Long and short Integrated Management of Childhood Illness (IMCI) training courses in Afghanistan: a cross- sectional cohort comparison of post-course knowledge and performance

Background: In 2003 the Afghan Ministry of Public Health (MoPH) adopted the Integrated Management of Childhood Illness (IMCI) for delivering child health services in primary care facilities. Key problems were subsequently identified: high cost of training, frequent health worker turnover and poor quality of IMCI implementation by those trained – specifically in the use of job aids and protocols for assessment, classification, treatment and counselling. The high financial, human resources and opportunity costs of implementing IMCI spurred the MoPH to prioritize developing a shortened IMCI course of comparable quality to the 11-Day training. Methods: This cross-sectional evaluation compared knowledge before and after training, and health worker performance in assessment, classification and treatment of sick children in two similar cohorts, eight months post-training. Results: The mean increase in knowledge scores of the thirty 7-Day course trainees was 29 [95% Confidence Interval (CI): 24, 34] compared to 23 (95% CI: 18, 28) in the 31 trained in the 11-Day course. During assessment visits, mean scores in the 7-Day course trainees and the 11-Day course trainees were 93% (95% CI: 91, 95) versus 94% (95% CI: 91, 96) in assessment; 95% (95% CI: 89, 100) versus 96% (95% CI: 91, 100) in classification; 95% (95% CI: 92, 100) versus 97% (95% CI: 95, 100) in treatment; and 81% (95% CI: 76, 86) versus 80% (95% CI: 75, 85) in counselling. The 7-Day course was 36% less expensive than the 11-Day course. For each course opportunity costs, measured as numbers of children who potentially received poorer care than usual during trainee absence, were 3,160 for the 11-Day course and 2,016 for the 7-Day course. This measure was chosen because trainee absence commonly resulted in higher patient volumes per remaining provider or complete closure of a health facility with one single health worker. Conclusion: Given similar performance and knowledge of health workers trained in both courses, potential cost savings, the possibility of training more health workers and the relative ease with which health workers in remote settings might participate in a shorter course, it seems prudent to standardize the 7-Day course in Afghanistan where child mortality rates remain unacceptably high

Prothrombin complex concentrate in the reduction of blood loss during orthotopic liver transplantation : PROTON-trial

Background: In patients with cirrhosis, the synthesis of coagulation factors can fall short, reflected by a prolonged prothrombin time. Although anticoagulants factors are decreased as well, blood loss during orthotopic liver transplantation can still be excessive. Blood loss during orthotopic liver transplantation is currently managed by transfusion of red blood cell concentrates, platelet concentrates, fresh frozen plasma, and fibrinogen concentrate. Transfusion of these products may paradoxically result in an increased bleeding tendency due to aggravated portal hypertension. The hemostatic effect of these products may therefore be overshadowed by bleeding complications due to volume overload. In contrast to these transfusion products, prothrombin complex concentrate is a low-volume highly purified concentrate, containing the four vitamin K dependent coagulation factors. Previous studies have suggested that administration of prothrombin complex concentrate is an effective method to normalize a prolonged prothrombin time in patients with liver cirrhosis. We aim to investigate whether the pre-operative administration of prothrombin complex concentrate in patients undergoing liver transplantation for end-stage liver cirrhosis, is a safe and effective method to reduce perioperative blood loss and transfusion requirements. Methods/Design: This is a double blind, multicenter, placebo-controlled randomized trial. Cirrhotic patients with a prolonged INR (>= 1.5) undergoing liver transplantation will be randomized between placebo or prothrombin complex concentrate administration prior to surgery. Demographic, surgical and transfusion data will be recorded. The primary outcome of this study is RBC transfusion requirements. Discussion: Patients with advanced cirrhosis have reduced plasma levels of both pro- and anticoagulant coagulation proteins. Prothrombin complex concentrate is a low-volume plasma product that contains both procoagulant and anticoagulant proteins and transfusion will not affect the volume status prior to the surgical procedure. We hypothesize that administration of prothrombin complex concentrate will result in a reduction of perioperative blood loss and transfusion requirements. Theoretically, the administration of prothrombin complex concentrate may be associated with a higher risk of thromboembolic complications. Therefore, thromboembolic complications are an important secondary endpoint and the occurrence of this type of complication will be closely monitored during the study.Peer reviewe

Long and Short Integrated Management of Childhood Illness (IMCI) Training Courses in Afghanistan: A Cross-sectional Cohort Comparison of Post-Course Knowledge and Performance

Background: In 2003 the Afghan Ministry of Public Health (MoPH) adopted the Integrated Management of Childhood Illness (IMCI) for delivering child health services in primary care facilities. Key problems were subsequently identified: high cost of training, frequent health worker turnover and poor quality of IMCI implementation by those trained – specifically in the use of job aids and protocols for assessment, classification, treatment and counselling. The high financial, human resources and opportunity costs of implementing IMCI spurred the MoPH to prioritize developing a shortened IMCI course of comparable quality to the 11-Day training. Methods:This cross-sectional evaluation compared knowledge before and after training, and health worker performance in assessment, classification and treatment of sick children in two similar cohorts, eight months post-training. Results:The mean increase in knowledge scores of the thirty 7-Day course trainees was 29 [95% Confidence Interval (CI): 24, 34] compared to 23 (95% CI: 18, 28) in the 31 trained in the 11-Day course. During assessment visits, mean scores in the 7-Day course trainees and the 11-Day course trainees were 93% (95% CI: 91, 95) versus 94% (95% CI: 91, 96) in assessment; 95% (95% CI: 89, 100) versus 96% (95% CI: 91, 100) in classification; 95% (95% CI: 92, 100) versus 97% (95% CI: 95, 100) in treatment; and 81% (95% CI: 76, 86) versus 80% (95% CI: 75, 85) in counselling. The 7-Day course was 36% less expensive than the 11-Day course. For each course opportunity costs, measured as numbers of children who potentially received poorer care than usual during trainee absence, were 3,160 for the 11-Day course and 2,016 for the 7-Day course. This measure was chosen because trainee absence commonly resulted in higher patient volumes per remaining provider or complete closure of a health facility with one single health worker. Conclusion:Given similar performance and knowledge of health workers trained in both courses, potential cost savings, the possibility of training more health workers and the relative ease with which health workers in remote settings might participate in a shorter course, it seems prudent to standardize the 7-Day course in Afghanistan where child mortality rates remain unacceptably high

Comparative study of the haemostatic effects of two antifibrinolytic agents during liver transplantation

Bleeding secondary to hyperfibrinolysis remains a subject ol' major concern during orthotopic liver transplantation (OLT) and has been controlled with variable success by antifibrinolytic agents. The aim of the present study is to compare the effect of two antifibrinolytic drugs, aprotinin and tranexamic acid, on blood loss, on the in vitro coagulation tests and on the markers of in vivo haemostatic and fibrinolytic systems during OLT. Thirty patients undergoing primary liver transplantation for liver cirrhosis have been randomly allocated in two groups treated either with aprotinin (group 1) or with tranexamic acid (group 2). The results obtained have been compared with a group of patients who did not receive antifibrinolytic drugs. Aprotinin was started during the anhepalic phase at a dosis of 16 millions protease inhibitor units (P1U) (Iniprol® institut Choay) injected in thirty minutes followed by a perfusion of 4 millions PIU per hour until the end of the procedure. Tranexamic acid (Exacyl® Institut Choay) was administrated at a dosis of 80 mg/kg during the first hour of the anhepatic phase followed by a dosis of 40 mg/kg/hour until the end of the surgery. Blood samples were collected before surgery, at the end of the dissection phase, at the end of the anhepatic phase and 5, 30, 6U, and 120 minutes after reperfusion of the grafted liver. The following analyses were performed on each sample: activated partial thromboplastin time (APTT), prothrombin time (PT), Thrombin time (TT), fibrinogen (Fg), platelet count (pit), thrombin-antithrombin complexes (TAT), prothrombin fragment 1+2 (Fl +2), plasmin-antiplasnun complexes (PAP) fibrinogen degradation products (fgdp) and fibrin degradation products (fbdp). No differences between mean blood loss was observed between the three groups {4588ml, 4692ml and 3950ml for the control, aprotinin and tranexamic acid groups,respectively). No marked variation of the PT, TT, Fg and pit was observed during the surgical procedure and the results were similar in the three groups of patients. On the other hand, APTT was markedly prolonged m the aprotinin group due to the contact phase inhibition properties of the drug. The results the highest mean value of the assay of the activation products of the hemostatic and the librinolytic systems are shown in the following table: Assay Aprotinin Tranexamic acid Control mean(sd) mean(sd) mean (sd) Fl-2(nmoll) 13.1(1.7) 7.6(0.8) 7.4(0.75) TAT (μg/1) 582(107) 343(67) 281 (40) PAP(μg/l) 2033(219) 2661(291) 14984(4778) Fgdp (μg/1) 9303 (3044) 1101 (253) 17586(9910) Fbdp(μg/l) 30599(13696) 5642(1257) 49017(24465) In conclusion, this study does not demonstrate any blood saving effect of antifibrinolytic drugs during liver transplantation. Tranexamic acid has a higher antifibrinolytic effect as compared with aprotinin, which is probabely related to the high dosis used. A lower in vivo activation of the coagulation system is observed with tranexamic acid, as compared with aprotinin, as evidenced by lower Fl-2 and TAT. If this observation is still observed for an equal anliiibrinolytic effect, this would suggest that tranexamic acid presents a lower thiombogenic potential than aprotinin.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

A patient with a papulo‐nodular lesion on the shoulder

No abstract availabl

Combined pancreatic and kidney transplantation: en bloc retrieval and transplantation - a new surgical technique

We designed and performed on two patients a new surgical procedure of en bloc kidney and pancreatic transplantation. The liver, pancreas and kidneys were removed en bloc in the donor. On the bench, the liver and the left kidney were separated from the bloc, leaving the pancreas and the right kidney for combined kidney and pancreatic transplantation, The portal vein was divided near to the emergence of the splenic vein. The coeliac axis was taken with an aortic patch. The left renal vein was cut at its entrance to the inferior vena cava (IVC) and the left renal artery was taken with an aortic patch. Reconstruction of the pancreatic vessels was performed with a double anastomosis: the portal vein was anastomosed to the hole in the IVC resulting from the section of the left renal vein and the splenic artery was anastomosed to the hole in the aorta resulting from the section of the left renal artery. The proximal ends of the aorta and IVC were closed with running sutures. In the recipient, the iliac vessels on the right side were dissected. Anastomosis of the distal part of the aorta and the IVC was performed with the right iliac vessels. Duodenocystostomy and reimplantation of the ureter were done according to the usual techniques. This new surgical technique allowed an easy vascular reconstruction of the pancreatic vessels. In the recipient, only one side was used for renal and pancreatic transplantation. Moreover, the length of the transplant procedure was significantly reduced.SCOPUS: ar.jFLWNAinfo:eu-repo/semantics/publishe

Effect of two different dosages of aprotonin on perioperative blood loss during liver transplantation.

Clinical TrialComparative StudyControlled Clinical TrialJournal ArticleSCOPUS: cp.jinfo:eu-repo/semantics/publishe

Prevention of OKT3 nephrotoxicity afeter kidney transplantation

In our experience the use of OKT3 as prophylaxis in renal transplantation has been associated with an increased incidence of both delayed graft function and thromboses of graft vessels. OKT3 nephrotoxicity might have been favored by restriction of perioperative fluid infusion to prevent pulmonary edema and by the use of very high dose (30 mg/kg) of methylprednisolone (mPDS) before the first OKT3 injection to reduce the release of cytokines. This led us to modify our perioperative management in three ways: (1) hydration status was optimalized; (2) the calcium-channel blocker diltiazem, considered beneficial for recovery of graft function, was administered on the day of transplantation; and (3) the dose of mPDS given before the first OKT3 injection was fixed at 8 mg/kg. Comparison of two consecutive series of patients (group 1, control patients, N = 172; group 2, managed as described above, N = 173) showed that: (1) the incidence of delayed graft function fell from 52% in group 1 to 22% in group 2 (P < 0.0001): (2) the incidence of pulmonary edema was not significantly increased in group 2 (3.5% vs. 1.7% in group 1, P = 0.5); and (3) the frequency of intragraft thrombosis fell from 7.6% in group 1 to 1.2% in group 2 (P = 0.0034). Multivariate analysis showed that the volemia/diltiazem program and avoidance of high mPDS dose were the most important factors responsible for the reduced occurrence of delayed graft function and graft vessels thrombosis, respectively. We conclude that a combined strategy of appropriate dosage of steroids before the first OKT3 injection, administration of a calcium-channel blocker and optimalization of volemia is safe and efficiently prevents against OKT3 nephrotoxic effects.Journal ArticleResearch Support, Non-U.S. Gov'tinfo:eu-repo/semantics/publishe

Compliance with referral of sick children: a survey in five districts of Afghanistan

<p>Abstract</p> <p>Background</p> <p>Recognition and referral of sick children to a facility where they can obtain appropriate treatment is critical for helping reduce child mortality. A well-functioning referral system and compliance by caretakers with referrals are essential. This paper examines referral patterns for sick children, and factors that influence caretakers’ compliance with referral of sick children to higher-level health facilities in Afghanistan.</p> <p>Methods</p> <p>The study was conducted in 5 rural districts of 5 Afghan provinces using interviews with parents or caretakers in 492 randomly selected households with a child from 0 to 2 years old who had been sick within the previous 2 weeks with diarrhea, acute respiratory infection (ARI), or fever. Data collectors from local nongovernmental organizations used a questionnaire to assess compliance with a referral recommendation and identify barriers to compliance.</p> <p>Results</p> <p>The number of referrals, 99 out of 492 cases, was reasonable. We found a high number of referrals by community health workers (CHWs), especially for ARI. Caretakers were more likely to comply with referral recommendations from community members (relative, friend, CHW, traditional healer) than with recommendations from health workers (at public clinics and hospitals or private clinics and pharmacies). Distance and transportation costs did not create barriers for most families of referred sick children. Although the average cost of transportation in a subsample of 75 cases was relatively high (US$11.28), most families (63%) who went to the referral site walked and hence paid nothing. Most caretakers (75%) complied with referral advice. Use of referral slips by health care providers was higher for urgent referrals, and receiving a referral slip significantly increased caretakers’ compliance with referral.</p> <p>Conclusions</p> <p>Use of referral slips is important to increase compliance with referral recommendations in rural Afghanistan.</p