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1.  Development of a quality assurance handbook to improve educational courses in Africa 
The attainment of the Millennium Development Goals has been hampered by the lack of skilled and well-informed health care workers in many developing countries. The departure of health care workers from developing countries is one of the most important causes. One of the motivations for leaving is that developed countries have well-established health care systems that incorporate continuing medical education, which enables health care workers to develop their skills and knowledge base. This provision is lacking in many developing countries. The provision of higher-education programmes of good quality within developing countries therefore, contributes to building capacity of the health care workforce in these countries.
The Liverpool School of Tropical Medicine is involved in delivering off-site higher educational programmes to health care workers in Africa. Our colleagues at one of these sites requested a guide to help them ensure that their professional development courses met international educational standards. We reviewed published literature that outlines the principles of quality assurance in higher education from various institutions worldwide. Using this information, we designed a handbook that outlines the quality assurance principles in a simple and practical way. This was intended to enable institutions, even in developing countries, to adapt these principles in accordance with their local resource capacity. We subsequently piloted this handbook at one of the sites in Ghana. The feedback from this aided the development of the handbook. The development of this handbook was participatory in nature.
The handbook addresses six main themes that are the minimum requirements that a higher education course should incorporate to ensure that it meets internationally recognized standards. These include: recruitment and admissions, course design and delivery, student assessments, approval and review processes, support for students and staff training and welfare. It has been piloted in Ghana and the feedback was incorporated into the handbook. The handbook is currently available free of charge online and being used by various institutions across the world. We have had responses from individuals and institutions in Africa, Asia, North America and Europe.
The principles outlined in the handbook provide a regulatory framework for locally establishing higher education courses of good quality that will contribute to enhancing the teaching and learning experience of students in courses in the developing world. This would contribute to providing a skilled and sustainable health care workforce that would reduce the need for health care workers to travel overseas in search of good higher education courses.
PMCID: PMC2615788  PMID: 19094199
2.  Current Practice of Ophthalmic Anesthesia in Nigeria 
To assess the current techniques of ophthalmic anesthesia in Nigeria.
Materials and Methods:
A cross sectional survey among Nigerian ophthalmology delegates attending the 36th Annual Scientific Congress of the Ophthalmology Society of Nigeria. Self administered and anonymous questionnaires were used and data were collected to include details of the institution, preferred local anesthesia techniques, the grade of doctor who administers the local anesthesia, complications, preferred facial block techniques (if given separately), and type of premedication (if used).
Out of the 120 questionnaires distributed, 81 forms were completed (response rate 67.5%). Out of the 74 who indicated their grade, 49 (66.2%) were consultants, 22 (29.7%) were trainees, and 3 (7.1%) were ophthalmic medical officers. For cataract surgery, peribulbar anesthesia was performed by 49.1% of the respondents, followed by retrobulbar anesthesia (39.7%). Others techniques used were topical anesthesia (5.2%), subtenon anesthesia (4.3%), subconjunctival anesthesia (2.6%), and intracameral anesthesia (0.9%). For glaucoma surgery, 47.2% of the respondents use peribulbar anesthesia, 32.1% use retrobulbar anesthesia, 9.4% used general anesthesia, and 6.6% used subconjunctival anesthesia. Among the trainees, 57.8% routinely perform retrobulbar anesthesia while 55.6% routinely perform peribulbar anesthesia. At least one complication from retrobulbar anesthesia within 12 months prior to the audit was reported by 25.9% of the respondents. Similarly, 16.1% of the respondents had experienced complications from peribulbar anesthesia within the same time period. Retrobulbar hemorrhage is the most common complication experienced with both peribulbar and retrobulbar anesthesia.
Presently, the most common technique of local anesthesia for an ophthalmic procedure in Nigeria is peribulbar anesthesia, followed by retrobulbar anesthesia. Twelve months prior to the study, 25.9% of the respondents had experienced at least one complication from retrobulbar anesthesia and 16.1% from peribulbar anesthesia. Retrobulbar hemorrhage was the most common complication reported.
PMCID: PMC3841954  PMID: 24339686
Anesthesia; Ophthalmic; Peribulbar; Retrobulbar; Subtenon
4.  Ultrasound-Guided Fine-Needle Aspiration Biopsy of Thyroid Nodules: is it Necessary to Use Local Anesthesia for the Application of One Needle Puncture? 
Korean Journal of Radiology  2009;10(5):441-446.
This study was designed to evaluate the difference in the degree of patient pain for an ultrasound-guided fine-needle aspiration biopsy (USFNAB) of a thyroid nodule with one needle puncture with and without local anesthesia.
Materials and Methods
A total of 50 patients participated in the study. We examined prospective patients who would undergo US-FNABs of two thyroid nodules (larger than 10 mm maximum diameter), which were located in separate thyroid lobes. For one of these thyroid nodules, US-FNAB was performed following the administration of local anesthesia; for the other nodule, no anesthesia was administered. The application of anesthesia was alternatively administered between patients (either prior to the first US-FNAB procedure or prior to the second procedure). For all patients, the degree of pain during and after each US-guided FNAB was evaluated according to a 4-category verbal rating scale (VRS), an 11-point numeric rating scale (NRS) and a 100-mm visual analogue scale (VAS).
The mean maximum diameters of thyroid nodules examined by US-FNAB with the use of local anesthesia and with no local anesthesia were 13.6 mm and 13.0 mm, respectively. There was no significant difference in nodule size (p > 0.05) between two groups. For the VRS, there were 27 patients with a higher pain score when local anesthesia was used and four patients with a higher pain score when no local anesthesia was administered. Nineteen patients had equivalent pain score for both treatments. This finding was statistically significant (p < 0.001). For the NRS, there were 33 patients with a higher pain score when local anesthesia was used and 10 patients with a higher pain score when no local anesthesia was administered. Seven patients had an equivalent pain score for each treatment. This finding was statistically significant (p < 0.001). For the VAS, there were 35 patients with a higher pain score when local anesthesia was used and 11 patients with a higher pain score where no local anesthesia was administered. Four patients had an equivalent pain score for both treatments. This finding was also statistically significant (p = 0.001).
In our study, patient pain scales were significantly lower when no local anesthesia was used prior to US-FNABs of thyroid nodules as compared to when local anesthesia was administered. Therefore, we believe that when one needle puncture is used, US-FNAB should be performed without administering local anesthesia.
PMCID: PMC2731861  PMID: 19721828
Thyroid nodule; Fine-needle biopsy; Pain; Local anesthesia; Ultrasound (US)
5.  Comparison of postoperative pain and satisfaction after dacryocystorhinostomy in patients operated on under local and general anesthesia 
There has been only 1 study on postoperative pain after external dacryocystorhinostomy (DCR) that compared pain between 2 groups of patients; 1 group received local anesthesia and the other received general anesthesia. To further characterize the relationship between these 2 types of anesthesia and postoperative pain, we designed a study in which a single patient received these 2 different anesthesia modalities for a short interval on 2 different sides.
There were 50 participants in this study. External DCR was performed on the same participant on both sides using local anesthesia on 1 side and general anesthesia on the other. Postoperative pain was measured using the visual analogue scale (VAS), and localization and timing of pain were reported by the participants. Postoperative nausea and vomiting (PONV) were documented if present.
Pain levels were significantly higher with general anesthesia 3 hours post-surgery, and 6 hours post-surgery the pain remains higher following general anesthesia but is borderline insignificant (p=0.051). However, 12 hours post-surgery, there is no significant difference in the pain level (p=0.240). There was no significant difference in the localization of pain with local and general anesthesia. Postoperative nausea is significantly more frequent after general anesthesia, and vomiting only occurs with general anesthesia. Local anesthesia was preferred by 94% of the participants (47 out of 50).
The vast majority of patients in our study who have undergone both GA and LA DCR would choose LA again, providing a compelling case for use of the LA technique.
PMCID: PMC3560633  PMID: 22534704
dacryocystorhinostomy; anesthesia; pain; PONV
6.  How to do Open Hemorrhoidectomy Under Local Anesthesia and its Comparison with Spinal Anesthesia 
The Indian Journal of Surgery  2012;74(4):330-333.
Day care open hemorrhoidectomy under local anesthesia (LA) may be most effective approach to hemorrhoidectomy. We describe a technique for a surgeon to administer local anesthesia himself for open hemorrhoidectomy and also compare outcome and clinical perspectives of hemorrhoidectomy under Local anesthesia with that after open hemorrhoidectomy under spinal anesthesia (SA). Technique: 50 patients with III/IV degree hemorrhoids and grade II hemorrhoid not responding to conservative treatment were randomized to LA (5 grade II, 15 grade III and 5 grade IV) and SA (7 grade II, 14 grade III and 4 grade IV). Assessment was carried out afterwards in terms of pain scores (using Numerical Rating Scale, NRS at 30 mins, 90 mins, 6 h and 24 h) and post operative analgesia. Secondary outcomes were complications like urinary retention, post operative headache and surgical complications, and overall stay. Median pain scores were comparable in both the treatment groups during the whole study period except at 6 h where significantly higher (p < 0.05) pain scores were noted in spinal anesthesia group. Complications were much higher in Spinal anesthesia [Hypotension (4patients); post operative headache (6patients); urinary retention (9patients)]. Mean time at first bladder evacuation was significantly higher in patients operated under spinal anesthesia [8 h (SA) Vs 1.5 h (LA)]. Average hospital stay was significantly longer in patients operated under spinal anesthesia (p value < 0.001). Local anesthesia is an alternative mode of anesthesia that surgeon can safely carry out by their own. In our study hemorrhoidectomy under local anesthesia was associated with a shorter hospital stay, lower pain scores and lower post operative complications which supports the routine use of local anesthesia for hemorrhoidectomy.
PMCID: PMC3444595  PMID: 23904726
Hemorrhoidectomy; Day care; Local anesthesia; Intersphincteric
7.  Anesthesia-Based Evaluation of Outcomes of Lower-Extremity Vascular Bypass Procedures 
Annals of vascular surgery  2012;27(2):199-207.
This report examines the effects of regional versus general anesthesia for infrainguinal bypass procedures performed in the treatment of critical limb ischemia (CLI).
Nonemergent infrainguinal bypass procedures for CLI (defined as rest pain or tissue loss) were identified using the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Program database using International Classification of Disease, ninth edition, and Current Procedure Terminology codes. Patients were classified according to National Surgical Quality Improvement Program data as receiving either general anesthesia or regional anesthesia. The regional anesthesia group included those specified as having regional, spinal, or epidural anesthesia. Demographic, medical, risk factor, operative, and outcomes data were abstracted for the study sample. Individual outcomes were evaluated according to the following morbidity categories: wound, pulmonary, venous thromboembolic, genitourinary, cardiovascular, and operative. Length of stay, total morbidity, and mortality were also evaluated. Associations between anesthesia types and outcomes were evaluated using linear or logistic regression.
A total of 5,462 inpatient hospital visits involving infrainguinal bypasses for CLI were identified. Mean patient age was 69 ± 12 years; 69% were Caucasian; and 39% were female. In all, 4,768 procedures were performed using general anesthesia and 694 with regional anes­thesia. Patients receiving general anesthesia were younger and significantly more likely to have a history of smoking, previous lower-extremity bypass, previous amputation, previous stroke, and a history of a bleeding diathesis including the use of warfarin. Patients receiving regional anesthesia had a higher prevalence of chronic obstructive pulmonary disease.
Tibial-level bypasses were performed in 51% of procedures, whereas 49% of procedures were popliteal-level bypasses. Cases performed using general anesthesia demonstrated a higher rate of resident involvement, need for blood transfusion, and operative time. There was no difference in the rate of popliteal-level and infrapopliteal-level bypasses between groups. Infrapopliteal bypass procedures performed using general anesthesia were more likely to involve prosthetic grafts and composite vein. Mortality occurred in 157 patients (3%). The overall morbidity rate was 37%. Mean and median lengths of stay were 7.5 days (±8.1) and 6.0 days (Q1: 4.0, Q3: 8.0), respectively. Multivariate analyses demonstrated no significant differences by anesthesia type in the incidence of morbidity, mortality, or length of stay.
These results provide no evidence to support the systematic avoidance of general anesthesia for lower-extremity bypass procedures. These data suggest that anesthetic choice should be governed by local expertise and practice patterns.
PMCID: PMC4279240  PMID: 22944010
8.  Local and General Anesthesia in the Laparoscopic Preperitoneal Hernia Repair 
The extraperitoneal laparoscopic approach (EXTRA) has been shown to be an effective and safe repair for primary (PIH), recurrent (RIH) and bilateral hernia (BIH). There is very little data examining the merits of laparoscopic repair for hernias under local anesthesia. In this paper, we compare EXTRA performed under both general and local anesthesia.
This nonrandomized prospective study was performed selectively on a male population only. Patients with associated pulmonary disease and high risk for general surgery were selected. Patients with recurrence and previous abdominal operations were excluded to decrease confounding variables in the study. A Prolene mesh was used in all patients.
Between May 1997 and September 1998, 92 male patients underwent the repair of 107 groin hernias using the EXTRA technique. The procedure was explained to them, and different anesthesia options were given. Fourteen of these repairs were performed under local anesthesia and 93 under general anesthesia. Of the 10 patients who underwent a repair under local anesthesia, there were 8 indirect, 5 direct and 1 pantaloon. The mean age was 53 years. In the group of general anesthesia, the types of hernias repaired were 45 indirect, 30 direct and 11 pantaloon. The mean age was 45 years. The mean follow-up was 15 months. Each patient was sent home the same day.
Two peritoneal tears were recorded in the first group. The operative time was longer in the local group (47 ± 11 vs 18 ± 3). None of the patients required conversion to an open technique or change of anesthesia. No recurrences were found in either group. The average time of return to work and regular activity was 3.5 ± 1 and 3 ± 1 days, respectively.
There appears to be no significant difference in recurrence and complication rates when the EXTRA is performed under local anesthesia as compared to general. Blunt dissection of the preperitoneal space does not trigger pain and does not require lidocaine injection. The most painful area is the peritoneal reflection over the cord structure. The laparoscopic repair under local anesthesia represents an advantage in the repair of the inguinal hernia, particularly in the population where general anesthesia is contraindicated.
PMCID: PMC3113173  PMID: 10987398
Laparoscopic preperitoneal hernia repair
9.  Relevance of infiltration analgesia in pain relief after total knee arthroplasty 
Acta Ortopedica Brasileira  2013;21(5):262-265.
The aim of the study was to assess the effect of different types of anesthesia on pain intensity in early postoperative period.
A total of 87 patients (77 women, 10 men) scheduled for total knee arthroplasty (TKA) were assigned to receive either subarachnoid anesthesia alone or in combination with local soft tissue anesthesia, local soft tissue anesthesia and femoral nerve block and pre-emptive infiltration together with local soft tissue anesthesia. We assessed the pain intensity, opioid consumption, knee joint mobility, and complications of surgery.
Subjects with pre-emptive infiltration and local soft tissue anesthesia had lower pain intensity on the first postoperative day compared to those with soft tissue anesthesia and femoral nerve block (P=0.012, effect size 0.68). Subjects who received pre-emptive infiltration and local soft-tissue anesthesia had the greatest range of motion in the operated knee at discharge (mean 90 grades [SD 7], P=0.01 compared to those who received subarachnoid anesthesia alone, and P=0.001 compared to those with subarachnoid together with soft tissue anesthesia).
Despite the differences in postoperative pain and knee mobility, the results obtained throughout the postoperative period do not enable us to favour neither local nor regional infiltration anesthesia in TKA. Level of Evidence II, Prospective Comparative Study.
PMCID: PMC3875000  PMID: 24453679
Arthroplasty, replacement, knee; Anesthesia; Anesthesia, local; Nerve block; Femoral nerve
10.  Comparison of acceptance, preference and efficacy between pressure anesthesia and classical needle infiltration anesthesia for dental restorative procedures in adult patients 
Intraoral local anesthesia is essential for delivering dental care. Needless devices have been developed to provide anesthesia without injections. Little controlled research is available on its use in dental restorative procedures in adult patients. The aims of this study were to compare adult patients acceptability and preference for needleless jet injection with classical local infiltration as well as to evaluate the efficacy of the needleless anesthesia.
Materials and Methods:
Twenty non fearful adults with no previous experience of dental anesthesia were studied using split-mouth design. The first procedure was performed with classical needle infiltration anesthesia. The same amount of anesthetic solution was administered using MADA jet needleless device in a second session one week later, during which a second dental restorative procedure was performed. Patients acceptance was assessed using Universal pain assessment tool while effectiveness was recorded using soft tissue anesthesia and pulpal anesthesia. Patients reported their preference for the anesthetic method at the third visit. The data was evaluated using chi square test and student's t-test.
Pressure anesthesia was more accepted and preferred by 70% of the patients than traditional needle anesthesia (20%). Both needle and pressure anesthesia was equally effective for carrying out the dental procedures.
Patients experienced significantly less pain and fear (p<0.01) during anesthetic procedure with pressure anesthesia. However, for more invasive procedures needle anesthesia will be more effective.
PMCID: PMC4001276  PMID: 24778516
Injection pain; jet injection; local anesthesia; needleless anesthesia; oral anesthesia; pressure anesthesia
11.  Satisfaction level with topical versus peribulbar anesthesia experienced by same patient for phacoemulsification 
Saudi Journal of Anaesthesia  2012;6(4):363-366.
Various studies have assessed patient satisfaction with topical versus peribulbar anesthesia with conflicting results. Aim of study was to determine satisfaction level in same patient who gets topical anesthesia in one eye and peribulbar block in another eye. We propose that evaluation of various indicators of patient satisfaction will enable better selection of cases for topical anesthesia in the future.
Eighty patients scheduled for phacoemulsification were enrolled in prospective, randomized, double-blind study. Each patient scheduled twice for one eye under topical anesthesia and other in peribulbar block. Pain, discomfort and pressure during application of local anesthetic, during phacoemulsification and at 2 hours after procedure were assessed on standard scales. Before discharge patient satisfaction level was checked with Iowa satisfaction with anesthesia scale (ISAS). The Student's t-test was used to determine the significance of IOWA score in both groups. P<0.05 was considered significant.
Feeling of pain, pressure and discomfort scores during administration of topical anesthesia were all significantly lower compared to peribulbar anesthesia (P=0.004, 0.000, 0.002, respectively). In contrast, intraoperative scores were significantly higher in the topical anesthesia group compared to peribulbar anesthesia (P=0.022, 0.000, 0.000, respectively). Patient satisfaction measured with ISAS shows that peribulbar anesthesia with P=0.000 is strongly significant.
Peribulbar anesthesia provided significantly better patient satisfaction in comparison with topical anesthesia when used for cataract surgery.
PMCID: PMC3591555  PMID: 23493723
Patient's satisfaction; phacoemulsification; topical versus peribulbar
12.  Simplified local anesthesia technique for external dacryocystorhinostomy without nasal packing: a new technique and pilot study outcome 
The purpose of this paper is to describe a simplified local anesthesia technique for external dacryocystorhinostomy (EXT-DCR).
In this pilot, retrospective, noncomparative, interventional case series, 448 patients (480 eyes) underwent EXT-DCR using a simplified local anesthesia technique. Nasal mucosal anesthesia was achieved using combined application of 6 mL of oxymetazoline 0.025% nasal spray and lidocaine 1% in the same spray bottle, without any packing of the nose with either pledgets or ribbon gauze. Local infiltration anesthesia consisted of subcutaneous injection of a 7 mL mixture of 2% lidocaine with 1:100,000 epinephrine injected on the flat side of the nose beneath the incision site, in addition to a second medial peribulbar injection (3 mL, 2% lidocaine without epinephrine).
Successful unilateral or bilateral EXT-DCR was achieved in 432/448 patients (96.4%). Four patients could not tolerate the procedure under local anesthesia and were converted to general anesthesia. Four patients required additional local anesthetic injections because of intolerable pain. Heavy sedation was essential in eight uncooperative patients because surgical manipulation was impossible. The remaining patients tolerated the procedure well. The intraoperative bleeding rate was very low except in one patient. Mean operative time was 16 minutes. Severe postoperative epistaxis was observed in four patients. Temporary anosmia developed in one patient.
Our simplified local anesthesia approach of EXT-DCR is convenient for the patient because it avoids unnecessary nasal packing. It is also safe and effective, as evidenced by the high rate of successful completion of the procedure without conversion to general anesthesia or the need for supplemental local anesthesia.
PMCID: PMC3848926  PMID: 24348014
local anesthesia; external dacryocystorhinostomy
13.  Use of Local Anesthesia During Dental Rehabilitation With General Anesthesia: A Survey of Dentist Anesthesiologists 
Anesthesia Progress  2014;61(1):11-17.
The purpose of this study was to document current practices of dentist anesthesiologists who are members of the American Society of Dentist Anesthesiologists regarding the supplemental use of local anesthesia for children undergoing dental rehabilitation under general anesthesia. A survey was administered via e-mail to the membership of the American Society of Dentist Anesthesiologists to document the use of local anesthetic during dental rehabilitations under general anesthesia and the rationale for its use. Seventy-seven (42.1%) of the 183 members responded to this survey. The majority of dentist anesthesiologists prefer use of local anesthetic during general anesthesia for dental rehabilitation almost always or sometimes (90%, 63/70) and 40% (28/70) prefer its use with rare exception. For dentist anesthesiologists who prefer the administration of local anesthesia almost always, they listed the following factors as very important: “stabilization of vital signs/decreased depth of general anesthesia” (92.9%, 26/28) and “improved patient recovery” (82.1%, 23/28). There was a significant association between the type of practice and who determines whether or not local anesthesia is administered during cases. The majority of respondents favor the use of local anesthesia during dental rehabilitation under general anesthesia.
PMCID: PMC3975608  PMID: 24697820
Local anesthesia; Hospital dentistry; General anesthesia; Restorative dentistry
14.  Vocal local versus pharmacological treatments for pain management in tubal ligation procedures in rural Kenya: a non-inferiority trial 
BMC Women's Health  2014;14:21.
Vocal local (VL) is a non-pharmacological pain management technique for gynecological procedures. In Africa, it is usually used in combination with pharmacological analgesics. However, analgesics are associated with side-effects, and can be costly and subject to frequent stock-outs, particularly in remote rural settings. We compared the effectiveness of VL + local anesthesia + analgesics (the standard approach), versus VL + local anesthesia without analgesics, on pain and satisfaction levels for women undergoing tubal ligations in rural Kenya.
We conducted a site-randomised non-inferiority trial of 884 women receiving TLs from 40 Marie Stopes mobile outreach sites in Kisii and Machakos Districts. Twenty sites provided VL + local anesthesia + analgesics (control), while 20 offered VL + local anesthesia without additional analgesics (intervention). Pain was measured using a validated 11-point Numeric Rating Scale; satisfaction was measured using 11-point scales.
A total of 461 women underwent tubal ligations with VL + local anesthesia, while 423 received tubal ligations with VL + local anesthesia + analgesics. The majority were aged ≥30 years (78%), and had >3 children (99%). In a multivariate analysis, pain during the procedure was not significantly different between the two groups. The pain score after the procedure was significantly lower in the intervention group versus the control group (by 0.40 points; p = 0.041). Satisfaction scores were equally high in both groups; 96% would recommend the procedure to a friend.
VL + local anesthesia is as effective as VL + local anesthesia + analgesics for pain management during tubal ligation in rural Kenya. Avoiding analgesics is associated with numerous benefits including cost savings and fewer issues related to the maintenance, procurement and monitoring of restricted opioid drugs, particularly in remote low-resource settings where these systems are weak.
Trial registration
Pan-African Clinical Trials Registry PACTR201304000495942.
PMCID: PMC3916698  PMID: 24490628
Vocal local; Kenya; Family planning; Pain management; Tubal ligation
19.  Handbook of exercise in diabetes, 2nd edn 
PMCID: PMC2465235

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