Mohamed Samai

Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey

BACKGROUND Surgical care is increasingly recognised as an important part of global health yet data for the burden of surgical disease are scarce. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) was developed to measure the prevalence of surgical conditions and surgically treatable deaths in low-income and middle-income countries. We administered this survey countrywide in Sierra Leone, which ranks 180 of the 187 nations on the UN Development Index. METHODS The study was done between Jan 9 and Feb 3, 2012. 75 of 9671 enumeration areas, the smallest administrative units in Sierra Leone, were randomly selected for the study clusters, with a probability proportional to the population size. In each cluster 25 households were randomly selected to take part in the survey. Data were collected via handheld tablets by trained local medical and nursing students. A household representative was interviewed to establish the number of household members (defined as those who ate from the same pot and slept in the same structure the night before the interview), identify deaths in the household during the previous year, and establish whether any of the deceased household members had a condition needing surgery in the week before death. Two randomly selected household members underwent a head-to-toe verbal examination and need for surgical care was recorded on the basis of the response to whether they had a condition that they believed needed surgical assessment or care. FINDINGS Of the 1875 targeted households, data were analysed for 1843 (98%). 896 of 3645 (25%; 95% CI 22·9-26·2) respondents reported a surgical condition needing attention and 179 of 709 (25%; 95% CI 22·5-27·9) deaths of household members in the previous year might have been averted by timely surgical care. INTERPRETATION Our results show a large unmet need for surgical consultations in Sierra Leone and provide a baseline against which future surgical programmes can be measured. Additional surveys in other low-income and middle-income countries are needed to document and confirm what seems to be a neglected component of global health. FUNDING Surgeons OverSeas, Thompson Family Foundation.

α-Linolenic acid protects renal cells against palmitic acid lipotoxicity via inhibition of endoplasmic reticulum stress

Unsaturated fatty acids may counteract the lipotoxicity associated with saturated fatty acids. Palmitic acid induced endoplasmic reticulum (ER) stress and caused apoptotic and necrotic cell death in the renal proximal tubular cell line, NRK-52E. We investigated whether alpha-linolenic acid, an unsaturated fatty acid, protected against ER stress and cell death induced by palmitic acid or by other non-nutrient ER stress generators. Incubation of NRK-52E cells for 24h with palmitic acid produced a significant increase in apoptosis and necrosis. Palmitic acid also increased levels of three indicators of ER stress - the phosphorylated form of the eukaryotic initiation factor 2alpha (eIF2alpha), C/EBP homologous protein (CHOP), and glucose regulated protein 78 (GRP78). alpha-Linolenic acid dramatically reduced cell death and levels of all three indicators of ER stress brought about by palmitic acid. Tunicamycin, which induces ER stress by glycosylation of proteins, produced similar effects to those obtained using palmitic acid; its effects were partially reversed by alpha-linolenic acid. Salubrinal (a phosphatase inhibitor) causes increased levels of the phosphorylated form of eIF2alpha - this effect was partially reversed by alpha-linolenic acid. Palmitoleate, a monosaturated fatty acid, had similar effects to those of alpha-linolenic acid. These results suggest that part of the mechanism of protection of the kidney by unsaturated fatty acids is through inhibition of ER stress, eIF2alpha phosphorylation and consequential reduction of CHOP protein expression and apoptotic renal cell death.

Traumatic Injuries in Developing Countries: Report From a Nationwide Cross-Sectional Survey of Sierra Leone

OBJECTIVE To use a nationwide household survey tool to provide an estimate of injury prevalence, mechanisms of traumatic injuries, and number of injury-related deaths in a low-income country. DESIGN A randomized, cross-sectional nationwide survey using the Surgeons OverSeas Assessment of Surgical Need tool was conducted in 2012. SETTING Sierra Leone, Africa. PARTICIPANTS Three thousand seven hundred fifty randomly selected participants throughout Sierra Leone. MAIN OUTCOME MEASURES Mechanisms of injury based on age, sex, anatomic location, cause, and sociodemographic factors as well as mechanisms of injury-related deaths in the previous year were the primary outcome measures. RESULTS Data were collected and analyzed from 1843 households and 3645 respondents (98% response rate). Four hundred fifty-two respondents (12%) reported at least 1 traumatic injury in the preceding year. Falls were the most common cause of nonfatal injuries (40%). The extremities were the most common injury site regardless of age or sex. Traffic injuries were the leading cause of injury-related deaths (32% of fatal injuries). CONCLUSIONS This study provides baseline data on the mechanisms of traumatic injuries as well as the sociodemographic factors affecting injury prevalence in one of the worlds poorest nations. It is anticipated that these data will provide an impetus for further studies to determine injury severity, associated disability, and barriers to accessing care in these resource-poor areas.

Lipotoxicity in renal proximal tubular cells: Relationship between endoplasmic reticulum stress and oxidative stress pathways

Hyperlipidemia in the general population has been linked to the development of chronic kidney disease with both oxidative and endoplasmic reticulum stress implicated. Physiological levels (50-300 micromol/L) of saturated fatty acids such as palmitic acid (PA) cause cytotoxicity in vitro. We investigated cell type- and stimulus-specific signaling pathways induced by PA in renal proximal tubular cells and whether oxidative stress leads to ER stress or vice versa and which pathways predominate in signaling for PA-induced apoptosis and necrosis. NRK-52E cells were incubated with PA or hydrogen peroxide (H(2)O(2)) combined with SP600125 which blocks c-Jun N-terminal kinase (JNK) activation; salubrinal, which maintains eukaryotic initiation factor 2 alpha in its phosphorylated state and the antioxidant EUK-134 - a superoxide dismutase mimetic with catalase activity. We found that (i) PA causes both oxidative and ER stress leading to apoptosis which is mediated by phosphorylated JNK; (ii) oxidant-induced apoptosis generated by H(2)O(2) involves ER stress signaling and CHOP expression; (iii) the ER stress mediated by PA is largely independent of oxidative stress; (iv) in contrast, the apoptosis produced by PA is mediated partly via oxidative stress. PA-mediated cell signaling in renal NRK-52E cells therefore differs from that identified in neuronal, hepatic and pancreatic beta cells.

Implementing an Ebola Vaccine Study — Sierra Leone

In October 2014, the College of Medicine and Allied Health Sciences of the University of Sierra Leone, the Sierra Leone Ministry of Health and Sanitation, and CDC joined the global effort to accelerate assessment and availability of candidate Ebola vaccines and began planning for the Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE). STRIVE was an individually randomized controlled phase II/III trial to evaluate efficacy, immunogenicity, and safety of the recombinant vesicular stomatitis virus Ebola vaccine (rVSV-ZEBOV). The study population was health care and frontline workers in select chiefdoms of the five most affected districts in Sierra Leone. Participants were randomized to receive a single intramuscular dose of rVSV-ZEBOV at enrollment or to receive a single intramuscular dose 18-24 weeks after enrollment. All participants were followed up monthly until 6 months after vaccination. Two substudies separately assessed detailed reactogenicity over 1 month and immunogenicity over 12 months. During the 5 months before the trial, STRIVE and partners built a research platform in Sierra Leone comprising participant follow-up sites, cold chain, reliable power supply, and vaccination clinics and hired and trained at least 350 national staff. Wide-ranging community outreach, informational sessions, and messaging were conducted before and during the trial to ensure full communication to the population of the study area regarding procedures and current knowledge about the trial vaccine. During April 9-August 15, 2015, STRIVE enrolled 8,673 participants, of whom 453 and 539 were also enrolled in the safety and immunogenicity substudies, respectively. As of April 28, 2016, no Ebola cases and no vaccine-related serious adverse events, which by regulatory definition include death, life-threatening illness, hospitalization or prolongation of hospitalization, or permanent disability, were reported in the study population. Although STRIVE will not produce an estimate of vaccine efficacy because of low case frequency as the epidemic was controlled, data on safety and immunogenicity will support decisions on licensure of rVSV-ZEBOV.The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

Retention of health workers in rural Sierra Leone: findings from life histories

BackgroundSierra Leone has faced a shortage and maldistribution of staff in its post-conflict period. This long-standing challenge is now exacerbated by the systemic shock and damage wrought by Ebola. This study aimed to investigate the importance of different motivation factors in rural areas in Sierra Leone and thus to contribute to better decisions on financial and non-financial incentive packages, here and in similar contexts.MethodsThis article is based on participatory life histories, conducted in 2013 with 23 health workers (doctors, nurses, midwives and Community Health Officers) in four regions of Sierra Leone who had worked in the sector since 2000. Although the interviews covered a wide range of themes, here we present findings on motivating and demotivating factors for staff, especially those in rural areas, based on thematic analysis of transcripts.ResultsRural health workers face particular challenges, some of which stem from the difficult terrain, which add to common disadvantages of rural living (poor social amenities, etc.). Poor working conditions, emotional and financial costs of separation from families, limited access to training, longer working hours (due to staff shortages) and the inability to earn from other sources make working in rural areas less attractive. Moreover, rules on rotation which should protect staff from being left too long in rural areas are not reported to be respected.By contrast, poor management had more resonance in urban areas, with reports of poor delegation, favouritism and a lack of autonomy for staff. Tensions within the team over unclear roles and absenteeism are also significant demotivating factors in general.ConclusionsThis study provides important policy-focused insights into motivation of health workers and can contribute towards building a resilient and responsive health system, incorporating the priorities and needs of health workers. Their voices and experiences should be taken into account as the post-Ebola landscape is shaped.

The unmet surgical disease burden in the developing world.

Baselga J, Bradbury I, Eidtmann H, et al, on behalf of the NeoALTTO study team. Lapatinib with trastuzumab for HER2-positive early breast cancer (NeoALTTO): a randomised, open-label, multicentre, phase 3 trial. Lancet 2012; 379: 633–40—In the Methods section of the Summary of this Article (published online Jan 17), the loading dose of intravenous trastuzumab should have read 4 mg/kg. This correction has been made to the online version as of Feb 17, and to the printed Article.

The Sierra Leone Trial to Introduce a Vaccine Against Ebola: An Evaluation of rVSV∆G-ZEBOV-GP Vaccine Tolerability and Safety During the West Africa Ebola Outbreak

Clinical Trials Registration ClinicalTrials.gov [NCT02378753] and Pan African Clinical Trials Registry [PACTR201502001037220].

Untreated Head and Neck Surgical Disease in Sierra Leone: A Cross- sectional, Countrywide Survey

Objectives Demonstrate how the Surgeons OverSeas Assessment of Surgical Need (SOSAS) can be used to determine the burden of head and neck (H&N) surgical disease in developing countries and identify reasons for untreated disease. Study Design Cluster randomized, cross-sectional, countrywide survey. Setting Sierra Leone. Subjects and Methods The survey was administered to 75 of 9671 enumeration areas in Sierra Leone between January 9 and February 3, 2012, with 25 households in each cluster randomly selected for the survey. A household representative and 2 randomly selected household members were interviewed. Need for surgical care was based on participants’ responses to whether they had an H&N condition that they believed needed surgical care. Results Of 1875 households, data were analyzed for 1843 (98%), with 3645 total respondents. Seven hundred and one H&N surgical conditions were reported as occurring during the lifetime of the 3645 respondents (19.2%).The current prevalence of H&N conditions in need of a surgical consultation was 11.8%. No money (60.1%) was the most common reason respondents reported for not receiving medical care. A bivariate analysis demonstrated that age, village type, education, and type of condition may be predictors for seeking health care and/or receiving surgical care. Conclusions These results show limited access for patients to be evaluated for a potential H&N surgical condition in Sierra Leone. The true incidence of untreated surgical disease is unknown as most respondents were not evaluated by a surgeon. This survey could be used in other countries as health care professionals assess surgical needs throughout the world.

Participant Retention in a Randomized Clinical Trial in an Outbreak Setting: Lessons From the Sierra Leone Trial to Introduce a Vaccine Against Ebola (STRIVE)

Clinical Trials Registration ClinicalTrials.gov [NCT02378753] and Pan African Clinical Trials Registry [PACTR201502001037220].