Surgical residency: A tenant’s view

No Abstrac

Acute pancreatitis at the Aga Khan University Hospital, Nairobi: a two year audit

BACKGROUND: Acute pancreatitis ranges in severity from a mild, self-limiting to a fulminant disease with systemic decompensation. The treatment of the severe form of the disease may be difficult with mortality rates of up to 30%. There are published, evidence-based guidelines for optimizing outcome of the disease (1,2). We performed this audit to determine whether our clinical practice conformed to these guidelines. AIM: To audit the management of patients admitted with acute pancreatitis at the Aga Khan University Hospital (AKUH) and compare the current practice with accepted international guidelines (1,2) with respect to diagnostic modalities, severity stratification, critical care unit (CCU) management for severe disease, timing of treatment intervention strategies and mortality. DESIGN: Retrospective audit of hospital records. METHODS: The medical records of all patients admitted to the AKUH with a diagnosis of acute pancreatitis from 1st January 2005 to 31st January 2007 were reviewed. RESULTS: Thirty five patients were admitted with a confirmed diagnosis of acute pancreatitis in the two year period. Twenty six patients were males (74%). The median age was 46 years (range 29-82 years). The aetiology of the acute pancreatitis was alcohol in 51%, gallstones in 11%, other causes in 9% and idiopathic in 29% of patients. The median length of hospital stay was 11 days (range 1–38). The diagnosis of acute pancreatitis was confirmed by amylase and lipase assays or with CT scan evidence of pancreatitis. Only three patients (8%) had formal severity stratification (Ranson’s score). Eight patients (23%) had severe disease as defined by pancreatic necrosis and need for critical care. Twenty seven patients with mild disease also underwent abdominal CT scans and only 54% of all patients had an initial ultrasound to exclude gallstones. The timing of these investigations was arbitrary. Ten patients with mild disease received unnecessary prophylactic antibiotics including metronidazole, cefuroxime, and tazobactam/piperacillin for a median period of 7 days. In severe disease where antibiotic use is possibly justifiable, a carbapenem based antibiotic was prescribed for four patients. Nasojejunal feeding was instituted early in six patients with severe disease and parenteral nutrition was also used exclusively in one patient. The overall mortality was 2.9% with the only death occurring in the severe subgroup thereby making the mortality rate in those patients with severe acute pancreatitis in this audit 12.5%. CONCLUSIONS: The current management of acute pancreatitis at AKUH is physician dependant and not in conformity with the established and recommended guidelines. The CT scans were over-prescribed, their timing inappropriate and efforts to exclude the cause of pancreatitis moderate. The mortality rate is acceptable by international standards despite uniform application of diagnostic and risk stratification tools

Institutional Framing and Entrepreneurship Capital in Uganda

Institutions are made up of formal (e.g., rules, laws, constitutions), informal (e.g., norms of behavior, conventions, self-imposed codes of conduct) constraints and their enforcement characteristics that define the incentive structure of societies and economies (North, 1994)

Stigma, survivorship and solutions: Addressing the challenges of living with breast cancer in low-resource areas

Breast cancer in developing nations is characterised by late diagnosis. The causes are multifactorial and many are addressed in other articles in this edition of CME. Breast cancer is also seen in younger women. The late-presentation trend is slowly changing in some areas, and an increasing number of women are presenting with early disease. These patients, if managed appropriately, have a more favourable prognosis. As a result, developing nations must now begin to consider the concerns of breast cancer survivorship. In developed countries, there are a number of organisations that support breast cancer survivors. In this article, we highlight some of the psychosocial aspects of living with breast cancer in low-resource areas

Effect of a Participatory Multisectoral Maternal and Newborn Intervention on Birth Preparedness and Knowledge of Maternal and Newborn Danger Signs among Women in Eastern Uganda: A Quasiexperiment Study

Background: Knowledge of obstetric danger signs and adequate birth preparedness (BP) are critical for improving maternal services utilization. Objectives: This study assessed the effect of a participatory multi-sectoral maternal and newborn intervention on BP and knowledge of obstetric danger signs among women in Eastern Uganda. Methods: The Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study was implemented in three districts from 2013 to 2015 using a quasi-experimental pre–post comparison design. Data were collected from women who delivered in the last 12 months. Difference-in-differences (DiD) and generalized linear modelling analysis were used to assess the effect of the intervention on BP practices and knowledge of obstetric danger signs. Results: The overall BP practices increased after the intervention (DiD = 5, p < 0.05). The increase was significant in both intervention and comparison areas (7–39% vs. 7–36%, respectively), with a slightly higher increase in the intervention area. Individual savings, group savings, and identification of a transporter increased in both intervention and comparison area (7–69% vs. 10–64%, 0–11% vs. 0–5%, and 9–14% vs. 9–13%, respectively). The intervention significantly increased the knowledge of at least three obstetric danger signs (DiD = 31%) and knowledge of at least two newborn danger signs (DiD = 21%). Having knowledge of at least three BP components and attending community dialogue meetings increased the odds of BP practices and obstetric danger signs’ knowledge, respectively. Village health teams’ home visits, intervention area residence, and being in the 25+ age group increased the odds of both BP practices and obstetric danger signs’ knowledge. Conclusions: The intervention resulted in a modest increase in BP practices and knowledge of obstetric danger signs. Multiple strategies targeting women, in particular the adolescent group, are needed to promote behavior change for improved BP and knowledge of obstetric danger signs.DFI

Working with Community Health Workers to Improve Maternal and Newborn Health Outcomes: Implementation and Scale-Up Lessons from Eastern Uganda

Background: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation. Objectives: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy. Methods: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences. Results: CHWs’ knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (≥ 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles. Conclusions: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.DFI

Identification of tungiasis infection hotspots with a low-cost, high-throughput method for extracting Tunga penetrans (Siphonaptera) off-host stages from soil samples–An observational study

Background: The sand flea, Tunga penetrans, is the cause of a severely neglected parasitic skin disease (tungiasis) in the tropics and has received little attention from entomologists to understand its transmission ecology. Like all fleas, T. penetrans has environmental off-host stages presenting a constant source of reinfection. We adapted the Berlese-Tullgren funnel method using heat from light bulbs to extract off-host stages from soil samples to identify the major development sites within rural households in Kenya and Uganda. Methods and findings: Simple, low-cost units of multiple funnels were designed to allow the extraction of >60 soil samples in parallel. We calibrated the method by investigating the impact of different bulb wattage and extraction time on resulting abundance and quality of off-host stages. A cross-sectional field survey was conducted in 49 tungiasis affected households. A total of 238 soil samples from indoor and outdoor living spaces were collected and extracted. Associations between environmental factors, household member infection status and the presence and abundance of off-host stages in the soil samples were explored using generalized models. The impact of heat (bulb wattage) and time (hours) on the efficiency of extraction was demonstrated and, through a stepwise approach, standard operating conditions defined that consistently resulted in the recovery of 75% (95% CI 63–85%) of all present off-host stages from any given soil sample. To extract off-host stages alive, potentially for consecutive laboratory bioassays, a low wattage (15–25 W) and short extraction time (4 h) will be required. The odds of finding off-host stages in indoor samples were 3.7-fold higher than in outdoor samples (95% CI 1.8–7.7). For every one larva outdoors, four (95% CI 1.3–12.7) larvae were found indoors. We collected 67% of all off-host specimen from indoor sleeping locations and the presence of off-host stages in these locations was strongly associated with an infected person sleeping in the room (OR 10.5 95% CI 3.6–28.4). Conclusion: The indoor sleeping areas are the transmission hotspots for tungiasis in rural homes in Kenya and Uganda and can be targeted for disease control and prevention measures. The soil extraction methods can be used as a simple tool for monitoring direct impact of such interventions

Characteristics of community savings groups in rural Eastern Uganda: opportunities for improving access to maternal health services

Background: Rural populations in Uganda have limited access to formal financial Institutions, but a growing majority belong to saving groups. These saving groups could have the potential to improve household income and access to health services. Objective: To understand organizational characteristics, benefits and challenges, of savings groups in rural Uganda. Methods: This was a cross-sectional descriptive study that employed both quantitative and qualitative data collection techniques. Data on the characteristics of community-based savings groups (CBSGs) were collected from 247 CBSG leaders in the districts of Kamuli, Kibukuand Pallisa using self-administered open-ended questionnaires. To triangulate the findings, we conducted in-depth interviews with seven CBSG leaders. Descriptive quantitative and content analysis for qualitative data was undertaken respectively. Results: Almost a quarter of the savings groups had 5–14 members and slightly more than half of the saving groups had 15–30 members. Ninety-three percent of the CBSGs indicated electing their management committees democratically to select the group leaders and held meetings at least once a week. Eighty-nine percent of the CBSGs had used metallic boxes to keep their money, while 10% of the CBSGs kept their money using mobile money and banks, respectively. The main reasons for the formation of CBSGs were to increase household income, developing the community and saving for emergencies. The most common challenges associated with CBSG management included high illiteracy (35%) among the leaders, irregular attendance of meetings (22%), and lack of training on management and leadership (19%). The qualitative findings agreed with the quantitative findings and served to triangulate the main results. Conclusions: Saving groups in Uganda have the basic required structures; however, challenges exist in relation to training and management of the groups and their assets. The government and development partners should work together to provide technical support to the groups

Maternal and Neonatal Implementation for Equitable Systems. A Study Design Paper

Background: Evidence on effective ways of improving maternal and neonatal health outcomes is widely available. The challenge that most low-income countries grapple with is implementation at scale and sustainability. Objectives: The study aimed at improving access to quality maternal and neonatal health services in a sustainable manner by using a participatory action research approach. Methods: The study consisted of a quasi-experimental design, with a participatory action research approach to implementation in three rural districts (Pallisa, Kibuku and Kamuli) in Eastern Uganda. The intervention had two main components; namely, community empowerment for comprehensive birth preparedness, and health provider and management capacity-building. We collected data using both quantitative and qualitative methods using household and facility-level structured surveys, record reviews, key informant interviews and focus group discussions. We purposively selected the participants for the qualitative data collection, while for the surveys we interviewed all eligible participants in the sampled households and health facilities. Descriptive statistics were used to describe the data, while the difference in difference analysis was used to measure the effect of the intervention. Qualitative data were analysed using thematic analysis. Conclusions: This study was implemented to generate evidence on how to increase access to quality maternal and newborn health services in a sustainable manner using a multisectoral participatory approach.DFI