Kovarik, Carrie
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Publication Use of Mobile Telemedicine for Cervical Cancer Screening(2011-06-01) Gormley, Rachel H; Ratcliffe, Sarah; Quinley, Kelly E; Steiner, Ann; Ramogola-Masire, Doreen; Kovarik, Carrie; Shih, Ting; Szep, ZsofiaVisual inspection of the cervix with application of 4% acetic acid (VIA) is an inexpensive alternative to cytology-based screening in areas where resources are limited, such as in many developing countries. We have examined the diagnostic agreement between off-site (remote) expert diagnosis using photographs of the cervix (photographic inspection with acetic acid, PIA) and in-person VIA. The images for remote evaluation were taken with a mobile phone and transmitted by MMS. The study population consisted of 95 HIV-positive women in Gaborone, Botswana. An expert gynaecologist made a definitive positive or negative reading on the PIA results of 64 out of the 95 women whose PIA images were also read by the nurse midwives. The remaining 31 PIA images were deemed insufficient in quality for a reading by the expert gynaecologist. The positive nurse PIA readings were concordant with the positive expert PIA readings in 82% of cases, and the negative PIA readings between the two groups were fully concordant in 89% of cases. These results suggest that mobile telemedicine may be useful to improve access of women in remote areas to cervical cancer screening utilizing the VIA `see-andtreat' method.Publication Use of Mobile Learning by Resident Physicians in Botswana(2012-02-02) Chang, Aileen Y; Ghosh, Sankalpo; Littman-Quinn, Ryan; Anolik, Rachel B; Kyer, Andrea; Mazhani, Loeto; Seymour, Anne K; Kovarik, Carrie LWith the growth of mobile health in recent years, learning through the use of mobile devices (mobile learning [mLearning]) has gained recognition as a potential method for increasing healthcare providers' access to medical information and resources in resource-limited settings. In partnership with the University of Botswana School of Medicine (SOM), we have been exploring the role of smartphone-based mLearning with resident (physicians in specialty training) education. The SOM, which admitted its first class of medical students and residents in 2009, is committed to providing high-level on-site educational resources for resident physicians, even when practicing in remote locations. Seven residents were trained to use an Android-based myTouch 3G smartphone equipped with data-enabled subscriber identity module (SIM) cards and built-in camera. Phones contained locally loaded point-of-care and drug information applications, a telemedicine application that allows for the submission of cases to local mentors, and e-mail/Web access. Surveys were administered at 4 weeks and 8 weeks following distribution of phones. We found that smartphones loaded with point-of-care tools are effectively utilized by resident physicians in resource-limited settings, both for accessing point-of-care medical information at the bedside and engaging in self-directed learning at home.Publication Dermatology in Botswana: The American Academy of Dermatology’s Resident International Grant(2011-01-01) Introcaso, Camille E; Kovarik, CarriePublication Establishing Telepathology in Africa: Lessons From Botswana(2011-05-01) Fischer, Max K; Kayembe, Mukendi K; Introcaso, Camille E; Scheer, Arnold J; Kovarik, Carrie L; Binder, Scott WFew reports of telepathology in Africa exist in the medical literature. With the strong need for improvement in health care infrastructure and personnel training in many African nations, telepathology provides a rapid and versatile tool to improve clinical care and foster educational and research opportunities. We describe the challenges faced in establishing robotic telepathology (RT) services at a government referral center in Botswana and reflect on conditions under which such initiatives may be most likely to succeed in sub-Saharan Africa and other parts of the developing world.Publication Evaluation of txt2MEDLINE and Development of Short Messaging Service–Optimized, Clinical Practice Guidelines in Botswana(2012-02-02) Armstrong, Kathleen; Liu, Fang; Seymour, Anne; Mazhani, Loeto; Littman-Quinn, Ryan; Fontelo, Paul; Kovarik, CarrieObjective: Currently clinicians in sub-Saharan Africa have limited access to the Internet, whereas mobile phone access and use is extensive. The University of Pennsylvania in collaboration with the National Library of Medicine launched txt2MEDLINE, a short messaging service (SMS) query of PubMed/MEDLINE, and SMS-optimized clinical guidelines in Botswana. The objective of this project was to establish and evaluate the utility of these tools for clinicians in Botswana. Materials and Methods: A local server was established at the University of Botswana that allowed clinicians to send queries and receive results via local (in-country) SMS text messaging on any type of cellular phone. The queries sent via txt2MEDLINE were returned as abbreviated “the bottom line” summaries of abstracts. The 2007 Botswana Treatment Guide was converted into a format that can be queried by SMS. Various types of healthcare workers were recruited to use and evaluate these services. Results: Seventy-six healthcare workers attended training sessions for these services. In the preusage survey, most said they would use the services daily or weekly. During a 4-week trial period, use of these services dropped off dramatically. Participant feedback was collected and indicated that improvements in ease of use would increase the usage. Conclusions: This pilot project enables clinicians to query and receive PubMed abstract summaries and country-specific clinical guidelines using mobile phones. Feedback offers insight on how to improve this technology so that it can be adopted for long-term use. With further adjustments, these resources may provide an effective working model for other countries where limited Internet access impedes upon patient care.Publication HIV-Positive Patients in Botswana State That Mobile Teledermatology Is an Acceptable Method for Receiving Dermatology Care(2011-09-01) Azfar, Rahat S; Bilker, Warren B.; Weinberg, Jennifer L; Gelfand, Joel M; Cavric, Gordana; Kovarik, Carrie; Lee-Keltner, Ivy APublication Mobile Teledermatology in Sub-Saharan Africa: A Useful Tool in Supporting Health Workers in Low-Resource Centres(2012-03-26) Frühauf, Julia; Hofman-Wellenhof, Rainer; Kovarik, Carrie; Mulyowa, Grace; Alitwala, Caroline; Soyer, H. Peter; Kaddu, StevenIn developing countries, such as Uganda, skin problems are among the most common ailments seen in primary healthcare settings (1). Due to the dire lack of trained dermatologists, the vast majority of patients with skin diseases in these countries are treated by substitute auxiliary health workers with a limited education in skin disease management (1). To bridge this gap in access to dermatology services, we established a mobile teledermatology service and evaluated its applicability with regard to the impact of remote diagnoses on patient outcomes, as well as local health workers’ perception concerning this mode of dermatology consultation.Publication Lenalidomide Therapy in Treatment Refractory Cutaneous Lupus Erythematosus: Histologic and Circulating Leukocyte Profile and Potential Risk of a Systemic Lupus Flare(2012-04-01) Rosenbach, Misha; Okawa, Joyce; Braunstein, Inbal; Goodman, Noah G; Kovarik, Carrie; Prak, Eline Luning; Werth, Victoria P; Shah, Asha; Krathen, MichaelBackground Lenalidomide is a thalidomide analogue that may serve as an adjunctive therapy for treatment refractory cutaneous lupus erythematosus (CLE). Objectives We evaluate the use of lenalidomide in CLE and describe the skin and circulating leukocyte profile of treatment refractory patients before and after treatment. Patients/Methods Five subjects were treated with lenalidomide in an unblinded open-label study. Immunohistochemistry of skin was performed for T-cell markers, glycosaminoglycans and CXCL10, an interferon (IFN)-inducible chemokine, before and after treatment. Immunophenotyping and measurement of IFN-inducible genes from peripheral blood mononuclear cells was also performed before and after treatment. Results Four subjects demonstrated clinical improvement of their skin, however one of these responders subsequently developed symptoms of systemic lupus erythematosus. Small changes in rare circulating leukocyte subsets, plasmacytoid dendritic cells and regulatory T-cells, were observed with treatment and may correlate with clinical response. Treatment was associated with increased circulating HLA-DR expression and decreased markers of IFN-mediated pathways, regardless of clinical response. Limitations Our results are limited by small sample size and the measurement of rare populations of circulating cell subsets. Conclusions Lenalidomide may have utility as therapy for severe, treatment refractory CLE. However, our preliminary data suggest that lenalidomide may activate T-cells and trigger systemic disease in some CLE patients. We also saw a unique histologic and circulating leukocyte phenotype in the nonresponding subject. Further characterization of the skin and circulating leukocyte profile of treatment refractory patients will improve our understanding of CLE.