Results: 473 of 875 questionnaires were returned (response rate 54.1%; mean age 37.4 years, range 18–79). 90.0% of participants were aware of PrEP and, of these, 48.2% felt well informed about it. Among the 17.2% of participants reporting PrEP use, 59.3% indicated obtaining some or all of it from informal sources. 23.7% of those with no history of PrEP use reported having condomless anal intercourse (CAI) with two or more partners over the past six months. Worries about side effects, cost, not having a doctor who prescribes it, and a lack of information were the most frequently reported barriers to PrEP use. A desire to use PrEP and history of PrEP use were associated in our multivariable model with having multiple CAI partners. A history of PrEP use was associated with having a university degree, one or two parents born outside Germany, or friends living with HIV. Conclusions: We found high awareness of PrEP among MSM in Berlin, but also a strong need for more education on its pros, cons and proper use. The frequency of informal PrEP use was also high, raising urgent individual and public health concerns. Policy makers need to consider recent calls to improve access to PrEP and PrEP education through regular health services. [ABSTRACT FROM AUTHOR]

Background: Caesarean section rates are increasing worldwide and are a growing concern with limited explanation of the factors that influence the rising trend. Understanding obstetricians’ and midwives’ views can give insight to the problem. This systematic review aimed to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report obstetricians’ and midwives’ views on the factors that influence the decision to perform caesarean section. Methods: The electronic databases of PubMed (1958–2016), CINAHL (1988–2016), Maternity and Infant Care (1971–2016), PsycINFO (1980–2016) and Web of Science (1991–2016) were searched in September 2016. All quantitative, qualitative and mixed methods studies, published in English, whose aim was to explore obstetricians’ and/or midwives’ views of factors influencing decision-making for caesarean section were included. Papers were independently reviewed by two authors for selection by title, abstract and full text. Thomas et al’s 12 assessment criteria checklist (2003) was used to assess methodological quality of the included studies. Result: The review included 34 studies: 19 quantitative, 14 qualitative, and one using mixed methods, involving 7785 obstetricians and 1197 midwives from 20 countries. Three main themes, each with several subthemes, emerged. Theme 1: “clinicians’ personal beliefs”–(‘Professional philosophies’; ‘beliefs in relation to women’s request for CS’; ‘ambiguous versus clear clinical reasons’); Theme 2: “health care systems”–(‘litigation’; ‘resources’; ‘private versus public/insurance/payments’; ‘guidelines and management policy’). Theme 3: “clinicians’ characteristics” (‘personal convenience’; ‘clinicians’ demographics’; ‘confidence and skills’). Conclusion: This systematic review and metasynthesis identified clinicians’ personal beliefs as a major factor that influenced the decision to perform caesarean section, further contributed by the influence of factors related to the health care system and clinicians’ characteristics. Obstetricians and midwives are directly involved in the decision to perform a caesarean section, hence their perspectives are vital in understanding various factors that have influence on decision-making for caesarean section. These results can help clinicians identify and acknowledge their role as crucial members in the decision-making process for caesarean section within their organisation, and to develop intervention studies to reduce caesarean section rates in future. [ABSTRACT FROM AUTHOR]

Introduction: Successful breast conserving cancer surgeries come along with tumor free resection margins and account for cosmetic outcome. Positive margins increase the likelihood of tumor recurrence. Intra-operative fluorescence molecular imaging (IFMI) aims to focus surgery on malignant tissue thus substantially lowering the presence of positive margins as compared with standard techniques of breast conservation (ST). A goal of this paper is to assess the incremental number of surgeries and costs of IFMI vs. ST. Methods: We developed a decision analytical model and applied it for an early evaluation approach. Given uncertainty we considered that IFMI might reduce the proportion of positive margins found by ST from all to none and this proportion is assumed to be reduced to 10% for the base case. Inputs included data from the literature and a range of effect estimates. For the costs of IFMI, respective cost components were added to those of ST. Results: The base case reduction lowered number of surgeries (mean [95% confidence interval]) by 0.22 [0.15; 0.30] and changed costs (mean [95% confidence interval]) by €-663 [€-1,584; €50]. A tornado diagram identified the Diagnosis Related Group (DRG) costs, the proportion of positive margins of ST, the staff time saving factor and the duration of frozen section analysis (FSA) as important determinants of this cost. Conclusions: These early results indicate that IFMI may be more effective than ST and through the reduction of positive margins it is possible to save follow-up surgeries–indicating further health risk–and to save costs through this margin reduction and the avoidance of FSA. [ABSTRACT FROM AUTHOR]

Introduction: Health Care Workers (HCWs) are among the highest risk groups for contracting tuberculosis (TB), which is ranked the third most common occupational health disease in South Africa. Little is known about the true extent of the burden of TB among South African HCWs and current surveillance approaches are inadequate. The study aimed to determine the feasibility of using postal and web-based surveys accessed through registries of registered professionals to estimate the prevalence of TB among HCWs in South Africa. Materials and methods: We conducted a cross sectional survey on a sample of professional nurses and doctors (general practitioners) registered on the Medpages database platform; a subscription based registry for practising health care professionals. The survey included professionals who were actively involved in the clinical management of patients, either in public or private health care facilities. The paper based survey, including pre-paid return envelopes, was distributed via the post office and web-based surveys were distributed via e-mail through a hyperlink. Descriptive statistics were used to summarize the data and the Chi-square test to determine associations between categorical variables. Active TB was defined as any history of TB Results: Out of a total of 3,400 health care professionals contacted, 596 (18%) responses were received: 401 (67%) web-based and 195 (33%) postal. A significantly higher percentage of complete forms were from postal compared to web-based (97% [189/195] versus 87% [348/401], p<0.001). Younger (<60 years) professionals were more likely to use the web-based compared to postal (87% [236/270] versus 71% [134/189], p<0.001). Overall, the prevalence of active TB infection was 8.7%, (95%CI: 6.3%–11.7%) and there was no difference observed between doctors and nurses (10.8% [18/167] versus 7.5% [22/292], p = 0.236). Conclusion: This novel approach demonstrated the feasibility of using an existing registry of professionals to conduct surveys to estimate the prevalence of TB. Our findings showed a high TB prevalence; however the estimate might have been biased by the low response rate. Further research to optimise our approach could lead to a viable option in improving surveillance among health care professionals. [ABSTRACT FROM AUTHOR]

Education is undergoing profound changes due to permanent technological innovations. This paper reports the results of a pilot study aimed at developing, implementing and evaluating the course, "Applicative Use of Information and Communication Technologies (ICT) in Medicine," upon medical school entry. The Faculty of Medicine, University of Belgrade, introduced a curriculum reform in 2014 that included the implementation of the course, “Applicative Use of ICT in Medicine” for first year medical students. The course was designed using a blended learning format to introduce the concepts of Web-based learning environments. Data regarding student knowledge, use and attitudes towards ICT were prospectively collected for the classes of 2015/16 and 2016/17. The teaching approach was supported by multimedia didactic materials using Moodle LMS. The overall quality of the course was also assessed. The five level Likert scale was used to measure attitudes related to ICT. In total, 1110 students were assessed upon medical school entry. A small number of students (19%) had previous experience with e-learning. Students were largely in agreement that informatics is needed in medical education, and that it is also useful for doctors (4.1±1.0 and 4.1±0.9, respectively). Ability in informatics and use of the Internet in education in the adjusted multivariate regression model were significantly associated with positive student attitudes toward ICT. More than 80% of students stated that they had learned to evaluate medical information and would use the Internet to search medical literature as an additional source for education. The majority of students (77%) agreed that a blended learning approach facilitates access to learning materials and enables time independent learning (72%). Implementing the blended learning course, "Applicative Use of ICT in Medicine," may bridge the gap between medicine and informatics upon medical school entry. Students displayed positive attitudes towards using ICT and gained adequate skills necessary to function effectively in an information-rich environment. [ABSTRACT FROM AUTHOR]

In health sector, trust is considered important because it indirectly influences the quality of health care through patient satisfaction, adherence and the continuity of its relationship with health care professionals and the promotion of accurate and timely diagnoses. One of the important requirements of TRSs in the health sector is rating secrecy, which mandates that the identification information about the service consumer should be kept secret to prevent any privacy violation. Anonymity and trust are two imperative objectives, and no significant explicit efforts have been made to achieve both of them at the same time. In this paper, we present a framework for solving the problem of reconciling trust with anonymity in the health sector. Our solution comprises Anonymous Reputation Management (ARM) protocol and Context-aware Trustworthiness Assessment (CTA) protocol. ARM protocol ensures that only those service consumers who received a service from a specific service provider provide a recommendation score anonymously with in the specified time limit. The CTA protocol computes the reputation of a user as a service provider and as a recommender. To determine the correctness of the proposed ARM protocol, formal modelling and verification are performed using High Level Petri Nets (HLPN) and Z3 Solver. Our simulation results verify the accuracy of the proposed context-aware trust assessment scheme. [ABSTRACT FROM AUTHOR]

Background: The 16-item Vitamin D Status Predictor (VDSP) questionnaire helps to identify, without resorting to a blood test, older adults with low vitamin D concentrations. Our objective was to determine whether a self-administered VDSP was concordant with the VDSP administered by a physician, and to examine the concordance of every single item of the VDSP. Methods: A total of 349 older in- and outpatients (mean, 83.2±7.2years; 59% female) were consecutively recruited in the geriatric ward of the University Hospital of Angers, France. All participants completed a self-administered VDSP questionnaire (self-VDSP) in paper format composed of 17 items exploring age, gender, general condition, nutrition, vision, mood, cognition, gait and falls, and osteoporosis. All participants underwent subsequently a full clinical examination by a physician exploring the same areas (rater-VDSP). Results: The agreement between the self-VDSP and the rater-VDSP was almost perfect for the probability of having low vitamin D concentrations, regardless of the definition used (i.e., ≤25, ≤50 or ≤75 nmol/L). The agreements between physicians’ and patients’ responses were significant for every single VDSP item. The agreement was fair to perfect for all items, except for cognitive disorders, undernutrition and polymorbidity (poor agreement). Conclusions: Older adults are able to evaluate their own probabilities of severe vitamin D deficiency, deficiency and insufficiency. A self-questionnaire may promote the use of the VDSP tool in this population, and help clinicians in decisions to supplement their patients in a reasoned way. [ABSTRACT FROM AUTHOR]

In this paper we address the problem of automated grading of invasive breast carcinoma through the encoding of histological images as VLAD (Vector of Locally Aggregated Descriptors) representations on the Grassmann manifold. The proposed method considers each image as a set of multidimensional spatially-evolving signals that can be efficiently modeled through a higher-order linear dynamical systems analysis. Subsequently, each H&E (Hematoxylin and Eosin) stained breast cancer histological image is represented as a cloud of points on the Grassmann manifold, while a vector representation approach is applied aiming to aggregate the Grassmannian points based on a locality criterion on the manifold. To evaluate the efficiency of the proposed methodology, two datasets with different characteristics were used. More specifically, we created a new medium-sized dataset consisting of 300 annotated images (collected from 21 patients) of grades 1, 2 and 3, while we also provide experimental results using a large dataset, namely BreaKHis, containing 7,909 breast cancer histological images, collected from 82 patients, of both benign and malignant cases. Experimental results have shown that the proposed method outperforms a number of state of the art approaches providing average classification rates of 95.8% and 91.38% with our dataset and the BreaKHis dataset, respectively. [ABSTRACT FROM AUTHOR]

Background: The implementation of Computerised Physician Order Entry (CPOE) and Clinical Decision Support (CDS) has been found to have some unintended consequences. The aim of this study is to explore pharmacists and physicians perceptions of their interprofessional communication in the context of the technology and whether electronic messaging and CDS has an impact on this. Method: This qualitative study was conducted in two acute hospitals: the University Hospitals Birmingham NHS Foundation Trust (UHBFT) and Guy’s and St Thomas’ NHS Foundation Trust (GSTH). UHBFT use an established locally developed CPOE system that can facilitate pharmacist-physician communication with the ability to assign a message directly to an electronic prescription. In contrast, GSTH use a more recently implemented commercial system where such communication is not possible. Focus groups were conducted with pharmacists and physicians of varying grades at both hospitals. Focus group data were transcribed and analysed thematically using deductive and inductive approaches, facilitated by NVivo 10. Results: Three prominent themes emerged during the study: increased communication load; impaired decision-making; and improved workflow. CPOE and CDS were found to increase the communication load for the pharmacist owing to a reduced ability to amend electronic prescriptions, new types of prescribing errors, and the provision of technical advice relating to the use of the system. Decision-making was found to be affected, owing to the difficulties faced by pharmacists and physicians when trying to determine the context of prescribing decisions and knowledge of the patient. The capability to communicate electronically facilitated a non-interruptive workflow, which was found to be beneficial for staff time, coordination of work and for limiting distractions. Conclusion: The increased communication load for the pharmacist, and consequent workload for the physician, has the potential to impact on the quality and coordination of care in the hospital setting. The ability to communicate electronically has some benefits, but functions need to be designed to facilitate collaborative working, and for this to be optimised through interprofessional training. [ABSTRACT FROM AUTHOR]

Self-measurement and documentation of blood-glucose are critical elements of diabetes management, particularly in regimes including insulin. In this study, we analyze the usability of iBG-STAR, the first blood glucose meter connectable to a smartphone. This technology records glucometer measurements, removing the burden of documentation from diabetic patients. This study assesses the potential for implementation of iBG-STAR in routine care. Twelve long-term diabetic patients (4 males; median age of 66.5 years) were enrolled in the study. N = 4/12 reported diabetic polyneuropathy. Reported subjective mental workload for all tasks related to iBG-STAR was on average lower than 12 points, corresponding to the verbal code ‘nearly no effort needed’. A “Post Study System Usability Questionnaire”, evaluated the glucometer at an average value of 2.06 (SD = 1.02) on a 7-Likert-scale (1 = ‘I fully agree’ to 7 = ‘I completely disagree’) for usability. These results represent a positive user-experience. Patients with polyneuropathy may experience physical difficulties in completing the tasks, thereby affecting usability. Technologically savvy patients (n = 6) with a positive outlook on diabetes assessed the product as a suitable tool for themselves and would recommend to other diabetic patients. The main barrier to regular use was treating physicians’ inability to retrieve digitally recorded data. This barrier was due to a shortcoming in interoperability of mobile devices and medical information systems. [ABSTRACT FROM AUTHOR]

Introduction: Financial incentives are utilised in healthcare systems in a number of countries to improve quality of care delivered to patients by rewarding practices or practitioners for achieving set targets. Objectives: To systematically review the evidence investigating the impact of financial incentives for implementation of supported self-management on quality of care including: organisational process outcomes, individual behavioural outcomes, and health outcomes for individuals with asthma or diabetes; both conditions with an extensive evidence base for self-management. Methods: We followed Cochrane methodology, using a PICOS search strategy to search eight databases in November 2015 (updated May 2017) including a broad range of implementation methodologies. Studies were weighted by robustness of methodology, number of participants and the quality score. We used narrative synthesis due to heterogeneity of studies. Results: We identified 2,541 articles; 12 met our inclusion criteria. The articles were from the US (n = 7), UK (n = 4) and Canada (n = 1). Measured outcomes were HbA1c tests undertaken and/or the level achieved (n = 10), written action plans for asthma (n = 1) and hospital/emergency department visits (n = 1). Three of the studies were part of a larger incentive scheme including many conditions; one focused on asthma; eight focussed on diabetes. In asthma, the proportion receiving ‘perfect care’ (including providing a written action plan) increased from 4% to 88% in one study, and there were fewer hospitalisations/emergency department visits in another study. Across the diabetes studies, quality-of-care/GP performance scores improved in three, were unchanged in six and deteriorated in one. Conclusions: Results for the impact of financial incentives for the implementation of self-management were mixed. The evidence in diabetes suggests no consistent impact on diabetic control. There was evidence from a single study of improved process and health outcomes in asthma. Further research is needed to confirm these findings and understand the process by which financial incentives may impact (or not) on care. Trial registration: Protocol registration number: CRD42016027411 [ABSTRACT FROM AUTHOR]

Background: Rare diseases (RD) result in a wide variety of clinical presentations, and this creates a significant diagnostic challenge for health care professionals. We hypothesized that there exist a set of consistent and shared phenomena among all individuals affected by (different) RD during the time before diagnosis is established. Objective: We aimed to identify commonalities between different RD and developed a machine learning diagnostic support tool for RD. Methods: 20 interviews with affected individuals with different RD, focusing on the time period before their diagnosis, were performed and qualitatively analyzed. Out of these pre-diagnostic experiences, we distilled key phenomena and created a questionnaire which was then distributed among individuals with the established diagnosis of i.) RD, ii.) other common non-rare diseases (NRO) iii.) common chronic diseases (CD), iv.), or psychosomatic/somatoform disorders (PSY). Finally, four combined single machine learning methods and a fusion algorithm were used to distinguish the different answer patterns of the questionnaires. Results: The questionnaire contained 53 questions. A total sum of 1763 questionnaires (758 RD, 149 CD, 48 PSY, 200 NRO, 34 healthy individuals and 574 not evaluable questionnaires) were collected. Based on 3 independent data sets the 10-fold stratified cross-validation method for the answer-pattern recognition resulted in sensitivity values of 88.9% to detect the answer pattern of a RD, 86.6% for NRO, 87.7% for CD and 84.2% for PSY. Conclusion: Despite the great diversity in presentation and pathogenesis of each RD, patients with RD share surprisingly similar pre-diagnosis experiences. Our questionnaire and data-mining based approach successfully detected unique patterns in groups of individuals affected by a broad range of different rare diseases. Therefore, these results indicate distinct patterns that may be used for diagnostic support in RD. [ABSTRACT FROM AUTHOR]

To enable selection of a safer suspension site to use in face and neck lifting procedures, the spatial relationship between the tympanoparotid fascia and the great auricular nerve should be clarified. In this study, we aimed to elucidate the position of the tympanoparotid fascia and the pathway of the lobular branch of the great auricular nerve traversing the tympanoparotid fascia. Twenty hemifaces from non-preserved bequeathed Korean cadavers (5 males, 7 females; mean age, 77.0 years) were dissected to determine the great auricular nerve distribution close to the tympanoparotid fascia of clinical significance for face and neck lift procedures. We observed the tympanoparotid fascia in all specimens (20 hemifaces). The tympanoparotid fascia was located anteriorly between the tragus and intertragic notch. Regarding the spatial relationship between the tympanoparotid fascia and the great auricular nerve, we found the sensory nerve entering the tympanoparotid fascia in all specimens (100%), and the depth from the skin was approximately 4.5 mm; in 65% of the specimens, the lobular branch was found to run close to the tympanoparotid fascia before going into the earlobe. Provided with relatively safer surface mapping to access the tympanoparotid fascia free of the lobular branch of the great auricular nerve, surgeons may better protect the lobular branch by anchoring the SMAS-platysma flap and thread to the deeper superior and anterior portions of the expected tympanoparotid fascia. [ABSTRACT FROM AUTHOR]

We aim to determine whether a game-theoretic model between an insurer and a healthcare practice yields a predictive equilibrium that incentivizes either player to deviate from a fee-for-service to capitation payment system. Using United States data from various primary care surveys, we find that non-extreme equilibria (i.e., shares of patients, or shares of patient visits, seen under a fee-for-service payment system) can be derived from a Stackelberg game if insurers award a non-linear bonus to practices based on performance. Overall, both insurers and practices can be incentivized to embrace capitation payments somewhat, but potentially at the expense of practice performance. [ABSTRACT FROM AUTHOR]

Objective: Adoption of pre-exposure prophylaxis (PrEP) to prevent HIV infection has been slow. The purpose of this study was to evaluate knowledge, attitudes and referral practices for PrEP among non-prescribing providers, who may play key role. Methods: We performed a cross-sectional survey on PrEP knowledge, attitudes, and referral practices among 66 non-prescribing HIV prevention providers (1st August to 31st December, 2016), in Philadelphia, followed by qualitative interviews with 12 of them (5th April to 10th May, 2017). Results: Participants had a mean age of 36 years, with 62% females. Majority were HIV case managers and rapid testers. For half of the respondents, PrEP eligibility screening was part of rapid HIV testing at their organization, 40% never had PrEP training and only 27% indicated personally screening clients for eligibility. Qualitative data revealed that participants held positive attitudes about PrEP and perceived organizational support, but had concerns about potential negative impacts and barriers to routine HIV screening. Conclusion: Results highlight the importance of training non-prescribing HIV prevention providers about PrEP, addressing their concerns, and incorporating PrEP screening and referral into routine HIV testing. [ABSTRACT FROM AUTHOR]

Various agents including Ca. Piscichlamydia salmonis, Ca. Branchiomonas cysticola, Desmozoon lepeophtherii, Paramoeba perurans and salmon gill poxvirus may be associated with complex gill disease in Atlantic salmon. Co-infections involving two or more of these agents are common and histopathological interpretation of lesions is therefore challenging. In this study, we developed a semi-quantitative scoring system for examination of histopathological gill lesions in sea-farmed Atlantic salmon suffering from gill disease. Following qPCR analysis of gills sampled for Ca. P. salmonis, Ca. B. cysticola, D. lepeophtherii and P. perurans from 22 geographically spread outbreaks, five cases representing different infectious loads and combinations of agents were chosen for histopathological scoring. Twenty-eight histological features were evaluated and potential associations between individual pathological changes and the occurrence of individual agents studied. The inter-observer agreement in interpretation of histological parameters between the three pathologists involved, was calculated to validate robustness of the scoring scheme. Seventeen histological parameters met the criteria for inter-observer agreement analysis and were included in the calculation. The three most frequent findings were identification of subepithelial leukocytes, epithelial cell hyperplasia and mucus cell hyperplasia. While few findings could be specifically related to particular agents, necrosis in hyperplastic lesions, pustules and necrosis of subepithelial cells appeared to be associated with the presence of Ca. B. cysticola. Further, lesion profiles clearly support the previously identified association between P. perurans and pathological changes associated with AGD. Very few pathological changes were observed in the single case in which Ca. P. salmonis was the dominating agent. Some lesions were only very rarely observed e.g. chloride cell necrosis, epithelial cell apoptosis, lamellar deposition of melanin and haemophagocytosis. The scoring scheme developed and applied was robust and sensitive. A less extensive scheme for routine diagnostic use is proposed. [ABSTRACT FROM AUTHOR]

Background and objective: To take full advantage of decision support, machine learning, and patient-level prediction models, it is important that models are not only created, but also deployed in a clinical setting. The KETOS platform demonstrated in this work implements a tool for researchers allowing them to perform statistical analyses and deploy resulting models in a secure environment. Methods: The proposed system uses Docker virtualization to provide researchers with reproducible data analysis and development environments, accessible via Jupyter Notebook, to perform statistical analysis and develop, train and deploy models based on standardized input data. The platform is built in a modular fashion and interfaces with web services using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard to access patient data. In our prototypical implementation we use an OMOP common data model (OMOP-CDM) database. The architecture supports the entire research lifecycle from creating a data analysis environment, retrieving data, and training to final deployment in a hospital setting. Results: We evaluated the platform by establishing and deploying an analysis and end user application for hemoglobin reference intervals within the University Hospital Erlangen. To demonstrate the potential of the system to deploy arbitrary models, we loaded a colorectal cancer dataset into an OMOP database and built machine learning models to predict patient outcomes and made them available via a web service. We demonstrated both the integration with FHIR as well as an example end user application. Finally, we integrated the platform with the open source DataSHIELD architecture to allow for distributed privacy preserving data analysis and training across networks of hospitals. Conclusion: The KETOS platform takes a novel approach to data analysis, training and deploying decision support models in a hospital or healthcare setting. It does so in a secure and privacy-preserving manner, combining the flexibility of Docker virtualization with the advantages of standardized vocabularies, a widely applied database schema (OMOP-CDM), and a standardized way to exchange medical data (FHIR). [ABSTRACT FROM AUTHOR]

Background: Knowledge of antibiotic prescription practices in low- and middle-income countries is limited due to a lack of adequate surveillance systems. Objective: To assess the prescription of antibiotics for the treatment of acute respiratory tract infections (ARIs) in primary care. Method: An explanatory sequential mixed-methods study was conducted in 4 private not-for-profit outreach clinics located in slum areas in Nairobi, Kenya. Claims data of patients who received healthcare between April 1 and December 27, 2016 were collected in real-time through a mobile telephone-based healthcare data and payment exchange platform (branded as M-TIBA). These data were used to calculate the percentage of ARIs for which antibiotics were prescribed. In-depth interviews were conducted among 12 clinicians and 17 patients to explain the quantitative results. Results: A total of 49,098 individuals were registered onto the platform, which allowed them to access healthcare at the study clinics through M-TIBA. For 36,210 clinic visits by 21,913 patients, 45,706 diagnoses and 85,484 medication prescriptions were recorded. ARIs were the most common diagnoses (17,739; 38.8%), and antibiotics were the most frequently prescribed medications (21,870; 25.6%). For 78.5% (95% CI: 77.9%, 79.1%) of ARI diagnoses, antibiotics were prescribed, most commonly amoxicillin (45%; 95% CI: 44.1%, 45.8%). These relatively high levels of prescription were explained by high patient load, clinician and patient perceptions that clinicians should prescribe, lack of access to laboratory tests, offloading near-expiry drugs, absence of policy and surveillance, and the use of treatment guidelines that are not up-to-date. Clinicians in contrast reported to strictly follow the Kenyan treatment guidelines. Conclusion: This study showed successful quantification of antibiotic prescription and the prescribing pattern using real-world data collected through M-TIBA in private not-for-profit clinics in Nairobi. [ABSTRACT FROM AUTHOR]

Background: The second largest Ebola virus disease (EVD) epidemic in history is currently raging in Eastern Democratic Republic of Congo (DRC). Stubbornly persistent EVD transmission has been associated with social resistance, ranging from passive non-compliance to overt acts of aggression toward EVD reponse teams. Methods: We explored community resistance using focus group discussions and assessed the prevalence of resistant views using standardized questionnaires. Results: Despite being generally cooperative and appreciative of the EVD response (led by the government of DRC with support from the international community), focus group participants provided eyewitness accounts of aggressive resistance to control efforts, consistent with recent media reports. Mistrust of EVD response teams was fueled by perceived inadequacies of the response effort (“herd medicine”), suspicion of mercenary motives, and violation of cultural burial mores (“makeshift plastic morgue”). Survey questionnaires found that the majority of respondents had compliant attitudes with respect to EVD control. Nonetheless, 78/630 (12%) respondents believed that EVD was fabricated and did not exist in the area, 482/630 (72%) were dissatisfied with or mistrustful of the EVD response, and 60/630 (9%) sympathized with perpetrators of overt hostility. Furthermore, 102/630 (15%) expressed non-compliant intentions in the case of EVD illness or death in a family member, including hiding from the health authorities, touching the body, or refusing to welcome an official burial team. Denial of the biomedical discourse and dissatisfaction/mistrust of the EVD response were statistically significantly associated with indicators of social resistance. Conclusions: We concluded that social resistance to EVD control efforts was prevalent among focus group and survey participants. Mistrust, with deep political and historical roots in this area besieged by chronic violence and neglected by the outside world, may fuel social resistance. Resistant attitudes may be refractory to short-lived community engagement efforts targeting the epidemic but not the broader humanitarian crisis in Eastern DRC. [ABSTRACT FROM AUTHOR]

Objective: Many jurisdictions lack comprehensive population-based antibiotic use data and rely on third party companies, most commonly IQVIA. Our objective was to validate the accuracy of the IQVIA Xponent antibiotic database in identifying high prescribing physicians compared to the reference standard of a highly accurate population-wide database of outpatient antimicrobial dispensing for patients ≥65 years. Methods: We conducted this study between 1 March 2016 and 28 February 2017 in Ontario, Canada. We evaluated the agreement and correlation between the databases using kappa statistics and Bland-Altman plots. We also assessed performance characteristics for Xponent to accurately identify high prescribing physicians with sensitivity, specificity, positive predictive value (PPV), and negative predictive value. Results: We included 9,272 physicians. The Xponent database has a specificity of 92.4% (95%CI 92.0%-92.8%) and PPV of 77.2% (95%CI 76.0%-78.4%) for correctly identifying the top 25th percentile of physicians by antibiotic volume. In the sensitivity analysis, 94% of the top 25th percentile physicians in Xponent were within the top 40th percentile in the reference database. The mean number of antibiotic prescriptions per physician were similar with a relative difference of -0.4% and 2.7% for female and male patients, respectively. The error was greater in rural areas with a relative difference of -8.4% and -5.6% per physician for female and male patients, respectively. The weighted kappa for quartile agreement was 0.68 (95%CI 0.67–0.69). Conclusion: We validated the IQVIA Xponent antibiotic database to identify high prescribing physicians for patients ≥65 years, and identified some important limitations. Collecting accurate population-based antibiotic use data will remain vital to global antimicrobial stewardship efforts. [ABSTRACT FROM AUTHOR]

Background: In response to a physician shortage in Ethiopia, the number of medical students admitted to public universities was rapidly increased through a “flooding” policy. Objectives: To assess medical student perceptions on the impact of the “flooding” policy on medical education and e-learning initiatives, as well as plans for future emigration. Design: A cross-sectional survey of medical students at AAU was implemented in 2014. Attitude and practice items were assessed using a Likert scale. Logistic regression analysis was performed to identify characteristics associated with an interest in future emigration. Results: 673 (99.6%) of 676 students approached completed the survey, representing 39.5% of all 1705 medical students enrolled at AAU in 2014. Most students felt the “flooding” policy had a negative impact on their medical education and >90% felt there was not adequate infrastructure to support the increased student body. E-learning activities to accommodate increased class size included distribution of electronic tablets, but at the time of the survey only 34.8% of students still had a working tablet and 82.3% reported problems with internet connectivity. Most preclinical students (85.1%) who had attended live-streamed lectures preferred traditional classroom lectures. Half of the students (49.5%) intended to practice medicine in Ethiopia. Independent risk factors for planning to emigrate included age <21 years (aOR = 1.30, 95% CI 1.04, 1.97); having applied to medical school for reasons other than “wanting to be a physician” (aOR = 1.55, 95% CI 1.14, 2.20), and not believing that “flooding” policy would increase the number of physicians working in Ethiopia (aOR = 1.87, 95% CI 1.33, 2.58). Conclusions: The “flooding” policy lead to significant educational challenges that were not fully alleviated by e-learning initiatives. Concomitant increases in resources for infrastructure development and faculty expansion are needed to maintain quality medical education. Additional research is needed on factors that influence medical graduates decision to emigrate. [ABSTRACT FROM AUTHOR]

Objectives: To assess the impact of sources of drug information on antibiotic prescribing patterns (quantity and quality) among primary care physicians. Methods: We conducted a cohort study on primary care physicians who were actively engaged in medical practice in 2010 in a region in north-west Spain (Galicia), fulfilling inclusion criteria (n = 2100). As the independent variable, we took the perceived utility of 6 sources of information on antibiotics, as measured by the validated KAAR-11 questionnaire. As dependent variables, we used: (1) a quality indicator (appropriate quality, defined as any case where 6 of the 12 indicators proposed by the European Surveillance of Antimicrobial Consumption Network [ESAC-Net] were better than the mean values for Spain); and, (2) a quantity indicator (high prescribing), defined as any case where defined daily doses (DDD) per 1 000 inhabitants per day of antibacterials for systemic use were higher than the mean values for Spain. The adjusted odds ratio for a change in the interquartile range (IqOR) for each sources of information on antibiotics was calculated using Generalized Linear Mixed Models. Results: The questionnaire response rate was 68%. Greater perceived utility of pharmaceutical sales representatives increases the risk of having high prescribing (1/IqOR = 2.50 [95%CI: 1.63–3.66]) and reduces the probability of having appropriate quality (1/IqOR = 2.28 [95%CI: 1.77–3.01]). Greater perceived utility of clinical guidelines increases the probability of having appropriate quality (1/IqOR = 1.25 [95%CI: 1.02–1.54]) and reduces the probability of high prescribing (1/IqOR = 1.25 [95%CI: 1.02–1.54]). Conclusions: Sources of information on antibiotics are an important determinant of the quantity and quality of antibiotic prescribing in primary care. Commercial sources of information influence prescribing negatively, and clinical guidelines are associated with better indicators. [ABSTRACT FROM AUTHOR]

Background: Empathy and compassion are vital components of health care quality; however, physicians frequently miss opportunities for empathy and compassion in patient care. Despite evidence that empathy and compassion training can be effective, the specific behaviors that should be taught remain unclear. We synthesized the biomedical literature on empathy and compassion training in medical education to find the specific curricula components (skills and behaviors) demonstrated to be effective. Methods: We searched CENTRAL, MEDLINE, EMBASE, and CINAHL using a previously published comprehensive search strategy. We screened reference lists of the articles meeting inclusion criteria to identify additional studies for potential inclusion. Study inclusion criteria were: (1) intervention arm in which subjects underwent an educational curriculum aimed at enhancing empathy and/or compassion; (2) clearly defined control arm in which subjects did not receive the curriculum; (3) curriculum was tested on physicians (or physicians-in-training); and (4) outcome measure assessing the effect of the curriculum on physician empathy and/or compassion. We performed a qualitative analysis to collate and tabulate effects of tested curricula according to recommended methodology from the Cochrane Handbook. We used the Cochrane Collaboration’s tool for assessing risk of bias. Results: Fifty-two studies (total n = 5,316) met inclusion criteria. Most (75%) studies found that the tested curricula improved physician empathy and/or compassion on at least one outcome measure. We identified the following key behaviors to be effective: (1) sitting (versus standing) during the interview; (2) detecting patients’ non-verbal cues of emotion; (3) recognizing and responding to opportunities for compassion; (4) non-verbal communication of caring (e.g. eye contact); and (5) verbal statements of acknowledgement, validation, and support. These behaviors were found to improve patient perception of physician empathy and/or compassion. Conclusion: Evidence suggests that training can enhance physician empathy and compassion. Training curricula should incorporate the specific behaviors identified in this report. [ABSTRACT FROM AUTHOR]

Background: Auscultation is one of the first examinations that a patient is subjected to in a GP’s office, especially in relation to diseases of the respiratory system. However it is a highly subjective process and depends on the physician’s ability to interpret the sounds as determined by his/her psychoacoustical characteristics. Here, we present a cross-sectional assessment of the skills of physicians of different specializations and medical students in the classification of respiratory sounds in children. Methods and findings: 185 participants representing different medical specializations took part in the experiment. The experiment comprised 24 respiratory system auscultation sounds. The participants were tasked with listening to, and matching the sounds with provided descriptions of specific sound classes. The results revealed difficulties in both the recognition and description of respiratory sounds. The pulmonologist group was found to perform significantly better than other groups in terms of number of correct answers. We also found that performance significantly improved when similar sound classes were grouped together into wider, more general classes. Conclusions: These results confirm that ambiguous identification and interpretation of sounds in auscultation is a generic issue which should not be neglected as it can potentially lead to inaccurate diagnosis and mistreatment. Our results lend further support to the already widespread acknowledgment of the need to standardize the nomenclature of auscultation sounds (according to European Respiratory Society, International Lung Sounds Association and American Thoracic Society). In particular, our findings point towards important educational challenges in both theory (nomenclature) and practice (training). [ABSTRACT FROM AUTHOR]

Introduction: End-stage renal disease (ESRD) is increasing globally, and renal transplantation (RT) is the preferred renal replacement therapy to treat ESRD. Internationally, there are only a few countries with RT rates above 50 per million population (pmp), while most of the countries have RT rates between 30–40 pmp. The low- and middle-income countries (LMIC) makes up the majority for the RT rates below 20 pmp in which Malaysia belongs to despite its increasing ESRD rates. There is a need to explore the barriers to access RT with targeted solutions to improve the RT rates and service in LMIC. Thus, a qualitative study was undertaken in Malaysia to address this issue. Method: A qualitative methodological approach was performed between March-May 2018. Semi-structured interviews were used to explore current RT policy and service availability. Key-informants were identified from a detailed stakeholder analysis of RT system in Malaysia. Interviews were digitally audio-recorded, transcribed verbatim, coded with ATLAS.ti software and underwent thematic analysis thoroughly. Results: Eight key-informants participated in the study. Barriers and related solutions were classified using the socio-ecological model (SEM). As reported, the barriers and solutions of RT in Malaysia are the results of a complex interplay of personal, cultural, and environmental factors. Key barriers are linked to public’s attitude and perception towards RT and the unaccommodating practices in the healthcare fraternity for RT. Key-informants provided a systematic solution that shed light on how RT could be improved at each SEM level via effective communication, education and inter-agency collaboration. Conclusion: The SEM provided a framework to foster a better understanding of current practice, barriers, and solutions to RT in Malaysia. This study is the first to explore the barriers and related solutions to RT comprehensively as a whole. Implications of these findings could prompt a policy change for a better RT service delivery model not just for Malaysia but also for other LMIC. Further stakeholder engagement and evaluation of the systems are required to provide insight into best practices that will help to improve the RT rates and service in Malaysia. [ABSTRACT FROM AUTHOR]

Background: The German Committee on Vaccination recommends pneumococcal vaccination for infants, seniors 60+ years and patients at risk with defined underlying diseases. Aim of this study was to assess the pneumococcal vaccination rate (pnc-VR) in patients with certain incident inherited or acquired immunodeficiency or immunosuppression and to understand who vaccinates these patients who are particularly at high risk to develop a pneumococcal infection. Methods: We conducted a cohort study in patients aged 2 years or older, with a first episode of a “high-risk” condition between January 2013 and December 2014 based on a representative sample of German claims data. Pnc-VR was calculated as the proportion of patients receiving any pneumococcal vaccine within two years after first episode of “high-risk” condition. Further analyses cover pnc-VR stratified by high risk conditions and region, time to vaccination, and physician specialty administering the pneumococcal vaccination. Results: The study population comprised 204,088 incident “high-risk” patients (56% female). The overall pnc-VR within two years was 4.4% (95%-confidence interval: 4.3%-4.5%). Within specific high-risk conditions, we found the highest vaccination rate of 11.5% (10.1%-13.0%) among patients starting immunosuppressants with underlying rheumatoid arthritis followed by 9.9% (7.8%-12.4%) in HIV patients. Stratification by region revealed a slightly higher vaccination rate in Eastern (6.5%: 6.0%-6.9%) compared to Western Germany (4.2%: 4.1–4.3%). Median time to vaccination within the first two years in vaccinated patients was 332.5 days (Q1 142 days, Q3 528 days). The majority of patients (92.6%) got vaccinated by a general practitioner. Conclusion: Although these vulnerable patients need protection most, our study suggests that the overall pnc-VR after a first episode of a high-risk condition for pneumococcal disease is very low and vaccination is far too late. To prevent pneumococcal disease in patients at high risk, further efforts are needed to increase awareness and improve the timeliness of pneumococcal vaccination. [ABSTRACT FROM AUTHOR]

Background: Patient feedback after contact with a hospital is regarded as an important source of information for the improvement of local healthcare services. Routine patient surveys are in widespread use to obtain such feedback. While general principles for the composition of this kind of surveys have been described in the literature, it is unknown which method of contact and topics of feedback are important to patients in postcontact healthcare surveys. Material and methods: We invited 2931 consecutive patients who had in- or outpatient contact with the Department of Orthopaedics and Traumatology at the University Hospital Basel to an anonymous survey. They were asked whether they were generally in favor of feedback surveys. They also had the opportunity to state their preferred form of contact (text message, app, email, online or letter) and provide up to three topics that they regarded as specifically important in patient surveys. Results: A total of 745 patients participated in the survey (25.4%), of these 61.9% expressed the preference to be surveyed, and 69.1% selected `letter’ as one of the preferred forms of contact. Favoring only `letter’ contact increased substantially with age. Overall 54.6% of patients stated at least one topic that they wished to give feedback on. The most frequent topics were related to treatment and rather general aspects regarding staff and overall impression. The wish to include suggestions for improvements was rarely mentioned as specific topic. Conclusions: The majority of patients seem to be rather indifferent to the existence and content of patient surveys. They mention a wide range of topics from general to specific ones, but do not express interest in the opportunity to suggest changes. There is a need to effectively engage patients in healthcare planning using new approaches to obtain valuable feedback on patients’ hospital stay and contact experiences. These new approaches should ideally be more informative and cost-effective than the current practice. [ABSTRACT FROM AUTHOR]

With the advent of continuous antiretroviral therapy, HIV has become a complex chronic, rather than acute, condition. The Chronic Care Model (CCM) provides an integrated approach to the delivery of care for people with chronic conditions that could therefore be applied to the delivery of care for people living with HIV. Our objective was to assess the alignment of HIV care settings with the CCM. We conducted a mixed methods study to explore structures, organization and care processes of Canadian HIV care settings. The quantitative results of phase one are published elsewhere. For phase two, we conducted semi-structured interviews with key informants from 12 HIV care settings across Canada. Irrespective of composition of the care setting or its location, HIV care in Canada is well aligned with several components of the CCM, most prominently in the areas of linkage to community resources and delivery system design with inter-professional team-based care. We propose the need for improvements in the availability of electronic clinical information systems and self-management support services to support better care delivery and health outcomes among people living with HIV in Canada. [ABSTRACT FROM AUTHOR]

Objectives: To estimate tobacco use prevalence in healthcare workers (HCW) by country income level, occupation and sex, and compare the estimates with the prevalence in the general population. Methods: We systematically searched five databases; Medline, EMBASE, CINHAL Plus, CAB Abstracts, and LILACS for original studies published between 2000 and March 2016 without language restriction. All primary studies that reported tobacco use in any category of HCW were included. Study extraction and quality assessment were conducted independently by three reviewers, using a standardised data extraction and quality appraisal form. We performed random effect meta-analyses to obtain prevalence estimates by World Bank (WB) country income level, sex, and occupation. Data on prevalence of tobacco use in the general population were obtained from the World Health Organisation (WHO) Global Health Observatory website. The review protocol registration number on PROSPERO is CRD42016041231. Results: 229 studies met our inclusion criteria, representing 457,415 HCW and 63 countries: 29 high-income countries (HIC), 21 upper-middle-income countries (UMIC), and 13 lower-middle-and-low-income countries (LMLIC). The overall pooled prevalence of tobacco use in HCW was 21%, 31% in males and 17% in females. Highest estimates were in male doctors in UMIC and LMLIC, 35% and 45%, and female nurses in HIC and UMIC, 21% and 25%. Heterogeneity was high (I2 > 90%). Country level comparison suggest that in HIC male HCW tend to have lower prevalence compared with males in the general population while in females the estimates were similar. Male and female HCW in UMIC and LMLIC tend to have similar or higher prevalence rates relative to their counterparts in the general population. Conclusions: HCW continue to use tobacco at high rates. Tackling HCW tobacco use requires urgent action as they are at the front line for tackling tobacco use in their patients. [ABSTRACT FROM AUTHOR]

In this article, patient activity in 8 audio recorded specialist consultations on fetal cardiology is investigated in order to explore how, why and when patients tend to participate in encounters in which the doctor dominates the interaction. The overall question is: How can the participation of patients in the consultations be connected to the development of higher levels of health literacy, i.e. to interactive literacy and to critical literacy? Patient participation is here understood as interactive action and is analyzed in terms of different interactive moves, which are related to different recurring topics. Despite the highly standardized format of the consultations, there is a large variation between the patients’ participation: between 0.7 and 2.8 moves per minute. The patients participate most during the topics ‘Prevalence’ and ‘Consultations’ and least during the topic ‘The normal heart’. Although most of the patients' moves are responses to what the doctor says, they remarkably often pose questions and use so called rejoinders. By posing questions, they take control of the information flow and sometimes even change the topics. By using rejoinders, they analyze the problems involved in the discussion e.g. by asking for clarifications or confirmation. Patients with a low over-all participation rate also use fewer moves that indicate higher literacy levels. The qualitative analysis problematizes the idea of a simple scale from basic literacy to critical literacy. Moves that indicate basic literacy skills are interactively important for the learning activity, led by the doctor. However, patients who mainly support the doctor’s initiatives don’t take the opportunity to influence the flow of information in ways that might favor their health literacy development. [ABSTRACT FROM AUTHOR]

Objectives: To analyse the internal consistency of an adaption of the methotrexate intolerance severity score (MISS); and to describe and compare the level of methotrexate intolerance evaluated by the MISS in Danish children with juvenile idiopathic arthritis (JIA) or acute lymphoblastic leukaemia (ALL), treated with low-dose methotrexate (MTX). Methods: Cross-sectional study of children diagnosed with JIA or ALL, treated with low-dose MTX, aged 9 years or above, and cognitively intact. The patient’s parents completed the MISS. MTX intolerance was defined as a total MISS score above 6. Results: We enrolled 120 children with JIA and 23 children with ALL. The MISS had a good internal consistency in the JIA group. The median MISS score was higher in the JIA group than in the ALL group (JIA: 8; ALL: 1; p<0.0001); and the JIA group had a larger proportion of MTX intolerant children than the ALL group (JIA: 73/120; ALL: 4/23; p<0.001). Within both the JIA group and the ALL group, the MISS total score was not significantly correlated with age, MTX dose or the duration of low-dose MTX treatment. Conclusion: In the JIA group the level of MTX intolerance was higher and more attributed to anticipatory, associative and behavioural symptoms than in the ALL group. The MISS may help to uncover whether MTX intolerance is present and which aspects are affected in the individual patient, thus guiding intervention. The MISS may also be applicable within leukaemia care. [ABSTRACT FROM AUTHOR]

Background: English editing services are effective for improving manuscript quality as well as providing learning opportunities for non-native English-speaking authors. Herein, we describe the effects of a combined system of in-house and external editing services for handling large volumes of editing requests and providing personalized editing service in academic hospitals. Methods: We established the Scientific Publications Team (SPT), an in-house editing team in Asan Medical Center in Seoul, Korea. The SPT is composed of two professional editors who manage editing requests sent to external companies while also providing one-on-one in-house editing services. We gathered author satisfaction data from 936 surveys between July 2017 and December 2018 and analyzed the number of editing requests and research publications by segmented regression analysis of interrupted time series data. Results: The SPT processed 3931 editing requests in 2017–2018, which was a marked increase compared with prior to its establishment (P = 0.0097). The authors were generally satisfied with the quality of editing services from both in-house and external editors. Upon conducting regular quality control, overall author satisfaction with one external company gradually increased over the course of one year (P for trend = 0.086). Author satisfaction survey results revealed that overall satisfaction of editing service was most strongly correlated with how well the edits conformed to the authors’ intentions (R = 0.796), and was only weakly correlated with quick turnaround time (R = 0.355). We also observed a significant increase in the trend of the number of research publications (P = 0.0007) at one year after the establishment of the SPT. Conclusion: Providing a combination of in-house and external editing services resulted in high author satisfaction and subsequent hospital-wide increases in manuscript writing and publication. Our model system may be adapted in academic hospitals to better address the editing needs of non-native English-speaking researchers. [ABSTRACT FROM AUTHOR]

We investigated what factors may foster or hinder physicians’ cancer screening risk literacy–specifically the ability to understand evidence regarding screening effectiveness and make evidence-based recommendations to patients. In an experiment, physicians in training (interns and residents) read statistical information about outcomes from screening for cancer, and had to decide whether to recommend it to a patient. We manipulated the effectiveness of the screening (effective vs. ineffective at reducing mortality) and the demand of the patient to get screened (demand vs. no demand). We assessed participants’ comprehension of the presented evidence and recommendation to the patient, as well as a-priori screening beliefs (e.g., that screening is always a good choice), numeracy, science literacy, knowledge of screening statistics, statistical education, and demographics. Stronger positive a-priori screening beliefs, lower knowledge of screening statistics, and lower numeracy were related to worse comprehension of the evidence. Physicians recommended against the ineffective screening but only if they showed good comprehension of the evidence. Physicians’ recommendations were further based on the perceived benefits from screening but not on perceived harms, nor the patient’s demands. The current study demonstrates that comprehension of cancer screening statistics and the ability to infer the potential benefits for patients are essential for evidence-based recommendations. However, strong beliefs in favor of screening fostered by promotion campaigns may influence how physicians evaluate evidence about specific screenings. Fostering physician numeracy skills could help counteract such biases and provide evidence-based recommendations to patients. [ABSTRACT FROM AUTHOR]

Background: Malaysia is widely credited to have achieved universal health coverage for citizens. However, the accessibility of healthcare services to migrant workers is questionable. Recently, medical fees for foreigners at public facilities were substantially increased. Mandatory health insurance only covers public hospital admissions and excludes undocumented migrants. This study explores barriers to healthcare access faced by documented and undocumented migrant workers in Malaysia. Methods: We use qualitative data from 17 in-depth interviews conducted with key informants from civil society organisations, trade unions, academia, medical professionals, as well as migrant workers and their representatives. We interviewed doctors working in public hospitals and private clinics frequented by migrants. Data were analysed using thematic analysis. Results: We found that healthcare services in Malaysia are often inaccessible to migrant workers. Complex access barriers were identified, many beyond the control of the health sector. Major themes include affordability and financial constraints, the need for legal documents like valid passports and work permits, language barriers, discrimination and xenophobia, physical inaccessibility and employer-related barriers. Our study suggests that government mandated insurance for migrant workers is insufficient in view of the recent increase in medical fees. The perceived close working relationship between the ministries of health and immigration effectively excludes undocumented migrants from access to public healthcare facilities. Language barriers may affect the quality of care received by migrant workers, by inadvertently resulting in medical errors, while preventing them from giving truly informed consent. Conclusions: We propose instituting migrant-friendly health services at public facilities. We also suggest implementing a comprehensive health insurance to enable healthcare access and financial risk protection for all migrant workers. Non-health sector solutions include the formation of a multi-stakeholder migration management body towards a comprehensive national policy on labour migration which includes health. [ABSTRACT FROM AUTHOR]

Background: Late HIV diagnosis remains one of the challenges in combating the epidemic. Primary care providers play an important role in screening for HIV infection. Our study aims to evaluate the relationship between knowledge and barriers to HIV testing and screening outcomes. The impact of an education program for primary care providers, towards improving HIV testing and late diagnosis rates, is also assessed. Methods: A self-administered questionnaire that was developed within the framework of the European project OptTEST was used to examine HIV knowledge and barriers to HIV testing scores before and after being involved in an HIV education program. A quasi-experimental design with pre- and post-intervention measures was performed to investigate its impact. We performed multivariable logistic regression analysis to assess the relationship between variables for the HIV testing offer. Results: A total of 20 primary care centers and 454 primary care staff were included. Baseline OptTEST results showed that more knowledgeable staff offered an HIV test more frequently (OR 1.07; CI 95% 1.01–1.13; p = 0.027) and had lower barrier scores (OR 0.89; CI 95% 0.77–0.95; p = 0.005). Nurses had lower scores in knowledge-related items (OR 0.28; CI 95% 0.17–0.46; p<0.001), but higher scores in barrier-related items than physicians (OR 3.28; CI 95% 2.01–5.46; p<0.001). Specific centers with more knowledgeable staff members had a significant association with a greater level of new HIV diagnosis rates (OR 1.61; CI 95% 1.04–2.49; p = 0.032). After the intervention, we found that 12 out of 14 individual questions showed improved scores. In the 6 months after the training program, we similarly found a higher HIV testing rate (OR 1.19; CI 1.02–1.42; p = 0.036). Conclusions: This study highlights the association between knowledge and barriers to HIV testing, including HIV testing rates. It shows that it is possible to modify knowledge and reduce perceived barriers through educational programs, subsequently improving HIV screening outcomes. [ABSTRACT FROM AUTHOR]

Objectives: In August 2016, new prescription guidelines were introduced in Hungary to reduce the co-payments for antibiotics among children aged 0-4. This study aims at analysing the implementation of this policy and its effect on the use of antibiotics. Methods: The analysis is based on administrative prescription records between January 2010—February 2018, covering the entire population of Hungary aged 0-7. Spatial autocorrelation indices are calculated and settlement level regression models are estimated to analyse the spatial variation in the application of the new guidelines. The effect of reduced co-payments on antibiotic use is estimated with a difference-in-differences type model: the treatment and control groups are children aged 0-4 and 5-7, respectively; the treatment and control periods are August 2016—February 2018 and January 2010—July 2016, respectively. Results: The new prescription guidelines are more widely applied in settlements with higher per capita income and lower unemployment rate. Adherence to the new guidelines is spatially clustered. A 10–15% decrease in the out-of-pocket costs of antibiotics is estimated to increase the consumption of antibiotics by about 5% (95% CI: 2.63%–7.55%). Conclusions: In the absence of clear enforcement mechanisms, the adoption of the new prescription guidelines is selective, contradicting the aims of the policy of making antibiotics affordable for the poor children. The results point to the possible role of physicians’ information networks in the application of prescription guidelines. The use of antibiotics among children aged 0-4 is responsive to the price subsidy of antibiotics. [ABSTRACT FROM AUTHOR]

Purpose: Software solutions such as mRay allow review of radiological images on handheld devices. We investigated if the quality is adequate for evaluating CT scans of patients with suspected stroke. Methods: 50 patients (Median age 80 years, 28 females) were retrospectively selected. All patients had undergone multidetector CT angiography ± perfusion and presented with clinical signs of acute stroke. Out of the 50 patients, 19 had large-vessel occlusion (LVO), 5 had intracranial hemorrhage (ICH), 10 had severe intracranial stenosis of at least one major vessel, 2 had intracranial tumor and 15 had no or an unrelated pathology. One experienced neuroradiologist and one resident scored the anonymized pictures separately on two handheld devices (iPhone 7 Plus, MED-TAB) equipped with mRay Software and on a PACS workstation. Each case was reviewed on all three devices with a break in-between of at least 12 weeks. The scoring on the traditional workstation was compared with the two handheld devices, regarding detection of early ischemic signs, LVOs, CBV/CBF-mismatch, ICHs and severe stenosis. Both raters were asked to rate the diagnostic quality of both handheld devices regarding detection of LVOs, ICHs, early ischemic signs and overall. Results: All LVOs, intracranial tumors and ICHs were detected on both mobile devices. There was no significant difference in the rating of CCT and CBF ASPECTS between all three devices, while the sensitivity for detecting a CBF/CBV-mismatch was above 80% on both devices. Both raters assessed the diagnostic quality to be sufficient on both mobile devices to base treatment decisions on. Conclusion: Software solutions such as mRay for handheld devices provide adequate diagnostic quality for the review of CT scans of suspected stroke patients. [ABSTRACT FROM AUTHOR]