Omental patch to control hepatic exsanguination

Acute spontaneous intra-abdominal hemorrhage can be life-threatening and is particularly challenging in resource-poor settings. A 35-year-old woman presented in acutely hypotensive with a distended, rigid abdomen. A paracentesis produced >10 mL of non-clotting blood and she was taken to the operating room where significant bleeding from a liver cancer nodule was identified. With no other option, the generalists doing the surgery used a novel technique - the omental patch - to stem the hemorrhage. The patient recovered from the surgery. The urgency of performing surgery for  spontaneous intraperitoneal hemorrhage increases with the scarcity of transfusable blood and general medical officers’ lack surgical experience. In this case, they rapidly improvised, innovatively adapting the omental patch procedure, normally used to close duodenal ulcers, to save a life. They had neither performed nor seen this procedure previously. An omental patch to stop massive localized intra-abdominal hemorrhage may be an important tool for all surgeons.Key words: Omental patch, Intraperitoneal hemorrhage, Hepatic cance

The interrelationship between water access, exclusive breastfeeding and diarrhea in children: a cross-sectional assessment across 19 African countries

Background Access to an improved water supply and practicing exclusive breastfeeding are essential for improving maternal and child health outcomes. However, few studies have been equipped to assess the interdependencies between access to improved water, practicing exclusive breastfeeding, and child health. The primary aim of our study was to assess whether access to an improved water supply and water-fetching were associated with mothers’ practice of exclusive breastfeeding. Methods We analyzed data on 247090 mothers with children 5 months old or less using Multiple Indicator Cluster Surveys from 19 African countries. Multivariable logistic regression was used to estimate the relationship between our exposures and exclusive breastfeeding practice, while meta-analytic methods were used to pool adjusted estimates across 19 countries. Results The prevalence of exclusive breastfeeding ranged from 22% in Nigeria to 70% in Malawi. Pooled results showed water-fetching was not associated with exclusive breastfeeding (adjusted prevalence odds ratios (aPOR)=1.04, 95% confidence interval (CI)=0.89, 1.21). Access to an improved water source was also not associated with exclusive breastfeeding (aPOR=1.06, 95% CI=0.94, 1.21). Across all countries many women were spending a significant amount of time water-fetching each day (mean time varied from 20 minutes in Ghana to 115 minutes in Mauritania). Exclusively breastfed children had 33% lower odds of diarrhea than those who were not exclusively breastfed (aPOR=0.67, 95% CI=0.56, 0.78). Conclusion Our study is the first to assess the relationship between access to improved water supply, water-fetching and exclusive breastfeeding. We found that access to water supply and time spent by mothers fetching water were not associated with exclusive breastfeeding practice, even though mothers spent significant time fetching wate

The role of state breastfeeding laws and programs on exclusive breastfeeding practice among mothers in the special supplemental nutrition program for Women, Infants, and Children (WIC)

Background: It is unclear if state laws supporting breastfeeding are associated with exclusive breastfeeding (EBF) practice among low-income mothers participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The main objectives of our study were to assess the relationship between such laws and EBF among WIC-participating mothers and to assess whether this association varied by employment status. We also assessed how mother’s exposure to WIC breastfeeding consultation was associated with EBF. Methods: A cross-sectional study was conducted across seven WIC program locations (i.e., Georgia, Massachusetts, Nevada, Pennsylvania, Wisconsin, Wyoming, Chickasaw Nation) between July–August 2020. Data were collected using convenient sampling from each program location and surveys were administered electronically or on paper to WIC-participating mothers. We restricted our analysis to data from 1161 WIC-participating mothers with infants aged zero to five months old. Multivariable mixed models were used to estimate the relationship between our exposures of interest (i.e., number of laws supporting breastfeeding, employment-related breastfeeding laws, WIC breastfeeding consultation) and EBF, while controlling for potential confounders and accounting for clustering by program location. Effect modification by employment status was assessed on the additive and multiplicative scales. Results: Among WIC-participating mothers living in program locations with no employment-related breastfeeding laws, EBF was 26% less prevalent for employed mothers compared to unemployed mothers (adjusted prevalence ratios [aPR]: 0.74, 95% CI: 0.67,0.83). Among all mothers, a one-unit increase in laws supporting breastfeeding was not associated with EBF (aPR: 0.88, 95% CI: 0.71,1.10). However, among employed mothers, living in areas with more employment-related laws was associated with a higher prevalence of EBF (aPR: 1.43, 95% CI: 0.83, 2.44). Infants whose mothers received a WIC breastfeeding consultation had 33% higher prevalence of being exclusively breastfed compared to infants whose mothers did not receive a WIC breastfeeding consultation (aPR: 1.33, 95% CI: 1.05,1.70). Conclusions: Infants whose WIC-participating mothers were employed, were less likely to be exclusively breastfed, but our effect modification analyses showed that laws supporting breastfeeding at the workplace may promote EBF among employed women. EBF was more prevalent among mothers who received a WIC breastfeeding consultation compared to those who did not receive such a consultation

Evaluation of the Safety and Immunogenicity of the RTS,S/AS01E Malaria Candidate Vaccine When Integrated in the Expanded Program of Immunization

Background. The RTS,S/AS01E malaria candidate vaccine is being developed for immunization of African infants through the Expanded Program of Immunization (EPI). Methods. This phase 2, randomized, open, controlled trial conducted in Ghana, Tanzania, and Gabon evaluated the safety and immunogenicity of RTS,S/AS01E when coadministered with EPI vaccines. Five hundred eleven infants were randomized to receive RTS,S/AS01E at 0, 1, and 2 months (in 3 doses with diphtheria, tetanus, and wholecell pertussis conjugate [DTPw]; hepatitis B [HepB]; Haemophilus influenzae type b [Hib]; and oral polio vaccine [OPV]), RTS,S/AS01E at 0, 1, and 7 months (2 doses with DTPwHepB/Hib+OPV and 1 dose with measles and yellow fever), or EPI vaccines only. Results. The occurrences of serious adverse events were balanced across groups; none were vaccine-related. One child from the control group died. Mild to moderate fever and diaper dermatitis occurred more frequently in the RTS,S/AS01E coadministration groups. RTS,S/AS01E generated high anti-circumsporozoite protein and anti- hepatitis B surface antigen antibody levels. Regarding EPI vaccine responses upon coadministration when considering both immunization schedules, despite a tendency toward lower geometric mean titers to some EPI antigens, predefined noninferiority criteria were met for all EPI antigens except for polio 3 when EPI vaccines were given with RTS,S/AS01E at 0, 1, and 2 months. However, when antibody levels at screening were taken into account, the rates of response to polio 3 antigens were comparable between groups. Conclusion. RTS,S/AS01E integrated in the EPI showed a favorable safety and immunogenicity evaluation. Trial registration. ClinicalTrials.gov identifier: NCT00436007. GlaxoSmithKline study ID number: 106369 (Malaria-050

Randomized Controlled Trial of RTS,S/AS02D and RTS,S/AS01E Malaria Candidate Vaccines Given According to Different Schedules in Ghanaian Children

Background:The target delivery channel of RTS,S candidate malaria vaccines in malaria-endemic countries in Africa is the World Health Organisation Expanded Program on Immunization. As an Adjuvant System, age de-escalation and schedule selection step, this study assessed 3 schedules of RTS,S/AS01E and RTS,S/AS02D in infants and young children 5–17 months of age in Ghana.Methodology:A Phase II, partially-blind randomized controlled study (blind to vaccine, not to schedule), of 19 months duration was conducted in two (2) centres in Ghana between August 2006 and May 2008. Subjects were allocated randomly (1:1:1:1:1:1) to one of six study groups at each study site, each defining which vaccine should be given and by which schedule (0,1-, 0,1,2- or 0,1,7-months). For the 0,1,2-month schedule participants received RTS,S/AS01E or rabies vaccine at one center and RTS,S/AS01E or RTS,S/AS02D at the other. For the other schedules at both study sites, they received RTS,S/AS01E or RTS,S/AS02D. The primary outcome measure was the occurrence of serious adverse events until 10 months post dose 1.Results:The number of serious adverse events reported across groups was balanced. One child had a simple febrile convulsion, which evolved favourably without sequelae, considered to be related to RTS,S/AS01E vaccination. Low grade reactions occurred slightly more frequently in recipients of RTS,S/AS than rabies vaccines; grade 3 reactions were infrequent. Less local reactogenicity occurred with RTS,S/AS01E than RTS,S/AS02D. Both candidate vaccines were highly immunogenic for anti-circumsporozoite and anti-Hepatitis B Virus surface antigen antibodies. Recipients of RTS,S/AS01E compared to RTS,S/AS02D had higher peak anti-circumsporozoite antibody responses for all 3 schedules. Three dose schedules were more immunogenic than 2 dose schedules. Area under the curve analyses for anti-circumsporozoite antibodies were comparable between the 0,1,2- and 0,1,7-month RTS,S/AS01E schedules.Conclusions:Both candidate malaria vaccines were well tolerated. Anti-circumsporozoite responses were greater with RTS,S/AS01E than RTS,S/AS02D and when 3 rather than 2 doses were given. This study supports the selection of RTS,S/AS01E and a 3 dose schedule for further development in children and infants

T Cell Responses to the RTS,S/AS01E and RTS,S/AS02D Malaria Candidate Vaccines Administered According to Different Schedules to Ghanaian Children

BACKGROUND: The Plasmodium falciparum pre-erythrocytic stage candidate vaccine RTS,S is being developed for protection of young children against malaria in sub-Saharan Africa. RTS,S formulated with the liposome based adjuvant AS01(E) or the oil-in-water based adjuvant AS02(D) induces P. falciparum circumsporozoite (CSP) antigen-specific antibody and T cell responses which have been associated with protection in the experimental malaria challenge model in adults. METHODS: This study was designed to evaluate the safety and immunogenicity induced over a 19 month period by three vaccination schedules (0,1-, 0,1,2- and 0,1,7-month) of RTS,S/AS01(E) and RTS,S/AS02(D) in children aged 5-17 months in two research centers in Ghana. Control Rabies vaccine using the 0,1,2-month schedule was used in one of two study sites. RESULTS: Whole blood antigen stimulation followed by intra-cellular cytokine staining showed RTS,S/AS01(E) induced CSP specific CD4 T cells producing IL-2, TNF-α, and IFN-γ. Higher T cell responses were induced by a 0,1,7-month immunization schedule as compared with a 0,1- or 0,1,2-month schedule. RTS,S/AS01(E) induced higher CD4 T cell responses as compared to RTS,S/AS02(D) when given on a 0,1,7-month schedule. CONCLUSIONS: These findings support further Phase III evaluation of RTS,S/AS01(E). The role of immune effectors and immunization schedules on vaccine protection are currently under evaluation. TRIAL REGISTRATION: ClinicalTrials.gov NCT00360230

How are surgical theatres in rural Africa utilized? A review of five years of services at a district hospital in Ghana.

Although the extent of the unmet need for surgeries is well-known, little is known about the surgery performed in district hospitals in sub-Saharan Africa. We review five years of utilization of theatre services at the Kintampo Hospital in rural Ghana. The source of data was the theatre logbook and other hospital records for the period 2005-2009. During this time, 1391 surgeries were performed in the theatre. This approximates a rate of 250/100,000 population. Fifty-two percent were performed in patients aged 18-35 years. The most frequently performed surgeries were: caesarean sections (46%); hernia repair (41%); and other laparotomies (10%). The major indications were cephalopelvic disproportion, right inguinal hernia and typhoid perforation, respectively. Typhoid perforation was the main indication for surgery in children aged less than 10 years. The potential for an expansion of the scope of services should be explored in order to improve access to essential surgery for this population

Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana

Ghana is positioned to become the first country in sub-Saharan Africa to implement universal health coverage based on nationwide expansion of geographic access through the Community-based Health Planning and Services initiative. This achievement is the outcome of 3 decades of implementation research that health authorities have used for guiding the development of its primary health care program. This implementation research process has comprised Ghana's official endorsement of the 1978 Alma Ata Declaration, leading to the institutionalization of evidence relevant to the strategic design of primary health care and national health insurance policies and services. Rather than relying solely upon the dissemination of project results, Ghana has embraced a continuous and systemic process of knowledge capture, curation, and utilization of evidence in expanding geographic access by a massive expansion in the number of community health service points that has taken decades. A multisectoral approach has been pursued that has involved the creation of systematic partnerships that included all levels of the political system, local development officials, community groups and social networks, multiple university-based disciplines, external development partners, and donors. However, efforts to achieve high levels of financial access through the roll-out of the National Health Insurance Scheme have proceeded at a less consistent pace and been fraught with many challenges. As a result, financial access has been less comprehensive than geographical access despite sequential reforms having been made to both programs. The legacy of activities and current research on primary health care and national health insurance are reviewed together with unaddressed priorities that merit attention in the future. Factors that have facilitated or impeded progress with research utilization are reviewed and implications for health systems strengthening in Ghana and elsewhere in Africa and globally are discussed