Scale up of anaesthesia services in underserved rural Tanzania.

BACKGROUND: Because of critical shortage of physician anaesthesiologists, the government of Tanzania adopted a task shifting strategy for provision of anaesthesia services. This paper describes the results of an operational study designed to increase the number of anaesthesia providers for emergency obstetric surgeries in order to reduce maternal and perinatal mortality in underserved rural Tanzania. METHODS: In 2016 a before-after cohort study was conducted in seven health centres in rural Tanzania. Five health centres received an intervention and two were selected to track secular trends (control group). Ten associate clinicians, i.e. assistant medical officers, clinical officers, and nurse midwives, from five health centres were trained in anaesthesia skills for emergency obstetric surgeries for three months followed by quarterly supportive supervision, mentoring and teleconsultation to reinforce skills. Primary and secondary outcome measures included Caesarean delivery (CD) rate, quality and safety of anaesthesia, and uptake of the educational program for anaesthesia. RESULTS: Out of the 2,179 CDs performed in the intervention facilities from 2016 to 2019, two women died from complications of anaesthesia. The risk of death from anaesthetic complications was 0.9 per 1000 CD (95% CI 0.1-3.3. The risk of death was not established in the control group because of inadequate documentation and records keeping. The proportion of CD performed under spinal anaesthesia in intervention facilities doubled from 28% (60/214 with 95% CI 22-35) at baseline (July 2014 - June 2016) to 57% (558/971 with 95% CI of 54-61) in year three (July 2018 - June 2019), while in the control group increased by only 40% from 19% (92/475 with 95% CI of 16-23) at baseline and 27% (68/251 with 95% CI of 22-33) in year three. In 2020I, this educational training program was then adopted by the government with minor content changes and increasing duration of training to six months. CONCLUSIONS: This three month educational training program for associate clinicians in anaesthesia, complemented by supportive supervision, can increase the CD rate to one that fills the "unmet need" and the proportion of operations performed under spinal anaesthesia, the gold standard technique for CD. The program can be used to meet the urgent demand for anaesthesia services in other underserved areas in Africa.

Fabricating tubular scaffolds with a radial pore size gradient by a spinning technique.

A novel fabrication process has been developed to produce collagen-based, porous tubular scaffolds to facilitate the study of myofibroblast migration during peripheral nerve regeneration; however, this fabrication technique offers broader appeal for the production of a variety of tubular structures without the use of a complicated mold system. A collagen-glycosaminoglycan (CG) suspension in acetic acid was spun in a cylindrical copper mold about its longitudinal axis at variable angular velocities and for different times, resulting in variable relative sedimentation of the CG content towards the mold outer edge; after the specified spinning time, the spinning mold was placed into a bath of liquid nitrogen where the CG suspension was rapidly frozen. Due to the rapid solidification, the CG content remained sedimented while an interconnected network of ice crystals formed throughout. Sublimation of the frozen mass removed the solvent (acetic acid) content, producing a porous, tubular structure defined by sedimentation and ice crystal nucleation processes. A porous, tubular scaffold with a sharply defined inner tube wall can be produced; further, increasing the spinning time and/or spinning velocity increases the sedimentation effect leading to the production of a hollow tube with a larger inner diameter. The tube walls display a radially aligned pore structure, even in cases where sedimentation was not sufficient to produce a hollow tube. A gradient of porosity along the tube radius was also observed in cases of extreme sedimentation: the pore structure of the external portion of the tube wall had a larger solid volume fraction and a smaller mean pore size compared to the internal portion of the tube. This tubular structure may allow preferential cell migration from the inner tube lumen towards the outer tube edge while blocking cell entrance into the tube through its outer surface due to increased scaffold relative density and decreased pore size.