Growing research in global surgery with an eye towards equity.

BACKGROUND: Global surgery research is often generated through collaborative partnerships between researchers from both low- and middle-income countries (LMICs) and high-income countries (HICs). Inequitable engagement of LMIC collaborators can limit the impact of the research. METHODS: This article describes evidence of inequities in the conduct of global surgery research and outlines reasons why the inequities in this research field may be more acute than in other global health research disciplines. The paper goes on to describe activities for building a collaborative research portfolio in rural Rwanda. RESULTS: Inequities in global surgery research collaborations can be attributed to: a limited number and experience of researchers working in this field; time constraints on both HIC and LMIC global surgery researchers; and surgical journal policies. Approaches to build a robust, collaborative research portfolio in Rwanda include leading research trainings focused on global surgery projects, embedding surgical fellows in Rwanda to provide bidirectional research training and outlining all research products, ensuring that all who are engaged have opportunities to grow in capacities, including leading research, and that collaborators share opportunities equitably. Of the 22 published or planned papers, half are led by Rwandan researchers, and the research now has independent research funding. CONCLUSION: It is unacceptable to gather data from an LMIC without meaningful engagement in all aspects of the research and sharing opportunities with local collaborators. The strategies outlined here can help research teams build global surgery research portfolios that optimize the potential for equitable engagement.

Prevalence and predictors of surgical-site infection after caesarean section at a rural district hospital in Rwanda.

BACKGROUND: There are few prospective studies of outcomes following surgery in rural district hospitals in sub-Saharan Africa. This study aimed to estimate the prevalence and predictors of surgical-site infection (SSI) following caesarean section at Kirehe District Hospital in rural Rwanda. METHODS: Adult women who underwent caesarean section between March and October 2017 were given a voucher to return to the hospital on postoperative day (POD) 10 (±3 days). At the visit, a physician evaluated the patient for an SSI. A multivariable logistic regression model was used to identify risk factors for SSI, built using backward stepwise selection. RESULTS: Of 729 women who had a caesarean section, 620 were eligible for follow-up, of whom 550 (88·7 per cent) returned for assessment. The prevalence of SSI on POD 10 was 10·9 per cent (60 women). In the multivariable analysis, the following factors were significantly associated with SSI: bodyweight more than 75 kg (odds ratio (OR) 5·98, 1·56 to 22·96; P = 0·009); spending more than €1·1 on travel to the health centre (OR 2·42, 1·31 to 4·49; P = 0·005); being a housewife compared with a farmer (OR 2·93, 1·08 to 7·97; P = 0·035); and skin preparation with a single antiseptic compared with a combination of two antiseptics (OR 4·42, 1·05 to 18·57; P = 0·043). Receiving either preoperative or postoperative antibiotics was not associated with SSI. CONCLUSION: The prevalence of SSI after caesarean section is consistent with rates reported at tertiary facilities in sub-Saharan Africa. Combining antiseptic solutions for skin preparation could reduce the risk of SSI.

Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing.

BACKGROUND: In low- and middle-income countries, the majority of patients lack access to surgical care due to limited personnel and infrastructure. The Lancet Commission on Global Surgery recommended laparotomy for district hospitals. However, little is known about the cost of laparotomy and associated clinical care in these settings. METHODS: This costing study included patients with acute abdominal conditions at three rural district hospitals in 2015 in Rwanda, and used a time-driven activity-based costing methodology. Capacity cost rates were calculated for personnel, location and hospital indirect costs, and multiplied by time estimates to obtain allocated costs. Costs of medications and supplies were based on purchase prices. RESULTS: Of 51 patients with an acute abdominal condition, 19 (37 per cent) had a laparotomy; full costing data were available for 17 of these patients, who were included in the costing analysis. The total cost of an entire care cycle for laparotomy was US$1023·40, which included intraoperative costs of US$427·15 (41·7 per cent) and preoperative and postoperative costs of US$596·25 (58·3 per cent). The cost of medicines was US$358·78 (35·1 per cent), supplies US$342·15 (33·4 per cent), personnel US$150·39 (14·7 per cent), location US$89·20 (8·7 per cent) and hospital indirect cost US$82·88 (8·1 per cent). CONCLUSION: The intraoperative cost of laparotomy was similar to previous estimates, but any plan to scale-up laparotomy capacity at district hospitals should consider the sizeable preoperative and postoperative costs. Although lack of personnel and limited infrastructure are commonly cited surgical barriers at district hospitals, personnel and location costs were among the lowest cost contributors; similar location-related expenses at tertiary hospitals might be higher than at district hospitals, providing further support for decentralization of these services.

After Muskoka.

Substantial progress has been accomplished in reducing maternal, neonatal, and infant mortality, but the work to meet the Millennium Development Goals, boosted by numerous initiatives, including Muskoka, is far from finished. Since 2016, the Sustainable Development Goals, as well as the International Strategy for Women's, Children's, and Adolescent Health 2016 - 2030, have provided to the countries and development partners a consistent framework for action enlarged to all of the dimensions of human development, while keeping women, children, and adolescents at its heart. In this context, the Muskoka program, after an initial 5-year cycle, will continue in 2017.

The effect of turbidity levels and Moringa oleifera concentration on the effectiveness of coagulation in water treatment.

Laboratory experiments were carried out to assess the water purification and antimicrobial properties of Moringa oleifera (MO). Hence different concentrations (25 to 300 mg/L) were prepared from a salt (1 M NaCl) extract of MO fine powder and applied to natural surface water whose turbidity levels ranged from 50 to 450 NTU. The parameters determined before and after coagulation were turbidity, pH, colour, hardness, iron, manganese and Escherichia coli. The experiments showed that turbidity removal is influenced by the initial turbidity since the lowest turbidity removal of 83.2% was observed at 50 NTU, whilst the highest of 99.8% was obtained at 450 NTU. Colour removal followed the same trend as the turbidity. The pH exhibited slight variations through the coagulation. The hardness removal was very low (0 to 15%). However, high removals were achieved for iron (90.4% to 100%) and manganese (93.1% to 100%). The highest E. coli removal achieved was 96.0%. Its removal was associated with the turbidity removal. The optimum MO dosages were 150 mg/L (50 NTU and 150 NTU) and 125 mg/L for the rest of the initial turbidity values. Furthermore all the parameters determined satisfied the WHO guidelines for drinking water except for E. coli.

[Infectious diarrhea in African acquired immunodepression syndrome (AIDS). Apropos of 100 patients studied in Bujumbura (Burundi)]. / Diarrhées infectieuses au cours du syndrome d'immunodépression acquise africain (SIDA). A propos de 100 malades étudiés à Bujumbura (Burundi).

The authors carried out a prospective survey on 100 cases of AIDS in order to find out the different etiologies of infections diarrhoea in terms of frequency and diagnosis behaviour. 84 out of 100 patients got diarrhoea. All 100 patients had their stools examined, 78 underwent high digestive fibroscopy with irrigation and aspiration of duodenal liquid (IADL), 40 duodenal biopsies. 98 infecting agents were revealed in stool exams, 50 in IADL, 7 at the occasion of histopathological exam of duodenal biopsies. All together, stool exams and IADL gave evidence that Isospora belli and Cryptosporidium are the opportunistic infecting agents most often revealed (16.2 and 13.1 p.c., respectively). The role of yeasts in diarrhoea is not evident, but esophageal candidosis is the most frequent opportunistic digestive infection (48 p.c.). Anguillula is the only intestinal worm appearing to play a role: the role of bacteria and viruses cannot be evaluated precisely, but histopathological study revealed neither an atypical mycobacteriosis nor a virus disease (herpes, cytomegalovirus). If diagnosis appears to be still difficult in 1989 when confronted with AIDS and diarrhoea, it seems highly advisable to examine the stools, to perform high digestive fibroscopy with IADL and biopsies. On the other hand, indications for colonoscopy appear to be restricted.

[Parasites, etiologic agents of diarrhea in AIDS. Significance of duodenal aspiration fluid test]. / Les parasites, agents étiologiques des diarrhées du SIDA. Intérêt de l'examen du liquide d'aspiration duodénale.

A research was made on one hundred cases of diarrhoeas in Aids-patients by stool examination including examination of duodenal aspirated liquid. Concerning the examination of duodenal fluid, we founded the parasites in almost one hundred patients of the cases. Among parasites observed, Isospora belli was the most frequent (20% of cases), followed by Cryptosporidium (15%). Strongyloides stercoralis represented 10% of the cases. The majority of other parasites was miscellaneous protozoa and some helminths.