A prospective study of the factors affecting access to equitable surgical care in the Southern Province of Rwanda

Background: Access to equitable surgical care significantly reduces morbidity and mortality from traumatic injuries, abdominal, extra-abdominal, acquired and congenital conditions. In Rwanda, like many other developing countries, there are is a wide range of factors affecting access to surgical care across the different levels of health care delivery. The main objective of this study was to document the factors affecting access to surgical care in the Southern Province of Rwanda. Methods: This prospective observational study randomly selected 5 of the 11 district hospitals in the province. The other health unit included was the regional referral hospital for the province, Butare (CHUB). The variables tested included surgical capacity, timeliness, safety, and affordability, for all the included health units in the province. The lists of elective surgical patients, compared with the lists of operated patients over a period of six months, were used to indicate the performance and outputs to surgical access for the various health units in this study. In addition, 5 patient interviews were conducted at each health unit, from patients who were randomly selected, from both the surgical outpatients and the surgical wards. They were questioned regarding their views to surgical care access. Percentages were used to indicate the extent of the challenges to surgical access. Results: The lack of adequate surgical staff was the commonest challenge to surgical access (75% for the district hospitals, and10% for the regional referral hospital) identified. At the regional referral hospital (CHUB), limited operating theatre space was a challenge in 50% of the cases. This was followed by the limited number of specialists and sub-specialties rated at 10%, and limited anesthetic plus ICU facilities rated at 10%. The other challenge was the issue of affordability for the consumables required, rated at 10% The average surgical output and the pending (representing unmet need), calculated from the elective waiting lists for a period of 6 months, indicated that the number of operated patients were rated at 75 %, and an unmet need of surgical access of 25% for CHUB; while for the district hospitals it was 63% with an unmet need of 37%. The patients’ views also pointed at challenges of limited surgical services at the district hospital (70%), and affordability (30%). Conclusions: Access to surgical care in the Southern Province of Rwanda was affected by the limited number of specialists and doctors with the minimum skills to carry out non-specialized operations at the district hospitals, the limited operating theatre facilities, limited sub-specialist services, and specialized investigations. Keywords: surgical care; access; challenges; capacity; safety; affordability; timing

Teaching surgical skills in a resource-limited setting: Comparing massed versus distributed practice in an ultrasound-guided breast biopsy simulator

Background: Teaching surgical skills in the simulation lab has increased markedly compared to teaching only in the operating room. Although many studies have been performed investigating the optimal teaching methodology for skills acquisition, there is no consensus on the best method. Massed and distributed practices are important methods in teaching procedural skills. Considering the limited human and logistical resources in low and middle-income settings, it is valuable to understand the optimal methodology for learning and acquiring surgical skills. Methods: Thirty-two core needle biopsy-naïve first-year residents and final year medical students rotating in general surgery were enrolled in and completed the study at University Teaching Hospital of Kigali, a tertiary, teaching and referral hospital in Kigali, Rwanda. They were assigned to a “massed” group (i.e., one time, 3-hour practice) or “distributed” group (i.e., 1-hour practice per week for 3 weeks). Trainees were taught ultrasound-guided core needle biopsy on a high-fidelity breast simulator. All participants completed pre- and post-tests and an evaluation of skill retention was performed one month after completion of the training. Analysis of performance was completed, and p-value ≤ 0.05 was considered statistically significant. Results: There was no difference between performance on the pretest (p=0.985) and the posttest (p=0.680). Both groups demonstrated improvement after implementation of the simulation training when comparing pretest and posttest results (p<0.001); there were no differences in the evaluation of skills retention after one month after the training between the two groups (p=0.273). Conclusions: The results of this study demonstrate that both groups have improved significantly their knowledge and skills. Trainees have similar retention of skills in ultrasound guided core needle biopsy on a breast simulator whether trained under a massed or distributed practice schedule. Both methods may be considered in our setting for teaching surgical skills. Keywords: surgical simulation; resource-limited setting; global surgery

On the Formation of Degenerate Heavy Neutrino Stars

The dynamics of a self-gravitating cold Fermi gas is described using the analogy with an interacting self-gravitating Bose condensate having the same Thomas-Fermi limit. The dissipationless formation of a heavy neutrino star through gravitational collapse and ejection of matter is demonstrated numerically. Such neutrino stars offer an alternative to black holes for the supermassive compact dark objects at the centers of galaxies.Comment: 11 pages, 3 figures, Latex, elsart.sty, fig1 improved, to appear in Phys. Lett.

A Head-to-Head Comparison of Four Artemisinin-Based Combinations for Treating Uncomplicated Malaria in African Children: A Randomized Trial

BackgroundArtemisinin-based combination therapies (ACTs) are the mainstay for the management of uncomplicated malaria cases. However, up-to-date data able to assist sub-Saharan African countries formulating appropriate antimalarial drug policies are scarce.Methods and findingsBetween 9 July 2007 and 19 June 2009, a randomized, non-inferiority (10% difference threshold in efficacy at day 28) clinical trial was carried out at 12 sites in seven sub-Saharan African countries. Each site compared three of four ACTs, namely amodiaquine-artesunate (ASAQ), dihydroartemisinin-piperaquine (DHAPQ), artemether-lumefantrine (AL), or chlorproguanil-dapsone-artesunate (CD+A). Overall, 4,116 children 6-59 mo old with uncomplicated Plasmodium falciparum malaria were treated (1,226 with AL, 1,002 with ASAQ, 413 with CD+A, and 1,475 with DHAPQ), actively followed up until day 28, and then passively followed up for the next 6 mo. At day 28, for the PCR-adjusted efficacy, non-inferiority was established for three pair-wise comparisons: DHAPQ (97.3%) versus AL (95.5%) (odds ratio [OR]: 0.59, 95% CI: 0.37-0.94); DHAPQ (97.6%) versus ASAQ (96.8%) (OR: 0.74, 95% CI: 0.41-1.34), and ASAQ (97.1%) versus AL (94.4%) (OR: 0.50, 95% CI: 0.28-0.92). For the PCR-unadjusted efficacy, AL was significantly less efficacious than DHAPQ (72.7% versus 89.5%) (OR: 0.27, 95% CI: 0.21-0.34) and ASAQ (66.2% versus 80.4%) (OR: 0.40, 95% CI: 0.30-0.53), while DHAPQ (92.2%) had higher efficacy than ASAQ (80.8%) but non-inferiority could not be excluded (OR: 0.35, 95% CI: 0.26-0.48). CD+A was significantly less efficacious than the other three treatments. Day 63 results were similar to those observed at day 28.ConclusionsThis large head-to-head comparison of most currently available ACTs in sub-Saharan Africa showed that AL, ASAQ, and DHAPQ had excellent efficacy, up to day 63 post-treatment. The risk of recurrent infections was significantly lower for DHAPQ, followed by ASAQ and then AL, supporting the recent recommendation of considering DHAPQ as a valid option for the treatment of uncomplicated P. falciparum malaria.Trial registrationClinicalTrials.gov NCT00393679; Pan African Clinical Trials Registry PACTR200901000091175

Carrot Purple Leaf: A New Spiroplasmal Disease Associated with Carrots in Washington State

During the growing seasons of 2003 and 2004, a disease occurred in several carrot crops in south central Washington with symptoms suggestive of infection by phytopathogenic mollicutes (phytoplasmas and spiroplasmas). In the fall, many affected carrot plants exhibited extensive purple or yellow-purple leaf discoloration, general stunting of shoots and taproots, and formation of bunchy, fibrous secondary roots. For detection of the putative causal agents, polymerase chain reaction (PCR) assays were performed using primers specific to phytoplasmas as well as primers specific to plant-pathogenic spiroplasmas. Restriction fragment length polymorphism (RFLP) analyses of PCR-amplified 16S rDNA sequences revealed that about 81% of affected plants showing dark purple or yellow-purple leaf symptoms tested positive for Spiroplasma citri. Of affected plants showing mild purple discoloration of leaf margins, 18% tested positive for a phytoplasma strain belonging to the clover proliferation group (16SrVI), subgroup 16SrVI-A, and 11% for another phytoplasma strain belonging to the aster yellows group (16SrI), subgroup 16SrI-A. Nucleotide sequence analysis of cloned 16S rDNA confirmed the phytoplasma group affiliations. Some symptomatic plants were co-infected with S. citri and either aster yellows phytoplasma or clover proliferation group phytoplasma. To our knowledge, this is the first documentation of spiroplasma infection of carrot in the United States

A Head-to-Head Comparison of Four Artemisinin-Based Combinations for Treating Uncomplicated Malaria in African Children: A Randomized Trial

BACKGROUND: Artemisinin-based combination therapies (ACTs) are the mainstay for the management of uncomplicated malaria cases. However, up-to-date data able to assist sub-Saharan African countries formulating appropriate antimalarial drug policies are scarce. METHODS AND FINDINGS: Between 9 July 2007 and 19 June 2009, a randomized, non-inferiority (10% difference threshold in efficacy at day 28) clinical trial was carried out at 12 sites in seven sub-Saharan African countries. Each site compared three of four ACTs, namely amodiaquine-artesunate (ASAQ), dihydroartemisinin-piperaquine (DHAPQ), artemether-lumefantrine (AL), or chlorproguanil-dapsone-artesunate (CD+A). Overall, 4,116 children 6-59 mo old with uncomplicated Plasmodium falciparum malaria were treated (1,226 with AL, 1,002 with ASAQ, 413 with CD+A, and 1,475 with DHAPQ), actively followed up until day 28, and then passively followed up for the next 6 mo. At day 28, for the PCR-adjusted efficacy, non-inferiority was established for three pair-wise comparisons: DHAPQ (97.3%) versus AL (95.5%) (odds ratio [OR]: 0.59, 95% CI: 0.37-0.94); DHAPQ (97.6%) versus ASAQ (96.8%) (OR: 0.74, 95% CI: 0.41-1.34), and ASAQ (97.1%) versus AL (94.4%) (OR: 0.50, 95% CI: 0.28-0.92). For the PCR-unadjusted efficacy, AL was significantly less efficacious than DHAPQ (72.7% versus 89.5%) (OR: 0.27, 95% CI: 0.21-0.34) and ASAQ (66.2% versus 80.4%) (OR: 0.40, 95% CI: 0.30-0.53), while DHAPQ (92.2%) had higher efficacy than ASAQ (80.8%) but non-inferiority could not be excluded (OR: 0.35, 95% CI: 0.26-0.48). CD+A was significantly less efficacious than the other three treatments. Day 63 results were similar to those observed at day 28. CONCLUSIONS: This large head-to-head comparison of most currently available ACTs in sub-Saharan Africa showed that AL, ASAQ, and DHAPQ had excellent efficacy, up to day 63 post-treatment. The risk of recurrent infections was significantly lower for DHAPQ, followed by ASAQ and then AL, supporting the recent recommendation of considering DHAPQ as a valid option for the treatment of uncomplicated P. falciparum malaria. TRIAL REGISTRATION: ClinicalTrials.gov NCT00393679; Pan African Clinical Trials Registry PACTR2009010000911750status: publishe