Medical Research Council of South Africa.

Background Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. Methods A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. Findings Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0•7 per 100 000 population (IQR 0•2-2•0). Maternal mortality was 20 (0•5%) of 3684 patients (95% CI 0•3-0•8). Complications occurred in 633 (17•4%) of 3636 mothers (16•2-18•6), which were predominantly severe intraoperative and postoperative bleeding (136 [3•8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4•47 [95% CI 1•46-13•65]), and perioperative severe obstetric haemorrhage (5•87 [1•99-17•34]) or anaesthesia complications (11•47 (1•20-109•20]). Neonatal mortality was 153 (4•4%) of 3506 infants (95% CI 3•7-5•0). Interpretation Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa.

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. Methods: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. Results: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. Conclusions: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. Clinical trial registration: NCT03044899.

Our results show that there is a high prevalence of thyroid dysfunction in pregnant women of Lubumbashi, and this high prevalence is associated with iodine deficiency. To prevent obstetrical adverse outcomes and neurological damage in children, iodine supplementation is needed before conception or in early pregnancy in Lubumbashi.

Objective: Adequate iodine and Fe intakes are imperative during pregnancy to prevent fetal defects, but such data are not available in the Democratic Republic of Congo. We aimed to assess iodine and Fe status in pregnant women from Lubumbashi. Design: Cross-sectional study. We measured urinary iodine concentration (UIC) in random urine samples using a modified Sandell-Kolthoff digestion method; the WHO reference medians were used to classify iodine intake as deficient, adequate, more than adequate or excessive. Serum ferritin concentrations were measured by immunoenzymatic assay and considered insufficient when ,12 ng/ml. Setting: Maternity units from rural, semi-urban and urban areas of Lubumbashi, Democratic Republic of Congo. Subjects: Two hundred and twenty-five randomly selected pregnant women attending prenatal consultation, seventy-five postpartum women and seventy-five non-pregnant women as controls. Results: Overall median UIC in pregnant women was 138 (interquartile range: 105-172) mg/l, indicating iodine deficiency, whereas postpartum and nonpregnant women had adequate iodine intake: median UIC 5 144 mg/l and 204 mg/l, respectively. Median UIC values were lower in late pregnancy than in early pregnancy: in the first, second and third trimester respectively 255 mg/l, 70 mg/l and 88 mg/l in the rural area; 306 mg/l, 166 mg/l and 68 mg/l in the semi-urban area; and 203 mg/l, 174 mg/l and 99 mg/l in the urban area. Fe was insufficient in 39 % of pregnant women compared with 21 % of non-pregnant and postpartum women. In the third trimester, deficiencies in both iodine and Fe were high: 40 %, 12 % and 18 % in the rural, semi-urban and urban areas, respectively. Conclusions: Our data suggest that pregnant women are at risk of iodine and Fe deficiencies in Lubumbashi. Country policies fighting against iodine and Fe deficiencies during pregnancy should be reinforced.

Background. DR Congo has adopted universal salt iodization to reduce disorders due to iodine deficiency. Since 1994, only (IQR, 19.0 ppm (IQR, in semiurban areas, and 20.1 ppm (IQR,

Objective. To investigate the relationship between IGF-I and the nutritional status of West-African children hospitalised for nutritional rehabilitation. Patients and methods. A cohort study was performed in two centres for nutritional rehabilitation and education (CREN) in Burkina Faso. Children were followed and the anthropometric data as well as the capillary blood samples were taken on the 7th and on the 14th days after their admission. IGF-I levels were determined from dried blood spots on filter paper on IGF-I RIA, after separation of the IGF-I from its binding proteins, using Sep-Pak chromatography. Results. A total of 59 children was included in the cohort. The IGF-I mean geometric values (SD) were 6.3 (1.4) μg/L on admission, 8.6 (1.8) μg/L at day 7 and 13.6 (2.0) μg/L at day 14. The differences between these values were statistically significant (P < .001). There is a significant correlation between the changes of IGF-I with the change of weight for height Z-score (P = .01). Conclusion. These results suggest that IGF-I can be considered as a potential marker to follow the nutritional status of children admitted in hospital for protein and energy malnutrition.

In the context of the flat-rate reimbursements in healthcare, we reviewed physicians' behavior towards laboratory test ordering. We demonstrated how it could be improved when a specific stage of the patient management is considered. We took a multi-step approach to analyze the laboratory test orders in the context of planned laparoscopic cholecystectomy in a general teaching hospital. A reference order set was defined through a collaborative analysis between clinicians and laboratory physicians. The clinical and financial impacts were then evaluated over a period of 24 months. After the introduction of the reference order set, the number of laboratory tests per order decreased significantly for patients with cholecystitis of low severity. Above the monitoring of repeated orderings during a single stay, the major impacts were achieved by a drastic reduction of inappropriate orders, particularly in the field of bacteriology. The main effects of the order set were maintained throughout a follow-up period of 24 months. Our study demonstrated that, when considering laboratory test ordering optimization, reference order sets could achieve high levels of efficiency. To ensure high compliance to reference order sets, extensive collaboration between clinicians and laboratory physician is mandatory even if very sophisticated information systems are available.