RESUMEN

INTRODUCTION: Enteral resuscitation (EResus) is operationally advantageous to intravenous resuscitation for burn-injured patients in some low-resource settings. However, there is minimal guidance and no training materials for EResus tailored to non-burn care providers. We aimed to develop and consumer-test a training flipbook with doctors and nurses in Nepal to aid broader dissemination of this life-saving technique. MATERIALS AND METHODS: We used individual cognitive interviews with Nepali (n = 12) and international (n = 4) burn care experts to define key elements of EResus and specific concepts for its operationalization at primary health centers and first-level hospitals in Nepal. Content, prototype illustrations, and wireframe layouts were developed and revised with the burn care experts. Subsequently, eight consumer testing focus groups with Nepali stakeholders (5-10 people each) were facilitated. Prompts were generated using the Questionnaire Appraisal System (QAS) framework. The flipbook was iteratively revised and tested based on consumer feedback organized according to the domains of clarity, assumptions, knowledge/memory, and sensitivity/bias. RESULTS AND DISCUSSION: The flipbook elements were iterated until consumers made no additional requests for changes. Examples of consumer inputs included: clarity-minimize medical jargon, add shrunken organs and wilted plants to represent burn shock; assumptions-use locally representative figures, depict oral rehydration salts sachet instead of a graduated bottle; knowledge/memory-clarify complex topics, use Rule-of-9 s and depict approximately 20% total body surface area to indicate the threshold for resuscitation; sensitivity/bias-reduce anatomic illustration details (e.g. urinary catheter placement, body contours). CONCLUSION: Stakeholder engagement, consumer testing, and iterative revision can generate knowledge translation products that reflect contextually appropriate education materials for inexperienced burn providers. The EResus Training Flipbook can be used in Nepal and adapted to other contexts to facilitate the implementation of EResus globally.

Asunto(s)

RESUMEN

More than 95% of the 11 million burns that occur annually happen in low-resource settings, and 70% of those occur among children. Although some low- and middle-income countries have well-organized emergency care systems, many have not prioritized care for the injured and experience unsatisfactory outcomes after burn injury. This chapter outlines key considerations for burn care in low-resource settings.

Asunto(s)

RESUMEN

Introduction: The hand is a complex organ responsible for activities of daily living, making it susceptible to injuries and accidents. Hand injuries can result in significant functional impairment and it occurs in a younger productive age group. Therefore, it is important to understand the prevalence and patterns of hand injuries. The aim of the study was to find out the prevalence of hand injuries among patients visiting the emergency department of a tertiary care centre. Methods: A descriptive cross-sectional study was in the Emergency Department of a dedicated trauma centre from 1 June 2022 to 31 August 2022. Ethical approval was obtained from the Institutional Review Board (Reference number: 148412078179). Demographic profile, pattern, and mechanism of hand Injuries of all 96 consecutive patients were assessed after taking informed consent. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 4679 patients visiting the emergency department of the trauma centre, hand injuries were seen in 96 (2.05 %) (1.64-2.46, 95% Confidence Interval). Conclusions: The prevalence of hand injuries was found to be lower than in other similar studies done in similar settings. Keywords: finger injuries; hand injuries; occupational injuries.

Asunto(s)

RESUMEN

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43-79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.

Asunto(s)

RESUMEN

BACKGROUND: Speech therapy is important for ideal functional outcome after cleft palate surgery. Nationwide lockdown due to outbreak of COVID-19 in Nepal restricted the ability of patients to travel to nearby outreach centers for regular speech therapy. The objectives were to assess the feasibility and challenges of conducting online speech therapy with postpalatoplasty children during COVID-19 pandemic; and evaluate the ways to overcome them. METHODS: Patients with cleft palate surgery done at least 3 months prior were given online speech therapy. Feasibility, advantages and challenges of online speech therapy were evaluated through interviewing the guardians and speech therapy providers. RESULTS: A total of 89 patients were included in the study. Only 11.2% had secondary palatine procedures. Almost all the children (97.8%) had face to face speech therapy prior to study period. Best use of time, use of audiovisual aid, no need to travel and rapid progress were the most commonly perceived strengths of online speech therapy. The most frequent challenges were internet connectivity, unclear voice, lack of direct interaction and unstable power supply. Recommended ways to improve online speech therapy were cited as better internet connectivity, having a fixed schedule and availing free or affordable Wifi. CONCLUSIONS: Despite the challenges, online speech therapy provided us with a way to reach out to the cleft palate children when face-to-face therapy was not possible due to COVID-19 pandemic. We see its role even during non-pandemic situations for the children who are unable to visit the speech therapy centers.

Asunto(s)

RESUMEN

Background: In Nepal's remote regions, challenging topography prevents patients with cleft lip and palate (CLP) from seeking care. Objective: To measure the effect of a mobile surgical scout program on CLP surgical care in remote regions of Nepal. Methods: Forty-four lay people were trained as mobile surgical scouts and over 5 months traversed remote districts of Nepal on foot to detect and refer CLP patients for surgical care. Surgical patients from remote districts were compared with matched time periods in the year before intervention. Diagnostic accuracy of the surgical scouts was assessed. Findings: Mobile surgical scouts accurately diagnosed (90%) and referred (82%) patients for cleft surgery. Before the intervention, CLP surgeries from remote districts represented 3.5% of cleft surgeries performed. With mobile surgical scouting, patients from remote districts comprised 8.2% of all cleft surgeries (p = 0.007). When transportation and accompaniment was provided in addition to mobile surgical scouts, patients from remote districts represented 13.5% (p ≤ 0.001) of all cleft surgeries. Conclusion: Task-shifting the surgical screening process to trained scouts resulted in accurate diagnoses, referrals, and increased access to cleft surgery in remote districts of Nepal.

Asunto(s)

RESUMEN

BACKGROUND: Worldwide, different strategies have been chosen to face the COVID-19-patient surge, often affecting access to health care for other patients. This observational study aimed to investigate whether the standard of burn care changed globally during the pandemic, and whether country´s income, geographical location, COVID-19-transmission pattern, and levels of specialization of the burn units affected reallocation of resources and access to burn care. METHODS: The Burn Care Survey is a questionnaire developed to collect information on the capacity to provide burn care by burn units around the world, before and during the pandemic. The survey was distributed between September and October 2020. McNemar`s test analyzed differences between services provided before and during the pandemic, χ2 or Fisher's exact test differences between groups. Multivariable logistic regression analyzed the independent effect of different factors on keeping the burn units open during the pandemic. RESULTS: The survey was completed by 234 burn units in 43 countries. During the pandemic, presence of burn surgeons did not change (p = 0.06), while that of anesthetists and dedicated nursing staff was reduced (<0.01), and so did the capacity to manage patients in all age groups (p = 0.04). Use of telemedicine was implemented (p < 0.01), collaboration between burn centers was not. Burn units in LMICs and LICs were more likely to be closed, after adjustment for other factors. CONCLUSIONS: During the pandemic, most burn units were open, although availability of standard resources diminished worldwide. The use of telemedicine increased, suggesting the implementation of new strategies to manage burns. Low income was independently associated with reduced access to burn care.

Asunto(s)

RESUMEN

BACKGROUND: Plastic surgery varies in scope, especially in different settings. This study aimed to quantify the plastic surgery workforce in low-income countries (LICs), understand commonly treated conditions by plastic surgeons working in these settings, and assess the impact on reducing global disease burden. METHODS: We queried national and international surgery societies, plastic surgery societies, and non-governmental organizations to identify surgeons living and working in LICs who provide plastic surgical care using a cross-sectional survey. Respondents reported practice setting, training experience, income sources, and perceived barriers to care. Surgeons ranked commonly treated conditions and reported which of the Disease Control Priorities-3 essential surgery procedures they perform. RESULTS: An estimated 63 surgeons who consider themselves plastic surgeons were identified from 15 LICs, with no surgeons identified in the remaining 16 LICs. Responses were obtained from 43 surgeons (70.5%). The 3 most commonly reported conditions treated were burns, trauma, and cleft deformities. Of the 44 "Essential Surgical Package'' procedures, 37 were performed by respondents, with the most common being skin graft (73% of surgeons performing), cleft lip/palate repair (66%), and amputations/escharotomy (61%). The most commonly cited barrier to care was insufficient equipment. Only 9% and 5% of surgeons believed that there are enough plastic surgeons to handle the burden in their local region and country, respectively. CONCLUSIONS: Plastic surgery plays a significant role in the coverage of essential surgical conditions in LICs. Continued expansion of the plastic surgical workforce and accompanying infrastructure is critical to meet unmet surgical burden in low- and middle-income countries.

RESUMEN

In Nepal, preventable death and disability from burn injuries are common due to poor population-level spatial access to organized burn care. Most severe burns are referred to a single facility nationwide, often after suboptimal burn stabilization and/or significant care delay. Therefore, we aimed to identify existing first-level hospitals within Nepal that would optimize population-level access as "burn stabilization points" if their acute burn care capabilities are strengthened. A location-allocation model was created using designated first-level candidate hospitals, a population density grid for Nepal, and road network/travel speed data. Six models (A-F) were developed using cost-distance and network analyses in ArcGIS to identify the three vs five candidate hospitals at ≤2, 6, and 12 travel-hour thresholds that would optimize population-level spatial access. The baseline model demonstrated that currently 20.3% of the national population has access to organized burn care within 2 hours of travel, 37.2% within 6 travel-hours, and 72.6% within 12 travel-hours. If acute burn stabilization capabilities were strengthened, models A to C of three chosen hospitals would increase population-level burn care access to 45.2, 89.4, and 99.8% of the national population at ≤2, 6, and 12 travel-hours, respectively. In models D to F, five chosen hospitals would bring access to 53.4, 95.0, and 99.9% of the national population at ≤2, 6, and 12 travel-hours, respectively. These models demonstrate developing capabilities in three to five hospitals can provide population-level spatial access to acute burn care for most of Nepal's population. Organized efforts to increase burn stabilization points are feasible and imperative to reduce the rates of preventable burn-related death and disability country-wide.

Asunto(s)

RESUMEN

BACKGROUND: This study assessed the lower limb reconstruction outcome so that it will provide a baseline evidence to enable data-driven decision making to improve outcome in the future. METHODS: In this study, hospital records from 1st January to 31st December 2019 were collected retrospectively. Complete data of all patients' records treated for lower limb defects at Kirtipur Hospital were included and incomplete data were excluded. Univariate and Bivariate analyses were performed Results: In total 110 patients were included in this study with a male predominance of 66.4% (n=73). The mean age of the patients was 38.7 years (+/- 20). The majority of the patients were from outside Kathmandu valley 79.1% (n=87) and referred 55.5% (n=61). The commonest cause of lower limb defects was trauma 69.1% (n=76), the procedure performed was skin graft 48.5% (n=72), and complication was wound infections, 43% (n=13) of total complications. The hospital stay of more than two weeks was more common among the referred patients 63.9% (n=39) as compared to non-referred patients 30.6% (n=15) and trauma etiology 34.2% (n=26) had more complications than other etiology. The mean age of patients with complications (32.4 years) was lower than those without complications (41.1 years). More number of referred patients (n=43) required multiple surgeries than non-referred patients (n=21). CONCLUSIONS: Referred cases were more likely to have multiple surgeries and a longer hospital stay than non-referred cases. Infection was the commonest complication and the majority of complications were seen in trauma and younger age group.

Asunto(s)

RESUMEN

Background: Scald burns result from exposure to high-temperature fluids and are more common in the pediatric age group. They occur mainly by two mechanisms: (i) spill and (ii) immersion (hot cauldron) burns. These two patterns differ in clinical characteristics and outcomes. Scalds cause significant morbidity and mortality in children. The objective of this study was to compare accidental spill burns and hot cauldron burns in a hospital setting. Methods: An analytical cross-sectional study was conducted by reviewing the secondary data of scald cases admitted during the years 2019 and 2020 in a burn-dedicated tertiary care center. Total population sampling was adopted. Data analysis was done partly using SPSS, version-23, and Stata-15. Mann Whitney U-test and Chi-square/Fisher's exact test were done appropriately to find associations between different variables. Regression analysis was performed taking mortality events as the outcome of interest. Results: Out of 108 scald cases, 43 (39.8%) had hot cauldron burns and 65 (60.2%) had accidental spill burns. Overall mortality was 16 (14.8%), out of which hot cauldron burns and accidental spill burns comprised 12 (75.0%) and 4 (25.0%), respectively. Multinomial logistic regression analysis showed the type of scald, age, and Baux score found to be associated with mortality. Every one-year increment in age had a 29% lower odds of occurrence of mortality event (adjusted odds ratio [OR], 0.71; 95% confidence interval [CI], 0.50-0.99, p=0.042). Likewise, every one-point increment in Baux score was associated with 19% higher odds of mortality (adjusted OR, 1.190; 95% CI, 1.08-1.32; p<0.001). Conclusions: Accidental spill burns were more common but mortality was significantly higher for hot cauldron burns. The majority of burn injuries occurred inside the kitchen emphasizing appropriate parental precautions. The risk of mortality was significantly higher in burn events occurring outside the house, and burns involving back, buttocks, perineum, and lower extremities.

Asunto(s)

RESUMEN

Antimicrobial stewardship (AMS) programs can decrease non-optimal use of antibiotics in hospital settings. There are limited data on AMS programs in burn and chronic wound centers in low- and middle-income countries (LMIC). A post-prescription review and feedback (PPRF) program was implemented in three hospitals in Nepal with a focus on wound and burn care. A total of 241 baseline and 236 post-intervention patient chart data were collected from three hospitals. There was a significant decrease in utilizing days of therapy per 1000 patient days (DOT/1000 PD) of penicillin (p = 0.02), aminoglycoside (p < 0.001), and cephalosporin (p = 0.04). Increases in DOT/1000 PD at post-intervention were significant for metronidazole (p < 0.001), quinolone (p = 0.01), and other antibiotics (p < 0.001). Changes in use of antibiotics varied across hospitals, e.g., cephalosporin use decreased significantly at Kirtipur Hospital (p < 0.001) and Pokhara Academy of Health Sciences (p = 0.02), but not at Kathmandu Model Hospital (p = 0.59). An independent review conducted by infectious disease specialists at the Henry Ford Health System revealed significant changes in antibiotic prescribing practices both overall and by hospital. There was a decrease in mean number of intravenous antibiotic days between baseline (10.1 (SD 8.8)) and post-intervention (8.8 (SD 6.5)) (t = 3.56; p < 0.001), but no difference for oral antibiotics. Compared to baseline, over the 6-month post-intervention period, we found an increase in justified use of antibiotics (p < 0.001), de-escalation (p < 0.001), accurate documentation (p < 0.001), and adherence to the study antibiotic prescribing guidelines at 72 h (p < 0.001) and after diagnoses (p < 0.001). The evaluation data presented provide evidence that PPRF training and program implementation can contribute to hospital-based antibiotic stewardship for wound and burn care in Nepal.

RESUMEN

INTRODUCTION: Dental anomaly is one of the major problems in a child born with cleft lip and palate. These anomalies have deleterious effects on the dentition leading to aesthetic problems, impairment of mastication andimproper phonation. The aim of our study was to find out the prevalence of dental anomalies in patient with cleft lip and/or palate radiographically. METHODS: A descriptive cross-sectional study was conducted from the 208 radiographs, collected by the convenience samplingtechnique with cleft lip and/or palate in Department of Burns, Plastic and Reconstructive Surgery, Nepal Cleft and Burn Centre, Kirtipur Hospital from January 2017 to July 2019.Ethical clearance for the study was obtained from Institutional Review Committee. Demographic data were collected and radiographs were evaluated for possible dental anomalies. Data obtained were entered and analysed in Statistical Package for Social Sciences version 23. RESULTS: Dental anomalies were highly prevalent among cleft lip and palate patients with at least one anomaly present in 188 (90.4%) of patients with male 120 (57.4%) presenting more anomalies than female 88 (42.6%) population. The most common anomaly was dental agenesis 161 (77.9%). The prevalence of positional anomaly, morphological anomaly and supernumerary teeth were found to be 54 (26%), 33 (15.9%) and 20 (10%) respectively. Lateral incisor showed the highest incidence of agenesis among all other missing teeth 223 (65.2%). CONCLUSIONS: The prevalence of dental anomalies among patients with cleft lip and/or palate was found to be high. Tooth agenesis was the most common anomaly observed in the study with lateral incisor having the highest incidence of agenesis.

Asunto(s)

RESUMEN

Wound excision and temporary coverage with a biologic dressing can improve survival for patients with large burns. Healthcare systems in low- and middle-income countries (LMICs) rarely have access to allografts, which may contribute to the limited survival of patients with large burns in these settings. Therefore, we aimed to describe the lessons learned from the implementation and maintenance of tissue banks in LMICs to guide system planning and organization. PubMed, MEDLINE, CINAHL, and World Health Organization Catalog were systematically searched with database-specific language to represent a priori terms (eg, skin, allograft, and tissue bank) and all LMICs as defined by the World Bank. Data regarding tissue banking programs were extracted and described in a narrative synthesis. The search returned 3346 records, and 33 reports from 17 countries were analyzed. Commonly reported barriers to ideal or planned implementation included high capital costs and operational costs per graft, insufficient training opportunities, opt-in donation schemes, and sociocultural stigma around donation and transplantation. Many lessons were learned from the implementation and management of tissue banks around the world. The availability of skin allografts can be improved through strategic investments in governance and regulatory structures, international cooperation initiatives, training programs, standardized protocols, and inclusive public awareness campaigns. Furthermore, capacity-building efforts that involve key stakeholders may increase rates of pledges, donations, and transplantations. Some issues were ubiquitously reported and could be addressed by current and future tissue banking programs to ensure allograft availability for patients living in countries of all income levels.

Asunto(s)

RESUMEN

PURPOSE OF REVIEW: Cleft lip with or without palate is one of the most common pediatric birth anomalies. Patients with cleft palate often have speech difficulties from underlying anatomical defects that can persist after surgery. This significantly impacts child development. There is a lack of evidence exploring, which surgical techniques optimize speech outcomes. The purpose of this update is to report on recent literature investigating how to optimize speech outcomes for cleft palate. RECENT FINDINGS: The two-flap palatoplasty with intravelar veloplasty (IVVP) and Furlow double-opposing Z-plasty has the strongest evidence for optimizing speech. One-stage palatal repair is favored at 10-14 months of age, while delays are associated with significant speech deficits. For postoperative speech deficits, there is no significant difference between the pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. Surgical management should be guided by closure pattern and velopharyngeal gap but few studies stratify by these characteristics. SUMMARY: According to recent evidence, the two-flap palatoplasty with IVVP and Furlow palatoplasty result in the best speech. The pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation are all viable techniques to correct residual velopharyngeal insufficiency. Future research should focus on incorporating standardized measures and more robust study designs.

Asunto(s)

RESUMEN

INTRODUCTION: Though access to surgical care for cleft lip/palate has expanded in low- and middle-income countries (LMICs), post-palatoplasty speech therapy is often lacking due to limited healthcare infrastructure and personnel. This mixed-methods study seeks to: 1) evaluate the impact of task-shifted speech therapy on a standardized speech score; 2) describe the experiences of families with post-operative cleft care and associated barriers; and 3) understand how to optimize cleft care by exploring the experiences of children who had nominal improvements after task-shifted speech therapy. METHODS: A convergent parallel mixed-methods study was conducted in Nepal. Standardized speech scores were compared by a blinded speech-language pathologist before and after the speech intervention. Semi-structured interviews (SSIs) and focus groups with families evaluated cleft care experiences and barriers. Qualitative and quantitative data were merged and analyzed. RESULTS: Thirty-nine post-palatoplasty children with speech deficits (ages 3-18) underwent task-shifted speech therapy, and demonstrated significant improvements in composite speech scores targeted by exercises (p<0.0001) and weakness (p=0.0002), with improvements in misarticulation (p=0.07) and glottal stop (p=0.05) that trended towards significance. Forty-seven SSIs demonstrated that the greatest barriers to follow-up were family responsibilities (62%), travel/distance (53%), and work (34%). In five focus groups, families expressed a desire to improve their child's speech and seek formal speech therapy. The speech intervention was found to be beneficial because of the compassionate staff, free lodging/food, and ability to socialize with other cleft patients and families. After merging quantitative and qualitative data, we noted that younger children between 3 and 5 years old and families who traveled greater distances for healthcare access benefited less from the speech therapy intervention. CONCLUSIONS: Task-shifted speech therapy has the potential to improve cleft lip/palate speech in LMICs. Multiple biosocial issues limit access to appropriate post-operative care.

Asunto(s)

RESUMEN

OBJECTIVE: To translate and validate the velopharyngeal insufficiency (VPI) effects on life outcomes (VELO) instrument into Nepali, and test its internal consistency and validity. DESIGN: Quality-of-life instrument translation and validation. SETTING: Community served by Nepal's craniofacial referral hospital. PARTICIPANTS: Twenty-three postpalatoplasty children with VPI, 19 family guardians of VPI cases, and 29 non-VPI controls. INTERVENTIONS: The VELO instrument was translated to Nepali by 2 independent bilingual translators, reconciled, backward-translated, compared, and modified using patient cognitive interviews. All VPI children, guardians, and controls completed the VELO-Nepali. MAIN OUTCOME MEASURE(S): The VELO internal consistency was evaluated using Cronbach α coefficient. Concurrent validity and discriminant validity were assessed using 2-sample t test: assuming unequal variances. RESULTS: The VELO was translated and optimized using cognitive interviews. The VELO-Nepali demonstrated excellent internal consistency, with Cronbach α coefficients of 0.93, 0.94, and 0.90 for VPI cases, guardians of VPI cases, and non-VPI controls, respectively. The VELO-Nepali exhibited strong discriminant validity between VPI cases (x¯ = 45.4, standard deviation [SD] = 22.1) and non-VPI controls (x¯ = 84.9, SD = 12.3), (P < .001). The VELO-Nepali showed strong concurrent validity with similarities in VPI case scores (x¯ = 45.4, SD = 22.1), and guardian scores (x¯ = 52.9, s = 22.8; P = .473). CONCLUSION: The translated VELO-Nepali demonstrates strong internal consistency, discriminant validity, and concurrent validity, and can assess quality of life for Nepali VPI patients. This instrument represents the first VPI quality of life assessment validated in Nepali, and supports the feasibility of its implementation in other low- and low-middle-income countries.

Asunto(s)

RESUMEN

Globally, medical errors are associated with an estimated $42 billion in costs to healthcare systems. A variety of errors in the delivery of healthcare have been identified by the World Health Organization and it is believed that about 50% of all errors are preventable. Initiatives to improve patient safety are now garnering increased attention across a range of countries in all regions of the world. From June 28--29, 2019, the first International Patient Safety Conference (IPSC) was held in Kathmandu, Nepal and attended by over 200 healthcare professionals as well as hospital, government, and non-governmental organization leaders. During the conference, presentations describing the experience with errors in healthcare and solutions to minimize future occurrence of adverse events were presented. Examples of systems implemented to prevent future errors in patient care were also described. A key outcome of this conference was the initiation of conversations and communication among important stakeholders for patient safety. In addition, attendees and dignitaries in attendance all reaffirmed their commitment to furthering actions in hospitals and other healthcare facilities that focus on reducing the risk of harm to patients who receive care in the Nepali healthcare system. This conference provides an important springboard for the development of patient-centered strategies to improve patient safety across a range of patient care environments in public and private sector healthcare institutions.

RESUMEN

There is an evident need for Negative Pressure Wound Therapy (NPWT) systems specifically designed for use in resource-constrained settings to aid in the treatment of open wounds. METHODS: Prospective single-arm interventional pilot study of 14 patients with complex wounds was conducted at Kirtipur Hospital in Kathmandu, Nepal. A novel NPWT device, the Kyron Suction Unit, was used by 4 plastic surgeons. Primary outcomes were ease of use (10-point Likert scale) and device safety (adverse events recorded). Pain (Visual Analogue Scale score), quality of life (modified EuroQol Derived Single Index scores), and wound dimensions were recorded. RESULTS: User ratings on the 10-point Likert scale indicated high confidence and ease of use: median confidence setting up the device of 1.0 [interquartile range (IQR), 1.0; mean 2.3], median confidence maintaining the device of 1.0 (IQR, 1.0; mean, 1.5), and median ease of disassembly of 1.0 (IQR, 1.0; mean, 1.4). Significant improvement in Visual Analogue Scale scores (P = 0.03), modified EuroQol Derived Single Index scores (P < 0.001), and a reduction in wound volume [median, 47.25-9.75 cm3 (P = 0.01)]. Image analysis of wounds pretreatment and posttreatment demonstrated increase in granulation tissue surface area [median, 7.6-28.7 cm2 (P = 0.003)] and decrease in open wound surface area [median, 48.33-33.6 cm2 (P = 0.01)]. CONCLUSIONS: The Kyron Suction Unit was safe and easily managed by plastic surgeons. The device design promoted access to NPWT, a therapy proven to reduce healing time and decrease complications for patients with open wounds, in a resource-constrained setting.

RESUMEN

Capacity building is needed in low- and middle-income countries (LMICs) to combat antimicrobial resistance (AMR). Stewardship programs such as post-prescription review and feedback (PPRF) are important components in addressing AMR. Little data are available regarding effectiveness of PPRF programs in LMIC settings. An adapted PPRF program was implemented in the medicine, surgery, and obstetrics/gynecology wards in a 125-bed hospital in Kathmandu. Seven "physician champions" were trained. Baseline and post-intervention patient chart data were analyzed for changes in days of therapy (DOT) and mean number of course days for intravenous and oral antibiotics, and for specific study antibiotics. Charts were independently reviewed to determine justification for prescribed antibiotics. Physician champions documented recommendations. Days of therapy per 1,000 patient-days for courses of aminoglycoside (P < 0.001) and cephalosporin (P < 0.001) decreased. In the medicine ward, data indicate increased justified use of antibiotics (P = 0.02), de-escalation (P < 0.001), rational use of antibiotics (P < 0.01), and conforming to guidelines in the first 72 hours (P = 0.02), and for definitive therapy (P < 0.001). Physician champions documented 437 patient chart reviews and made 138 recommendations; 78.3% of recommendations were followed by the attending physician. Post-prescription review and feedback can be successfully implemented in LMIC hospitals, which often lack infectious disease specialists. Future program adaptation and training will focus on identifying additional stewardship programming and support mechanisms to optimize antibiotic use in LMICs.

Asunto(s)