Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing.

Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.

Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes.

BACKGROUND: Management of emergency general surgical conditions remains a challenge in rural sub-Saharan Africa due to issues such as insufficient human capacity and infrastructure. This study describes the burden of emergency general surgical conditions and the ability to provide care for these conditions at three rural district hospitals in Rwanda. METHODS: This retrospective cross-sectional study included all patients presenting to Butaro, Kirehe and Rwinkwavu District Hospitals between January 1st 2015 and December 31st 2015 with emergency general surgical conditions, defined as non-traumatic, non-obstetric acute care surgical conditions. We describe patient demographics, clinical characteristics, management and outcomes. RESULTS: In 2015, 356 patients presented with emergency general surgical conditions. The majority were male (57.2%) and adults aged 15-60 years (54.5%). The most common diagnostic group was soft tissue infections (71.6%), followed by acute abdominal conditions (14.3%). The median length of symptoms prior to diagnosis differed significantly by diagnosis type (p < 0.001), with the shortest being urological emergencies at 1.5 days (interquartile range (IQR):1, 6) and the longest being complicated hernia at 17.5 days (IQR: 1, 208). Of all patients, 54% were operated on at the district hospital, either by a general surgeon or general practitioner. Patients were more likely to receive surgery if they presented to a hospital with a general surgeon compared to a hospital with only general practitioners (75% vs 43%, p < 0.001). In addition, the general surgeon was more likely to treat patients with complex diagnoses such as acute abdominal conditions (33.3% vs 4.1%, p < 0.001) compared to general practitioners. For patients who received surgery, 73.3% had no postoperative complications and 3.2% died. CONCLUSION: While acute abdominal conditions are often considered the most common emergency general surgical condition in sub-Saharan Africa, soft tissue infections were the most common in our setting. This could represent a true difference in epidemiology in rural settings compared to referral facilities in urban settings. Patients were more likely to receive an operation in a hospital with a general surgeon as opposed to a general practitioner. This provides evidence to support increasing the surgical workforce in district hospitals in order to increase surgical availability for patients.

Synthesis of Aryl C-Glycosides via Iron-Catalyzed Cross Coupling of Halosugars: Stereoselective Anomeric Arylation of Glycosyl Radicals.

We have developed a novel diastereoselective iron-catalyzed cross-coupling reaction of various glycosyl halides with aryl metal reagents for the efficient synthesis of aryl C-glycosides, which are of significant pharmaceutical interest due to their biological activities and resistance toward metabolic degradation. A variety of aryl, heteroaryl, and vinyl metal reagents can be cross-coupled with glycosyl halides in high yields in the presence of a well-defined iron complex, composed of iron(II) chloride and a bulky bisphosphine ligand, TMS-SciOPP. The chemoselective nature of the reaction allows the use of synthetically versatile acetyl-protected glycosyl donors and the incorporation of various functional groups on the aryl moieties, producing a diverse array of aryl C-glycosides, including Canagliflozin, an inhibitor of sodium-glucose cotransporter 2 (SGLT2), and a prevailing diabetes drug. The cross-coupling reaction proceeds via generation and stereoselective trapping of glycosyl radical intermediates, representing a rare example of highly stereoselective carbon-carbon bond formation based on iron catalysis. Radical probe experiments using 3,4,6-tri-O-acetyl-2-O-allyl-α-d-glucopyranosyl bromide (8) and 6-bromo-1-hexene (10) confirm the generation and intermediacy of the corresponding glycosyl radicals. Density functional theory (DFT) calculations reveal that the observed anomeric diastereoselectivity is attributable to the relative stability of the conformers of glycosyl radical intermediates. The present cross-coupling reaction demonstrates the potential of iron-catalyzed stereo- and chemoselective carbon-carbon bond formation in the synthesis of bioactive compounds of certain structural complexity.

Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda.

BACKGROUND: In developing countries, 9 out of 10 patients lack access to timely operative care. Most patients seek care at district hospitals that often lack operative capacity, creating a need for referral. Delays in referrals contribute to substantial disability and death. This study assessed the predictors of delayed referrals for injured patients. METHODS: This retrospective cohort study included injured patients, recommended for referral between January 1, 2013, and December 31, 2013, from 3 rural district hospitals in Rwanda. We defined delay as nonexecution of referral 2 days after referral recommendation. We performed a multivariate logistic regression using stepwise backward selection to identify the predictors of delayed referral. RESULTS: Of the 1,227 injured patients, 23.0% (n = 282) were recommended for referral. Of these, 36.5% (n = 103) had road traffic injuries and 53.6% (n = 151) were diagnosed with closed fractures/dislocation. Among 231 patients, 108 (46.8%) had a delay in referral execution. The predictors of delay included age >35 years (odds ratio = 2.45, 95% confidence interval: 1.09-5.50), closed fractures/dislocation (odds ratio = 16.37, 95% confidence interval: 3.13-85.78), admission to surgical wards (odds ratio = 10.25, 95% confidence interval: 2.70-38.82), and a duration ≥7 days from admission to referral recommendation (odds ratio = 4.80, 95% confidence interval: 1.38-16.63). CONCLUSION: Over 50% of referrals were completed in a timely fashion due to a strong referral system and a patient support program. Empowering district hospitals with trained staff and appropriate equipment could reduce the need for referral, and increasing surgeons at referral hospitals could reduce referral delays.

Non-Obstetric Surgical Care at Three Rural District Hospitals in Rwanda: More Human Capacity and Surgical Equipment May Increase Operative Care.

BACKGROUND: Most mortality attributable to surgical emergencies occurs in low- and middle-income countries. District hospitals, which serve as the first-level surgical facility in rural sub-Saharan Africa, are often challenged with limited surgical capacity. This study describes the presentation, management, and outcomes of non-obstetric surgical patients at district hospitals in Rwanda. METHODS: This study included patients seeking non-obstetric surgical care at three district hospitals in rural Rwanda in 2013. Demographics, surgical conditions, patient care, and outcomes are described; operative and non-operative management were stratified by hospitals and differences assessed using Fisher's exact test. RESULTS: Of the 2660 patients who sought surgical care at the three hospitals, most were males (60.7 %). Many (42.6 %) were injured and 34.7 % of injuries were through road traffic crashes. Of presenting patients, 25.3 % had an operation, with patients presenting to Butaro District Hospital significantly more likely to receive surgery (57.0 %, p < 0.001). General practitioners performed nearly all operations at Kirehe and Rwinkwavu District Hospitals (98.0 and 100.0 %, respectively), but surgeons performed 90.6 % of the operations at Butaro District Hospital. For outcomes, 39.5 % of all patients were discharged without an operation, 21.1 % received surgery and were discharged, and 21.1 % were referred to tertiary facilities for surgical care. CONCLUSION: Significantly more patients in Butaro, the only site with a surgeon on staff and stronger surgical infrastructure, received surgery. Availing more surgeons who can address the most common surgical needs and improving supplies and equipment may improve outcomes at other districts. Surgical task sharing is recommended as a temporary solution.

Global Surgery 2030: a roadmap for high income country actors.

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.

Premonition of death in trauma: a survey of healthcare providers.

Prognostication in western medicine has traditionally been based on objective scientific criteria, yet providers often rely on a feeling or "sense" based on experience to provide prognoses. In trauma, some providers believe that patients who express a feeling of death are more likely to die. We randomly surveyed 302 members of the Eastern Association for the Surgery of Trauma regarding patient's premonitions of death (POD). Ninety-five per cent of respondents reported encountering patients who expressed POD. Fifty per cent agreed patients expressing POD had a higher mortality rate. Fifty-seven per cent believe patient willpower affects outcome. Forty-four per cent agreed patients have an innate ability to sense their ultimate outcome after injury; 85 per cent believe patient's POD do not cause deviations from protocols. Most trauma providers have encountered patients expressing POD. Whereas most believe that a patient's willpower affects outcome, they do not believe that expressing a desire to live decreases mortality with seemingly fatal injuries. Providers who have witnessed negative POD believe these patients are more likely to die, however, they do not deviate from treatment protocols. This survey represents the first attempt to understand the magnitude of premonition of death in trauma and the need for future research.