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1.  Development of a quality assurance handbook to improve educational courses in Africa 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1478-4491-6-28
PMCID: PMC2615788  PMID: 19094199
3.  Current Practice of Ophthalmic Anesthesia in Nigeria 
Purpose:
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).
Results:
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.
Conclusion:
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.
doi:10.4103/0974-9233.120022
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.
Objective
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).
Results
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).
Conclusion
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.
doi:10.3348/kjr.2009.10.5.441
PMCID: PMC2731861  PMID: 19721828
Thyroid nodule; Fine-needle biopsy; Pain; Local anesthesia; Ultrasound (US)
5.  COMPARATIVE STUDY OF SPINAL AND LOCAL ANESTHESIA WITH PROPOFOL INFUSION FOR KNEE ARTHROSCOPY 
Revista Brasileira de Ortopedia  2015;47(1):108-112.
Spinal anesthesia for knee arthroscopy is a well-documented and safe procedure. However, some complications and higher costs have been reported. Also, many orthopaedic surgeons are reluctant to use local anesthesia for fear of having to convert to general anesthesia due to inadequate pain control. The purpose of this study is to compare local with spinal anesthesia in two groups of patients submitted to knee arthroscopy. Sixty-five patients were divided in two groups; based on the anesthesia method used, and submitted to the same surgical routine and postoperative analgesia protocol. They were evaluated for analgesia, level of postoperative pain, and level of satisfaction with the type of anesthetic. The two groups did not present any significant differences in relation to perioperative analgesia and pain on the first postoperative day, neither was there any difference in relation to emotional state. However, there was a significant difference in terms of acceptance of the procedure; 100% said they would accept the procedure again in the local anesthesia group, compared with 60.5% in the spinal anesthesia group; also, 100% in the local anesthesia group said they felt encouraged by the type of anesthesia, compared with 67.7% in the spinal anesthesia group. We can conclude that local anesthesia is similar to spinal anesthesia in almost all the aspects investigated, except in terms of acceptance and patients’ level of satisfaction with the procedure. Local anesthesia can be a good alternative to spinal anesthesia, especially in outpatient departments, or when patients have restrictions to traditional models of anesthesia.
doi:10.1016/S2255-4971(15)30353-0
PMCID: PMC4799334  PMID: 27027089
Arthroscopy; Knee; Anesthesia
6.  Pilonidal Sinus Operations Performed Under Local Anesthesia versus the General Anesthesia: Clinical Trial Study 
Global Journal of Health Science  2016;8(9):200-206.
Backgrounds:
Various methods were defined to prepare patients for the pilonidal sinus surgery including local, spinal, and general anesthesia. But there is no powerful evidence to differ these procedures. Therefore, in the current study, we compared local and general anesthesia in the pilonidal sinus surgery.
Methods and Material:
In this clinical trial (IRCT201312031786N5) study 60 patients with the pilonidal sinus disease divided to two groups of local anesthesia versus general anesthesia. For local anesthesia we used 6ml of 2% lidocaine with an epinephrine (1:200,000), 6 ml of 0.5% bupivacaine, 1ml fentanyl (50 μg/ml), 1ml clonidine (75 μg/ml) and for general anesthesia fentanyl 1.5 μg.kg-1, thiopental 3-5 mg.kg-1, followed by the trachea intubation facilitated by atracurim 0.5 mg.kg-1 with maintenance of isoflurane 1-3% in nitrous oxygen 70% and oxygen 30%. The student t-test and Chi-square test were applied to evaluate the differences.
Results:
There were 30 patients with the mean age of 27.43±8.42 years in local anesthesia group and 30 cases with the mean age of 27.5±8.44 years underwent general anesthesia. The recovery time was significantly lower in the local anesthesia group (P=0.000). The oxygen saturation of the general anesthesia group was significantly higher at 1 and 20 minutes after the operation. The average of pain score was significantly higher in general anesthesia group at 3h and 6h after surgery (P<0.001). There were no significant differences in post-operative complications and hospital length of stay.
Conclusion:
This investigation revealed that local anesthesia has decreased pain during 48 hours after the surgery, shorter recovery time, and the less consumption of painkillers. So, we concluded that we can consider local anesthesia as a good alternative for the general anesthesia in the pilonidal sinus surgery.
doi:10.5539/gjhs.v8n9p200
PMCID: PMC5064075  PMID: 27157165
local; general; anesthesia; pilonidal sinus; operation
13.  The Maternal and Child Health (MCH) Handbook in Mongolia: A Cluster-Randomized, Controlled Trial 
PLoS ONE  2015;10(4):e0119772.
Objective
To assess the effectiveness of the Maternal and Child Health (MCH) handbook in Mongolia to increase antenatal clinic attendance, and to enhance health-seeking behaviors and other health outcomes.
Methods
A cluster randomized trial was conducted using the translated MCH handbook in Bulgan, Mongolia to assess its effectiveness in promoting antenatal care attendance. Pregnant women were recruited from 18 randomly allocated districts using shuffled, sealed envelopes. The handbook was implemented immediately for women at their first antenatal visit in the intervention group, and nine months later in the control group. The primary outcome was the number of antenatal care visits of all women residing in the selected districts. Cluster effects were adjusted for using generalized estimation equation. Masking was not possible among care providers, pregnant women and assessors.
Findings
Nine districts were allocated to the intervention group and the remainder to the control group. The intervention group (253 women) attended antenatal clinics on average 6•9 times, while the control group (248 women) attended 6•2 times. Socioeconomic status affected the frequency of clinic attendance: women of higher socioeconomic status visited antenatal clinics more often. Pregnancy complications were more likely to be detected among women using the handbook.
Conclusion
The MCH handbook promotes continuous care and showed an increase in antenatal visits among the intervention group. The intervention will help to identify maternal morbidities during pregnancy and promote health-seeking behaviors.
Trial Registration
UMIN Clinical Trial Registry UMIN000001748
doi:10.1371/journal.pone.0119772
PMCID: PMC4390384  PMID: 25853511
14.  Handbook of Chronic Kidney Disease Management 
NDT Plus  2011;4(3):636-224.
doi:10.1093/ndtplus/sfr063
PMCID: PMC4421593
19.  Oxford Handbook of Nurse Prescribing 
doi:10.1111/j.1365-2125.2007.02879.x
PMCID: PMC2000618
20.  Wiley Handbook of Current and Emerging Drug Therapies 
doi:10.1111/j.1365-2125.2007.03054.x
PMCID: PMC2291250
21.  The Oxford Handbook of Clinical Pharmacy 
doi:10.1111/j.1365-2125.2008.03114.x
PMCID: PMC2432496
23.  Drugs Handbook 2010 
doi:10.1111/j.1365-2125.2010.03723.x
PMCID: PMC2949923
24.  Adverse Drug Interactions: A Handbook for Prescribers 
doi:10.1111/j.1365-2125.2010.03820.x
PMCID: PMC3040554

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