Improving starting time in operating rooms of a tertiary hospital in Rwanda: a quality improvement project

Background: Delay in the first surgery start time at operating room (OR) could inevitably decrease utilization, lose very expensive OR resources, reduce satisfaction of patients and staff and potentially affect quality of patient care.Objectives: This study utilized the Strategic Problem Solving (SPS) quality improvement approach to increase the percentage of first surgeries started on time at a tertiary hospital in Rwanda.Methods: A pre- and post-intervention study was conducted between March 2016 and March 2017. The intervention included developing a policy on staff arrival time, training sessions on the policy and regular supervision of OR managers to ensure staff were arriving on time.Results: Chi square tests were performed to analyze the pre- and post-intervention results. The percentage of first surgeries started on time significantly increased from 3% pre-intervention to 25% postintervention (P<0.001), average duration of delay decreased by 55 minutes (P<0.001) and the percentages of nurses, anesthetists and surgeon arrived on time also significantly increased (P<0.001).Conclusion: The SPS approach can be useful in addressing the starting time of first surgery at OR. Support from the senior management team and buy-in from staff are essential. This project cannot eliminate confounding factors and the results cannot be generalizable to other settings. Longer term evaluation on sustainability is needed.Keywords: Delay first surgery, operating room efficiency, quality improvement, strategic problem solvin

Assessing the knowledge and attitude of menstrual hygiene among high school students, and menstrual practices among high school girls in rural Rwanda

Background: This study sought to assess the knowledge, attitude about menstruation among high school teachers, boys and girls in Butaro, a rural area in northern Rwanda. In addition, the menstrual hygiene practices of the high school girls were also assessed; to inform the design of intervention.Methods: A school-based cross-sectional questionnaire was administered to 339 people in three high schools in a rural region in Rwanda.Results: Thirty-two teachers and 307 secondary school boys and girls were surveyed. Only 9.8% of students had good knowledge related to menstrual health, with slightly more schoolgirls (13.9%) than schoolboys (5%). Feeling insecure, scared, and worried that others could smell them, were the common menstrual-related concerns cited by girls. About 20% of girls used cloth to manage their menstrual flow and 22.3% reported menstrual-related school absenteeism; lack of sanitary protection products and fear of being teased were among the most prominent reasons.Conclusions: Providing accessible facilities for girls to change, pain medication, and sufficient sanitary pads are necessary. Reusable sanitary pads and menstrual cups could be cheaper and more sustainable alternatives to commercial menstrual products. Cultivating a psychologically safe school environment is necessary

Podoconiosis in Rwanda: knowledge, attitudes and practices among health professionals and environmental officers

Background Podoconiosis is a neglected tropical disease commonly found in volcanic regions, where soil is rich in silica. It usually manifests as bilateral lower limb edema. The majority of people affected by podoconiosis are farmers who do not wear shoes. The condition was recently documented in all 30 districts in Rwanda but knowledge, attitudes and practices (KAP) of Rwandan health professionals and environmental officers towards podoconiosis are unknown. Methodology/Findings The objective of this study was to assess the knowledge, attitudes and practices (KAP) of Rwandan health providers and environmental officers towards podoconiosis in order to improve patient healthcare experiences and health outcomes, and to reduce stigma against affected individuals. To achieve this goal, we administered a KAP assessment to physicians (N = 13), nurses/midwives (N = 59), community health workers (N = 226), and environmental officers (N = 38) in the third highest podoconiosis prevalence district in Rwanda (Musanze). All 336 respondents had heard of podoconiosis, but 147 (44%) respondents correctly identified soil as the only direct cause of podoconiosis. The awareness of signs and symptoms and risk groups was lower than any other category (31.5% and 47.5%, respectively). The overall attitude toward podoconiosis was positive (86.1%), with CHWs least likely to harbor negative beliefs against podoconiosis patients. One particular area where most respondents (76%) expressed negative attitude was that they saw people with podoconiosis as a threat to their own health and their family’s health. Prescription of antibiotics and use of ointments/soap to manage wounds was low (5% and 32.2%, respectively), in part due to supply shortages at health facilities. Conclusions This study identified clear gaps in health provider knowledge and practices that affect patient care for those with podoconiosis. Improved access to essential medicines at health facilities and podoconiosis-focused training sessions for practicing health providers are necessary to minimize the burden and stigma of affected individuals

Implementing the World Health Organization safe childbirth checklist in a district Hospital in Rwanda: a pre- and post-intervention study

Background: Worldwide maternal mortality remains high, with approximately 830 maternal deaths occurring each day. About 90% of these deaths occur in low-income countries. Evidenced-based essential birth practices administered during routine obstetrical care and childbirth are key to reducing maternal and neonatal deaths. The WHO Safe Childbirth Checklist (SCC) is a low-cost tool designed to ensure birth attendants perform 29 essential birth practices (EBP) at four critical periods in the birth continuum. This study aimed to evaluate compliance with EBP in Masaka District Hospital both before and after the implementation of the WHO-SCC. Methods: This quality improvement project took place in the Masaka District Hospital in Rwanda. Observations of the 29 EBPs were done before and after WHO SCC implementation. The implementation process consisted of providing training in the use of the checklist to all clinical staff and posting SCC posters at different locations in the maternity unit. Results: A total 391 birth events were observed pre-intervention and 389 post-intervention. The overall EBP compliance rate increased from 46% pre-intervention to 56% post-intervention (P = 0.005). Significant improvements were seen in 11 out of 29 EBPs. Conclusion: The implementation of the WHO SCC improved the overall EBP compliance rate in Masaka District Hospital. Determining the root cause of low compliance rate of some EBP may allow for more successful implementation of EBP interventions in the future. After further study, the SCC should be considered for scale up

Gender Differences in Presentation, Management, and In-Hospital Outcomes for Patients with AMI in a Lower-Middle Income Country: Evidence from Egypt

BACKGROUND: Many studies in high-income countries have investigated gender differences in the care and outcomes of patients hospitalized with acute myocardial infarction (AMI). However, little evidence exists on gender differences among patients with AMI in lower-middle-income countries, where the proportion deaths stemming from cardiovascular disease is projected to increase dramatically. This study examines gender differences in patients in the lower-middle-income country of Egypt to determine if female patients with AMI have a different presentation, management, or outcome compared with men. METHODS AND FINDINGS: Using registry data collected over 18 months from 5 Egyptian hospitals, we considered 1204 patients (253 females, 951 males) with a confirmed diagnosis of AMI. We examined gender differences in initial presentation, clinical management, and in-hospital outcomes using t-tests and χ(2) tests. Additionally, we explored gender differences in in-hospital death using multivariate logistic regression to adjust for age and other differences in initial presentation. We found that women were older than men, had higher BMI, and were more likely to have hypertension, diabetes mellitus, dyslipidemia, heart failure, and atrial fibrillation. Women were less likely to receive aspirin upon admission (p<0.01) or aspirin or statins at discharge (p = 0.001 and p<0.05, respectively), although the magnitude of these differences was small. While unadjusted in-hospital mortality was significantly higher for women (OR: 2.10; 95% CI: 1.54 to 2.87), this difference did not persist in the fully adjusted model (OR: 1.18; 95% CI: 0.55 to 2.55). CONCLUSIONS: We found that female patients had a different profile than men at the time of presentation. Clinical management of men and women with AMI was similar, though there are small but significant differences in some areas. These gender differences did not translate into differences in in-hospital outcome, but highlight differences in quality of care and represent important opportunities for improvement

Candida parapsilosis Characterization in an Outbreak Setting

Candida parapsilosis is an important non-albicans species which infects hospitalized patients. No studies have correlated outbreak infections of C. parapsilosis with multiple virulence factors. We used DNA fingerprinting to determine genetic variability among isolates from a C. parapsilosis outbreak and from our clinical database. We compared phenotypic markers of pathogenesis, including adherence, biofilm formation, and protein secretion (secretory aspartic protease [SAP] and phospholipase). Adherence was measured as colony counts on silicone elastomer disks immersed in agar. Biofilms formed on disks were quantified by dry weight. SAP expression was measured by hydrolysis of bovine albumin; a colorimetric assay was used to quantitate phospholipase. DNA fingerprinting indicated that the outbreak isolates were clonal and genetically distinct from our database. Biofilm expression by the outbreak clone was greater than that of sporadic isolates (p < 0.0005). Adherence and protein secretion did not correlate with strain pathogenicity. These results suggest that biofilm production plays a role in C. parapsilosis outbreaks

Inputs to quality: supervision, management, and community involvement in health facilities in Egypt in 2004

<p>Abstract</p> <p>Background</p> <p>As low- and middle-income countries experience economic development, ensuring quality of health care delivery is a central component of health reform. Nevertheless, health reforms in low- and middle-income countries have focused more on access to services rather than the quality of these services, and reporting on quality has been limited. In the present study, we sought to examine the prevalence and regional variation in key management practices in Egyptian health facilities within three domains: supervision of the facility from the Ministry of Health and Population (MOHP), managerial processes, and patient and community involvement in care.</p> <p>Methods</p> <p>We conducted a cross-sectional analysis of data from 559 facilities surveyed with the Egyptian Service Provision Assessment (ESPA) survey in 2004, the most recent such survey in Egypt. We registered on the Measure Demographic and Health Survey (DHS) website <url>http://legacy.measuredhs.com/login.cfm</url> to gain access to the survey data. From the ESPA sampled 559 MOHP facilities, we excluded a total of 79 facilities because they did not offer facility-based 24-hour care or have at least one physician working in the facility, resulting in a final sample of 480 facilities. The final sample included 76 general service hospitals, 307 rural health units, and 97 maternal and child health and urban health units (MCH/urban units). We used standard frequency analyses to describe facility characteristics and tested the statistical significance of regional differences using chi-square statistics.</p> <p>Results</p> <p>Nearly all facilities reported having external supervision within the 6 months preceding the interview. In contrast, key facility-level managerial processes, such as having routine and documented management meetings and applying quality assurance approaches, were uncommon. Involvement of communities and patients was also reported in a minority of facilities. Hospitals and health units located in Urban Egypt compared with more rural parts of Egypt were significantly more likely to have management committees that met at least monthly, to keep official records of the meetings, and to have an approach for reviewing quality assurance activities.</p> <p>Conclusions</p> <p>Although the data precede the recent reform efforts of the MOHP, they provide a baseline against which future progress can be measured. Targeted efforts to improve facility-level management are critical to supporting quality improvement initiatives directed at improving the quality of health care throughout the country.</p

Variant-specific pathophysiological mechanisms of AFF3 differently influence transcriptome profiles

Background We previously described the KINSSHIP syndrome, an autosomal dominant disorder associated with intellectual disability (ID), mesomelic dysplasia and horseshoe kidney, caused by de novo variants in the degron of AFF3. Mouse knock-ins and overexpression in zebrafish provided evidence for a dominant-negative mode of action, wherein an increased level of AFF3 resulted in pathological effects. Methods Evolutionary constraints suggest that other modes-of-inheritance could be at play. We challenged this hypothesis by screening ID cohorts for individuals with predicted-to-be damaging variants in AFF3. We used both animal and cellular models to assess the deleteriousness of the identified variants. Results We identified an individual with a KINSSHIP-like phenotype carrying a de novo partial duplication of AFF3 further strengthening the hypothesis that an increased level of AFF3 is pathological. We also detected seventeen individuals displaying a milder syndrome with either heterozygous Loss-of-Function (LoF) or biallelic missense variants in AFF3. Consistent with semi-dominance, we discovered three patients with homozygous LoF and one compound heterozygote for a LoF and a missense variant, who presented more severe phenotypes than their heterozygous parents. Matching zebrafish knockdowns exhibit neurological defects that could be rescued by expressing human AFF3 mRNA, confirming their association with the ablation of aff3. Conversely, some of the human AFF3 mRNAs carrying missense variants identified in affected individuals did not rescue these phenotypes. Overexpression of mutated AFF3 mRNAs in zebrafish embryos produced a significant increase of abnormal larvae compared to wild-type overexpression further demonstrating deleteriousness. To further assess the effect of AFF3 variation, we profiled the transcriptome of fibroblasts from affected individuals and engineered isogenic cells harboring + / + , KINSSHIP/KINSSHIP, LoF/ + , LoF/LoF or KINSSHIP/LoF AFF3 genotypes. The expression of more than a third of the AFF3 bound loci is modified in either the KINSSHIP/KINSSHIP or the LoF/LoF lines. While the same pathways are affected, only about one third of the differentially expressed genes are common to the homozygote datasets, indicating that AFF3 LoF and KINSSHIP variants largely modulate transcriptomes differently, e.g. the DNA repair pathway displayed opposite modulation. Conclusions Our results and the high pleiotropy shown by variation at this locus suggest that minute changes in AFF3 function are deleterious

Clinical practice: The care of children with Down syndrome

Down syndrome (DS) is one of the most common chromosomal abnormalities. Because of medical advances and improvements in overall medical care, the median survival of individuals with DS has increased considerably. This longer life expectancy requires giving the necessary care to the individual with DS over their total longer lifespan. DS medical guidelines are designed for the optimal care of the child in whom a diagnosis of DS has been confirmed. We present an overview of the most important issues related to children with DS based on the most relevant literature currently available

The clinical effectiveness of different surveillance strategies to prevent colorectal cancer in people with intermediate-grade colorectal adenomas: a retrospective cohort analysis, and psychological and economic evaluations

Background: The UK guideline recommends 3-yearly surveillance for patients with intermediate-risk (IR) adenomas. No study has examined whether or not this group has heterogeneity in surveillance needs. Objectives To examine the effect of surveillance on colorectal cancer (CRC) incidence; assess heterogeneity in risk; and identify the optimum frequency of surveillance, the psychological impact of surveillance, and the cost-effectiveness of alternative follow-up strategies. Design: Retrospective multicentre cohort study. Setting: Routine endoscopy and pathology data from 17 UK hospitals (n = 11,944), and a screening data set comprising three pooled cohorts (n = 2352), followed up using cancer registries. Subjects: Patients with IR adenoma(s) (three or four small adenomas or one or two large adenomas). Primary outcomes: Advanced adenoma (AA) and CRC detected at follow-up visits, and CRC incidence after baseline and first follow-up. Methods: The effects of surveillance on long-term CRC incidence and of interval length on findings at follow-up were examined using proportional hazards and logistic regression, adjusting for patient, procedural and polyp characteristics. Lower-intermediate-risk (LIR) subgroups and higher-intermediate-risk (HIR) subgroups were defined, based on predictors of CRC risk. A model-based cost–utility analysis compared 13 surveillance strategies. Between-group analyses of variance were used to test for differences in bowel cancer worry between screening outcome groups (n = 35,700). A limitation of using routine hospital data is the potential for missed examinations and underestimation of the effect of interval and surveillance. Results: In the hospital data set, 168 CRCs occurred during 81,442 person-years (pys) of follow-up [206 per 100,000 pys, 95% confidence interval (CI) 177 to 240 pys]. One surveillance significantly lowered CRC incidence, both overall [hazard ratio (HR) 0.51, 95% CI 0.34 to 0.77] and in the HIR subgroup (n = 9265; HR 0.50, 95% CI 0.34 to 0.76). In the LIR subgroup (n = 2679) the benefit of surveillance was less clear (HR 0.62, 95% CI 0.16 to 2.43). Additional surveillance lowered CRC risk in the HIR subgroup by a further 15% (HR 0.36, 95% CI 0.20 to 0.62). The odds of detecting AA and CRC at first follow-up (FUV1) increased by 18% [odds ratio (OR) 1.18, 95% CI 1.12 to 1.24] and 32% (OR 1.32, 95% CI 1.20 to 1.46) per year increase in interval, respectively, and the odds of advanced neoplasia at second follow-up increased by 22% (OR 1.22, 95% CI 1.09 to 1.36), after adjustment. Detection rates of AA and CRC remained below 10% and 1%, respectively, with intervals to 3 years. In the screening data set, 32 CRCs occurred during 25,745 pys of follow-up (124 per 100,000 pys, 95% CI 88 to 176 pys). One follow-up conferred a significant 73% reduction in CRC incidence (HR 0.27, 95% CI 0.10 to 0.71). Owing to the small number of end points in this data set, no other outcome was significant. Although post-screening bowel cancer worry was higher in people who were offered surveillance, worry was due to polyp detection rather than surveillance. The economic evaluation, using data from the hospital data set, suggested that 3-yearly colonoscopic surveillance without an age cut-off would produce the greatest health gain. Conclusions: A single surveillance benefited all IR patients by lowering their CRC risk. We identified a higher-risk subgroup that benefited from further surveillance, and a lower-risk subgroup that may require only one follow-up. A surveillance interval of 3 years seems suitable for most IR patients. These findings should be validated in other studies to confirm whether or not one surveillance visit provides adequate protection for the lower-risk subgroup of intermediate-risk patients