Research Articles (Emergency Medicine)
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- ItemAvailability, functionality and access of blood pressure machines at the points of care in public primary care facilities in Tororo district, Uganda(AOSIS, 2021-01) Besigye, Innocent K.; Okuuny, Vicent; Armstrong-Hough, Mari; Katahoire, Anne R.; Sewankambo, Nelson K.; Mash, Bob; Katamba, AchillesBackground: Early diagnosis of hypertension prevents a significant number of complications and premature deaths. In resource-variable settings, diagnosis may be limited by inadequate access to blood pressure (BP) machines. We sought to understand the availability, functionality and access of BP machines at the points of care within primary care facilities in Tororo district, Uganda. Methods: This was an explanatory sequential mixed-methods study combining a structured facility checklist and key informant interviews with primary care providers. The checklist was used to collect data on availability and functionality of BP machines within their organisational arrangements. Key informant interviews explored health providers’ access to BP machines. Results: The majority of health facilities reported at least one working BP machine. However, Health providers described limited access to machines because they are not located at each point of care. Health providers reported borrowing amongst themselves within their respective units or from other units within the facility. Some health providers purchase and bring their own BP machines to the health facilities or attempted to restore the functionality of broken ones. They are motivated to search the clinic for BP machines for some patients but not others based on their perception of the patient’s risk for hypertension. Conclusion: Access to BP machines at the point of care was limited. This makes hypertension screening selective based on health providers’ perception of the patients’ risk for hypertension. Training in proper BP machine use and regular maintenance will minimise frequent breakdowns.
- ItemRemdesivir for severe covid-19: a clinical practice guideline(2020-11) Rochwerg, Bram; Agarwal, Arnav; Zeng, Linan; Leo, Yee-Sin; Appiah, John Adabie; Agoritsas, Thomas; Bartoszko, Jessica; Brignardello-Petersen, Romina; Ergan, Begum; Ge, Long; Geduld, Heike; Gershengorn, Hayley B.; Manai, Hela; Huang, Minhua; Lamontagne, François; Kanda, Seema; Kawano-Dourado, Leticia; Kurian, Linda; Kwizera, Arthur; Murthy, Srinivas; Qadir, Nida; Siemieniuk, Reed; Silvestre, Maria Asuncion; Vandvik, Per Olav; Ye, Zhikang; Zeraatkar, Dena; Guyatt, GordonClinical question What is the role of remdesivir in the treatment of severe covid-19? This guideline was triggered by the ACTT-1 trial published in the New England Journal of Medicine on 22 May 2020. Current practice Remdesivir has received worldwide attention as a potentially effective treatment for severe covid-19. After rapid market approval in the US, remdesivir is already being used in clinical practice. Recommendations The guideline panel makes a weak recommendation for the use of remdesivir in severe covid-19 while recommending continuation of active enrolment of patients into ongoing randomised controlled trials examining remdesivir. How this guideline was created An international panel of patients, clinicians, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. The panel considered an individual patient perspective and allowed contextual factors (such as resources) to be taken into account for countries and healthcare systems. The evidence The linked systematic review (published 31 Jul 2020) identified two randomised trials with 1300 participants, showing low certainty evidence that remdesivir may be effective in reducing time to clinical improvement and may decrease mortality in patients with severe covid-19. Remdesivir probably has no important effect on need for invasive mechanical ventilation. Remdesivir may have little or no effect on hospital length of stay. Understanding the recommendation Most patients with severe covid-19 would likely choose treatment with remdesivir given the potential reduction in time to clinical improvement. However, given the low certainty evidence for critical outcomes and the fact that different perspectives, values, and preferences may alter decisions regarding remdesivir, the panel issued a weak recommendation with strong support for continued recruitment in randomised trials.
- ItemA living WHO guideline on drugs for covid-19(2022-09) Agarwal, Arnav; Rochwerg, Bram; Lamontagne, François; Siemieniuk, Reed AC; Agoritsas, Thomas; Askie, Lisa; Lytvyn, Lyubov; Leo, Yee-Sin; Macdonald, Helen; Zeng, Linan; Amin, Wagdy; Barragan, Fabian A Jaimes; Bausch, Frederique J.; Burhan, Erlina; Calfee, Carolyn S.; Cecconi, Maurizio; Chanda, Duncan; Dat, Vu Quoc; De Sutter, An; Du, Bin; Freedman, Stephen; Geduld, Heike; Gee, Patrick; Gotte, Matthias; Harley, Nerina; Hashmi, Madiha; Hunt, Beverley; Jehan, Fyezah; Kabra, Sushil K.; Kanda, Seema; Kim, Yae-Jean; Kissoon, Niranjan; Krishna, Sanjeev; Kuppalli, Krutika; Kwizera, Arthur; Castro-Rial, Marta Lado; Lisboa, Thiago; Lodha, Rakesh; Mahaka, Imelda; Manai, Hela; Mino, Greta; Nsutebu, Emmanuel; Preller, Jacobus; Pshenichnaya, Natalia; Qadir, Nida; Relan, Pryanka; Sabzwari, Saniya; Sarin, Rohit; Shankar-Hari, Manu; Sharland, Michael; Shen, Yinzhong; Ranganathan, Shalini S.; Souza, Joao P.; Stegemann, Miriam; Swanstrom, Ronald; Ugarte, Sebastian; Uyeki, Tim; Venkatapuram, Sridhar; Vuyiseka, Dubula; Wijewickrama, Ananda; Tran, Lien; Zeraatkar, Dena; Bartoszko, Jessica J.; Ge, Long; Brignardello-Petersen, Romina; Owen, Andrew; Guyatt, Gordon; Diaz, Janet; Kawano-Dourado, Leticia; Jacobs, Michael; Vandvik, Per OlavThis living guideline by Arnav Agarwal and colleagues (BMJ 2020;370:m3379, doi:10.1136/bmj.m3379) was last updated on 22 April 2022, but the infographic contained two dosing errors: the dose of ritonavir with renal failure should have read 100 mg, not 50 mg; and the suggested regimen for remdesivir should have been 3 days, not 5-10 days. The infographic has now been corrected.
- ItemFostering global primary care research : a capacity-building approach(BMJ Publishing, 2020-07) Ponka, David; Coffman, Megan; Fraser-Barclay, Krystle Elizabeth; Fortier, Richard D. W.; Howe, Amanda; Kidd, Michael; Lennon, Robert P.; Madaki, Jeremiah K. A.; Mash, Bob; Sidik, Sherina Mohd; Van Weel, Chris; Zawaly, Kristina; Goodyear-Smith, FelicityThe Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research-a core element of high-quality PHC-in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the micro (practice), meso (institutional) and macro (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and 'brain drain' may reduce available research support; however, we provide recommendations on how to deal with these tensions.
- ItemA multi-parameter diagnostic clinical decision tree for the rapid diagnosis of tuberculosis in HIV-positive patients presenting to an emergency centre(Wellcome Trust, 2020-04) Van Hoving, Daniël Jacobus; Meintjes, Graeme; Maartens, Gary; Kengne, Andre PascalBackground: Early diagnosis is essential to reduce the morbidity and mortality of HIV-associated tuberculosis. We developed a multi-parameter clinical decision tree to facilitate rapid diagnosis of tuberculosis using point-of-care diagnostic tests in HIV-positive patients presenting to an emergency centre. Methods: A cross-sectional study was performed in a district hospital emergency centre in a high-HIV-prevalence community in South Africa. Consecutive HIV-positive adults with ≥1 WHO tuberculosis symptoms were enrolled over a 16-month period. Point-of-care ultrasound (PoCUS) and urine lateral flow lipoarabinomannan (LF-LAM) assay were done according to standardized protocols. Participants also received a chest X-ray. Reference standard was the detection of Mycobacterium tuberculosis using Xpert MTB/RIF or culture. Logistic regressions models were used to investigate the independent association between prevalent microbiologically confirmed tuberculosis and clinical and biological variables of interest. A decision tree model to predict tuberculosis was developed using the classification and regression tree algorithm. Results: There were 414 participants enrolled: 171 male, median age 36 years, median CD4 cell count 86 cells/mm3. Tuberculosis prevalence was 42% (n=172). Significant variables used to build the classification tree included ≥2 WHO symptoms, antiretroviral therapy use, LF-LAM, PoCUS independent features (pericardial effusion, ascites, intra-abdominal lymphadenopathy) and chest X-ray. LF-LAM was positioned after WHO symptoms (75% true positive rate, representing 17% of study population). Chest X-ray should be performed next if LF-LAM is negative. The presence of ≤1 PoCUS independent feature in those with ‘possible or unlikely tuberculosis’ on chest x-ray represented 47% of non-tuberculosis participants (true negative rate 83%). In a prediction tree which only included true point-of-care tests, a negative LF-LAM and the presence of ≤2 independent PoCUS features had a 71% true negative rate (representing 53% of sample). Conclusions: LF-LAM should be performed in all adults with suspected HIV-associated tuberculosis (regardless of CD4 cell count) presenting to the emergency centre.