Health Care Simulation in Developing Countries and Low-Resource Situations.

INTRODUCTION: Health care simulation, as a complement to traditional learning, has spread widely and seems to benefit both students and patients. The teaching methods involved in health care simulation require substantial human, logistical, and financial investments that might preclude their spread in developing countries. The aim of this study was to analyze the health care simulation experiences in developing countries. METHODS: A comprehensive literature search was performed from January 2000 to December 2016. Articles reporting studies on educational health care simulation in developing countries were included. RESULTS: In total, 1161 publications were retrieved, of which 156 were considered eligible based on title and abstract screening. Thirty articles satisfied our predefined selection criteria. Most of the studies were case series; 76.7% (23/30) were prospective and comparative, and five were randomized trials. The development of dedicated task trainers and telesimulation were the primary techniques assessed. The retrieved studies showed encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly tested on the training tool itself. Two of the tools have been proven to be construct valid with clinical impact. CONCLUSION: Health care simulation in developing countries seems feasible with encouraging results. Higher-quality studies are required to assess the educational value and promote the development of health care simulation programs.

[Factors associated with first pregnancy in women who gave birth in a maternity hospital in Antananarivo: a retrospective cohort study]. / Facteurs associés à une première grossesse chez les femmes Malgaches ayant accouché dans un hôpital de maternité d'Antananarivo: une étude de cohorte rétrospective.

INTRODUCTION: There are very few African and Malagasy literatures on general risk factors among primigravidae. This study aimed to determine the potential risk factors associated with a first pregnancy. METHODS: We conducted a retrospective cohort study among primigravidae and multigravidae women at the Hospital Sainte Fleur Pavilion between October 2014 and December 2016. The relative risks were adjusted after examinations according to sociodemographic features. RESULTS: Primigravidae were far more likely to experience prolonged labour lasting more than 12h (aRR = 2.28; 95% CI 1.74-3.00), emergency cesarean section (RR = 1.47; 95% CI 1.35-1.60) and episiotomy (aRR = 2.98; 95% CI 2.61-3.40). Children were more likely to show signs of fetal distress associated with fetal rhythm abnormalities during labor (aRR = 1.96; 95% CI 1.45-2.65) and an increased risk for intensive care unit admission after birth (aRR = 2.08; 95% CI 1.25-3.45). CONCLUSION: Complications arising during labor may expose primigravidae to cascading risks concerning delivery outcomes and children's health. The management of labour in primigravidae should require close attention from medical staff.

Hemorrhage of hepatocellular adenoma: a complication that can be treated by conservative management without surgery.

BACKGROUND: Hemorrhage is the main complication of hepatocellular adenoma (HCA). The aim of this study was to describe a single center's evolving management of patients with hemorrhagic HCA. METHOD: Between 1990 and 2013, all patients with hemorrhagic HCA were included. During the study period, the management evolved from urgent surgery (period <2004) to arterial embolization with (period, 2004-2010) or without (period > 2010) delayed resection. RESULTS: A total of 56 patients were identified. The median (range) size of HCA and the hematoma was 80 mm (35-160) and 50 mm (10-160). Patients were treated by urgent resection (group 1, n = 6), delayed resection with or without embolization (group 2, n = 43) and systematic embolization without surgery (group 3, n = 7). Embolization was performed in 0/6, 15/43 and 7/7 in groups 1, 2 and 3. Urgent resection was associated with higher morbidity (p < 0.001). Complete necrosis was observed in 0/6, 13/43 and 3/7 patients, and on histology it was associated with embolization (p = 0.001), a hematoma-tumor ratio > 60% (p = 0.046) and a cystic non-viable lesion before surgery (p < 0.001). CONCLUSION: Hemodynamic stability can be achieved in patients presenting with hemorrhagic HCA by none surgical means. Subsequent surgery can be completely avoided with such an approach in up to 40% of patients.

Facteurs associés à une première grossesse chez les femmes Malgaches ayant accouché dans un hôpital de maternité d'Antananarivo: une étude de cohorte rétrospective

Introduction: il y a très peu de littératures africaines et Malgaches concernant les détails sur les facteurs de risques qu'encourent les primigestes en général. Le but de notre étude est de déterminer les facteurs de risques potentiels associés à une première grossesse.Méthodes: une étude cohorte rétrospective a été menée auprès des femmes primigestes et multigestes de l'hôpital Pavillon sainte Fleur entre Octobre 2014 et Décembre 2016. Les risques relatifs étaient ajustés après contrôle avec les caractéristiques sociodémographiques.Résultats: les primigestes étaient beaucoup plus exposées à un travail prolongé de plus de 12h (RRa = 2,28; IC 95% 1,74-3,00), à une césarienne en urgence (RRa = 1,47; IC 95% 1,35-1,60) et à une épisiotomie (RRa = 2,98; IC 95% 2,61-3,40). Leurs enfants étaient plus susceptibles de présenter des signes de souffrance fœtale avec anomalie du rythme cardiaque fœtale au cours de la phase de travail (RRa = 1,96; IC 95% 1,45-2,65) et un risque accru d'être admis dans une unité de soins intensifs après l'accouchement (RRa = 2,08; IC 95% 1,25-3,45).Conclusion: les complications survenues pendant le travail auraient exposé les primigestes à d'autres risques en cascades sur l'issue de leurs accouchements et sur la santé de leurs enfants. La prise en charge des primigestes nécessiterait, de la part des personnels médicaux, une attention particulière sur la durée de la phase de travail

Laparoscopic fenestration of pancreatic serous cystadenoma: Minimally invasive approach for symptomatic benign disease.

Serous cystadenoma (SC) is a benign pancreatic cystic tumor. Surgical resection is recommended for symptomatic forms, but laparoscopic fenestration of large symptomatic macrocystic SC was not yet described in the literature. In this study, 3 female patients underwent laparoscopic fenestration for macrocystic SC (12-14 cm). Diagnosis was established via magnetic resonance imaging and endoscopic ultrasound, with intra-cystic dosage of tumors markers (ACE and CA19-9) in 2 patients. All patients were symptomatic and operated on 15-60 mo after diagnosis. Radiological evaluation showed constant cyst growth. Patients were informed about this new surgical modality that can avoid pancreatic resection. The mean operative time was 103 min (70-150 min) with one conversion. The post-operative course was marked by a grade A pancreatic fistula in one patient and was uneventful in the other two. The hospital stay was 3, 10, and 18 d, respectively. The diagnosis of macrocystic SC was histologically-confirmed in all cases. At the last follow-up (13-26 mo), all patients were symptom-free, and radiological evaluation showed complete disappearance of the cyst. Laparoscopic fenestration, as opposed to resection, should be considered for large symptomatic macrocystic SC, thereby avoiding pancreatic resection morbidity and mortality.

Laparoscopic middle pancreatectomy: how do I do it?

BACKGROUND: Although laparoscopic surgery is now extensively used, laparoscopic middle pancreatectomy (LMP) has rarely been described. STUDY DESIGN AND METHODS: A 45-year-old woman was diagnosed with branch duct intraductal papillary mucinous neoplasia (IPMN) at the pancreatic neck, which was discovered after numerous attacks of acute pancreatitis. LMP was decided on for treatment. RESULTS: The patient underwent pure LMP with right to left dissection and one-layer pancreatogastric anastomosis. Surgery lasted 160 minutes, with 20 mL of blood loss. A frozen section showed negative margins on both sides. The postoperative course was uneventful with 15 days in the hospital. Histology confirmed the diagnosis of branch duct IPMN with moderate dysplasia and negative margins. The patient is symptom free 6 months after surgery. CONCLUSIONS: Our results and the data in the literature suggest that the laparoscopic approach is indicated for middle pancreatectomy because there are no technical or oncological contraindications and the outcome is similar to that with the open approach.