Resource-restricted Countries Research Articles

Surgical simulation in Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course

The use of laparoscopy in resource-restricted countries has increased in recent years. Although simulation is now considered an important adjunct to operating-room-based training for learning laparoscopic skills, there is very little literature assessing the use of simulation in resource-restricted countries. The purpose of this study was to determine the feasibility and impact of a 3-day Fundamentals of Laparoscopic Surgery (FLS) course in Botswana, Africa. A total of 20 surgeons and trainees participated in a 3-day FLS course. A pretest FLS score was obtained for each subject, followed by 2 days of practice with feedback. A final FLS posttest score was then obtained. Participants also watched the FLS instructional CD-ROM and took the written test on day 3. Mean posttest scores were significantly higher than pretest scores for each FLS task and for the total normalized FLS simulator score (285 +/- 94 versus 132 +/- 92, p < 0.001). The mean score on the written test was 242 (116). In total, only two surgeons achieved a passing score on both the cognitive and skills assessment required to obtain FLS certification. To our knowledge, this is the first time the FLS program has been taught in Africa. We have shown that giving the FLS course in a resource-restricted country is feasible and resulted in a significant improvement in FLS technical skills after 3 days. Most surgeons, however, still did not reach FLS passing scores, indicating that more than 3 days will be required in future courses to help surgeons obtain FLS certification.

Simplified cytometry for routine monitoring of infectious diseases

The interacting epidemics of HIV/AIDS, tuberculosis (TB) and malaria in resource-poor areas of the world have created a critical need for rapid, simple, affordable apparatus and tests that will permit patients with these diseases to be promptly diagnosed and properly managed. As documented in the current issue of Clinical Cytometry, complex flow cytometric analyses used in affluent countries for CD4+ T cell counting in HIV/AIDS have been simplified, introduced, and quality assessed in resource-restricted countries of Africa and the Caribbean, where simple gating protocols such as panleucogating now provide accurate and precise CD4+ T cell counts on a large scale. CD4/CD8 ratios in infants may replace more expensive molecular tests for HIV infection; simplified flow cytometry is also compatible with HIV viral load-associated lymphocyte activation tests and with antigen-specific cellular immune response assays that rapidly diagnose active TB in both HIV-negative and HIV-TB co-infected individuals. In addition, it is becoming evident that smaller, much less expensive fluorescence imaging cytometers can be used for CD4 counting, immunophenotyping, and hematology and for other applications such as diagnosis and drug-susceptibility testing of TB and diagnosis of malaria. With the gradual, organized expansion of the much-needed diagnostic networks in the underprivileged countries, the most cost-effective apparatus may be one capable of performing tests for all the three diseases mentioned. The most sustainable systems will be those that can be assembled and maintained, to the greatest extent possible, in the countries where they will be used.

Programs to Facilitate Tuberculosis Drug Discovery: The Tuberculosis Antimicrobial Acquisition and Coordinating Facility

There is a real need to discover new drugs that are active on drug-resistant tuberculosis (TB), and for drugs that will shorten the time of therapy. Large pharmaceutical companies have traditionally led the quest for discovering and developing new antiinfective agents but this is not the case when it comes to diseases like tuberculosis that primarily occur in resource restricted countries. Throughout the world many research groups are actively engaged in the scientific discovery of new TB drugs. Unfortunately, most research laboratories do not have the necessary safety facilities or resources for all facets of TB drug discovery. The Tuberculosis Antimicrobial Acquisition and Coordinating Facility (TAACF) was established in order to make comprehensive testing services available at no cost to research laboratories with an interest in discovering new TB drugs. The TAACF is a consortium of contracts managed and funded by the National Institute of Allergy and Infectious Diseases (National Institutes of Health, Bethesda, MD) as a resource to support preclinical drug discovery and development. The core of the TAACF is the Southern Research Institute, Birmingham, AL, which supports compound acquisition, storage, medicinal chemistry, and high throughput assays. Other collaborating groups provide biological data on antimycobacterial activity and cytotoxicity, preliminary in vivo toxicity, oral bioavailability and efficacy in animal models, specialty testing (such as activity against non-replicating persistent bacteria), and assistance in technology transfer for developing comprehensive promotional packages and facilitating partnerships with pharmaceutical companies for drug development. The TAACF program and recent progress that has been publicly disclosed by suppliers is reviewed. There are many aspects promising of the program that will not be discussed due to confidentially.