Mechanical Heart Valve Replacement in a Low-Middle Income Region in the Modern Era: Midterm Results from a Sub-Saharan Center.

Background The management of patients with mechanical heart valves remains a major concern in populations with limited resources and medical facilities. This study reports the clinical outcomes of patients who underwent mechanical valve implantation in a sub-Saharan center over an 8-year period.

Methods A total of 291 mechanical valves were implanted in 233 patients in our institution between February 2008 and June 2016. A total of 117 patients underwent mitral valve replacement (MVR, 50.2%), 57 had aortic valve replacement (AVR, 24.4%), and 59 underwent both AVR and MVR (double valve replacement [DVR], 25.7%). The mean age at surgery was 27.6 ± 13.4 years (range, 7–62 years). Rheumatic etiology was found in 80.6% of the patients. Hospital mortality, late deaths, and valve-related events were reviewed at follow-up (839 patient-years, range: 1–9.4 years, complete in 93%).

Results The 30-day mortality was 4.7% (11/233). The overall survival at 1 and 6 years for the whole cohort was 88.8 ± 2.1% and 78.7 ± 3.3%, respectively. The 6-year survival for AVR, MVR, and DVR was 89.3 ± 4.8%, 73.2 ± 5.4%, and 79.3 ± 5.8%, respectively (p = 0.15). The freedom from neurologic events and anticoagulation-related bleeding at 6 years was 93.1 ± 2.1% and 78.9 ± 3.7%, respectively. No patient had reoperation at follow-up. No case of prosthetic valve thrombosis was identified. Eight full-term pregnancies were reported.

Conclusion This preliminary experience reports acceptable midterm results after mechanical heart valve implantation in our region. Both accurate surgical evaluation and strategies, either financial or social, facilitating patient’s education and medical assistance are crucial to ensure good results. Long-term follow-up and further studies comparing current nonthrombogenic options are warranted to draw reliable conclusions.

Linking household and health facility surveys to assess obstetric service availability, readiness and coverage: evidence from 17 low- and middle-income countries.

Improving access and quality of obstetric service has the potential to avert preventable maternal, neonatal and stillborn deaths, yet little is known about the quality of care received. This study sought to assess obstetric service availability, readiness and coverage within and between 17 low- and middle-income countries.We linked health facility data from the Service Provision Assessments and Service Availability and Readiness Assessments, with corresponding household survey data obtained from the Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Based on performance of obstetric signal functions, we defined four levels of facility emergency obstetric care (EmOC) functionality: comprehensive (CEmOC), basic (BEmOC), BEmOC-2, and low/substandard. Facility readiness was evaluated based on the direct observation of 23 essential items; facilities “ready to provide obstetric services” had ?20 of 23 items available. Across countries, we used medians to characterize service availability and readiness, overall and by urban-rural location; analyses also adjusted for care-seeking patterns to estimate population-level coverage of obstetric services.Of the 111?500 health facilities surveyed, 7545 offered obstetric services and were included in the analysis. The median percentages of facilities offering EmOC and “ready to provide obstetric services” were 19% and 10%, respectively. There were considerable urban-rural differences, with absolute differences of 19% and 29% in the availability of facilities offering EmOC and “ready to provide obstetric services”, respectively. Adjusting for care-seeking patterns, results from the linking approach indicated that among women delivering in a facility, a median of 40% delivered in facilities offering EmOC, and 28% delivered in facilities “ready to provide obstetric services”. Relatively higher coverage of facility deliveries (?65%) and coverage of deliveries in facilities “ready to provide obstetric services” (?30% of facility deliveries) were only found in three countries.The low levels of availability, readiness and coverage of obstetric services documented represent substantial missed opportunities within health systems. Global and national efforts need to prioritize upgrading EmOC functionality and improving readiness to deliver obstetric service, particularly in rural areas. The approach of linking health facility and household surveys described here could facilitate the tracking of progress towards quality obstetric care.

Operations for Suspected Neoplasms in a Resource-Limited Setting: Experience and Challenges in the Eastern Democratic of Congo.

Introduction
Surgery is an essential component of a functional health system, with surgical conditions accounting for nearly 11–15% of world disability. While communicable diseases continue to burden low- and low–middle-income countries, non-communicable diseases, such as cancer, are an important cause of morbidity and mortality worldwide. Preliminary data on malignancies in low- and middle-income countries, specifically in Africa, suggest a higher mortality compared to other regions of the world, a difference partially explained by limited availability of screening and early detection systems as well as poorer access to treatment.

Objective
To evaluate the diagnosed tumor burden in the Eastern Democratic Republic of Congo (DRC) and review literature on existing and suspected barriers to accessing appropriate oncologic care.

Methods
This is a retrospective study carried out at Healthcare, Education, community Action, and Leadership development Africa, a 197-bed tertiary referral hospital, in the Province of North Kivu, along the eastern border of the DRC from 2012 to 2015. Patient charts were reviewed for diagnoses of presumed malignancy with biopsy results.

Results
A total of 252 cases of suspected cancer were reviewed during the study period; 39.7% were men. The average age of patients was 43 years. Amongst adult patients, the most common presenting condition involved breast lesions with 5.8% diagnosis of fibrocystic breast changes and 2.9% invasive ductal carcinoma of the breast. 37.3% of female patients had lesions involving the cervix or uterus. The most common diagnosis amongst male adults was prostate disease (16.7% of men). For pediatric patients, the most common diagnoses involved bone and/or cartilage (27.3%) followed by skin and soft tissue lesions (20.0%). All patients underwent surgical resection of lesions; some patients were advised to travel out of country for chemotherapy and radiation for which follow-up data are unavailable.

Conclusion
Adequate and timely treatment of malignancy in the DRC faces a multitude of challenges. Access to surgical services for diagnosis and management as well as chemotherapeutic agents is prohibitively limited. Increased collaboration with local clinicians and remote specialist consultants is needed to deliver subspecialty care in resource-poor settings.

Urbanization in Sub-Saharan Africa: Declining Rates of Chronic and Recurrent Infection and Their Possible Role in the Origins of Non-communicable Diseases.

Non-communicable diseases (NCDs), such as atherosclerosis and cancers, are a leading cause of death worldwide. An important, yet poorly explained epidemiological feature of NCDs is their low incidence in under developed areas of low-income countries and rising rates in urban areas.With the goal of better understanding how urbanization increases the incidence of NCDs, we provide an overview of the urbanization process in sub-Saharan Africa, discuss gene expression differences between rural and urban populations, and review the current NCD determinant model. We conclude by identifying research priorities.Declining rates of chronic and recurrent infection are the hallmark of urbanization in sub-Saharan Africa. Gene profiling studies show urbanization results in complex molecular changes, with almost one-third of the peripheral blood leukocyte transcriptome altered. The current NCD determinant model could be improved by including a possible effect from declining rates of infection and expanding the spectrum of diseases that increase with urbanization.Urbanization in sub-Saharan Africa provides a unique opportunity to investigate the mechanism by which the environment influences disease epidemiology. Research priorities include: (1) studies to define the relationship between infection and risk factors for NCDs, (2) explaining the observed differences in the inflammatory response between rural and urban populations, and (3) identification of animal models that simulate the biological changes that occurs with urbanization. A better understanding of the biological changes that occur with urbanization could lead to new prevention and treatment strategies for some of the most common surgical diseases in high-income countries.