Rhabdomyolysis, acute kidney injury, and mortality in Ebola virus disease: retrospective analysis of cases from Eastern Democratic Republic of the Congo, 2019.

BACKGROUND: Skeletal muscle injury in Ebola virus disease (EVD) has been reported, but its association with morbidity and mortality remains poorly defined. METHODS: Retrospective study of patients admitted to two EVD Treatment Units, over an eight-month period in 2019, during a large EVD epidemic in the Democratic Republic of the Congo. RESULTS: 333 patients (median age 30 years, 58% female) had at least one creatine kinase (CK) measurement (total 2,229 CK measurements, median 5 (IQR 1-11) per patient). 271 patients (81%) had an elevated CK (>380U/L), 202 (61%) had rhabdomyolysis (CK>1,000 IU/L), and 45 (14%) had severe rhabdomyolysis (≥5,000U/L). Among survivors, the maximum CK level was median 1,600 (IQR 550 to 3,400), peaking 3.4 days after admission (IQR 2.3 to 5.5) and decreasing thereafter. Among fatal cases, the CK rose monotonically until death, with maximum CK level of median 2,900 U/L (IQR 1,500 to 4,900). Rhabdomyolysis at admission was an independent predictor of AKI (aOR 2.2 [95%CI 1.2-3.8], p=0.0065) and mortality (aHR 1.7 [95%CI 1.03-2.9], p=0.037). CONCLUSIONS: Rhabdomyolysis is associated with AKI and mortality in EVD patients. These findings may inform clinical practice by identifying lab monitoring priorities and highlighting the importance of fluid management.

Psychosocial impact of surgical complications and the coping mechanisms among surgeons in Uganda and Eastern Democratic Republic of the Congo.

We aimed to assess the psychosocial impact from postoperative complications on the surgical workforce and the coping mechanisms they use following these complications in Uganda and Eastern Democratic Republic of the Congo (DRC). This was a cross-sectional multi-center study conducted from first February 2022 to 31st March 2022 in the preselected main teaching hospitals of Uganda and Eastern DRC. We surveyed the surgical workforce (practicing surgeons, Obstetrician-Gynecologists, and residents in surgery/ Obstetrics-Gynecology) who had experienced postoperative complications in their career. Data was analysed using SPSS version 23. One hundred ninety-eight participants responded to the questionnaire. Worry about patient and reputation were the commonest psychological impacts in 54.0% and 45.5% of the participants respectively. Majority of the participants (55.1%) used positive coping mechanisms with a positive impact on their practice (94.4%). Being a female doctor (AOR = 2.637, CI 1.065-6.533, P = 0.036), worrying about reputation (AOR = 3.057, CI = 1.573-5.939, P = 0.001) and guilt after a complication (AOR = 4.417, CI = 2.253-8.659, P = <0.001) were predictors of a negative coping mechanism. Postoperative surgical complications continue to cause a huge psychological impact on the operating doctors in Uganda and the Eastern DRC. Female doctors, those that worry about the reputation and those that feel guilty following a complication should be given more support and guidance by peers when surgical complications occur to their patients.

Evaluation des connaissances théoriques des étudiants en médecine sur les gestes de premiers secours en République Démocratique du Congo: Theoretical knowledge assessment of medical students on first aid in the Democratic Republic of Congo.

Introduction: The Democratic Republic of Congo regularly faces several health emergencies. The presence of medical doctors in the first line of the response is a spontaneous phenomenon. Gaps in first aid knowledge have been identified in the population; hence the need for training. Medical students could play a crucial role in this context. This study assesses the theoretical knowledge of first aid among them. Methods: Our study is descriptive and transversal. It was conducted from June 01 to August 30, 2021 in the Faculty of Medicine of the Catholic University of Graben. Our sample consisted of 279 students. Data collection was done through a survey questionnaire covering various aspects of first aid. Data were processed using Epi Info software. The chi-square test was used to estimate the association of variables with knowledge and a p-value <0.05 was considered as significant. Results: No participant demonstrated a satisfactory level of theoretical knowledge of first aid while 38.7% and 61.3% demonstrated an intermediate and low level respectively. A positive association was noted between the study level, a previous training in first aid and the level of knowledge. The media is the main source of information. Nearly half of the students said they had never taken a rescue action because of lack of knowledge (47.7%). The vast majority (98%) had a positive attitude regarding the introduction of first aid in school's curriculum. Conclusion: Our study showed a poor level of first aid knowledge among medical students, but a great willingness to learn. There is a great need to incorporate first aid trainings in all training curricula in the DRC.

Introduction: La République Démocratique du Congo fait régulièrement face à plusieurs urgences sanitaires. La présence des médecins en première ligne dans la riposte y est un phénomène spontané. Des lacunes ont été identifiées dans la connaissance des premiers secours au sein de la population; d'où la nécessité de formation. Les étudiants en médecine y joueraient un rôle crucial. Cette étude évalue les connaissances théoriques en premiers secours chez ceux-ci. Méthodologie: Notre étude est de type descriptif et transversal. Elle a été conduite du 01 Juin au 30 Août 2021 à la Faculté de médecine de l'Université Catholique du Graben. Notre échantillon était constitué de 279 étudiants. La collecte des données a été faite par un questionnaire d'enquête couvrant divers aspects des premiers secours. Les données ont été traitées par le logiciel Epi Info version 3.4.5. Résultats: Aucun participant n'a démontré un niveau satisfaisant de connaissances théoriques en premiers secours tandis que 38,7% et 61,3 % ont démontré un niveau intermédiaire et bas respectivement. Une corrélation positive a été notée entre la promotion d'étude, une formation antérieure en premiers secours et le niveau de connaissance. Le média est la principale source d'information. Près de la moitié des étudiants ont affirmé n'avoir jamais posé un geste de premier secours à cause du manque de connaissance (47,7%). La quasi-totalité a montré une attitude positive en rapport avec l'introduction d'une formation en premiers secours en milieu universitaire. Conclusion: Cette étude a démontré un faible niveau de connaissances des gestes de premiers secours parmi les étudiants en médicine, mais une volonté d'apprendre. Il y a nécessité d'intégrer la formation en gestes de premiers secours dans tous les curriculums de l'enseignement en RDC.

Perceptions of ebola virus disease among the bambuti hunter group: a mixed-methods study.

The second largest Ebola virus disease (EVD) epidemic occurred in the Democratic Republic of the Congo (DRC) from 2018-20. The Bambuti, a hunter population in the Ituri Forest of the DRC, may be vulnerable to the zoonotic spread of EVD due to their frequent handling of forest animals. We conducted five focus group discussions and surveyed 113 Bambuti and 91 Bantu (control group), to discern how the Bambuti perceived and responded to EVD. Thematic analysis of focus group discussions revealed three major themes: (1) deprivation and discrimination; (2) mistrust; and (3) epistemic dissonance with public health messages emphasizing risks posed by forest animals. In surveys, 98% of Bambuti were deprived using the multidimensional poverty index (versus 78% of Bantu controls, p < 0.0001) and 77% had no formal education (versus 29% of controls, p < 0.0001). Bambuti were more dependent on wild meat for survival (51% versus 32% of controls, p = 0.008) and more frequently opposed the implementation of a bushmeat ban (48% versus 19% of controls, p < 0.0001). Trust in government was similar among Bambuti and Bantu. Comprehensive EVD knowledge was poor overall, and lower among the Bambuti (2% versus 8% of controls, p = 0.041). Compliance with public health measures was associated with higher levels of education and trust in government but did not differ between Bambuti and Bantu survey respondents. Together, our findings point to a particular vulnerability of the Bambuti to the effects of EVD, attributable at least in part to multidimensional poverty.

Evaluation des connaissances théoriques des étudiants en médecine sur les gestes de premiers secours en République Démocratique du Congo / Theoretical knowledge assessment of medical students on first aid in the Democratic Republic of Congo

Introduction: La République Démocratique du Congo fait régulièrement face à plusieurs urgences sanitaires. La présence des médecins en première ligne dans la riposte y est un phénomène spontané. Des lacunes ont été identifiées dans la connaissance des premiers secours au sein de la population; d'où la nécessité de formation. Les étudiants en médecine y joueraient un rôle crucial. Cette étude évalue les connaissances théoriques en premiers secours chez ceux-ci. Méthodologie: Notre étude est de type descriptif et transversal. Elle a été conduite du 01 Juin au 30 Août 2021 à la Faculté de médecine de l'Université Catholique du Graben. Notre échantillon était constitué de 279 étudiants. La collecte des données a été faite par un questionnaire d'enquête couvrant divers aspects des premiers secours. Les données ont été traitées par le logiciel Epi Info version 3.4.5. Résultats: Aucun participant n'a démontré un niveau satisfaisant de connaissances théoriques en premiers secours tandis que 38,7% et 61,3 % ont démontré un niveau intermédiaire et bas respectivement. Une corrélation positive a été notée entre la promotion d'étude, une formation antérieure en premiers secours et le niveau de connaissance. Le média est la principale source d'information. Près de la moitié des étudiants ont affirmé n'avoir jamais posé un geste de premier secours à cause du manque de connaissance (47,7%). La quasi-totalité a montré une attitude positive en rapport avec l'introduction d'une formation en premiers secours en milieu universitaire. Conclusion: Cette étude a démontré un faible niveau de connaissances des gestes de premiers secours parmi les étudiants en médicine, mais une volonté d'apprendre. Il y a nécessité d'intégrer la formation en gestes de premiers secours dans tous les curriculums de l'enseignement en RDC

Introduction: The Democratic Republic of Congo regularly faces several health emergencies. The presence of medical doctors in the first line of the response is a spontaneous phenomenon. Gaps in first aid knowledge have been identified in the population; hence the need for training. Medical students could play a crucial role in this context. This study assesses the theoretical knowledge of first aid among them. Methods: Our study is descriptive and transversal. It was conducted from June 01 to August 30, 2021 in the Faculty of Medicine of the Catholic University of Graben. Our sample consisted of 279 students. Data collection was done through a survey questionnaire covering various aspects of first aid. Data were processed using Epi Info software. The chi-square test was used to estimate the association of variables with knowledge and a p-value. Results: No participant demonstrated a satisfactory level of theoretical knowledge of first aid while 38.7% and 61.3% demonstrated an intermediate and low level respectively. A positive association was noted between the study level, a previous training in first aid and the level of knowledge. The media is the main source of information. Nearly half of the students said they had never taken a rescue action because of lack of knowledge (47.7%). The vast majority (98%) had a positive attitude regarding the introduction of first aid in school's curriculum. Conclusion: Our study showed a poor level of first aid knowledge among medical students, but a great willingness to learn. There is a great need to incorporate first aid trainings in all training curricula in the DRC.

Huge scalp Morel-Lavallée lesion with eye involvement in a 3-year-old girl: a case report.

BACKGROUND: Morel-Lavallée lesions are posttraumatic, closed degloving injuries in which the skin and subcutaneous tissue are separated abruptly from superficial underlying fascia. This condition leads to an effusion containing hemolymph and necrotic fat. Magnetic resonance imaging, when available, is the modality of choice in the evaluation of Morel-Lavallée lesion. Early diagnosis and management is essential as any delay in diagnosis or missed lesion will lead to the effusion becoming infected or leading to extensive skin necrosis. We present a condition of a Morel-Lavallée lesion involving the scalp and complicated by conjunctival chemosis. CASE PRESENTATION: We report on a 3-year-old black African girl who presented a fluctuant swelling of entire scalp, extending to upper part of the face on the seventh day after a forehead trauma due to falling on a rock while playing. Skull x-ray revealed soft-tissue swelling, giving an impression of large fluid collection in the deep subcutaneous tissues with no bone fracture. A diagnosis of Morel-Lavallée lesion of the scalp complicated by conjunctival chemosis was made. The patient was managed with percutaneous drainage and compression bandage. The patient improved well and was subsequently discharged without any vision impairment. There was no recurrence of the lesion on follow-up. CONCLUSIONS: The Morel-Lavallée lesion of the scalp complicated with conjunctival chemosis is a rare presentation of this condition. Prompt diagnosis and management are crucial for preventing complications. Image-guided diagnosis and treatment still remain a challenge in the setting of low-resource health facilities.

Review of Ebola virus disease in children - how far have we come?

Ebola virus (EBOV) causes an extremely contagious viral haemorrhagic fever associated with high mortality. While, historically, children have represented a small number of total cases of Ebolavirus disease (EVD), in recent outbreaks up to a quarter of cases have been in children. They pose unique challenges in clinical management and infection prevention and control. In this review of paediatric EVD, the epidemiology of past EVD outbreaks with specific focus on children is discussed, the clinical manifestations and laboratory findings are described and key developments in clinical management including specific topics such as viral persistence and breastfeeding while considering unique psychosocial and anthropological considerations for paediatric care including of survivors and orphans and the stigma they face are discussed. In addition to summarising the literature, perspectives based on the authors' experience of EVD outbreaks in the Democratic Republic of the Congo (DRC) are described.Abbreviations: ARDS: acute respiratory distress syndrome; aOR: adjusted odds ratio; ALT: alanine transferase; ALIMA: Alliance for International Medical Action; AST: aspartate transaminase; BUN: blood urea nitrogen; CNS: central nervous system; CUBE: chambre d'urgence biosécurisée pour épidémie; COVID-19: coronavirus disease 2019; Ct: cycle threshold; DRC: Democratic Republic of Congo; ETC: ebola treatment centre; ETU: ebola treatment unit; EBOV: ebola virus; EVD: ebolavirus disease; FEAST: fluid expansion as supportive therapy; GP: glycoprotein; IV: intravenous; MEURI: monitored emergency use of unregistered interventions; NETEC: National Ebola Training and Education Centre; NP: nucleoprotein; ORS: oral rehydration solution; PALM: Pamoja Tulinde Maisha; PREVAIL: Partnership for Research on Ebola Virus in Liberia; PPE: personal protective equipment; PCR: polymerase chain reaction; PEP: post-exposure prophylaxis; RDTs: rapid diagnostic tests; RT: reverse transcriptase; RNA: ribonucleic acid; UNICEF: United Nations International Children's Emergency Fund; USA: United States of America; WHO: World Health Organization.

Ebola crisis in Eastern Democratic Republic of Congo: student-led community engagement.

The second largest outbreak of Ebolavirus is currently ongoing in Eastern Democratic Republic of the Congo (DRC) and is characterized by lack of compliance with recommended control measures. Trusted local health agents, including medical students, may be valuable social mobilizers in this challenging context. We report a student-led educational campaign to increase community awareness and engagement in EVD control efforts, with evaluation of student and community satisfaction. The outreach was conducted in November 2018, involving 600 students and reaching 5-10,000 community members. Key messages included: 'Ebola exists in Butembo' and 'Bring infected family members to the Ebola Treatment Unit.' Medical students (n = 355) and community participants (n = 319) evaluated the campaign. Satisfaction was high: 320 (90%) students agreed that medical students could contribute to the EVD response effort, and 233 (73%) community members agreed that the students had helped them understand Ebola in the area. Lower satisfaction scores were associated with intention to hide infected family member from authorities (ρ = -0.25, p < 0.0001), denial of the existence of Ebola (ρ = -0.17, p = 0.0018), and mistrust of the response team (ρ = -0.11, p = 0.042). Both students (77%) and community members (71%) agreed that they were more motivated to combat Ebola as a result of the outreach. In conclusion, medical students can lead to satisfactory community engagement and educational activities during an EVD epidemic. As trusted local health agents, medical students may be valuable allies in building public trust and cooperation in this epidemic.

Compliance of antibiotics used for surgical site infection prophylaxis among patients undergoing surgery in a Congolese teaching hospital.

BACKGROUND: Surgical antibiotic prophylaxis (SAP) is one of the measures used for preventing surgical site infections. SAP has high impact but there is low compliance with antimicrobial guidelines in many developing countries like the Democratic Republic of the Congo. This study aimed to assess the compliance of antibiotics used for surgical site infection prophylaxis with international guidelines among patients undergoing surgery at the "Cliniques Universitaires du Graben" (CUG). METHODS: This was a retrospective study including all patients who underwent surgery and received SAP between January 2017 and December 2018 at CUG. Surgical and Gynaecology-Obstetric patients were included. A total of 265 patients were included in the analysis. A standardized questionnaire was used for collecting pre-, per-, and post-operative data. The compliance of SAP was assessed for all patients. Data were analysed using SPSS version 22. RESULTS: The compliance rate ofSAP among patients undergoing surgery at CUG was 18.1%. Emergency surgery increased the risk of SAP non-compliance by three fold (OR=3.5, 95% CI: 1.0-11.8, p = 0.033). The most frequent antibiotics used in SAP were ampicillin, cloxacillin, gentamicin and ceftriaxone, alone or in combination. Categories of non-compliance included; inappropriate initial dose of antibiotic (compliance rate of 23.8%) and incorrect duration of antibiotic use (compliance rate of 30.9%). Among the included patients, 22 (8.3%) presented with a surgical site infection, of those 20 (90.9%) had received non-compliant SAP. CONCLUSION: The correct use of SAP among patients undergoing surgery at CUG is low. Implementing measures to optimize adherence to SAP guidelines should be encouraged. A high rate of surgical site infections is observed in cases where the SAP is prescribed or administered in a non-compliant manner.

Social resistance drives persistent transmission of Ebola virus disease in Eastern Democratic Republic of Congo: A mixed-methods study.

BACKGROUND: The second largest Ebola virus disease (EVD) epidemic in history is currently raging in Eastern Democratic Republic of Congo (DRC). Stubbornly persistent EVD transmission has been associated with social resistance, ranging from passive non-compliance to overt acts of aggression toward EVD reponse teams. METHODS: We explored community resistance using focus group discussions and assessed the prevalence of resistant views using standardized questionnaires. RESULTS: Despite being generally cooperative and appreciative of the EVD response (led by the government of DRC with support from the international community), focus group participants provided eyewitness accounts of aggressive resistance to control efforts, consistent with recent media reports. Mistrust of EVD response teams was fueled by perceived inadequacies of the response effort ("herd medicine"), suspicion of mercenary motives, and violation of cultural burial mores ("makeshift plastic morgue"). Survey questionnaires found that the majority of respondents had compliant attitudes with respect to EVD control. Nonetheless, 78/630 (12%) respondents believed that EVD was fabricated and did not exist in the area, 482/630 (72%) were dissatisfied with or mistrustful of the EVD response, and 60/630 (9%) sympathized with perpetrators of overt hostility. Furthermore, 102/630 (15%) expressed non-compliant intentions in the case of EVD illness or death in a family member, including hiding from the health authorities, touching the body, or refusing to welcome an official burial team. Denial of the biomedical discourse and dissatisfaction/mistrust of the EVD response were statistically significantly associated with indicators of social resistance. CONCLUSIONS: We concluded that social resistance to EVD control efforts was prevalent among focus group and survey participants. Mistrust, with deep political and historical roots in this area besieged by chronic violence and neglected by the outside world, may fuel social resistance. Resistant attitudes may be refractory to short-lived community engagement efforts targeting the epidemic but not the broader humanitarian crisis in Eastern DRC.

Sirenomelia associated with an anterior abdominal wall defect: a case report.

BACKGROUND: Sirenomelia is a rare and fatal congenital defect. The rarity of this case and its association with abdominal total wall defect drove us to report this case. CASE PRESENTATION: We report a rare case of sirenomelia characterized by lower limb fusion, thoracolumbar spinal anomalies, sacrococcygeal agenesis with a rudimentary tail, and genitourinary and anorectal atresia. Coexistent anterior abdominal wall defect in this case highlights its fatalness because of complications associated with the malformation. CONCLUSIONS: Sirenomelia syndrome has seldom been reported. The present case highlights the rare atypical association of sirenomelia with anterior abdominal wall defect. Because the investigations were done in a low-resource setting, the etiology regarding this case remains unclear.

3D analysis of child facial dimensions for design of medical devices in low-middle income countries (LMIC).

BACKGROUND: Facial anthropometric data are scarce in African children. However, such data may be useful for the design of medical devices for high disease burden settings. The aim of this study was to obtain 3D facial anthropometric data of Congolese children aged 0-5 years. METHODS & FINDINGS: The faces of 287 Congolese children were successfully scanned using a portable structured-light based 3D video camera, suitable for field work in low- income settings. The images were analyzed using facial analysis algorithms. Normal growth curves were generated for the following facial dimensions: distance between nares and distance from subnasion to upper lip. At birth, 1 year, and 5 years of age the median dimensions were: 13·92, 14·66, and 17.60 mm, respectively for distance between nares, and 10·16, 10.88, and 13·79 mm, respectively for distance from subnasion to upper lip. Modeled facial contours conveniently clustered into three average sizes which could be used as templates for the design of medical instruments. CONCLUSION: Capturing of 3D images of infants and young children in LMICs is feasible using portable cameras and computerized analysis. This method and these specific data on Congolese pediatric facial dimensions may assist in the design of appropriately sized medical devices (thermometers, face masks, pulse oximeters, etc.) for this population.

Delayed surgery leads to reduced elbow range of motion in children with supracondylar humeral fractures managed at a referral hospital in sub-Saharan Africa.

BACKGROUND: Supracondylar humeral fractures (SHFs) in children are associated with morbidity due to elbow stiffness. Timely operative management and/or physiotherapy are thought to reduce this complication, but pose challenges in settings with limited resources for health. METHODS: This prospective cohort study included 45 pediatric patients with isolated SHF at a large tertiary hospital in Nairobi, Kenya. Patients were managed non-operatively or operatively with varying wait times to surgery, with or without physiotherapy. The measurement of elbow ROM was done up to 12 weeks after removal of Kirshner wires and/or backslab. RESULTS: Elbow ROM increased in the follow-up period, yet residual restricted mobility in the flexion-extension plane was common. Delayed surgical management ≥7 days was associated with reduced elbow ROM in the flexion-extension plane at 12 weeks median IQR 105° 92°-118° vs 120° 108°-124°, p=0.029. Physiotherapy was associated with reduced ROM at 12 weeks p=0.003, possibly due to the use of prolonged immobilization. CONCLUSION: In this study of pediatric SHFs at a resource-limited hospital, elbow flexion was restricted at 12 weeks follow-up and was associated with major delays in operative management. Quality of orthopedic surgical care and physiotherapy services in low-resource settings deserves further attention.

Worms and war: a case report of trauma and tropical disease intersecting.

BACKGROUND: We report a case of heavy intestinal infestation with Ascaris lumbricoides complicating the surgical management of a gunshot injury to the abdomen. Co-existent traumatic and infectious pathologies in this case highlight the complex burden of illness among children living in areas of violent conflict, with clinical relevance to trauma surgeons in the tropics.