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  • br The Medical Education Partnership Initiative MEPI is an i

    2019-04-20


    The Medical Education Partnership Initiative (MEPI) is an innovative and potentially transformative 5-year programme, established by the US Government in 2010, to increase the number of doctors to meet crucial human resource needs in sub-Saharan Africa. MEPI allows African institutions that ampa are the direct grantees to define and direct programmes to address their own crucial gaps in medical education and workforce shortages in partnership with US academic partners.
    Subspecialty surgical care delivered through short-term medical missions is essential to reduce unmet need for surgical services in low-income countries, but to deliver value for patients, such projects must be integrated into the existing health-system infrastructure. According to the care delivery value chain framework proposed by Kim and colleagues, patients derive added value—or health—when providers depart from a single intervention mindset and take into consideration the full spectrum of patients\' circumstances. Farmer and colleagues put forward a vision for global surgery in which diverse experts join together to develop and implement sustainable solutions to complex surgical problems that maximise value for patients who have to overcome significant barriers, such as distance and cost, to seek treatment. We worked with visiting and host providers at Kibagabaga District Hospital in Kigali, Rwanda, the site dedicated to treatment and management of maternal birth-related trauma, to form an international and interdisciplinary working group to develop a standardised protocol to guide the management of patients diagnosed with both obstetric fistula and soil-transmitted helminthiasis. The protocol was aimed at lessening the likelihood that value created by the treated illness would be negated by the untreated one. Obstetric fistula is a birth-related pelvic injury resulting from prolonged and obstructed labour and is characterised by involuntary loss of urine, faecal matter, or both. Obstetric fistula affects more than 2 million women residing mainly in low-income countries located in sub-Saharan Africa and Asia who do not have access to proper care during pregnancy and childbirth. Between 50 000 and 100 000 new cases occur each year. In Rwanda, a central and east African nation of 11 million people, soil-transmitted helminthiasis is endemic, with prevalence reported to be more than 50% of the population. As a result, soil-transmitted helminthiasis is a frequent comorbidity in patients with obstetric fistula admitted to Kibagabaga District Hospital for surgical intervention. Despite a risk profile unique to patients infected with soil-transmitted helminths in perioperative settings that suggests the potential for serious complications, there is no consensus among practitioners who specialise in management of patients with pelvic floor disorders on the best way to handle patients with both obstetric fistula and soil-transmitted helminthiasis. In a randomised controlled trial Koul and colleagues found that patients diagnosed with pulmonary hydatid disease treated with combined albendazole and praziquantel for 4 weeks before surgery showed the greatest decrease in scolice viability compared with untreated patients and those treated for 2 weeks. Our working group extrapolated from this finding that, in surgical candidates with soil-transmitted helminthiasis, treatment of infection should take place before elective, non-emergency surgery. We identified additional compelling evidence to support the decision to delay surgery even when anthelmintic chemotherapy has been initiated, in the observed physiological response to anthelmintic agents. First, anthelmintic chemotherapy induces hyperactivity in parasites as they seek other sites to invade in a bid to escape death. In the perioperative context, parasite hyperactivity poses a threat to the integrity of the airway. When parasites migrate up the oesophagus, pulmonary aspiration of scolices can occur. Second, persistent emesis in the perioperative period can result in underdosing, thus reducing the efficacy of anthelmintic agents. Third, some antibiotics and anti-inflammatory drugs administered during the perioperative period can interfere with the bioavailability of anthelmintic drugs.