Scale up of anaesthesia services in underserved rural Tanzania

BACKGROUND

Because of critical shortage of physician anaesthesiologists, the government of Tanzania adopted a task shifting strategy for provision of anaesthesia services. This paper describes the results of an operational study designed to increase the number of anaesthesia providers for emergency obstetric surgeries in order to reduce maternal and perinatal mortality in underserved rural Tanzania.

METHODS

In 2016 a before-after cohort study was conducted in seven health centres in rural Tanzania. Five health centres received an intervention and two were selected to track secular trends (control group). Ten associate clinicians, i.e. assistant medical officers, clinical officers, and nurse midwives, from five health centres were trained in anaesthesia skills for emergency obstetric surgeries for three months followed by quarterly supportive supervision, mentoring and teleconsultation to reinforce skills. Primary and secondary outcome measures included Caesarean delivery (CD) rate, quality and safety of anaesthesia, and uptake of the educational program for anaesthesia.

RESULTS

Out of the 2,179 CDs performed in the intervention facilities from 2016 to 2019, two women died from complications of anaesthesia. The risk of death from anaesthetic complications was 0.9 per 1000 CD (95% CI 0.1-3.3. The risk of death was not established in the control group because of inadequate documentation and records keeping. The proportion of CD performed under spinal anaesthesia in intervention facilities doubled from 28% (60/214 with 95% CI 22-35) at baseline (July 2014 - June 2016) to 57% (558/971 with 95% CI of 54-61) in year three (July 2018 - June 2019), while in the control group increased by only 40% from 19% (92/475 with 95% CI of 16-23) at baseline and 27% (68/251 with 95% CI of 22-33) in year three. In 2020I, this educational training program was then adopted by the government with minor content changes and increasing duration of training to six months.

CONCLUSIONS

This three month educational training program for associate clinicians in anaesthesia, complemented by supportive supervision, can increase the CD rate to one that fills the "unmet need" and the proportion of operations performed under spinal anaesthesia, the gold standard technique for CD. The program can be used to meet the urgent demand for anaesthesia services in other underserved areas in Africa.

An inducible propane monooxygenase is responsible for N-nitrosodimethylamine degradation by Rhodococcus sp. strain RHA1

Rhodococci are common soil heterotrophs that possess diverse functional enzymatic activities with economic and ecological significance. In this study, the correlation between gene expression and biological removal of the water contaminant N-nitrosodimethylamine (NDMA) is explored. NDMA is a hydrophilic, potent carcinogen that has gained recent notoriety due to its environmental persistence and emergence as a widespread micropollutant in the subsurface environment. In this study, we demonstrate that Rhodococcus sp. strain RHA1 can constitutively degrade NDMA and that activity toward this compound is enhanced by approximately 500-fold after growth on propane. Transcriptomic analysis of RHA1 and reverse transcriptase quantitative PCR assays demonstrate that growth on propane elicits the upregulation of gene clusters associated with (i) the oxidation of propane and (ii) the oxidation of substituted benzenes. Deletion mutagenesis of prmA, the gene encoding the large hydroxylase component of propane monooxygenase, abolished both growth on propane and removal of NDMA. These results demonstrate that propane monooxygenase is responsible for NDMA degradation by RHA1 and explain the enhanced cometabolic degradation of NDMA in the presence of propane.

Long term effects of a home visit to prevent childhood injury: three year follow up of a randomized trial

OBJECTIVE

To assess the long term effect of a home safety visit on the rate of home injury.

DESIGN

Telephone survey conducted 36 months after participation in a randomized controlled trial of a home safety intervention. A structured interview assessed participant knowledge, beliefs, or practices around injury prevention and the number of injuries requiring medical attention.

SETTING

Five pediatric teaching hospitals in four Canadian urban centres.

PARTICIPANTS

Children less than 8 years of age presenting to an emergency department with a targeted home injury (fall, scald, burn, poisoning or ingestion, choking, or head injury while riding a bicycle), a non-targeted injury, or a medical illness.

RESULTS

We contacted 774 (66%) of the 1172 original participants. A higher proportion of participants in the intervention group (63%) reported that home visits changed their knowledge, beliefs, or practices around the prevention of home injuries compared with those in the non-intervention group (43%; p<0.001). Over the 36 month follow up period the rate of injury visits to the doctor was significantly less for the intervention group (rate ratio = 0.74; 95% CI 0.63 to 0.87), consistent with the original (12 month) study results (rate ratio = 0.69; 95% CI 0.54 to 0.88). However, the effectiveness of the intervention appears to be diminishing with time (rate ratio for the 12-36 month study interval = 0.80; 95% CI 0.64 to 1.00).

CONCLUSIONS

A home safety visit was able to demonstrate sustained, but modest, effectiveness of an intervention aimed at improving home safety and reducing injury. This study reinforces the need of home safety programs to focus on passive intervention and a simple well defined message.

Emergency department use by infants less than 14 days of age

OBJECTIVE

To determine the factors associated with nonacute presentation to the emergency department (ED) by infants less than 14 days of age.

METHODS

A prospective survey was conducted in the pediatric ED of a teaching hospital providing voluntary in-home follow-up for families discharged within 48 hours of delivery. Participants were families of infants less than 14 days of age presenting to the ED over a 1-year period. The main outcome measure was acuteness of presenting problem. Presenting problems were classified as nonacute if the following 4 criteria were met: (i) no physician referral; (ii) nonurgent triage code assigned by a triage nurse; (iii) no investigations performed in the ED; and (iv) discharge home.

RESULTS

Of the 142 eligible infants, 70 (49%) infants presented with nonacute problems. Ninety-two (65%) returned questionnaires. There was no significant difference in the proportion of nonacute problems between infants discharged at less than 48 hours of age and those discharged at more than 48 hours (P = 0.7). The proportion of nonacute problems among infants of primiparous mothers was significantly higher (64%) than among infants of multiparous mothers (24%) (P < 0.001). Infants of mothers less than 25 years of age were more likely to present with nonacute problems (P = 0.002).

CONCLUSIONS

Primiparity and maternal age less than 25 years were associated with nonacute ED presentation. Acuteness of presentation to the ED was not influenced by timing of neonatal discharge. Therefore, perinatal education might be best targeted at first time mothers and young mothers to reduce the number of nonacute ED visits.

The Apolipoprotein(a) Component of Lipoprotein(a) Stimulates Actin Stress Fiber Formation and Loss of Cell-Cell Contact in Cultured Endothelial Cells

Elevated plasma concentrations of lipoprotein(a) (Lp(a)) are a risk factor for a variety of atherosclerotic disorders including coronary heart disease. In the current study, we report that incubation of cultured human umbilical vein or coronary artery endothelial cells with Lp(a) elicits a dramatic rearrangement of the actin cytoskeleton characterized by increased central stress fiber formation and redistribution of focal adhesions. These effects are mediated by the apolipoprotein(a) (apo(a)) component of Lp(a) since incubation of apo(a) with the cells evoked similar cytoskeletal rearrangements, while incubation with low density lipoprotein had no effect. Apo(a) also produced a time-dependent increase in transendothelial permeability. The cytoskeletal rearrangements evoked by apo(a) were abolished by C3 transferase, which inhibits Rho, and by Y-27632, an inhibitor of Rho kinase. In addition to actin cytoskeleton remodeling, apo(a) was found to cause VE-cadherin disruption and focal adhesion molecule reorganization in a Rho- and Rho kinase-dependent manner. Cell-cell contacts were found to be regulated by Rho and Rac but not Cdc42. Apo(a) caused a transient increase in the extent of myosin light chain phosphorylation. Finally apo(a) did not evoke increases in intracellular calcium levels, although the effects of apo(a) on the cytoskeleton were found to be calcium-dependent. We conclude that the apo(a) component of Lp(a) activates a Rho/Rho kinase-dependent intracellular signaling cascade that results in increased myosin light chain phosphorylation with attendant rearrangements of the actin cytoskeleton. We propose that the resultant increase in endothelial permeability caused by Lp(a) may help explain the atherosclerotic risk posed by elevated concentrations of this lipoprotein.

Cost-effectiveness of interferon beta-1b in slowing multiple sclerosis disability progression. First estimates

OBJECTIVE

To estimate the cost-effectiveness (CE) of interferon beta-1b (IFN beta-1b) in slowing disability progression in persons with relapsing-remitting multiple sclerosis (RRMS).

METHODS

Treatment program costs and health outcomes are modeled for cohorts of 1,000 females and 1,000 males followed 40 years from onset. Fifteen scenarios model MS natural history progression, treatment efficacy, direct treatment costs, and MS healthcare costs. A single randomized placebo-controlled trial of IFN beta-1b found reduced disease activity by MRI, reduced frequency and severity of exacerbations, and a tendency toward slower disability progression. Disability years avoided are modeled as the primary health outcome analyzed. A ministry of health (MOH) perspective is adopted, using Nova Scotia population-based data. Annual IFN beta-1b direct treatment costs (Can $16,685) are high relative to both MOH healthcare costs per person with MS (Can $2,000) and estimated MOH costs avoided.

RESULTS

Given "reference case" assumptions for women with RRMS, treatment reduces lifetime disability years by 10%. Cost per disability year avoided before discounting is Can $189,230 (US $124,892), and Can $274,842 (US $181,395) after discounting at 5%. Estimates for alternative scenarios vary greatly, leaving main findings unchanged.

CONCLUSIONS

Using the Expanded Disability Status Scale, cost per disability year avoided due to interferon beta-1b treatment in RRMS is quite high. Comparable CE estimates, using MS-specific or generic health-related quality-of-life outcome measures, are even higher. Further research is required to better measure treatment effects, modification of MS natural history, and net societal costs of IFN beta-1b in RRMS.

Nosocomial respiratory syncytial virus infection in Canadian pediatric hospitals: a Pediatric Investigators Collaborative Network on Infections in Canada Study

OBJECTIVE

To determine nosocomial transmission of respiratory syncytial virus (RSV) in Canadian pediatric hospitals, outcomes associated with nosocomial disease, and infection control practices.

DESIGN

A prospective cohort study in the 1992 to 1994 winter respiratory seasons.

SETTING

Nine Canadian pediatric university-affiliated hospitals.

PARTICIPANTS

Hospitalized children with symptoms of lower respiratory tract infection (at least one of cough, wheezing, dyspnea, tachypnea, and apnea) and RSV antigen identified in a nasopharyngeal aspirate.

RESULTS

Of 1516 children, 91 (6%) had nosocomial RSV (NRSV), defined as symptoms of lower respiratory tract infection and RSV antigen beginning >72 hours after admission. The nosocomial ratio (NRSV/[com-munity-acquired RSV {CARSV})] + NRSV) varied by site from 2.8% to 13%. The median length of stay attributable to RSV for community-acquired illness was 5 days, but 10 days for nosocomial illness. Four children with NRSV (4. 4%) died within 2 weeks of infection, compared with 6 (0.42%) with CARSV (relative risk = 10.4, 95% confidence interval: 3.0, 36.4). All sites isolated RSV-positive patients in single rooms or cohorted them. In a multivariate model, no particular isolation policy was associated with decreased nosocomial ratio, but gowning to enter the room was associated with increased risk of RSV transmission (incidence rate ratio 2.81; confidence interval: 1.65, 4.77).

CONCLUSIONS

RSV transmission risk in Canadian pediatric hospitals is generally low. Although use of barrier methods varies, all sites cohort or isolate RSV-positive patients in single rooms. Children with risk factors for severe disease who acquire infection nosocomially have prolonged stays and excess mortality.

Efficacy of antimicrobial prophylaxis in placement of cerebrospinal fluid shunts: meta-analysis

The objective of this study was to determine if perioperative antimicrobial prophylaxis decreases the incidence of subsequent shunt infection in patients who require placement of internal CSF shunts. Data sources included a computerized search of two biomedical data bases, contact with colleagues, and a review of abstracts of meetings and of references of identified trials and reviews. Studies were chosen for detailed review if they involved human subjects who underwent CSF shunt placement, with random allocation of patients to groups receiving perioperative systemic antimicrobial agents or to a control group and an outcome measure of subsequent shunt infection. Twelve (32%) of 37 studies met selection criteria and were included. Features of trial design were extracted and trial quality was evaluated with use of a predetermined protocol by three independent investigators who were blinded to titles, authors, and institutions. Individually, only one of 12 trials achieved statistical significance favoring prophylaxis; in the aggregate, the use of prophylactic antibiotics was associated with a significant reduction in subsequent CSF shunt infection (Mantel-Haenszel weighted risk ratio: 0.52; 95% confidence interval: 0.37, 0.73; P = .0002; approximate risk reduction: 50%). This systematic overview of 12 trials of 1,359 randomized patients demonstrates that perioperative use of antimicrobial agents in CSF shunt placement significantly reduces the risk of subsequent infection.