Implementation and Effectiveness Outcomes of a Quality Improvement Intervention to Strengthen the Application of the World Health Organization Surgical Safety Checklist Tool in a Limited-Resource Setting.

BACKGROUND: There is a disparity in the provision of quality and safe surgical care in Nigeria. The capacity to track surgical safety through the use of the surgical safety checklist tool is variable in this setting. This study aimed to assess the outcomes of training on this checklist and the results of its pilot implementation. SUBJECTS, MATERIALS AND METHODS: A mixed-methods research comprising of quantitative and qualitative study designs was conducted to evaluate these 23 weeks intervention in our centre. Implementation was conducted in two phases: training of the surgical team and pilot testing of the intervention. Using the RE-AIM framework, implementation outcomes evaluated included reach of training, adoption of checklist and implementation challenges, while effectiveness outcomes evaluated included change in the knowledge score after the training and self-reported impact of the training and pilot test. Quantitative and qualitative data were collected and analyzed. RESULTS: There was a 2.4-point significant increase in the knowledge score after the training. During the pilot testing phase, 843 patients had surgery. The weekly checklist utilization rate for elective surgery rose to 64% at project completion. Despite logistic and manpower-related implementation challenges, the training intervention facilitated the translation of participant knowledge into practice (81.5%) and the pilot phase had a high impact on the practice of checklist use (3.8 ± 0.9). CONCLUSION: The quality improvement programme enhanced knowledge of checklist use and led to improved behaviour and positive organizational change. However, barriers need to be addressed to strengthen the sustainable use of the checklist tool.

CONTEXTE: Il existe une disparité dans la fourniture de soins chirurgicaux sûrs et de qualité au Nigéria. La capacité de suivre la sécurité chirurgicale par l'utilisation de la liste de contrôle de sécurité chirurgicale est variable dans ce contexte. Cette étude visait à évaluer les résultats de la formation à cette liste de contrôle et les résultats de sa mise en œuvre pilote. SUJETS, MATÉRIEL ET MÉTHODES: Une recherche à méthodes mixtes comprenant des études quantitatives et qualitatives a été menée pour évaluer cette intervention de 23 semaines dans notre centre. La mise en œuvre s'est déroulée en deux phases : formation de l'équipe chirurgicale et essai pilote de l'intervention. En utilisant le cadre REAIM, les résultats de la mise en œuvre évalués comprenaient la portée de la formation, l'adoption de la liste de contrôle et les défis de la mise en œuvre, tandis que les résultats de l'efficacité évalués comprenaient le changement dans le score des connaissances après la formation et l'impact auto-déclaré de la formation et de l'essai pilote. Des données quantitatives et qualitatives ont été recueillies et analysées. RÉSULTATS: Une augmentation significative de 2,4 points du score de connaissances a été observée après la formation. Au cours de la phase de test pilote, 843 patients ont été opérés. Le taux d'utilisation de la liste de contrôle hebdomadaire pour les opérations non urgentes est passé à 64 % à la fin du projet. Malgré les difficultés de mise en œuvre liées à la logistique et à la main-d'œuvre, l'intervention de formation a facilité l'application des connaissances des participants dans la pratique (81,5 %) et la phase pilote a eu un impact élevé sur la pratique de l'utilisation de la liste de contrôle (3,8 ± 0,9). CONCLUSION: Le programme d'amélioration de la qualité a renforcé les connaissances sur l'utilisation des listes de contrôle et a conduit à une amélioration des comportements et à un changement organisationnel positif. Toutefois, des obstacles doivent être surmontés pour renforcer l'utilisation durable de l'outil de la liste de contrôle. Mots-clés: Liste de contrôle, Sécurité des patients, Amélioration de la qualité, Chirurgie, Organisation mondiale de la santé.

Identifying the Clinical and Histological Risk Factors affecting Post-Biopsy Voiding Efficiency: An Observational Closed Cohort Study.

BACKGROUND: There is a variability in the reported rate of post-prostate biopsy voiding inefficiency. The burden and potential predictors of this morbidity is not well studied in African patients. This study aimed to evaluate the incidence as well as the clinical and histological factors affecting voiding function in patients undergoing trans-rectal prostate biopsy in an African population. SUBJECTS, MATERIALS AND METHODS: An observational cohort study was carried out in 68 adult males, 40 years and above, scheduled for trans-rectal prostate biopsy for suspected prostate cancer. Those who could not void spontaneously, had either neurological conditions or were on drugs that could affect voiding, were excluded from the research. Data on demographic characteristics of the patients were collected. Uroflowmetry was done to obtain the peak urine flow rate of the patients at baseline and seven days after the procedure. The prostate volume was determined and the presence of other potential clinical and histological risk factors were recorded. The presence of other bleeding-related biopsy complications was also recorded. Statistical analysis was done using SPSS with a p-value of less than 0.05 reported as significant. RESULTS: Voiding inefficiency was recorded in 28 (41.2%) of the patients with majority, 21 (75.0%), experiencing a five to nine-point decrease in their seventh day peak flow rate values. Post-biopsy haematuria occurred in 37 (54.4%) of the population. The presence of haematuria with blood clots was associated with a 10.9 times increased risk of voiding inefficiency after the procedure (p = 0.006). CONCLUSION: About two in five patients developed post-prostate biopsy voiding inefficiency. Blood clot presence was independently. associated with the occurrence of this morbidity.

CONTEXTE: Le taux d'inefficacité mictionnelle après une biopsie de la prostate est variable l'inefficacité prostate. Le fardeau et les et les prédicteurs potentiels de cette morbidité ne sont pas bien étudiés chez les patients africains. Cette étude visait à évaluer l'incidence ainsi que les facteurs cliniques et histologiques affectant la fonction mictionnelle chez les patients subissant une biopsie transrectale de la prostate dans une population africaine. SUJETS, MATÉRIEL ET MÉTHODES: Une étude de cohorte observationnelle a été réalisée chez 68 adultes âgés de 40 ans et plus, programmés pour une biopsie transrectale de la prostate. Ceux qui ne pouvaient pas uriner spontanément, souffraient de troubles neurologiques ou etaient drogues qui peut agissaient la miction ont été exclus de la recherche. Les données sur les caractéristiques démographiques des patients ont été recueillies. Une uroflowmétrie a été fait pour obtenir le débit urinaire de pointe des patients au début de l'étude et sept jours après l'intervention. Le volume de la prostate a été déterminé et la présence d'autres facteurs de risque cliniques et facteurs de risque potentiels, cliniques et histologiques, ont été enregistrés. La présence d'autres complications de la biopsie liées au saignement a également été enregistrée. L'analyse statistique a été effectuée à l'aide du logiciel SPSS, une valeur p inférieure à 0,05 étant considérée comme significative. RÉSULTATS: L'insuffisance mictionnelle a été enregistrée chez 28 (41,2 %) des patients. La majorité d'entre eux, 21 (75,0 %), présentant une diminution de cinq à neuf points dans leurs valeurs de débit de pointe au septième jour. Une hématurie post-biopsie est survenue chez 37 (54,4 %) de la population. La présence d'une hématurie avec caillots sanguins était associée à un risque 10,9 fois plus élevé d'inefficacité mictionnelle après la procédure (p = 0,006). CONCLUSION: Environ deux patients sur cinq ont développé une insuffisance mictionnelle après une biopsie de la prostate. La présence de caillots sanguins était indépendamment associée à l'apparition de cette morbidité. Mots-clés: Symptômes du bas appareil urinaire, biopsie de la prostate, facteurs de risque, rétention urinaire.

Evaluating Postgraduate Surgical Education Experience, Professional Satisfaction and Personal Well-Being: A Cross-Sectional Survey of Trainees in A Low-Middle Income Country in Sub-Saharan Africa.

BACKGROUND: Education at the postgraduate level is important in grooming competent specialists in different fields of surgical care. This study aimed to evaluate the training experience, professional satisfaction, and personal well-being of postgraduate surgical residents in northern Nigeria. SUBJECTS, MATERIALS AND METHODS: It was a cross-sectional survey of 157 medical doctors enrolled for a minimum of 6 months in surgical residency training in tertiary hospitals in the northern zone of the country. All participants filled a pre-tested questionnaire and their responses were analyzed using Statistical Package for the Social Sciences version 20. RESULTS: The respondents had a mean age of 34.4 ± 4.8 years. Thirty-two (20.5%) agreed that there was a balance between their training needs and rotation for clinical services. There was a marked disparity between the median time allocated for non-ward-based training activities (4.0 hours each per week) and the average time allocated for research activities (1.0 hours per week). Although 89 (57.4%) and 82 (53.3%) reported fair satisfaction in their professional role and private life respectively, a larger proportion expressed poor satisfaction with their participation in recreational (107 [68.6%]) and social activities (90 [58.4%]). One hundred and seventeen (74.5%) stated that a high level of stress was associated with their training. CONCLUSIONS: The surgical residents experienced relatively more training on patient management than on research work. Although their educational experience was associated with a high level of stress in majority of them, most of the trainees expressed fair satisfaction with activities in their professional role and private life.

Ultrasound guided percutaneous nephrostomy: Experience at ahmadu bello university teaching hospital, Zaria.

BACKGROUND: Obstructive uropathy is a common problem in urologic practice; temporary relief of obstruction in the upper tract poses a significant challenge. Ultrasound-guided percutaneous nephrostomy (PCN) is an option for upper tract drainage; compared to fluoroscopic guidance, it is readily available, affordable, and not associated with radiation exposure. We present our experience with ultrasound-guided PCN. PATIENTS AND METHODS: We studied all patients who had ultrasound-guided PCN in our center between January 2013 and January 2017. Information obtained included the patients' demographics, clinical details, primary pathology, indications, outcome, and complications within 30 days. Relevant data were extracted and analyzed using descriptive statistics. RESULTS: A total number of 35 PCNs were performed in 26 patients within the period of study. The median age was 44.5 years. There were 17 females and 9 males. About 88.2% of the females had ureteric obstruction from advanced carcinoma of the cervix while the predominant cause of obstruction in the males was advanced carcinoma of the bladder. Kidney access under ultrasound guidance required well dilated collecting systems for success and ease of puncture. The most common complication was hematuria, which resolved within 24-48 h in all patients uneventfully. CONCLUSION: PCN is an important and common procedure for temporary relief of upper urinary tract obstruction. While fluoroscopic guidance provides superior image guidance, ultrasound guidance is comparatively reliable, albeit with a longer learning curve. Adequate training, careful patients selection, and patience are key to success.

[Infections on catheters in hemodialysis: Temporal fluctuations of the infectious risk]. / Infections sur cathéters d'hémodialyse : variations du risque en fonction de la durée de cathétérisme.

BACKGROUND: International guidelines recommend to limit the long-term use of central-veinous catheters in patients undergoing hemodialysis, because they expose the patient to a higher infectious risk than the fistulas. However, for some patients with comorbidity, switching to a permanent vascular access is not possible. In such case, the catheter is used for a longer period. It seems therefore important to study the influence of a prolonged duration of catheterization on infectious complications. The temporal fluctuation profile of the infectious risk is poorly studied in the literature and the results published may be contradictory. METHODS: This multicentric prospective study included 1053 incident tunneled catheters. Multivariate logistic regression was used to identify significant risk factors of infection. An infection-free survival analysis was performed afterwards to estimate the variation of the instantaneous infectious risk during catheterization. RESULTS: The major risks factors of infections on tunneled catheters were: previous Staphylococcus aureus infection (aOR=1.95 [1.16-3.27]; P=0.012), diabetes (aOR=1.67 [1.16-2.41]; P=0.006), and long duration of catheterization (0-3months vs.≥24months: aOR=2.42 [1.34-4.36]; P=0.003). The survival analysis showed a higher risk of infections of tunneled catheters during the first months after placement. Risk declines over time. CONCLUSIONS: The fluctuation profile of the infectious risk show that preventive precautions should target the first months of catheterization.

Australian dentists' perspectives on rapid HIV testing.

BACKGROUND: Fourteen per cent of people living with HIV in Australia, as in other countries, are not aware of their infection or their infective status. Dentists have the necessary expertise and are well-placed for access by those sections of the population who would not normally access screening for HIV. METHODS: A national cross-sectional online survey of 532 Australian dentists was conducted during the period June to October 2013. We surveyed dentists' understanding and willingness to undertake rapid HIV testing (RHT). RESULTS: The majority of respondents (65.1%) believed that RHT was needed in dental clinics, with approximately two-thirds of respondents indicating that RHT should be made available immediately. If RHT was to be undertaken in a dental setting, 51.1% of dentists thought that it should be conducted on saliva only, as opposed to blood or blood/saliva. Only 21.9% of dentists would currently be comfortable advising a patient of a reactive (i.e. positive) result indicative of HIV infection, with male dentists (26.1% comfortable) more comfortable than female dentists (17.5% comfortable) (p = 0.009). CONCLUSIONS: The majority of respondents were willing to provide RHT in their community settings. However, our data indicate that dentists would need additional training in HIV medicine, test administration and giving reactive results.

Nonsteroid antiinflammatory agents as a substitute treatment for steroids in ATGAM-treated cadaver kidney recipients.

A nonsteroid antiinflammatory agent (Ibuprofen) was used in a controlled randomized study to determine its ability to replace steroids in the prophylaxis of cadaveric kidney rejection. Thirty-three cadaver kidney recipients were randomly assigned either to a control group (16 patients) receiving azathioprine, high doses of prednisolone, and antithymocyte globulin (ATGAM) for three months, or to an experimental group (17 patients) receiving azathioprine and ATGAM according to the same protocol, ibuprofen instead of steroids. The frequency of rejection was higher in the experimental group (2.18 episodes per patient) than in the control group (1.44 episodes per patient). Nevertheless, in the experimental group 5 patients had no early rejection episode, 60% of early rejections were totally reversible without steroids, and 3 patients never received steroids at all during the first year and had normal renal function and biopsies. Steroids had to be introduced in the treatment of 14 patients, but after an average period of 32.5 days after surgery OKT3+ cell level was higher in the experimental group than in the control group, but similar to the OKT3+ cell level of patients receiving conventional therapy without ATGAM. Whatever the type of treatment, an increase in the OKT4+/OKT8+ ratio was associated in most cases with increased serum creatinine values. Conversely, a decreased OKT4+/OKT8+ ratio associated with renal failure was found in cases showing biological evidence of cytomegalovirus infection.

Myxoedema coma: response of thyroid hormones with oral and intravenous high-dose L-thyroxine treatment.

Myxoedema coma is a medical emergency with high mortality. In this study, clinical response and plasma variations of thyroid hormones were analysed in 7 patients, 6 presenting with myxoedema coma and one with myxoedema ileus. These patients were treated with intravenous or oral l-thyroxine (l-T4). 1000 mu l-T4 iv were administered in two patients. Within 3 h, plasma T4 and triiodothyronine (T3) reached a peak upper normal range, then diminished slowly during 5-9 days. The 5 remaining patients were treated with 500 micrograms l-T4 po on the first day, then 100 micrograms l-T4 daily by mouth. Plasma T4 and T3 increased slowly, remaining in hypothyroid range but clinical response (assessed on mental status, pulse rate and body temperature) occurred within 24-72 h. Cortisone therapy was used in 3 patients. Two patients died of myocardial infarction, or septicemia, one while receiving cortisone therapy and i.v. l-T4, another one treated only by oral l-T4. This study suggests: 1) oral absorption of l-T4 is variable, but clinical response occurs quickly even in myxoedema ileus; 2) the intravenous route involves high peaks of plasma T4 and T3; 3) peripheral conversion of T4 to T3 allows gradually T3 delivery to organ systems, even if only l-T4 is used and 4) initial and daily dosage determinations need further studies.

Bicarbonate haemodialysis: an adequate treatment for lactic acidosis in diabetics treated by metformin.

Lactic acidosis in diabetics on metformin therapy is rare but still associated with poor prognosis. The authors report here five cases. Three patients were initially with a cardiovascular collapse and all had an acute renal failure. Sodium bicarbonate haemodialysis therapy led to a dramatic improvement. Consciousness and hemodynamic status recovered rapidly. Severe metabolic and blood gases derangements were also rapidly corrected. Plasma metformin removal, appreciated by repeated blood samplings in 3 cases, was satisfactory. All patients survived. However, blood metformin levels remained abnormally high at the end of the dialytic therapy. In conclusion, (1) bicarbonate dialysis is an adequate treatment of lactic acidosis observed in diabetic patients treated with metformin since it rapidly corrects the acid-base disorders and partially removes metformin; (2) the sole accumulation of metformin is not sufficient to explain lactic acidosis since this latter might be corrected in spite of persisting high levels of blood metformin.

[Treatment of peritonitis in peritoneal dialysis. Comparison between continuous lavage with a machine and intermittent lavage with 4 CAPD bags/day]. / Traitement des péritonites en dialyse péritonéale. Comparaison entre lavage continu avec machine et lavage intermittent par quatre sacs/jour de DPCA.

Since 1978, 54 episodes of PT occurred in patients treated by PD, first 26 PT (group A) were treated by CLM (40 l/day) and in situ antibiotics (AB): in the absence of Candida, the association of sulfamethoxazol (SMZ: 80 mg/l) and trimethoprime (TMP: 16 mg/l) was used. Only when a Candida was present amphotericine B (AMB: 5 mg/l) was used. CLM was continued until PT was cured. The last 29 PT (group B) were treated by 4 bags/day of CAPD with in situ AB: SMZ: 200 mg/l and TMP 40 mg/l and a systematic oral prophylaxis of Candida was performed by AMB 1,5 g/day. In group A, 5 patients died and 2 others in group B. Complications were more frequent in group A (14) than in group B (6): p less than 0.02. In group A, the AB was changed in 7 cases because of initial resistance (1) or bacterial superinfection (2) or Candida superinfection (4). In group B, AB was changed in 9 cases because of initial resistance (7) or Candida superinfection (2). In conclusion the treatment of PT by 4 bags per day with in situ AB cure PT as rapidly as CLM in spite of lower doses of SMZ - TMP. However, this method is easier to perform and give less complication than CLM. It must be the treatment of choice of PT from peritoneal dialysis.

[Diuretics and vascular risk factors. Comparison between tienilic acid and chlorothiazide (author's transl)]. / Diurétiques et facteurs de risque vasculaire. Comparaison entre les effets de l'acide tiénilique et du chlorothiazide sur la pression artérielle et les métabolismes lipidique, glucidique et urique.

Tienilic acid (250 mg/day) was compared with chlorothiazide (500 mg/day) in 25 hypertensive patients in a randomized cross-over study (2 periods of 2 months). Mean supine arterial pressure was lower with tienilic acid than with chlorothiazide (106 +/- 3 vs 111 +/- 3 mm Hg, p less than 0.05) whereas no difference could be noted in body weight, natriuresis and plasma renin activity. Glucose tolerance tests were altered in the same fashion. Serum cholesterol (234 with tienilic acid and 239 mg/dl with chlorothiazide) and serum triglyceride levels (178 with tienilic acid and 179 mg/dl with chlorothiazide) were not different. Serum urate concentrations were lower with tienilic acid (4.8 mg/dl) than with chlorothiazide (7.8 mg/dl) whereas fractional excretion of urate was much higher with tienilic acid (17 +/- 2%) than with chlorothiazide (7 +/- 2%). Thus, the only metabolic advantage of tienilic acid over chlorothiazide is its hypouricemic effect which warrants long term studies to evaluate its vascular prognostic significance.