Kathryn Chu

Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique

Background:As antiretroviral treatment cohorts continue to expand, ensuring patient retention over time is an increasingly important concern. This, together with capacity and human resource constraints, has led to the consideration of out-of-clinic models for the delivery of antiretroviral therapy (ART). In 2008, Médecins Sans Frontières and the Provincial authorities launched a model of ART distribution and adherence monitoring by community groups in Tete Province, Mozambique. Programme Approach:Patients who were stable on ART for 6 months were informed about the community ART group model and invited to form groups. Group members had 4 key functions: facilitate monthly ART distribution to other group members in the community, provide adherence and social support, monitor outcomes, and ensure each group member undergoes a clinical consultation at least once every 6 months. Group members visit the health centre on a rotational basis, such that each group member has contact with the health service every 6 months. Results:Between February 2008 and May 2010, 1384 members were enrolled into 291 groups. Median follow-up time within a group was 12.9 months (IQR 8.5-14.1). During this time, 83 (6%) were transferred out, and of the 1301 patients still in community groups, 1269 (97.5%) were remaining in care, 30 (2%) had died, and 2 (0.2%) were lost to follow-up. Discussion:The Community ART Group model was initiated by patients to improve access, patient retention, and decongest health services. Early outcomes are highly satisfactory in terms of mortality and retention in care, lending support to such out-of-clinic approaches.

Surgical Task Shifting in Sub-Saharan Africa

Kathryn Chu and colleagues discuss some of the experiences of surgical task shifting to date, and outline lessons from task shifting in the delivery of HIV/AIDS care.

Postoperative Venous Thromboembolism Rates Vary Significantly After Different Types of Major Abdominal Operations

BackgroundVenous thrombolism (VTE) is a significant cause of morbidity for surgical patients. Comparative risk across major procedures is unknown.MethodsRetrospective analysis of the Nationwide Inpatient Sample (2001–2005) was conducted. Eight surgeries were identified: bariatric surgery, colorectal surgery, esophagectomy, gastrectomy, hepatectomy, nephrectomy, pancreatectomy, splenectomy. Age < 18, patients with multiple major surgeries, and those admitted for treatment of VTE were excluded. Primary outcome was occurrence of VTE. Independent variables included age, gender, race, Charlson score, hospital teaching status, elective procedures, cancer/metastasis, trauma, and year.ResultsPatients, 375,748, were identified, 5,773 (1.54%) with VTE. Overall death rate was 3.97%, but 13.34% after VTE. Unadjusted rate (0.35%) and adjusted risk for VTE were lowest among bariatric patients. On multivariate analysis, highest risk for VTE was splenectomy (odds ratio 2.69, 95% CI 2.03–3.56). Odds ratio of in-hospital mortality following VTE was 1.84 (1.65–2.05), associated with excess stay of 10.88days and

Cesarean section rates and indications in sub-Saharan Africa: a multi-country study from Medecins sans Frontieres.

9,612 excess charges, translating into

Improving effective surgical delivery in humanitarian disasters: lessons from Haiti.

55 million/year nationwide.ConclusionHighest risk for VTE was associated with splenectomy, lowest risk with bariatric surgery. Since bariatric patients are known to have greater risk for this complication, these findings may reflect better awareness/prophylaxis. Further studies are necessary to quantify effect of best-practice guidelines on prevention of this costly complication.

Operative Mortality in Resource-Limited Settings: The Experience of Médecins Sans Frontières in 13 Countries

Objectives The World Health Organization considers Cesarean section rates of 5–15% to be the optimal range for targeted provision of this life saving intervention. However, access to safe Cesarean section in resource-limited settings is much lower, estimated at 1–2% reported in sub-Saharan Africa. This study reports Cesarean sections rates and indications in Democratic Republic of Congo, Burundi, and Sierra Leone, and describe the main parameters associated with maternal and early neonatal mortality. Methods Women undergoing Cesarean section from August 1 2010 to January 31 2011 were included in this prospective study. Logistic regression was used to model determinants of maternal and early neonatal mortality. Results 1276 women underwent a Cesarean section, giving a frequency of 6.2% (range 4.1–16.8%). The most common indications were obstructed labor (399, 31%), poor presentation (233, 18%), previous Cesarean section (184, 14%), and fetal distress (128, 10%), uterine rupture (117, 9%) and antepartum hemorrhage (101, 8%). Parity >6 (adjusted odds ratio [aOR] = 8.6, P = 0.015), uterine rupture (aOR = 20.5; P = .010), antepartum hemorrhage (aOR = 13.1; P = .045), and pre-eclampsia/eclampsia (aOR = 42.9; P = .017) were associated with maternal death. Uterine rupture (aOR = 6.6, P<0.001), anterpartum hemorrhage (aOR = 3.6, P<0.001), and cord prolapse (aOR = 2.7, P = 0.017) were associated with early neonatal death. Conclusions This study demonstrates that target Cesarean section rates can be achieved in sub-Saharan Africa. Identifying the common indications for Cesarean section and associations with mortality can target improvements in antenatal services and emergency obstetric care.

Safety of task-shifting for male medical circumcision: a systematic review and meta-analysis.

Kathryn Chu and colleagues describe the experiences of Médecins sans Frontières after the 2010 Haiti earthquake, and discuss how to improve delivery of surgery in humanitarian disasters.

Burden of Surgical Disease: Strategies to Manage an Existing Public Health Emergency

OBJECTIVE To determine operative mortality in surgical programs from resource-limited settings. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of 17 surgical programs in 13 developing countries by 1 humanitarian organization, Médecins Sans Frontières, was performed between January 1, 2001, and December 31, 2008. Participants included patients undergoing surgical procedures. MAIN OUTCOME MEASURE Operative mortality. Determinants of mortality were modeled using logistic regression. RESULTS Between 2001 and 2008, 19,643 procedures were performed on 18,653 patients. Among these, 8329 procedures (42%) were emergent; 7933 (40%) were for obstetric-related pathology procedures and 2767 (14%) were trauma related. Operative mortality was 0.2% (31 deaths) and was associated with programs in conflict settings (adjusted odds ratio [AOR] = 4.6; P = .001), procedures performed under emergency conditions (AOR = 20.1; P = .004), abdominal surgical procedures (AOR = 3.4; P = .003), hysterectomy (AOR = 12.3; P = .001), and American Society of Anesthesiologists classifications of 3 to 5 (AOR = 20.2; P < .001). CONCLUSIONS Surgical care can be provided safely in resource-limited settings with appropriate minimum standards and protocols. Studies on the burden of surgical disease in these populations are needed to improve service planning and delivery. Quality improvement programs are needed for the various stakeholders involved in surgical delivery in these settings.

Nevirapine-associated early hepatotoxicity: incidence, risk factors, and associated mortality in a primary care ART programme in South Africa

Introduction:Task-shifting for male medical circumcision is proposed as a strategy to overcome the lack of surgeons and doctors in high HIV prevalence settings. We undertook a systematic review and meta-analysis to review the safety of task-shifting for circumcision in Africa. Methods:We searched online databases and conference websites up to July 2011 without language restriction for studies reporting outcomes of task-shifting for circumcision in Africa. Information was extracted independently and in duplicate on study characteristics, quality, and outcome data. Case reports and case series were excluded. Results:Ten studies met our inclusion criteria, providing outcome data on 25 119 circumcisions. The proportion of adverse events ranged from 0.70 [95% confidence interval (CI) 0.44–1.02%] to 37.36% (95% CI 27.54–47.72%), with an overall pooled proportion of 2.31% (95% CI 1.46–3.16%; &tgr;2 = 1.21; P < 0.001). Two studies reported outcomes separately for both doctors and non-physicians; there was no difference in the risk of adverse events by provider (pooled relative risk 1.18; 95% CI 0.78–1.78). The frequency of excessive bleeding ranged from 0.30 (0.09–0.65%) to 24.71% (16.27–34.26%) with an overall pooled prevalence of 0.55% (95% CI 0.13–0.97%). Infection occurred in 0.30 (0.14–1.47%) to 1.85% (0.07–5.96%) of cases, with an overall pooled proportion of 0.88% (95% CI 0.29–1.47%). All adverse events were reported to be non-severe. Conclusion:Task-shifting of male medical circumcision to non-physician clinicians can be done safely, with reported rates of adverse events similar to doctors and specialists.

AIDS-associated Kaposi's sarcoma is linked to advanced disease and high mortality in a primary care HIV programme in South Africa

The World Health Organization estimates that the burden of surgical disease due to war, self-inflicted injuries, and road traffic incidents will rise dramatically by 2020. During the 2009 Harvard Humanitarian Initiatives Humanitarian Action Summit (HHI/HAS),members of the Burden of Surgical Disease Working Group met to review the state of surgical epidemiology, the unmet global surgical need, and the role international organizations play in filling the surgical gap during humanitarian crises, conflict, and war. An outline of the groups findings and recommendations is provided.