Laboratoires médicaux et qualité des soins: la partie la plus négligée au niveau des hôpitaux ruraux de la République Démocratique du Congo

Introduction: la qualité des soins est essentielle pour sauver des vies humaines de différentes maladies. Cependant, un diagnostic inapproprié ne peut en aucun cas aboutir à une prise en charge correcte des patients ainsi qu'à des soins de qualité. Nous avons effectué une analyse descriptive transversale dans trois laboratoires des hôpitaux généraux en République Démocratique du Congo.Méthodes: une équipe d'experts nationaux dans le domaine des laboratoires avait conduit l'enquête au niveau de trois laboratoires cliniques des hôpitaux généraux de la République Démocratique du Congo. Des observations, visites et entretiens structurés à l´aide d'un questionnaire ont été utilisées pour évaluer la performance de ces laboratoires cliniques. Nous avons également utilisé un guide d'évaluation développé au niveau national pour l'évaluation des laboratoires.Résultats: les laboratoires cliniques des hôpitaux généraux visités ont présenté de nombreux déficits notamment en ce qui concerne les infrastructures, la formation de base et continue des personnels, les équipements, la supervision et le contrôle de qualité. Le plateau technique de ces laboratoires n'était pas adapté pour répondre aux besoins de la population en ce qui concerne les maladies fréquemment rencontrées dans ces zones. Nous avons également noté que, ces laboratoires sont peu ou presque pas accompagnés et qu'il n'y avait aucune équipe de coordination dédiée à la supervision et évaluation des laboratoires au niveau de l'hôpital, voire même au niveau de la zone de santé. En plus, les techniciens de ses différents laboratoires n'ont pas été supervisés pendant de nombreuses années.Conclusion: les laboratoires cliniques doivent être améliorés pour permettre un diagnostic adéquat de différentes maladies. Cette amélioration doit s'appuyer sur les maladies locales. Au sein du système, il est important de consacrer plus d'attention aux laboratoires cliniques. Un plaidoyer pour cette composante négligée du système de santé est nécessaire, car cette situation pourrait être la même dans de nombreux pays en voie de développement

What presents to a rural district emergency department: a case mix

Background: There is little information available on the range of conditions presenting to generalist run rural district hospital emergency departments (EDs) which are the first point of acute care for many South Africans. Aim: This study aims to assess the range of acute presentations as well as the types of procedures required by patients in a rural district hospital context. Setting: Zithulele is a 147-bed district hospital in rural Eastern Cape. Methods: This is a cross-sectional study assessing all patients presenting to the Zithulele hospital emergency department from 01 October 2015 to 31 December 2015. Data collected included the triage acuity using the South African Triage Scale system, patient demographics, diagnosis, outcome and procedures performed. Diagnoses were coded retrospectively according to the international statistical classification of diseases and related health problems version 10 (ICD 10). Results: Of the 4 002 patients presenting to the ED during the study period, 2% were triaged as emergencies and 45% as non-urgent. The most common diagnostic categories were injuries, infections and respiratory illnesses respectively. Diagnoses from all broad categories of the ICD-10 were represented. 67% of patients required no procedure. Diagnostic procedures (n = 877) were more prevalent than therapeutic procedures (n = 377). Only 2.4% of patients were transferred to a referral centre acutely. Conclusion: Patients with conditions from all categories of the ICD-10 present for management at rural district hospitals. Healthcare professionals working in this setting need to independently diagnose and manage a wide range of ED presentations and execute an assortment of procedures

Programa de cooperación quirúrgica en un hospital rural de Etiopía. ¿Podemos ofrecer cirugía de calidad? / Surgical Cooperation Program in a Rural Hospital of Ethiopia. Can we Offer Quality Surgeries?

RESUMEN Introducción: En Etiopía la asistencia quirúrgica en el medio rural es deficitaria por la falta de cirujanos y por los limitados recursos sanitarios, y este escenario subóptimo puede provocar un incremento de morbilidad y mortalidad operatoria. Objetivos: Describir las intervenciones quirúrgicas realizadas durante ocho años de cooperación en el Hospital Rural de Gambo y analizar la morbilidad y mortalidad posoperatoria. Método: Se realizó un estudio descriptivo, retrospectivo, de las intervenciones quirúrgicas practicadas en el Hospital Rural de Gambo, por un grupo de cooperación quirúrgica entre 2007-2017 en ocho campañas quirúrgicas. Se recogieron en una base de datos el sexo, edad, diagnóstico, tipo de cirugía (urgente o programada), operaciones realizadas, complicaciones posoperatorias, infecciones del sitio quirúrgico, morbilidades, reintervenciones, transfusiones de sangre y mortalidad posoperatoria. Resultados: Se operaron 587 pacientes, 389 de cirugía general, 78 de obstetricia-ginecología, 77 lesiones urológicas y 38 pacientes de traumatología. El 13 por ciento (89) pacientes fueron operados de urgencia. Se aplicó anestesia general con intubación traqueal a 143 pacientes, anestesia raquídea en 167 casos y anestesia local en 277. En cirugía mayor (310 pacientes), la mortalidad fue 2 por ciento, con 5,3 por ciento de infección del sitio quirúrgico, 3 reintervenciones (1 por ciento) y 9 (3 por ciento) transfusiones sanguíneas perioperatorias. Conclusiones: Para la cooperación quirúrgica en el entorno rural de Etiopía es necesaria una formación adicional en cirugía obstétrica-ginecológica, urología y traumatología. A pesar de los escasos medios tecnológicos del Hospital Rural de Gambo es posible realizar una cirugía mayor con seguridad, con un bajo índice de infecciones de herida, de necesidades transfusionales, reoperaciones y mortalidad(AU)

ABSTRACT Introduction: In Ethiopia, surgical assistance in rural areas is deficient due to the lack of surgeons and limited health resources. This suboptimal setting can cause an increase in morbidity and surgical mortality. Objectives: To describe the surgical interventions carried out during eight years of cooperation in Gambo Rural Hospital and analyze the postoperative morbidity and mortality. Method: A retrospective and descriptive study of the surgical interventions performed at Gambo Rural Hospital was carried out by a surgical cooperation group between 2007-2017 in eight surgical campaigns. Sex, age, diagnosis, type of surgery (urgent or scheduled), carried out operations, postoperative complications, surgical site infections, morbidities, reoperations, blood transfusions and postoperative mortality were collected in a database. Results: 587 patients were operated on: 389 for general surgery, 78 for obstetrics-gynecology, 77 urological lesions, and 38 for traumatology. 13 percent (89) patients were operated urgently. General anesthesia with tracheal intubation was applied to 143 patients, spinal anesthesia was used in 167 cases and local anesthesia was used in 277 cases. In major surgery (310 patients), mortality was 2 percent, with 5.3 percent of surgical site infection, 3 reinterventions (1 percent) and 9 (3 percent) perioperative blood transfusions. Conclusions: Additional training in obstetric-gynecological surgery, urology and traumatology is necessary for surgical cooperation in the rural setting of Ethiopia. Despite the scarce technological means of Gambo Rural Hospital, it is possible to perform major surgery safely, with a low rate of wound infections, transfusion needs, reoperations and mortality(AU)

Triage conducted by lay-staff and emergency training reduces paediatric mortality in the emergency department of a rural hospital in Northern Mozambique

Introduction The majority of emergency paediatric death in African countries occur within the first 24 h of admission. A coloured triage system is widely implemented in high-income countries and the emergency triage and assessment treatment (ETAT) is recommended by the World Health Organization, but not put into practice in Mozambique. A retrospective, before and after, mortality analysis was performed using routine patient files from the district hospital between 2014 and 2017. The triage system was implemented in August 2016. Inclusion criteria were children under 15 years of age that entered the emergency centre. Primary outcome was child mortality rate. Secondary outcomes included the percentage agreement between the clinical and non-clinical staff and the duration from triage to first treatment. We used a negative binomial model in STATA 15 to compare mortality rates, and Kappa statistics to estimate the agreement between clinical and non-clinical staff. Results : 4176 admissions were included. The mortality rate ratio (MMR) was 45% lower after the start of the intervention (2016; MRR = 0.55; 0.38, 0.81; p = 0.002), compared to before. To estimate the agreement between non-clinical and clinical staff, 548 (of the 671) patient files were included. The agreement was estimated at 88.7% (Kappa = 0.644; p < 0.001). The median waiting time decreased with urgency of the triage: 2 h33 for 'green'/least serious (IQR 1 h58-3 h30), 21 min for yellow/serious (IQR 0 h10-0 h58) and nine minutes for 'red'/urgent (IQR 2­40 min). Conclusion : In a rural setting with nurse-led clinical care and non-clinician staff working at the triage reception, implementation of a three-coloured triage system was feasible. Triage and ETAT training was associated with a decrease of 45% of paediatric deaths. The impact on mortality, low cost, and ease of the implementation supports scaling this intervention in similar settings

Management of severe acute malnutrition in children under 5 years through the lens of health care workers in two rural South African hospitals

Background: Despite the widespread implementation of the World Health Organization (WHO) guidelines for the management of severe malnutrition in South Africa, poor treatment outcomes for children under 5 years are still observed in some hospitals, particularly in rural areas.Objective: To explore health care workers' perceptions about upstream and proximal factors contributing to poor treatment outcomes for severe acute malnutrition in two district hospitals in South Africa.Methods: An explorative descriptive qualitative study was conducted. Four focus group discussions were held with 33 hospital staff (senior clinical and management staff, and junior clinical staff) using interview guide questions developed based on the findings from an epidemiological study that was conducted in the same hospitals. Qualitative data were analysed using the framework analysis.Findings: Most respondents believed that critical illness, which was related to early and high case fatality rates on admission, was linked to a web of factors including preference for traditional medicine over conventional care, gross negligence of the child at household level, misdiagnosis of severe malnutrition at the first point of care, lack of specialised skills to deal with complex presentations, shortage of patient beds in the hospital and policies to discharge patients before optimal recovery. The majority believed that the WHO guidelines were effective and relatively simple to implement, but that they do not make much difference among severe acute malnutrition cases that are admitted in a critical condition. Poor management of cases was linked to the lack of continuity in training of rotating clinicians, sporadic shortages of therapeutic resources, inadequate staffing levels after normal working hours and some organisational and system-wide challenges beyond the immediate control of clinicians.Conclusion: Findings from this study suggest that effective management of paediatric severe acute malnutrition in the study setting is affected by a multiplicity of factors that manifest at different levels of the health system and the community. A verificatory study is encouraged to collaborate these findings

The management of diabetic ketoacidosis at a rural regional hospital in KwaZulu-Natal

Background: Diabetic ketoacidosis (DKA) is a biochemical triad of hyperglycaemia, ketoacidosis and ketonaemia and one of the potentially life-threatening acute metabolic complications of diabetes mellitus. This study aimed at describing the clinical profile of patients presenting with DKA to a busy rural regional hospital in KwaZulu-Natal. Methods: A retrospective review of clinical notes of patients presenting with DKA to the Emergency Department was performed over a 10-month period. Data included patients' demographic profile, clinical presentation, precipitating factors, comorbidities, biochemical profile, length of hospital stay and outcome.Results: One hundred and five black South African patients above the age of 12 years were included in the study. Sixty-four (60.95%) patients had type 1 diabetes mellitus (T1DM) and 41 (39.05%) patients had type 2 diabetes mellitus (T2DM). Patients with T2DM were significantly older than those with T1DM (52.1 ± 12.4 years vs. 24.4 ± 9.5 years, p < 0.0001). The acute precipitant was identified in 68 (64.76%) cases with the commonest precipitant in T1DM patients being poor adherence to treatment, whereas in T2DM, the most common precipitant was infection. Nausea and vomiting were the most common presenting symptoms with the majority of patients presenting with non-specific symptoms. Fifty-seven (54.29%) cases had pre-existing comorbidities, with higher prevalence in T2DM than T1DM patients. Glycated haemoglobin was severely elevated in the majority of patients. Patients remained hospitalised for an average of 8.9 ± 7.5 days. The mortality rate was 17.14%, and 12 of the 18 deaths occurred in patients with T2DM.Conclusion: The prevalence of DKA was higher in patients with T1DM and those with pre-existing comorbidities. The mortality rate remains alarmingly high in older patients with T2DM

Clinical profile and outcome of hyperglycaemic emergencies at a rural hospital in southern Nigeria

We have documented the clinical pattern of hyperglycaemic emergencies (HGEs) and predictors of outcome at a tertiary hospital in a rural setting in Nigeria. In a 2-year retrospective review, we identified 88 patients with HGEs. Fifty-four (61%) were females, and mean age was 55 years. Forty-seven (53%) had hyperglycaemic hyperosmolar states (HHS), 34 (39%) had diabetic ketoacidosis (DKA), and 7 (8%) had a mixed type of HGE. The commonest precipitating factor was infection and was seen in 39 (44.3%) patients; 28 (32%) were newly diagnosed with diabetes. The mortality rate overall was 34% and the case fatality rate of DKA, HHS, and mixed-type HGE was 23%, 38%, and 57% respectively. Elevated urea was a predictor of poor outcome; while age, gender, and the presence of chronic diabetes complications were not predictors of outcome. We conclude that the mortality rate in HGEs is high, and that elevated urea is a predictor of poor outcome.Effective diabetes education, prompt recognition of symptoms, and treatment of metabolic derangements in HGEs may reduce morbidity and mortality

Factors Influencing Nursing Students' Choices of a Place of Employment

BACKGROUND: Despite increasing the number of newly licensed nurses across Korea, shortages caused by geographical imbalances remains a significant concern. Therefore, understanding nursing students' attitudes to working and living, factors influencing where they first choose to work after graduation is useful in formulating appropriate interventions to retain nurses in regional areas. METHODS: A total of 329 senior nursing students from areas outside Metropolitan Seoul completed self-report questionnaires. Data were analyzed using t-test, chi-square test and multiple logistic regression analysis. RESULTS: Of the respondents, 57.8% reported that they planned to work in the region in which their school was located. The three factors ranked as having the greatest influence on their decision to work in non-metropolitan regions were: the cost of living, housing costs, and the proximity to family. Enjoyable aspects of rural life contributed positively to students' intentions to work in non-metropolitan regions, whereas isolation and socialization problems negatively affected their intentions to work in such areas. CONCLUSIONS: Greater consideration should be given to improving working conditions and housing environments in non-metropolitan regions.

Levels of adherence and factors associated with adherence to option B+ prevention of mother-to-child transmission among pregnant and lactating mothers in selected government health facilities of South Wollo Zone, Amhara Region, northeast Ethiopia, 2016 / 한국역학회지

OBJECTIVES: The aim of this study was to measure the levels of adherence and to identify factors associated with adherence to option B+ prevention of mother-to-child transmission (PMTCT) among pregnant and lactating mothers in selected government health facilities of South Wollo Zone, Amhara Region, northeast Ethiopia. METHODS: An institution-based cross-sectional quantitative study design was employed from March 1, 2016 to April 14, 2016, using a standard structured data collection instrument. A sample of 191 human immunodeficiency virus (HIV)-positive pregnant and lactating mothers who were receiving PMTCT follow-up in the selected health facilities participated in the study. The data were entered using EpiData 3.1 and analyzed using SPSS version 21. Bivariate and multivariate logistic regression analyses were employed to identify factors associated with adherence. The p-values <0.05 and 95% confidence intervals (CIs) were used to identify associations between independent predictors and the outcome variable. RESULTS: The level of adherence to option B+ PMTCT drugs was 87.9%. Women who received in-hospital treatment, who lived in rural areas, and faced challenges in initiating lifelong option B+ treatment on the same-day that they were diagnosed with HIV were less likely to adhere to the treatment (adjusted odds ratios [95% CI] of 0.3 [0.11 to 0.82], 0.26 [0.1 to 0.73], and 0.08 [0.02 to 0.37], respectively). CONCLUSIONS: Collaborative efforts of zonal health departments with health facility administrators and counselors are recommended for effective and efficient interventions focusing on hospitals, rural areas, and patients who face challenges on the day of their diagnosis.

Professional nurses' perception of their clinical teaching role at a rural hospital in Lesotho

Background. Nursing education institutions in Lesotho face an increasing number of enrolments owing to a high demand for professional nurses to work in the community. Enrolments have doubled during the last 3 years; without an increase in teaching resources or staff. Professional nurses in the wards are expected to mentor students and teach the clinical elements of nursing while continuing with their day-to-day clinical duties. Furthermore; professional nurses in Lesotho have not been trained for this clinical teaching role. Objective. To explore the perceptions of professional nurses with regard to their clinical teaching role in the development of competent nurses. Methods. A qualitative study was undertaken at a rural hospital in Lesotho. Data were gathered by conducting semi-structured interviews with professional nurses. Interview transcripts were coded and emerging themes identified. Data saturation was reached after eight interview transcripts were analysed. Results. Four themes representing the perceptions of the professional nurses emerged in the analysis: (i) the clinical teaching role; (ii) the complexities of clinical teaching; (iii) learners have their issues; and (iv) making it work. Conclusion. Professional nurses understand and appreciate their educational role in the development of competent nurses. This clinical teaching role is performed in difficult circumstances; including administrative challenges; limited resources and staff shortages; while maintaining clinical responsibilities. Despite these challenges; the nurses have remained resilient and solution focused. Nursing education institutions should re-orientate professional nurses with regard to current trends and principles of nursing education to enhance their clinical teaching role

Toxic and metabolic encephalopathies: iconographic essay / Encefalopatias tóxicas e metabólicas: ensaio iconográfico

Generally, toxic-metabolic diseases affecting the central nervous system can hardly be differentiated just on the basis of their clinical presentation. However, some typical neuroradiological features can guide the correct diagnosis. In this context, magnetic resonance imaging is an important tool which, in association with clinical and laboratory data, can establish an early and specific treatment. The present pictorial essay with selected cases from the archives of the authors' institution describes imaging findings which might help in the etiologic diagnosis of toxic-metabolic diseases.

As doenças toxicometabólicas do sistema nervoso central geralmente são de difícil diferenciação apenas pelo quadro clínico. Entretanto, existem algumas características neurorradiológicas típicas que podem orientar o diagnóstico correto. Neste sentido, a ressonância magnética é uma ferramenta importante que, junto ao quadro clinicolaboratorial, auxilia na instituição de uma terapêutica precoce e específica. Este ensaio iconográfico com casos selecionados dos arquivos da instituição dos autores tem como objetivo demonstrar achados de imagem que possam auxiliar no diagnóstico etiológico das doenças toxicometabólicas.

Ejercicio profesional en provincias: experiencia de un médico general de Zona en Vallenar / Professional practice in the provinces: experience of a general practitioner from the area in Vallenar

En 1968, el Departamento de Salud Pública del Colegio Médico de Chile realizó, como en años anteriores, un Concurso invitando a los Médicos Generales de Zona a presentar un relato de la labor realizada por el equipo de salud en áreas rurales de nuestro país. El Departamento de Salud Pública consideró que el relato que publicamos en esta edición de Cuadernos Médico-Sociales era acreedor al Primer Premio. En este trabajo se comprueba una vez más que el equipo de salud puede obtener resultados brillantes a corto plazo sí hace un diagnóstico racional de la situación económica, social y cultural de la población bajo su cuidado y se realiza un programa de medicina integral con la participación activa de la comunidad. En nuestras próximas ediciones continuaremos publicando otros trabajos que se destacaron en este Concurso.

Ejercicio profesional en provincias: acciones de salud integral realizadas por el equipo de salud del Hospital de Lonquimay 1969 - 1971 / Professional practice in the provinces: comprehensive health actions carried out by the health team of the Lonquimay Hospital 1969 - 1971

En una de las más extensas y más aisladas comunas del país, en plena Cordillera de Los Andes, y bajo un clima inclemente que dificulta enormemente el transporte local, funciona el Hospital de Lonquimay y tres pequeñas postas periféricas. La labor efectuada por el equipo de salud se desarrolló fundamentalmente hacia la apertura de sus acciones hacia los sectores rurales. De ahí que este relato esté demostrando como la labor tenaz y entusiasta logra interesar hacia la cooperación activa a una población que era indiferente.

Postnatal depression among women availing maternal health services in a rural hospital in south India

Postnatal depression, with an estimated prevalence of 13-19%, causes significant impairment of mental health among women worldwide and has long term consequences. However, more than half of all cases are not detected by healthcare providers. Screening for postnatal depression has not been given importance in maternal health programs in India. Our objective was to screen for postnatal depression among women attending a rural hospital in India, immediately postpartum and at 6-8 weeks post-delivery, and to study associated factors. A cross sectional study was done on 123 postnatal women attending a rural maternity hospital in Karnataka, South India, of whom 74 women were interviewed within one week of childbirth, and 49 women at 6-8 weeks post-delivery. The Edinburgh Postnatal Depression Scale was used to screen for postnatal depression. About 45.5% of the women screened positive for postnatal depression [44.6% of all subjects within one week of delivery and 46.9% at 6-8 weeks after delivery]. Postnatal depression was significantly associated with mood swings during antenatal period, staying with the family of birth during pregnancy and away from their husbands, and was significantly higher among women who perceived their life as stressful and having a low self-esteem [P<0.05] This study found a high prevalence of postnatal depression in women in rural Karnataka. This underlines the need for incorporating screening for postnatal depression in the routine care of women during pregnancy and delivery

Patient attrition from the HIV antiretroviral therapy program at two hospitals in Haiti / Abandono del programa de tratamiento antirretrovírico de la infección por el VIH en pacientes de dos hospitales de Haití

OBJECTIVE: To identify factors associated with antiretroviral therapy (ART) attrition among patients initiating therapy in 2005-2011 at two large, public-sector department-level hospitals, and to inform interventions to improve ART retention. METHODS: This retrospective cohort study used data from the iSanté electronic medical record (EMR) system. The study characterized ART attrition levels and explored the patient demographic, clinical, temporal, and service utilization factors associated with ART attrition, using time-to-event analysis methods. RESULTS: Among the 2 023 patients in the study, ART attrition on average was 17.0 per 100 person-years (95% confidence interval (CI): 15.8-18.3). In adjusted analyses, risk of ART attrition was up to 89% higher for patients living in distant communes compared to patients living in the same commune as the hospital (hazard ratio: 1.89, 95%CI: 1.54-2.33; P < 0.001). Hospital site, earlier year of ART start, spending less time enrolled in HIV care prior to ART initiation, receiving a non-standard ART regimen, lacking counseling prior to ART initiation, and having a higher body mass index were also associated with attrition risk. CONCLUSIONS: The findings suggest quality improvement interventions at the two hospitals, including: enhanced retention support and transportation subsidies for patients accessing care from remote areas; counseling for all patients prior to ART initiation; timely outreach to patients who miss ART pick-ups; "bridging services" for patients transferring care to alternative facilities; routine screening for anticipated interruptions in future ART pick-ups; and medical case review for patients placed on non-standard ART regimens. The findings are also relevant for policymaking on decentralization of ART services in Haiti.

OBJETIVO: Determinar los factores asociados con el abandono del tratamiento antirretrovírico en los pacientes que iniciaron el tratamiento en el período del 2005 al 2011 en dos grandes hospitales públicos de nivel departamental, y fundamentar las intervenciones necesarias para mejorar la retención de los pacientes en el tratamiento. MÉTODOS: Este estudio retrospectivo de cohortes empleó los datos del sistema de registro médico electrónico iSanté. Se describieron los niveles de abandono del tratamiento y se exploraron los factores demográficos, clínicos, temporales y de utilización de los servicios que se asociaban con su abandono, usando métodos de análisis del tiempo trascurrido hasta un evento. RESULTADOS: El abandono del tratamiento entre los 2 023 pacientes incluidos en el estudio fue en promedio de 17,0 por 100 personas-años (intervalo de confianza (IC) de 95%: 15,8-18,3). En los análisis ajustados, el riesgo de abandono del tratamiento fue de hasta 89% mayor en los pacientes que vivían en comunas distantes, en comparación con los pacientes que vivían en la misma comuna en que se ubicaba el hospital (razón de riesgo: 1,89; IC de 95%: 1,54-2,33; P < 0,001). La ubicación del hospital, el inicio del tratamiento en un año calendario anterior, un menor tiempo de inclusión en el programa de atención a la infección por el VIH antes de iniciar el tratamiento, la administración de un régimen terapéutico no estándar, la falta de orientación antes de iniciar el tratamiento y un mayor índice de masa corporal también se asociaron con un riesgo más elevado de abandono. CONCLUSIONES: Los resultados sugieren algunas intervenciones de mejora de la calidad en ambos hospitales, entre ellas: un mayor apoyo a la retención y subsidios de transporte para los pacientes que acuden desde zonas remotas para ser atendidos; la orientación a todos los pacientes antes del inicio del tratamiento antirretrovírico; el contacto oportuno de los servicios con los pacientes que omiten alguna recogida de medicación; "servicios de conexión" para transferir la atención de los pacientes a otros establecimientos alternativos; el tamizaje sistemático de las interrupciones previstas en las próximas recogidas de medicación; y la revisión médica de los casos de pacientes que siguen un tratamiento no estándar. Estos hallazgos son también pertinentes en materia de formulación de políticas de descentralización de los servicios de tratamiento antirretrovírico en Haití.

Management and transference of patients diagnosed with tuberculosis in a rural hospital in southern Ethiopia

Treatment of new tuberculosis [TB] cases in Directly Observed Treatment Short Course [DOTS] programmes is believed to be the most valuable strategy for TB control. The aim of this study is to describe the experience of diagnosed cases of TB in a district hospital situated in a rural zone of Ethiopia and of "transferred out" TB cases from the hospital to their local health facilities using the DOTS programme spanning a period of 8 years. Data collection was obtained by using a TB register book in a rural district hospital from 2004 to 2011. The collected information included the type of TB, age, HIV status, and treatment outcomes using standardized definitions; 6459 patients with all forms of TB were diagnosed. Twenty-eight percent were smear-positive pulmonary TB [PTB] cases, 28.97% were smear-negative PTB cases, and 42.8% were extra-pulmonary TB [EPTB]. The global "transferred out" rate was 78.5% [5073/6459]; the "transferred out" rate after diagnosis at hospital and before starting DOTS was 72.6% [4689/6459], and after finishing the intensive phase and admission was 21.8% [385/1770]. The proportion of total cases "transferred out" in smear-negative PTB cases [70.2%] was less than smear-positive PTB cases [79.2%] [odd ratio [OR]: 0.81; 95% confidence interval [CI]: 0.76-0.87] and was higher in EPTB cases [83.3%] [OR: 1.15; 95% CI: 1.05-1.19]. The percentage of "transferred out" after hospital admission was higher in HIV-positive cases [16.8%] than in HIV-negative cases [8.5%] [OR: 2.13; 95% CI: 1.28-3.53]. In conclusion, district hospitals are still important facilities for the diagnosis of TB cases, particularly EPTB

comparative study of the C - reactive protein and the ST-score [ECG] as prognostic indicators in acute myocardial infarction in a rural resource-constrained hospital setting in central India: a cross-sectional study

The electrocardiogram remains a crucial tool in identification of acute myocardial infarction [AMI]. High sensitivity C-reactive protein [hs-CRP] has been found to be strong predictor of coronary artery disease [CAD] and future cardiovascular events. The aim of the present study was to compare hs-CRP and ST-Score [STS] as prognostic indicator in acute ST segment elevated myocardial infarction [STEMI] in central rural India. Cross sectional study, rural hospital in central India. In all patients of STEMI, STS, ST index and hs-CRP were measured on admission and serially. The Primary outcome was all cause mortality at 30 days. Secondary outcome were heart failure, life threatening arrhythmia, cardiogenic shock, re-infarction, hospital stay and re-admission. We used Student's t test to compare means, Chi-square test to compare proportions and Mann Whitney test to compare medians. P value <0.05 will be considered significant. Crude odds ratios were computed to assess the strength of association between risk factors and independent variable along with 95% confidence intervals. STS was significantly higher in patients with poor outcome, when compared with good outcome [20.27mm vs.12.47mm, P = 0.002]. On multivariate regression model STS was significant predictor of composite outcome events [OR = 2.74; 95% [CI], 1.46 to 5.17; P = 0.002]. The area under the ROC curve was 0.70, with sensitivity of 73.5%, specificity of 58.7%; PPV of 68.3% and NPV of 64.2%. hs-CRP in patients with poor outcome vs. good outcome [6mg/L vs. 3.74mg/L, P = 0.003] and [P = 0.06, 0.85 and 0.12] respectively. STS on admission is independent predictor while hs- CRP is not in resource constrained settings.

Perfil de la consulta dermatológica en el servicio de urgencia del hospital de Quellón / Profile of dermatologic consultation in the emergency service of hospital Quellon

Las consultas por enfermedades dermatológicas en los servicios de urgencia presentan una baja frecuencia y poseen una pobre descripción de sus características en la literatura. A raíz de lo anterior, confeccionamos un estudio descriptivo y retrospectivo de las consultas dermatológicas realizadas en el Servicio de Urgencia del Hospital de Quellón, entre Abril 2010 y Marzo 2011. Los resultados mostraron que las causas dermatológicas representan un 4.9 por ciento del total de consultas. Esta cifra varía durante el transcurso del año, evidenciándose una mayor frecuencia en los meses de verano. Además, se observó que la proporción de consultas de urgencias atribuibles a una enfermedad de la piel es mayor en pacientes pediátricos y adolescentes que en los pacientes adultos. Finalmente, del total de consultas dermatológicas, las etiologías infecciosas y alérgicas fueron las diagnosticadas con mayor frecuencia. No se evidenció una diferencia estadísticamente significativa entre los promedios de consultas pediátrico adolescentes y de población adulta, entre las distintas estaciones del año.

The dermatological consultations in the emergency services have a low frequency and a poor description of its features in the literature. Therefore, we made a descriptive and retrospective study of dermatology consultations conducted in the hospital emergency service of Quellón, between April 2010 and March 2011. The results showed that skin pathology represent 4.9 percent of all consultations. This number varies throughout the year, showing a higher frequency in the summer months. In addition, we observed that the proportion of emergency visits attributable to a skin disease is higher in pediatric and adolescent patients than in adult patients. Finally, for all dermatological consultations, infectious and allergic etiologies were the more frequently diagnosed. No statistically significant difference was showed between pediatric adolescent and adult consultations, during the different seasons.

Tuberculosis and lactic acidosis as causes of death in adult patients from a regional hospital in Johannesburg

Background: Tuberculosis and adverse effects have been shown to affect both the quality of life and the survival of patients on antiretroviral treatment. This study sought to investigate the causes of death in a sample of adult HIV-infected patients on antiretroviral treatment at Thembisa Hospital, Johannesburg, South Africa. Methods: A retrospective study was conducted by examining the charts of 498 adult patients treated from January 2004 to December 2006 at the antiretroviral clinic of a regional hospital in Johannesburg. A data collection form was used to collate both sociodemographic and clinical data. Results: The majority of the patients were female (71.7%) with a mean age of 37.7 ± 11.6 years, and in the age group of 18­77 years. The greater number of the patients was South African citizens, with only 2.2% citizens of other Southern African countries. At baseline, 29.9% had been on anti-tuberculosis treatment. Most of the patients had been prescribed the regimen comprising stavudine, lamivudine, and nevirapine or efavirenz; two of them (0.4%) were on the second line regimen made of zidovudine, didanosine, and lopinavir­ritonavir. At least one side effect was documented in 82.1% of patients; the ten most documented side effects were skin rashes (62.9%), peripheral neuropathy (48.4%), headaches (38.2%), chest pain(21.9%), coughing (21.7%), anaemia (21.5%), diarrhoea (19.3%), vomiting (16.7%), dizziness (15.3%), and lactic acidosis (11.2%). A mortality rate of 3.6% was recorded during the 2-year study period. Although the cause of death was undetermined in 11.1% of patients, 50.0% and 38.9% of deaths respectively were a consequence of tuberculosis and lactic acidosis. Conclusions: In addition to tuberculosis, side effects in particular, lactic acidosis was the other main cause of death in patients treated at the study site. These findings suggest that patients on regimens containing drugs that cause lactic acidosis should be closely monitored when the first complaints suggesting lactic acidosis are reported or noticed