Essential surgery delivery in the Northern Kivu Province of the Democratic Republic of the Congo.

INTRODUCTION: Surgical services are an essential part of a functional healthcare system, but the Lancet Commission of Global Surgery (LCoGS) indicators of surgical capacity such as perioperative workforce and surgical volume are unknown in many low- and middle-income countries (LMICs) including the Democratic Republic of Congo (DRC). We aimed to determine the surgical capacity and its associated factors within the DRC. METHODS: Hospitals were assessed in the North Kivu province of the DRC. Hospital characteristics and surgical rates were determined using the WHO-PGSSC hospital assessment tool and operating room (OR) registries. The primary outcome of interest was the number of Bellwether operations (i.e. Caesarean sections, laparotomies, and external fixation for bone fractures) per 100,000 people. Univariate and multiple linear regressions were performed. Primary predictors were the number of trained surgeons, anaesthesiologists, and obstetricians (SAOs) and the number of perioperative providers (including clinical officers and nurse anaesthetists) per 100,000 people. RESULTS: Twenty-eight hospitals in North Kivu were assessed over one year in 2021; 24 (86%) were first-level referral health centres while 4 (14%) were second-level referral hospitals. In total, 11,176 Bellwether procedures were performed in the region in one year. Rates per 100,000 people were 1,461 Bellwether surgical interventions, 1.05 SAOs, and 13.1 perioperative providers. In univariate linear regression analysis, each additional SAO added 239 additional cases annually (p = 0.023), while each additional perioperative provider added 110 cases annually (p < 0.001). In our multiple regression analysis adjusting for other hospital services, the association between workforce and Bellwether surgeries was no longer significant. CONCLUSIONS: The surgical workforce in DRC did not meet the LCoGS benchmark of 20 SAOs per 100,000 people but was not an independent predictor of surgical capacity. Major investment is needed to simultaneously bolster healthcare facilities and increase surgical workforce training.

Determinants of Access to Essential Surgery in the Democratic Republic of Congo.

INTRODUCTION: In the Democratic Republic of Congo (DRC), the determinants and barriers of essential surgical care are not well described, hindering efforts to improve national surgical programs and access. METHODS: A cross-sectional study evaluated access to essential surgery in the Butembo and Katwa health zones in the North Kivu province of DRC. A double-clustered random sample of community members was surveyed using questions derived from the Surgeons OverSeas Surgical Needs Assessment Survey, a validated tool to determine the reasons for not seeking, reaching, or receiving a Bellwether surgery (i.e., caesarean delivery, laparotomy, and external fixation of a fracture) when needed. RESULTS: Overall, 887 households comprising 5944 community members were surveyed from April to August 2022. Six percent (n = 363/5944) of the study population involving 35% (n = 309/887) households needed a Bellwether surgery in the previous year, 30% (n = 108/363) of whom died. Of those who needed surgery, 25% (n = 78) did not go to the hospital to seek care and were more likely to find transportation unaffordable (P = 0.042). The most common reasons for not seeking care were lack of funds for hospitalization, prior poor hospital experience, and fear of hospital care. CONCLUSIONS: Access and delivery of essential surgery are drastically limited in the North Kivu province of the DRC, such that a quarter of households needing surgery fails to seek surgical care. Poor access was predominantly driven by households' inability to pay for surgery and community distrust of the hospital system.

Fake drugs: Using Baseline Spectral Fingerprinting and a sorting algorithm to infer quality of medications.

An estimated 30-70% of available medications in low-income countries and conflict states are of low quality or counterfeit. Reasons for this vary but most are rooted in regulatory agencies being poorly equipped to oversee quality of pharmaceutical stocks. This paper presents the development and validation of a method for point-of-care drug stock quality testing in these environs. The method is termed Baseline Spectral Fingerprinting and Sorting (BSF-S). BSF-S leverages the phenomena that all compounds in solution have nearly unique spectral profiles in the UV spectrum. Further, BSF-S recognizes that variations in sample concentrations are introduced when preparing samples in the field. BSF-S compensates for this variability by incorporating the ELECTRE-TRI-B sorting algorithm, which contains parameters that are trained in the laboratory using authentic, proxy low quality and counterfeit samples. The method was validated in a case study using fifty samples that include factually authentic Praziquantel and inauthentic samples prepared in solution by an independent pharmacist. Study researchers were blinded to which solution contained the authentic samples. Each sample was tested by the BSF-S method described in this paper and sorted to authentic or low quality/counterfeit categories with high levels of specificity and sensitivity. In combination with a companion device under development using ultraviolet light emitting diodes, the BSF-S method is intended to be a portable and low-cost method for testing medications for authenticity at or near the point-of-care in low income countries and conflict states.

Improving the tactical scanning of student pilots: A gaze-based training intervention for transition from visual flight into instrument meteorological conditions.

Eye tracking has been applied to train novice drivers and clinicians; however, such applications in aviation are limited. This study develops a gaze-based intervention using video-based, expert commentary, and 3M (Mistake, Mitigation, Mastery) training to instruct visual flight rule student pilots on an instrument cross-check to mitigate the risk of losing aircraft control when they inadvertently enter instrument meteorological conditions (IMC). Twenty general aviation student pilots were randomized into control and experimental groups. Dwell time, return time, entropy, Kullback-Leibler divergence, and deviations from flight paths were compared before and after training to straight-and-level-flight (LF) and standard left level turn (LT) scenarios. After the training, the experimental pilots significantly increased dwell time on primary instruments (PIs), reduced randomness in visual search, and fixated on the PIs in shorter times (in the scenario of LT). In terms of piloting, all experimental pilots successfully kept the aircraft control while five control pilots lost control in IMC; significant differences in altitude and rate of climb deviations were observed between groups (in the scenario of LF).

Albendazole Treatment Improves Work Capacity in Women Smallholder Farmers Infected with Hookworm: A Double-Blind Randomized Control Trial.

An estimated 4.7 billion people live in regions exposed to soil-transmitted helminths, intestinal parasites that have significant impacts on the health of women smallholder farmers. The goal of this trial was to determine whether treatment with albendazole impacts the work capacity of these farmers. This is a prospective double-blind, randomized effectiveness trial. Participants (N = 250) were randomly selected from safe motherhood groups in the Democratic Republic of Congo. Prevalence/intensity of hookworm infection, hemoglobin, and demographics was obtained. At study (Time = 0), participants were randomized into treatment (albendazole 400 mg) and placebo (similar placebo tablet) groups. A step test was administered as a proxy metric for work capacity. Work capacity was defined as ∆heart rate before and after 3 minutes of step testing, in beats per minute. At study (time = 7 months), the step test was repeated and work capacity remeasured. The ∆work capacity (time = 0 minus time = 7 months) was the primary outcome. Investigators/field assistants were blinded to who was enrolled in groups, hookworm status, and step test results. Regression showed highly significant interactive effects of hookworm status and treatment group relative to ∆work capacity after controlling for resting pulse rate and age (P < 0.002). Estimated marginal means for work capacity (WC) for each of four groups (hookworm positive plus placebo, hookworm positive plus treatment, hookworm negative plus placebo, and hookworm negative plus treatment) showed women who were hookworm positive and received treatment decreased heart rate by 9.744 (95% confidence interval [CI]: 6.42, 13.07) beats per minute (increased WC), whereas women who were hookworm positive and received placebo saw a nonsignificant decrease of 0.034 (95% CI: -3.16, 3.84) beats per minute. Treatment with albendazole was associated with improved aerobic work capacity posttreatment. Given modest costs of drug distributions, risk benefits of periodic deworming warrants further study in larger controlled trials.

Getting It Right the First Time: Defining Regionally Relevant Training Curricula and Provider Core Competencies for Point-of-Care Ultrasound Education on the African Continent.

Significant evidence identifies point-of-care ultrasound (PoCUS) as an important diagnostic and therapeutic tool in resource-limited settings. Despite this evidence, local health care providers on the African continent continue to have limited access to and use of ultrasound, even in potentially high-impact fields such as obstetrics and trauma. Dedicated postgraduate emergency medicine residency training programs now exist in 8 countries, yet no current consensus exists in regard to core PoCUS competencies. The current practice of transferring resource-rich PoCUS curricula and delivery methods to resource-limited health systems fails to acknowledge the unique challenges, needs, and disease burdens of recipient systems. As emergency medicine leaders from 8 African countries, we introduce a practical algorithmic approach, based on the local epidemiology and resource constraints, to curriculum development and implementation. We describe an organizational structure composed of nexus learning centers for PoCUS learners and champions on the continent to keep credentialing rigorous and standardized. Finally, we put forth 5 key strategic considerations: to link training programs to hospital systems, to prioritize longitudinal learning models, to share resources to promote health equity, to maximize access, and to develop a regional consensus on training standards and credentialing.

A survey of emergency medicine and orthopaedic physicians' knowledge, attitude, and practice towards the use of peripheral nerve blocks.

INTRODUCTION: Peripheral nerve blocks (also known as regional anaesthesia) are currently used by many anaesthesiologists and emergency physicians for perioperative and procedural pain management. METHODS: This is a cross sectional descriptive study conducted to evaluate knowledge, attitudes, and current practice towards use of peripheral nerve blocks for lower extremity injuries at Black Lion Hospital, a tertiary trauma centre in Addis Ababa. RESULTS: A standardised survey was conducted with 64 participants working in emergency medicine [30/64 (46.9%)] and orthopaedics [34/64 (53.1%)]. Twenty-three of 64 (35.9%) respondents had received formal training. Knowledge was acquired from didactic/workshop format for 15/23 (65.2%), followed by peer training 6/23 (39.1%). The majority, 62/64 (96.9%), believed that knowledge of general anatomy and nerve blocks are very important. Thirty-one of 64 (48%) of the respondents did not routinely perform peripheral nerve blocks. A majority, 27/31 (87.1%) stated they lacked the required skills. Ultrasound guidance of the femoral nerve 16/33 (48.5%) was the most commonly performed peripheral nerve block, followed by ankle block using anatomic landmarks 15/33 (45.5%). Almost all (15/16) ultrasound-guided nerve blocks were done by emergency medicine providers, while all anatomic land mark guided blocks were done by orthopaedic teams. A majority of the respondents (93.8%) (n = 60) were optimistic that their practice on peripheral nerve blocks would increase in future. A highly significant association was found between previous training on peripheral nerve blocks and the number of peripheral nerve blocks performed in a month; p value - 0.006. DISCUSSION: This study indicates peripheral nerve blocks are likely underutilised due to lack of training. There was a positive attitude towards peripheral nerve blocks but gaps on knowledge and practice.

INTRODUCTION: Les blocs nerveux périphériques (également connus sous le nom d'anesthésies locorégionales) sont actuellement utilisées par de nombreux anesthésistes et urgentistes à des fins de gestion de la douleur. MÉTHODES: Cette étude est une étude descriptive cross sectional menée afin d'évaluer les connaissances, attitudes et pratiques actuelles en matière d'utilisation des blocs nerveux périphériques pour les blessures aux extrémités inférieures au Black Lion Hospital, un centre de traumatologie tertiaire à Addis-Abeba. RÉSULTATS: Une étude standardisée a été menée auprès de 64 participants travaillant en médecine d'urgence [30/64 (46,9%)] et en orthopédie [34/64 (53,1%)]. Vingt-trois sur les 64 (35.9%) personnes interrogées ot bénéficié d'une formation formelle. Les connaissances ont été acquises sous forme didactique/d'atelier pour 15/23 (65,2%) d'entre eux, suivies d'une formation par les pairs pour 6/23 (39,1%) d'entre eux. La majorité, 62/64 (96,9 %) d'entre eux, considérait que les connaissances en anatomie générale et les blocs nerveux comme très importantes. Trente et un sur 64 (48%) personnes interrogées ne réalisaient pas régulièrement des blocs nerveux périphériques. Une majorité 27/31 (87,1%) de participants a indiqué ne pas disposer des compétences requises. Ultrasound guidance of the femoral nerve 16/33 (48,5%) était le bloc nerveux périphérique réalisé le plus fréquemment, suivi du ankle block using anatomic landmarks 15/33 (45,5%). La quasi-totalité (15/16) des blocs nerveux ultrasound-guided étaient réalisés par des emergency medicine providers, while all anatomic land mark guided blocks étaient réalisés par des équipes d'orthopédistes. Une majorité de personnes interrogées (93,8%) (n = 60) indiquaient être optimistes quant au fait que leur pratique sur les blocs nerveux périphériques augmenterait à l'avenir. Une association hautement significative a été trouvée entre la formation antérieure sur les blocs nerveux périphériques et le nombre de blocs nerveux périphériques réalisés au cours d'un mois; p value ­ 0,006. DISCUSSION: Cette étude indique que les blocs nerveux périphériques sont probablement sous-utilisés en raison d'un manque de formation. On a pu observer une attitude positive à l'égard des blocs nerveux périphériques, mais des lacunes en matière de connaissances et de pratique.

Alternative Ultrasound Gel for a Sustainable Ultrasound Program: Application of Human Centered Design.

This paper describes design of a low cost, ultrasound gel from local products applying aspects of Human Centered Design methodology. A multidisciplinary team worked with clinicians who use ultrasound where commercial gel is cost prohibitive and scarce. The team followed the format outlined in the Ideo Took Kit. Research began by defining the challenge "how to create locally available alternative ultrasound gel for a low-resourced environment? The "End-Users," were identified as clinicians who use ultrasound in Democratic Republic of the Congo and Ethiopia. An expert group was identified and queried for possible alternatives to commercial gel. Responses included shampoo, oils, water and cornstarch. Cornstarch, while a reasonable solution, was either not available or too expensive. We then sought deeper knowledge of locally sources materials from local experts, market vendors, to develop a similar product. Suggested solutions gleaned from these interviews were collected and used to create ultrasound gel accounting for cost, image quality, manufacturing capability. Initial prototypes used cassava root flour from Great Lakes Region (DRC, Rwanda, Uganda, Tanzania) and West Africa, and bula from Ethiopia. Prototypes were tested in the field and resulting images evaluated by our user group. A final prototype was then selected. Cassava and bula at a 32 part water, 8 part flour and 4 part salt, heated, mixed then cooled was the product design of choice.

Nevo piloso gigante congénito / Giant congential hairy nevus

El nevo piloso gigante congénito, es una patología rara con una incidencia de 1 por cada 30.000 a 100.000 individuos. Se presenta con un tamaño mayor a los 20cm. Puede abarcar entre el 15 y el 35del cuerpo ocupando el tronco, un miembro, etc. Se presenta pigmentado, por lo general de forma dispareja, variando entre el castaño claro y el negro intenso, de consistencia semejante al caparazón de la tortuga y cubierto de pelos largos y gruesos. Comunicamos el caso de 3 niños que al nacimiento mostraron un nevo piloso gigante y múltiples nevos de menor tamaño. Esta Patología requiere extirpación quirúrgica agresiva por motivo estético y reducción del riesgo de degeneración hacia melanoma. En todos estos pacientes debe considerarse el diagnóstico de melanosis neurocutánea por lo que es preciso un seguimiento clínico y de neuroimagen, misma que no tiene tratamiento curativo.

A giant congenital hairy nevus is a rare pathology with an incidence of 1 for every 30,000 to 100,000 person. It is characterized for having a size greater than 20 cm, the color varies from brown to black, and surface texture may vary from smooth to warty and covered by long thick hairs. We have clinical cases of three children that when born had gigantic hairy nevus and multiple nevus of smaller size. This pathology requires surgical removal due to esthetics and the decrease risk of getting melanoma. In these patients we should consider a possible diagnosis of neurocutaneous melanosis a reason why image studies should be done.