International medical electives in Sub-Saharan Africa: experiences from a 19-year NGO-driven initiative.

BACKGROUND: Mainstream medical education remains largely focused on national health issues. Therefore, in order to expose medical students to international health issues, it is beneficial to facilitate international medical electives. METHODS: This article describes the Junior Project Officer (JPO) program, a medical experience based on clinical electives in Sub-Saharan Africa, supported by a Non-Governmental Organisation (NGO). Residents spend 6 months as part of a multidisciplinary medical team in Africa. A post-elective online survey was administered to all who participated in the program in the period 2002-2020. The questionnaire comprised three domains: (i) general and pre-departure information; (ii) the experience; (iii) the post-experience. RESULTS: Questionnaires were received from 157/241 subjects, a response rate of 65%. The most common specialties were pediatrics, public health, and internal medicine. Of all, 87% carried out clinical activities; 45% also worked in the management of health services, and 60% carried out research activities. About 64% reported difficulties linked to a lack of equipment, different ways of working (57%), and exposure to situations for which they did not feel technically prepared (56%). In 25% of cases, residents reported that their school's attitude to their doing the elective was not positive: upon their return, over 50% felt that their experience was not sufficiently valued by their institution. Respondents considered the experience important for professional and personal growth (93% and 80% respectively ). Forty-two participants (27%) reported that the experience had a significant impact on their future career choices. CONCLUSION: Despite the difficulties encountered, a well-structured experience in international health can have a positive impact on residents, professionally and personally. Key factors behind the positive outcomes are the substantial length (6 months) of the experience, and the long term working relationships between the sending and receiving institutions. The schools in Italy that provide the students for the electives need to see more evidence that international electives are worth the investment.

An integrated hospital-district performance evaluation for communicable diseases in low-and middle-income countries: Evidence from a pilot in three sub-Saharan countries.

INTRODUCTION: The last two decades saw an extensive effort to design, develop and implement integrated and multidimensional healthcare evaluation systems in high-income countries. However, in low- and middle-income countries, few experiences of such systems implementation have been reported in the scientific literature. We developed and piloted an innovative evaluation tool to assess the performance of health services provision for communicable diseases in three sub-Saharan African countries. MATERIAL AND METHODS: A total of 42 indicators, 14 per each communicable disease care pathway, were developed. A sub-set of 23 indicators was included in the evaluation process. The communicable diseases care pathways were developed for Tuberculosis, Gastroenteritis, and HIV/AIDS, including indicators grouped in four care phases: prevention (or screening), diagnosis, treatment, and outcome. All indicators were calculated for the period 2017-2019, while performance evaluation was performed for the year 2019. The analysis involved four health districts and their relative hospitals in Ethiopia, Tanzania, and Uganda. RESULTS: Substantial variability was observed over time and across the four different districts. In the Tuberculosis pathway, the majority of indicators scored below the standards and below-average performance was mainly reported for prevention and diagnosis phases. Along the Gastroenteritis pathway, excellent performance was instead evaluated for most indicators and the highest scores were reported in prevention and treatment phases. The HIV/AIDS pathway indicators related to screening and outcome phases were below the average score, while good or excellent performance was registered within the treatment phase. CONCLUSIONS: The bottom-up approach and stakeholders' engagement increased local ownership of the process and the likelihood that findings will inform health services performance and quality of care. Despite the intrinsic limitations of data sources, this framework may contribute to promoting good governance, performance evaluation, outcomes measurement and accountability in settings characterised by multiple healthcare service providers.

Management of mothers and neonates in low resources setting during covid-19 pandemia.

The coronavirus disease (COVID-19) epidemic started in the Hubei province of China, but is rapidly spreading all over the world. Much of the information and literature have been centered on the adult population while a few reports pertaining to COVID-19 and neonates have been published so far. Actual guidelines are based on expert opinion and show significant differences among the official neonatal societies around the world. Recommendations for the care of neonates born to suspected or confirmed COVD-19 positive mothers in low-resource settings are very limited. This perspective aims to provide practical support for the planning of delivery, resuscitating, stabilizing, and providing postnatal care to an infant born to a mother with suspected or confirmed COVID-19 in low-resource settings where resources for managing emergency situations are limited.

Back rubs or foot flicks for neonatal stimulation at birth in a low-resource setting: A randomized controlled trial.

BACKGROUND: Approximately 15% of infants require stimulation in low-resource settings, but data on effectiveness of different stimulation approaches are limited. We aimed to compare two recommended approaches of stimulation (back rubs vs. foot flicks) in reducing the need for face-mask ventilation in newly born infants who were not crying immediately after birth in a low-resource setting. METHODS: A single center, open-label, randomized, superiority trial was conducted at St. Kizito Hospital in Matany (Uganda) between November 2019 and May 2020. Newly born infants with expected birthweight > 1500 grams who were not crying immediately after birth were randomly assigned to stimulation using back rubs or foot flicks. The primary outcome measure was the success rate of the stimulation, defined as the achievement of an effective crying preventing the need for face-mask ventilation. RESULTS: Success of stimulation was achieved in 76/93 neonates (82%) using back rubs and 68/93 neonates (73%) using foot flicks (risk ratio 1.12, 95% confidence interval 0.96-1.31). No procedure-associated complications arose during the study. Time to first cry was not statistically different between the two arms (mean difference -11 seconds, 95% confidence interval -39 to 18). CONCLUSIONS: In newly born infants who were not crying immediately after birth, this trial did not provide a conclusive message in favor of back rubs or foot flicks. Nonetheless, we could not exclude a possible benefit of back rubs in avoiding the need for positive pressure ventilation and, possibly, further advanced resuscitative maneuvers. CLINICAL TRIALS REGISTRATION: clinicalTrial.gov: NCT04056091.

Intestinal perforation due to typhoid fever in Karamoja (Uganda).

INTRODUCTION: This is a retrospective analysis of patients operated for typhoid perforation, aiming to analyze epidemiology, clinical-diagnostic and therapeutic aspects, mortality and prognosis. METHODS: 47 patients were operated at Matany Hospital from 2010 to 2016. We examined clinical files to collect data. Microbiological and isthological examinations were unavailable, so etiology was deducted operatively. RESULTS: Median age: 17.85 years, 61.7% of patients were male, 74.47% perforated within two weeks from the onset of symptoms. Every radiological investigation (X-Rays and Ultrasound Scans) resulted positive. 40 patients underwent primary repair, 4 underwent resection. 72.34% experienced postoperative complications, SSI (Surgical Site Infection) occurred in 40.42%. Mortality rate reached 5.56% in patients without organ failure (vs 31.03%) and 11.76% (vs 20.51%) in patients operated within 24 hours from perforation. An MPI (Mannheim Peritonitis Index) score >30 was related with a mortality rate of 36% (vs 3.45%). CONCLUSIONS: Peak of incidence occurs at the end of rainy season. Majority of patients are young men. Main symptoms are fever and signs of intestinal obstruction, with a shorter period before perforation. Primary repair is the technique of choice for single perforations, resection for multiple ones, right colectomy in case of cecal involvement, ileostomy for important peritoneal contamination. SSI are the most frequent complications, enteric fistulas the most severe ones. Mortality rate is around 21.28%. Important prognostic factors are time between perforation and operation and the presence of organ failure. An MPI score >30 is related with a poorer prognosis. KEY WORDS: Prognostic factors, Surgical treatment, Typhoid perforation, Uganda.