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Vermiform appendix torsion is a rare condition that mimics acute appendicitis and is diagnosed during surgery. On the other hand, pylephlebitis (or septic thrombophlebitis) is a complication that occurs due to occlusive thrombosis of mesenteric venous system branches secondary to intra-abdominal infections. Although rare since the antibiotic era, it must be considered in the differential diagnosis of postoperative fever. We report the case of a 63-year-old man who was diagnosed with acute appendicitis. During laparoscopy, an anti-clockwise vermiform appendix torsion (360°) was identified. On postoperative day 3, the patient developed recurrent pyrexia related to ileocolic vein pylephlebitis, requiring specific management. Vermiform appendix torsion is a rare condition that is indistinguishable from acute appendicitis until an appendicectomy is performed. Whereas previous studies have reported an uneventful postoperative period in cases of vermiform appendix torsion, we present the first case of pylephlebitis as a rare complication and discuss adequate treatment., Competing Interests: None declared., (Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2023.)

Background: Patient referral is a process in which a healthcare provider decides to seek assistance due to the limitations of available skills, resources and services offered locally. Paper-based referrals predominantly used in low-income countries hardly follow any procedure. This causes a major gap in communication, coordination, and continuity of care between primary and specialized levels, leading to poor access, delay, duplication and unnecessary costs. The goal of this study is to assess the formats and completeness of existing paper-based referral letters in order to improve health information exchange, coordination, and continuity of care., Methods: A retrospective exploratory research was conducted in eight public and three private healthcare facilities in the city of Kigali from May to October 2021. A purposive sampling method was used to select hospitals and referral letters from patients' files. A data capture sheet was designed according to the contents of the referral letters and the resulting responses were analyzed descriptively., Results: In public hospitals, five types of updated referral letters were available, in total agreement with World Health Organization (WHO) standards of which two (neonatal transfer form and patient monitoring transfer form) were not used. There was also one old format that was used by most hospitals and another format designed and used by a district hospital (DH) separately. Three formats were designed and used by private hospitals (PH) individually. A total of 2,304 referral letters were perused and the results show that "external transfer" forms were completed at 58.8%; "antenatal, delivery, and postnatal external transfer" forms at 47.5%; "internal transfer" forms at 46.6%; "Referral/counter referral" forms at 46.0%; district hospital referrals (DH2) at 73.4%. Referrals by private hospitals (PH1, PH2 and PH3) were completed at 97.7%, 70.7%, and 0.0% respectively. The major completeness deficit was observed in counter referral information for all hospitals., Conclusion: We observed inconsistencies in the format of the available referral letters used by public hospitals, moreover some of them were incompatible with WHO standards. Additionally, there were deficits in the completeness of all types of paper-based referral letters in use. There is a need for standardization and to disseminate the national patient referral guideline in public hospitals with emphasis on referral feedback, referral registry, triage, archiving and a need for regular training in all organizations., (© 2022. The Author(s).)

Background: Innovative use of mobile health (mHealth) technology in timely management of childbirth complications is a promising strategy, but its evidence base is limited. The Safe Delivery mHealth Application (SDA) is one of the recent mhealth applications (loaded in smartphones) which is a clinical decision support and training tool for basic emergency obstetric and newborn care (BEmONC). This paper describes, the health providers' experiences, perceptions, and acceptability of using the SDA, as well as the perceptions of key stakeholders., Methods: A mixed-methods approach was utilized. Quantitative methods consisted of a self-reported acceptability survey, administered to 54 nurses and midwives, including questions on their usage and perceptions of the SDA. Descriptive statistics were employed to analyze the survey data. Qualitative methods included two focus group discussions with 24 nurses and midwives, and six key informant interviews with stakeholders (maternity matrons, responsible for maternal and child health, and district hospital managers). Thematic analysis was performed and selected quotations used to illustrate themes. The study took place in two district hospitals in Rwanda., Results: Quantitative results found that 31 (57.4%) participants used the SDA four to six times per week. Many participants felt more confident (53.7%) and better at their job (40.7%) since having the SDA. Likert scale survey responses (1-5, 1 = Strongly Disagree, 5 = Strongly Agree) indicated general agreement that SDA is easy to use (Mean = 4.46), is an effective decision support tool (4.63), and training tool (4.65). Qualitative results included themes on perceived usefulness; professional growth acquired through the use of the SDA; SDA, an empowering, intuitive, and user-friendly technology; desired SDA features and functions; benefits of SDA as perceived by key informants, and future use of the SDA., Conclusions: The nurses and midwives perceive the SDA as having improved their ability to manage childbirth complications. Key stakeholders also perceive the SDA as a useful tool with a reasonable cost and recommend its implementation in routine practices. This study deepens the understanding of the potential benefits of mHealth such as the SDA in low-income settings, like Rwanda. It also provides more evidence on the impact of mHealth in assuring quality BEmONC., (© 2022. The Author(s).)

Background: Globally, mobile health (mHealth) applications are known for their potential to improve healthcare providers' access to relevant and reliable health information. Besides, electronic decision support tools, such as the Safe Delivery mHealth Application (SDA), may help to reduce clinical errors and to ensure quality care at the point of service delivery. The current study investigated the use of the SDA and its relationship to basic emergency obstetric and newborn care (BEmONC) outcomes for the most frequent complications in Rwanda; post-partum haemorrhage (PPH) and newborn asphyxia., Methods: The study adopted a pre-post intervention design. A pre-intervention record review of BEmONC outcomes: Apgar score and PPH progressions, was conducted for 6 months' period (February 2019 - July 2019). The intervention took place in two district hospitals in Rwanda and entails the implementation of the SDA for 6 months (October 2019- March 2020), and included 54 nurses and midwives using the SDA to manage PPH and neonatal resuscitation. Six months' post-SDA intervention, the effect of the SDA on BEmONC outcomes was evaluated. The study included 327 participants (114 cases of PPH and 213 cases of neonatal complications). The analysis compared the outcome variables between the baseline and the endline data. Fisher's exact test was used to compare the proportions and test between-group differences and significance level set at p < 0.05., Results: Unstable newborn outcomes following neonatal resuscitation were recorded in 62% newborns cases at baseline and 28% newborns cases at endline, P-value = 0.000. Unstable maternal outcomes following PPH management were recorded in 19% maternal cases at baseline and 6% maternal cases at endline, P-value = 0.048. There was a significant association between the SDA intervention and newborns' and maternal' outcomes following neonatal resuscitation and PPH management, 6 months after baseline., Conclusion: The use of the SDA supported nurses and midwives in the management of PPH and neonatal resuscitation which may have contributed to improved maternal and neonatal outcomes during 6 months of the SDA intervention. The findings of this study are promising as they contribute to a broader knowledge about the effectiveness of SDA in low and middle income hospital settings., (© 2022. The Author(s).)

Background: In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into experiences of these healthcare workers in managing obstetric emergencies are critical for improving the quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. Rwanda has made remarkable progress in obstetric care. However, challenges remain in the provision of high-quality basic emergency obstetric and newborn care (BEmONC). This study is a qualitative part of a broader research project about implementation of an mLearning and mHealth decision support tool in BEmONC services in Rwanda., Methods: In this exploratory qualitative aspect of the research, four focus group discussions (FGDs) with 26 nurses and midwives from two district hospitals in Rwanda were conducted. Each FGD was made up of two parts. The first part focused on the participants' reflections on the research results (from the previous study), while the second part explored their experiences of delivering obstetric care services. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis., Results: The analysis revealed three main themes: (1) reflections to the baseline research results, (2) self-reflection on the current practices, and (3) contextual factors influencing the delivery of BEmONC services. Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants' narratives of lived experiences of providing BEmONC services are also presented., Conclusion: The insights of nurses and midwives regarding the management of birth-related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on PPH management and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health, particularly in low and middle-income countries., (© 2022. The Author(s).)

Background: Globally, mobile learning (mLearning) tools have attracted considerable attention as a means of continuous training for healthcare workers. Rwanda like other low-resource settings with scarce in-service training opportunities requires innovative approaches that adapt technology to context to improve healthcare workers' knowledge and skills. One such innovation is the safe delivery application (SDA), a smartphone mLearning application for Basic Emergency Obstetric and Neonatal Care (BEmONC) content. This study assessed the effect of the SDA intervention on nurses' and midwives' knowledge and skills for the management of postpartum hemorrhage (PPH) and neonatal resuscitation (NR)., Methods: The study used a pre-post test design to compare knowledge and skills of nurses and midwives in the management of PPH and NR at two measurement points: immediately prior to SDA intervention and after 6 months of SDA intervention. The intervention took place in two district hospitals in Rwanda and included 54 participants. A paired-sample t-test was used to measure the pre-post intervention, mean knowledge and skills scores differences. Confidence intervals (CIs) and effect size were calculated. A t-test and a one-way Anova were used to test for potential confounders., Results: The analysis included 54 participants. Knowledge scores and skills scores on PPH management and NR increased significantly from baseline to endline measurements. The mean difference for PPH knowledge is 17.1 out of 100; 95% CI 14.69 to 19.49 and 2.6% for PPH skills; 95% CI 1.01 to 4.25. The mean difference for NR knowledge is 19.1 out of 100; 95% CI 16.31 to 21.76 and 5.5% for NR skills; 95% CI 3.66 to 7.41. Increases were unaffected by participants' attendance to in-service training 6 months prior and during SDA intervention and previous smartphone use. However, pre- and post-intervention skills scores were significantly different by years of experience in obstetric care., Conclusion: The SDA intervention improved the knowledge and skills of nurses and midwives on the management of PPH and NR as long as 6 months after SDA introduction. The results are highly relevant in low-income countries like Rwanda, where quality of delivery care is challenged by a lack of in-service continuous training for healthcare providers.

Background: Worldwide, the burden of allergies-in particular, drug allergies-is growing. In the process of prescribing, dispensing, or administering a drug, a medication error may occur and can have adverse consequences; for example, a drug may be given to a patient with a documented allergy to that particular drug. Computerized physician order entry (CPOE) systems with built-in clinical decision support systems (CDSS) have the potential to prevent such medication errors and adverse events., Objective: The aim of this review is to provide a comprehensive overview regarding all aspects of CDSS for drug allergy, including documenting, coding, rule bases, alerts and alert fatigue, and outcome evaluation., Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed as much as possible and searches were conducted in 5 databases using CPOE, CDSS, alerts, and allergic or allergy as keywords. Bias could not be evaluated according to PRISMA guidelines due to the heterogeneity of study types included in the review., Results: Of the 3160 articles considered, 60 met the inclusion criteria. A further 9 articles were added based on expert opinion, resulting in a total of 69 articles. An interrater agreement of 90.9% with a reliability Κ=.787 (95% CI 0.686-0.888) was reached. Large heterogeneity across study objectives, study designs, study populations, and reported results was found. Several key findings were identified. Evidence of the usefulness of clinical decision support for drug allergies has been documented. Nevertheless, there are some important problems associated with their use. Accurate and structured documenting of information on drug allergies in electronic health records (EHRs) is difficult, as it is often not clear to healthcare providers how and where to document drug allergies. Besides the underreporting of drug allergies, outdated or inaccurate drug allergy information in EHRs poses an important problem. Research on the use of coding terminologies for documenting drug allergies is sparse. There is no generally accepted standard terminology for structured documentation of allergy information. The final key finding is the consistently reported low specificity of drug allergy alerts. Current systems have high alert override rates of up to 90%, leading to alert fatigue. Important challenges remain for increasing the specificity of drug allergy alerts. We found only one study specifically reporting outcomes related to CDSS for drug allergies. It showed that adverse drug events resulting from overridden drug allergy alerts do not occur frequently., Conclusions: Accurate and comprehensive recording of drug allergies is required for good use of CDSS for drug allergy screening. We found considerable variation in the way drug allergy are recorded in EHRs. It remains difficult to reduce drug allergy alert overload while maintaining patient safety as the highest priority. Future research should focus on improving alert specificity, thereby reducing override rates and alert fatigue. Also, the effect on patient outcomes and cost-effectiveness should be evaluated., (©Laura Légat, Sven Van Laere, Marc Nyssen, Stephane Steurbaut, Alain G Dupont, Pieter Cornu. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 07.09.2018.)

Background: Scarring of the liver is the result of prolonged exposure to exogenous or endogenous stimuli. At the onset of fibrosis, quiescent hepatic stellate cells (HSCs) activate and transdifferentiate into matrix producing, myofibroblast-like cells., Aim and Methods: To identify key players during early HSC activation, gene expression profiling was performed on primary mouse HSCs cultured for 4, 16 and 64 hours. Since valproic acid (VPA) can partly inhibit HSC activation, we included VPA-treated cells in the profiling experiments to facilitate this search., Results: Gene expression profiling confirmed early changes for known genes related to HSC activation such as alpha smooth muscle actin (Acta2), lysyl oxidase (Lox) and collagen, type I, alpha 1 (Col1a1). In addition we noticed that, although genes which are related to fibrosis change between 4 and 16 hours in culture, most gene expression changes occur between 16 and 64 hours. Insulin-like growth factor binding protein 3 (Igfbp3) was identified as a gene strongly affected by VPA treatment. During normal HSC activation Igfbp3 is up regulated and this can thus be prevented by VPA treatment in vitro and in vivo. siRNA-mediated silencing of Igfbp3 in primary mouse HSCs induced matrix metalloproteinase (Mmp) 9 mRNA expression and strongly reduced cell migration. The reduced cell migration after Igfbp3 knock-down could be overcome by tissue inhibitor of metalloproteinase (TIMP) 1 treatment., Conclusion: Igfbp3 is a marker for culture-activated HSCs and plays a role in HSC migration. VPA treatment prevents Igfbp3 transcription during activation of HSCs in vitro and in vivo.

Background: With the introduction of the electronic health record, physiotherapists too are encouraged to store their patient records in a structured digital format. The typical nature of a physiotherapy treatment requires a specific record structure to be implemented, with special attention to user-friendliness and communication with other healthcare providers., Objective: The objective of this study was to establish a framework for the electronic physiotherapy record and to define a model for the interoperability with the other healthcare providers involved in the patients' care. Although we started from the Belgian context, we used a generic approach so that the results can easily be extrapolated to other countries. The framework we establish here defines not only the different building blocks of the electronic physiotherapy record, but also describes the structure and the content of the exchanged data elements., Methods: Through a combined effort by all involved parties, we elaborated an eight-level structure for the electronic physiotherapy record. Furthermore we designed a server-based model for the exchange of data between electronic record systems held by physicians and those held by physiotherapists. Two newly defined XML messages enable data interchange: the physiotherapy prescription and the physiotherapy report., Results: We succeeded in defining a solid, structural model for electronic physiotherapist record systems. Recent wide scale implementation of operational elements such as the electronic registry has proven to make the administrative work easier for the physiotherapist. Moreover, within the proposed framework all the necessary building blocks are present for further data exchange and communication with other healthcare parties in the future., Conclusions: Although we completed the design of the structure and already implemented some new aspects of the electronic physiotherapy record, the real challenge lies in persuading the end-users to start using these electronic record systems. Via a quality label certification procedure, based on adequate criteria, the Ministry of Health tries to promote the use of electronic physiotherapy records. We must keep in mind that physiotherapists will show an interest in electronic record keeping, only if this will lead to a positive return for them.