Sparks creating light? Strengthening peripheral disease surveillance in the Democratic Republic of Congo.

SETTING: The Democratic Republic of Congo suffers from an amalgam of disease outbreaks and other medical emergencies. An efficient response to these relies strongly on the national surveillance system. The Pool d'Urgence Congo (PUC, Congo Emergency Team) of Médecins Sans Frontières is a project that responds to emergencies in highly remote areas through short-term vertical interventions, during which it uses the opportunity of its presence to reinforce the local surveillance system. OBJECTIVE: To investigate whether the ancillary strengthening of the peripheral surveillance system during short-term interventions leads to improved disease notification. DESIGN: A descriptive paired study measuring disease notification before and after 12 PUC interventions in 2013-2014. RESULTS: A significant increase in disease notification was observed after seven mass-vaccination campaigns and was sustained over 6 months. For the remaining five smaller-scaled interventions, no significant effects were observed. CONCLUSION: The observed improvements after even short-term interventions underline, on the one hand, how external emergency actors can positively affect the system through their punctuated actions, and, on the other hand, the dire need for investment in surveillance at peripheral level.

Contexte : La République Démocratique du Congo souffre d'un amalgame de flambées épidémiques et d'autres urgences médicales. Une réponse efficace à ces problèmes est basée sur le système national de surveillance. Le Pool d'Urgence Congo (PUC) de Médecins Sans Frontières est un projet répondant aux urgences dans les zones très reculées grâce à des interventions verticales à court terme, pendant lesquelles le projet met à profit l'opportunité de sa présence pour renforcer le système de surveillance local.Objectif : Vérifier si le renforcement complémentaire du système de surveillance périphérique pendant des interventions à court terme amène une amélioration de la notification des maladies.Schéma : Une étude descriptive par paires mesurant la notification des maladies avant et après 12 interventions PUC en 2013­2014.Résultats : Une augmentation significative de la notification des maladies a été observée après sept campagnes de vaccination de masse et elle s'est maintenue pendant 6 mois. En ce qui concerne les cinq interventions restantes à plus petite échelle, aucun effet significatif n'a été observé.Conclusion : Les améliorations observées, même après des interventions à court terme, soulignent d'un côté comment des acteurs externes de l'urgence peuvent affecter positivement le système à travers leurs actions ponctuelles et, d'un autre côté, le besoin pressant d'investir dans la surveillance au niveau périphérique.

Marco de referencia: La República Democrática del Congo adolece de una amalgama de brotes epidémicos y otras urgencias médicas y la eficiencia de la respuesta a esta situación depende en gran medida del sistema nacional de vigilancia. El proyecto 'Pool d'Urgence Congo' (PUC, en francés) de Médecins Sans Frontières responde a las situaciones de urgencia en zonas muy remotas, mediante intervenciones verticales a corto plazo, durante las cuales se aprovecha la presencia en el terreno con el fin de reforzar el sistema local de vigilancia sanitaria.Objetivo: Investigar si el fortalecimiento complementario del sistema periférico de vigilancia sanitaria durante las intervenciones de corta duración contribuye a mejorar la notificación de las enfermedades.Método: Un estudio descriptivo emparejado, en el cual se midió la notificación de las enfermedades antes y después de 12 intervenciones del PUC del 2013 al 2014.Resultados: Se observó un aumento estadísticamente significativo de la notificación de las enfermedades después de siete campañas de vacunación colectiva, el cual se mantuvo durante 6 meses. En las cinco intervenciones restantes de menor escala no se observaron efectos considerables.Conclusión: El progreso observado incluso después de intervenciones a corto plazo, por una parte, pone de manifiesto que los actores externos en situaciones de emergencia pueden inducir modificaciones positivas del sistema mediante sus actividades puntuales y, en segundo lugar, destaca la necesidad urgente de invertir en el sistema de vigilancia sanitaria a nivel periférico.

Ebola, fragile health systems and tuberculosis care: a call for pre-emptive action and operational research.

The Ebola outbreak that started in late 2013 is by far the largest and most sustained in history. It occurred in a part of the world where pre-existing health systems were already fragile, and these deteriorated further during the epidemic due to a large number of health worker deaths; temporary or permanent closure of health facilities; non-payment of health workers; intrinsic fear of contracting or being stigmatised by Ebola among the population, which negatively influenced health-seeking behaviour; enforced quarantine of Ebola-affected communities, restricting the access of vulnerable individuals to health facilities; and late response by the international community. There are also reports of drug and consumable stockouts due to deficiencies in the procurement and supply chain as a result of overriding Ebola-related priorities. Providing tuberculosis (TB) care and achieving favourable treatment outcomes require a fully functioning health system, accurate patient tracking and high patient adherence to treatment. Furthermore, as Ebola is easily transmitted through body fluids, the use of needles-essential for TB diagnosis and treatment-needs to be avoided during an outbreak. We highlight ways in which a sustained Ebola outbreak could jeopardise TB activities and suggest pre-emptive preventive measures while awaiting operational research evidence.

Effect of dexamethasone on nausea, vomiting, and pain in paediatric tonsillectomy.

BACKGROUND: The efficacy of dexamethasone (DEX) to reduce morbidity after paediatric tonsillectomy remains controversial. We evaluated the effect of 0.15 and 0.5 mg kg(-1) DEX on the incidence of postoperative nausea and vomiting (PONV) and on pain intensity after paediatric tonsillectomy. METHODS: A total of 147 children aged 2-8 yr undergoing elective tonsillectomy were included in this prospective randomized double-blind study. At the induction of anaesthesia, subjects received 0.15 mg kg(-1) (DEX 0.15), 0.5 mg kg(-1) (DEX 0.5) DEX, or an equivalent volume of saline solution (placebo). Anaesthetic and surgical techniques were standardized. The incidence of PONV and the need for anti-emetic drugs and additional analgesia (tramadol and/or morphine) were recorded. Postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale, the visual analogue scale, and the postoperative pain measure for parents. RESULTS: The incidence of early PONV (primary outcome variable) was lower in both DEX groups (DEX 0.15: 21%; DEX 0.5: 22%; placebo: 49%; P=0.001). The incidence of severe pain was reduced in the DEX groups on the second postoperative day (DEX 0.15: 20%; DEX 0.5: 5%; placebo: 47%; P<0.001). The study was not powered to assess a difference between the two DEX dose groups. CONCLUSIONS: A single i.v. injection of DEX at the induction of anaesthesia was effective in reducing the incidence of early and late PONV and the level of pain on the second postoperative day. A 0.15 mg kg(-1) DEX dose appeared to be as effective as a 0.5 mg kg(-1) dose to reduce the incidence of PONV.

Effects of dynamic office chairs on trunk kinematics, trunk extensor EMG and spinal shrinkage.

Seated work has been shown to constitute a risk factor for low-back pain. This is attributed to the prolonged and monotonous low-level mechanical load imposed by a seated posture. To evaluate the potential health effects with respect to the low back of office chairs with a movable seat and back rest, trunk kinematics, erector spinae EMG, spinal shrinkage and local discomfort were assessed in 10 subjects performing simulated office work. On three separate occasions subjects performed a 3 h task consisting of word processing, computer-aided design and reading. Three chairs were used, one with a fixed seat and back rest and two dynamic chairs, one with a seat and back rest movable in a fixed ratio with respect to each other, and one with a freely movable seat and back rest. Spinal shrinkage measurements showed a larger stature gain when working on the two dynamic chairs as compared with working on the chair with fixed seat and back rest. Trunk kinematics and erector spinae EMG were strongly affected by the task performed but not by the chair type. The results imply that dynamic office chairs offer a potential advantage over fixed chairs, but the effects of the task on the indicators of trunk load investigated were more pronounced than the effects of the chair.

Use of surface electromyography to estimate neck muscle activity.

This paper reviews the literature concerning the use of surface electromyography (sEMG) for the study of the neck musculature in response to work and workplace design during light work and semi-static tasks. The paper also draws upon basic research and biomechanical modeling in order to provide methodological recommendations for the use of surface electromyography in this region of the body and to identify areas which require further investigation. The paper includes review and discussion of electrode site location, methods of normalization, data reliability, and factors that can affect sEMG signals from this region, including noise, physiologic artifact, stress, visual deficiencies, and pain. General guidance for maximum exertions with the neck musculature, for sEMG normalization or other purposes, is also included.

Relation between differences in electromyographic adaptations during static contractions and the muscle function.

This study determines whether changes in the EMG values of two important muscles of the shoulder and neck region, the anterior deltoid and the upper trapezius, are due to changes in torque production or due to fatigue processes during sustained activity. Contractions at 20, 40, 60, 80 and 100% MVC were performed during a flexion of the arm in the sagittal plane at 90 degrees, to examine the relation between torque and EMG. A sustained contraction at 20% MVC was performed to endurance point in the same position. RMS, a new parameter called activity, (ACT), and MPF of the deltoid anterior and the upper trapezius were analysed. The amplitude values correlated highly with increasing torque production, both for the deltoid muscle (range r = 0.95-0.96), and the trapezius muscle (range r = 0.83-0.87), whereas no significant difference was found for MPF. For the endurance task, the decrease in MPF was far more pronounced for the deltoid than for the trapezius, whereas the opposite occurred with RMS (P < or = 0.01). Furthermore, there was no significant difference over time for the ACT values of the deltoid, whereas there were significant increases in ACT for the trapezius (P < or = 0.01). The RMS/ACT ratio correlated highly (r = 0.81) with the MPF. Regression coefficients of these parameters differed significantly for the trapezius muscle but not for the deltoid muscle. Therefore, the RMS/ACT ratio may be extremely important in analysing the fatigue effects during sustained efforts, independent of torque variations, which can influence indicators of fatigue.

Lipoatrophia semicircularis and the relation with office work.

The relation between lipoatrophia semicircularis (LS--band-like circular depressions and isolated atrophy of the subcutaneous fatty tissue on the anterior thighs and sitting posture or pressure on the seat surface of office chairs was investigated in an office environment. A questionnaire was presented to 21 subjects and electromyographic measurements, video analysis and pressure measurements were performed. Remarkable posture differences between the LS group and the group without LS were found: less use of the lumbar support of the chair, static sitting postures and a too high seat surface of the office chair were characteristics of the subjects with LS. These observations were confirmed by higher pressure measurements for the subjects with LS. In addition, highly significant pressure differences were found between different chairs.

Muscular activity of the shoulder and neck region during sustained and intermittent exercise.

Sustained isometric contractions of the neck and shoulder muscles in laboratory conditions are often assumed to be representative of muscular load in occupational tasks. The present study aims to investigate whether differences can be found between these contractions and those in intermittent tasks. Ten subjects performed forward flexions of the right arm during three tests to the limit of endurance: (1) a sustained contraction; (2) an intermittent contraction with a cycle time of 10 s and a duty cycle of 0.7; and (3) the same intermittent contraction with the possibility of changing the shoulder angle during relaxation. Muscular activities of the upper trapezius, deltoid pars anterior and medialis and infraspinatus were registered using surface electromyography, and changes in the signal were quantified by root mean square (RMS) and mean power frequency (MPF) values. During the continuous test, highly significant changes in both parameters were found for the four muscles. Significant changes were found during both intermittent conditions, although to a lesser degree than in the continuous test. Significant differences between the regression coefficients of the sustained test and the two intermittent tests were found on all occasions: for RMS and MPF of the four muscles. Significant differences were also found regarding the intermittent tests. The test in which no variation in limb position was allowed during relaxation caused a more pronounced MPF decrease for the trapezius (P < or = 0.01), which was confirmed by the subjective scores of perceived exertion and a higher RMS increase (P < or = 0.01) for the middle part of the deltoid. The intermittent condition with changes in shoulder angle showed more MPF decrease for the deltoid, significant for the middle part (P < or = 0.05), not significant for the anterior part and a larger RMS increase for infraspinatus (P < or = 0.05). It can be concluded that the latter condition represents more the trapezius and deltoid activity as in occupational tasks.

Influence of electrode position on changes in electromyograph parameters of the upper trapezius muscle during submaximal sustained contractions.

The purpose of the present study was to evaluate whether differences could be found in the changes in mean power frequency (MPF) and root-mean-square (rms) due to electrode positions on the upper trapezius muscle during a sustained submaximal task. A group of 25 healthy subjects performed a continuous forward flexion of the right arm at 20% of their maximal voluntary contraction (MVC). Three pairs of bipolar surface electrodes were positioned on a straight line between the spine of the seventh cervical vertebra (C7) and the lateral edge of the acromion. The fourth pair (the caudal position) was placed 2 cm below the midpoint of this line. The analysis of variance revealed significant differences between the electrode positions during the short 20% MVC and during MVC (P < or = 0.01). Furthermore, lower rms values were found when the electrodes were placed symmetrically around the midpoint of the reference line, which confirms previous studies. A statistical model has been developed to discriminate additionally the very small changes in the electromyogram parameters due to electrode position during the sustained 20% MVC. It was found that the slope coefficients of rms and MPF were significantly different from 0 (P < or = 0.01), although to a lesser degree for rms and more clearly for MPF of the caudal position (P < or = 0.05). Furthermore, significant differences were found between several combinations of the uppermost electrodes and the caudal position (P < or = 0.01). From this study, it is concluded that it is important to evaluate several electrode positions on the upper trapezius muscle to be able to represent the behaviour of this muscle accurately during a sustained contraction.