The African Surgical OutcomeS-2 (ASOS-2) Pilot Trial, a mixed-methods implementation study

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. The working hypothesis is that patients die as a result of failure to rescue following complications in the postoperative period. The African Surgical OutcomeS-2 (ASOS-2) Trial plans to test the efficacy of increased postoperative surveillance in high risk patients for decreasing perioperative morbidity and mortality. This pilot trial aimed i) to evaluate the adequacy of data produced by the data collection strategies of the ASOS-2 Trial, ii) to evaluate the fidelity of implementation of the increased postoperative surveillance intervention, and iii) to understand the acceptability, appropriateness and feasibility of the intervention and the trial processes.Methods: The ASOS-2 Pilot Trial was a mixed-methods (quantitative-qualitative) implementation study focusing on the intervention arm of the proposed ASOS-2 Trial. The intervention is increased postoperative surveillance for high-risk surgical patients. The intervention protocol was implemented at all sites for a seven-day period. A post pilot trial survey was used to collect data on the implementation outcomes.Results: 803 patients were recruited from 16 hospitals in eight African countries. The sampling and data collection strategies provided 98% complete data collection. Seventy-three percent of respondents believed that they truly provided increased postoperative surveillance to high risk patients. In reality 83/125 (66%) of high-risk patients received some form of increased postoperative surveillance. However, the individual components of the increased postoperative surveillance intervention were implemented in less than 50% of high-risk patients (excepting increasing nursing observations). The components most frequently unavailable were the ability to provide care in a higher care ward (32.1%) and assigning the patient to a bed in view of the nurses’ station (28.4%). Failure to comply with available components of the intervention ranged from 27.5% to 54.3%. The post pilot survey had a response rate of 30/40 (75%). In Likert scale questions about acceptability, appropriateness, and feasibility of the ASOS-2 intervention, 63% to 87% of respondents indicated agreement. Respondents reported barriers related to resources, trial processes, teamwork and communication as reasons for disagreement.Conclusions: The proposed ASOS-2 Trial appears to be appropriate, acceptable and feasible in Africa. This pilot trial provides support for the proposed ASOS-2 Trial. It emphasises the need for establishing trial site teams which address the needs of all stakeholders during the trial. A concerted effort must be made to help participating hospitals to increase compliance with all the components of the proposed intervention of ‘increased postoperative surveillance’ during the ASOS-2 Trial.Keywords: Trial, cluster randomised, Trial, pilot, Implementation science, Mixed methods, Mortality, Surger

The African surgical outcomes-2 (Asos-2) pilot trial, a mixed-methods implementation study

Funding Information: The ASOS-2 Pilot Trial was supported by a grant (OPP#1161108) from the Bill & Melinda Gates Foundation.Peer reviewe

Iatrogenic retractile quadriceps fibrosis within children in Benin: Epidemiological, clinical, therapeutical aspects

Background: In tropical countries, iatrogenic retractile quadriceps fibrosis (IRQF), the cause of walking handicap in children, is often the result of intraquadricipital injection of quinine salts. The aim of this review was to analyse the epidemiological, clinical, therapeutic aspects and outcome of IRQF in children admitted in three hospitals in Benin Republic. Patients and Methods: It was a 10-year retrospective, descriptive and analytic survey of IRQF, involving 81 children aged from 8 months to 15 years. Iterative mobilization of the knee (IMK) or modified distal quadriceps plasty by Thompson-Payr′s technique (MDQTPT), with a POP on the knee in flexion position, was performed with additional functional rehabilitation. The results were evaluated on knee flexion gain and walking quality. Data were processed using Epi Info 3.2 software. Results: Patients′ average age was 7.60 years. Children of 6-10 years were most affected; sex ratio was 1.02. Lesions were unilateral (71.6%) and bilateral (28.4%). The knees′ stiffness was in flexion (10.57%), rectitude (64.42%) and recurvatum (25%). The amyotrophy of the thigh was found in 79.42 %. The IMK was successful in eight cases (7.69 %) and the MDQTPT was done in 98 cases (94.23%) associated with femoral osteotomy in 13 cases (12.50%). In post-surgical period, skin necrosis and fractures occurred respectively in 15.31% and 5.10%. Results were good in 92.31% of cases. Conclusions: IRQF in children do exist in our settings. The treatment that is based on MDQTPT associated to rehabilitation leads to acceptable outcome

Anaesthetic Management of Homozygous Sickle Cell Patients at Niamey National Hospital, Niger

Background: Sickle cell disease is a common comorbidity in patient presenting for surgical care in our hospitals. The aim of this study was to evaluate the outcome of anaesthetic management of sickle cell disease patients in our hospital.Patients and method: A prospective audit was conducted for a period of 12 months, from 1st March 2015 to 29th February, 2016. Included were all homozygous sickle cell patients who underwent anaesthesia. The following variables were studied: age, sex, blood transfusion, hemoglobin level, ASA status, type of anaesthesia, pre-, intra- and post-operative management and outcome.Results: Thirty (30) patients with homozygous sickle-cell disease were found among the 3882 patients who were operated on (0.77%). Mean age was 12 ± 8 years, with a range from 9 months to 36 years. More than half of the patients were female (53.3%) with a sex ratio of 1.14. Hemoglobin level was less than 7 g / dl in 23.33%. Only 6.67% of patients had hemoglobin level above 10 g / dl. Of the 30 patients, 93.34% were ASA II, 36.70% had preoperative transfusion, surgery was elective in 93.30% and emergent in 6.70%. The commonest surgical procedures were tonsillectomy in 26.66%. General anaesthesia was performed in 96.70% of patients, spinal anaesthesia in 3.30%. Intraoperative incidents occurred in 23.33%. Intraoperative transfusion was given to 43.30% of patients. Mortality rate was 10%.Conclusion: Anaesthetic management of the sickle cell patient in our hospital is challenging due to lack of transfusion procedures and exchange transfusions.Keywords: Sickle cell disease, anaesthesia, outcome, Niamey, Nige

Anesthesia Provider Training and Practice Models: A Survey of Africa.

This is the accepted manuscript version of an article published in Anesthesia & Analgesia online at doi: 10.1213/ANE.0000000000004302BACKGROUND: In Africa, most countries have fewer than 1 physician anesthesiologist (PA) per 100,000 population. Nonphysician anesthesia providers (NPAPs) play a large role in the workforce of many low- and middle-income countries (LMICs), but little information has been systematically collected to describe existing human resources for anesthesia care models. An understanding of existing PA and NPAP training pathways and roles is needed to inform anesthesia workforce planning, especially for critically underresourced countries. METHODS: Between 2016 and 2018, we conducted electronic, phone, and in-person surveys of anesthesia providers in Africa. The surveys focused on the presence of anesthesia training programs, training program characteristics, and clinical scope of practice after graduation. RESULTS: One hundred thirty-one respondents completed surveys representing data for 51 of 55 countries in Africa. Most countries had both PA and NPAP training programs (57%; mean, 1.6 pathways per country). Thirty distinct training pathways to become an anesthesia provider could be discriminated on the basis of entry qualification, duration, and qualification gained. Of these 30 distinct pathways, 22 (73%) were for NPAPs. Physician and NPAP program durations were a median of 48 and 24 months (ranges: 36-72, 9-48), respectively. Sixty percent of NPAP pathways required a nursing background for entry, and 60% conferred a technical (eg, diploma/license) qualification after training. Physicians and NPAPs were trained to perform most anesthesia tasks independently, though few had subspecialty training (such as regional or cardiac anesthesia). CONCLUSIONS: Despite profound anesthesia provider shortages throughout Africa, most countries have both NPAP and PA training programs. NPAP training pathways, in particular, show significant heterogeneity despite relatively similar scopes of clinical practice for NPAPs after graduation. Such heterogeneity may reflect the varied needs and resources for different settings, though may also suggest lack of consensus on how to train the anesthesia workforce. Lack of consistent terminology to describe the anesthesia workforce is a significant challenge that must be addressed to accelerate workforce research and planning efforts

Participatory development and pilot testing of the Makasi intervention : a community-based outreach intervention to improve sub-Saharan and Caribbean immigrants' empowerment in sexual health

Background: Sub-Saharan and Caribbean immigrants are particularly affected by HIV in Europe, and recent evidence shows that a large portion of them acquired HIV after arrival. There is a need for efficient interventions that can reduce immigrants' exposure to HIV. We describe the pilot phase of a community-based empowerment outreach intervention among sub-Saharan and Caribbean immigrants in the greater Paris area aimed at 1) constructing the intervention, 2) assessing its feasibility, and 3) assessing the feasibility of its evaluation based on a stepped-wedge approach. Methods: 1) To develop the intervention, a literature review was conducted on existing interventions and participatory approaches developed, including the constitution of peer groups. 2) To assess the intervention's feasibility, a pilot was conducted between April 2018 and December 2018. A daily register was used to collect data on sociodemographic characteristics of all persons who visited the mobile team to assess eligibility and acceptability. 3) To assess the feasibility of performing a stepped-wedge trial to evaluate the intervention, we compared eligibility, enrolment and retention at 3 months in two arms (immediate vs deferred). Chi-squared tests were used to compare reach and retention between the two arms. Results: Intervention development. The Makasi intervention was designed as an outreach intervention that starts with the persons' capacities and helps them appropriate existing resources and information and obtain knowledge about sexual health, based upon motivational interviewing techniques. Intervention Feasibility. Between April 2018 and December 2018, a total of 485 persons were identified as eligible. Participation in the intervention was proposed to 79% of eligible persons. When proposed, the persons enrolled in the intervention with a response rate of 69%. Some were lost to follow-up, and 188 persons were finally included. Evaluation Feasibility. The proportions of eligible (45 and 42%) individuals and of enrolled individuals (65 and 74%) were similar and not significantly different in the immediate and deferred arms, respectively. Conclusions: A community-based outreach intervention aimed at improving sub-Saharan and Caribbean immigrants' empowerment in sexual health is feasible. The pilot phase was key to identifying challenges, designing a relevant intervention and validating the stepped-wedge protocol for evaluation

Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study : a 7-day prospective observational cohort study

CITATION: Bishop, D. et al. Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study : a 7-day prospective observational cohort study. The Lancet Global Health, 7(2):e513-e522. doi:10.1016/S2214-109X(19)30036-1The original publication is available at https://www.thelancet.com/journals/langlo/issue/vol7no2/PIIS2214-109X(19)X0002-9Background: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. Methods: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. Findings: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100000 population (IQR 0·2–2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3–0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2–18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46–13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99–17·34]) or anaesthesia complications (11·47 (1·20–109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7–5·0). Interpretation: Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa.https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30036-1/fulltextPublisher’s versio