Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study

Background
The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care.

Methods
Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil’s Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state.

Findings
Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog.

Interpretation
Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Practical considerations for expediting breast cancer treatment in Brazil

Patients in Brazil continue to present with late-stage breast cancer. Notwithstanding these figures, policies and programs to overcome this long-lasting scenario have had limited results. We enlist the main barriers for advancing breast cancer diagnosis in Brazil, based on the available evidence, and we propose feasible strategies that may serve as a platform to address this major public health challenge.

Communication Intervention Using Digital Technology to Facilitate Informed Choices at Childbirth in the Context of the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial

Background:
In Brazil and other low- and middle-income countries, excess interventions in childbirth are associated with an increase in preterm and early-term births, contributing to stagnant morbidity and mortality of mothers and neonates. The fact that women often report a negative experience with vaginal childbirth, with physical pain and feelings of unsafety, neglect, or abuse, may explain the high acceptability of elective cesarean sections. The recognition of information needs and of the right to informed choice during childbirth can help change this reality. The internet has been the main source of health information, but its quality is highly variable.

Objective:
This study aimed to develop and evaluate an information and communication strategy through a smartphone app with respect to childbirth, to facilitate informed choices for access to safer and evidence-based care in the context of the COVID-19 pandemic.

Methods:
A randomized controlled trial, with 2 arms (intervention and control) and a closed, blind, parallel design, will be conducted with a smartphone app designed for behavior and opinion research in Brazil, with women of reproductive age previously registered on the app. After completing an entry questionnaire to verify the eligibility criteria and obtaining ethical consent, approximately 20,000 participants will be randomly allocated to the intervention and control groups at a 1:1 ratio. Participants allocated to the intervention group will be invited to engage in a digital information and communication strategy, which is designed to expand evidence-based knowledge on the advantages and disadvantages of options for labor and childbirth and the safety of the care processes. The information is based on the guidelines of the Ministry of Health and the World Health Organization for a positive childbirth experience and has been updated to include the new challenges and disruptions in maternity care within the context of the COVID-19 pandemic. The control group will receive information regarding disposable and reusable diapers as a placebo intervention. The groups will be compared in their responses in generating the birth plan and the entry and exit questionnaires, regarding responses less or more aligned with the guidelines for a positive childbirth experience. A qualitative component to map information needs is included.

Results:
The digital trial started recruiting participants in late October 2020, and data collection has been projected to be complete by December 2020.

Conclusions:
This study will evaluate an innovative intervention that has the potential to promote better communication between women and providers, such that they can make better choices using an approach suitable for use during the COVID-19 pandemic

Feasibility of the application of multimedia animations as preoperative guides for urgent abdominal surgeries in public hospitals in Brazi

Introduction: Preoperative education helps patients feel less anxious and improve self-care while decreasing hospitalization time and demand for postoperative analgesia. Health literacy, culture and language play vital roles in patients’ understanding of health issues and may influence treatment outcomes. Obstacles are more evident in low and middle income countries (LMICs), where inadequate patient education levels are higher and hospital resources lower. Methodology: This is a prospective pilot study assessing the feasibility of online preoperative multimedia animations as guides for surgical patients in an LMIC. Patients admitted to a public hospital in Brazil for acute cholecystitis or appendicitis were included. Feasibility was represented by acceptability rate and ease of integration with department protocols. Results: Thirty-four patients were included in the study. Twenty-six patients concluded the intervention (feasibility rate of 76.5%). Demographic factors seemed to affect results, indicated by higher acceptability from those with lower education levels, from younger patients and from women. No issues were reported regarding integration to local protocols. Discussion: Few studies have evaluated use of multimedia resources for preoperative patients. No studies assessed the use of animations and none analyzed digital patient education resources in an LMIC. This study demonstrated that the use of animations for patient education in LMICs is feasible. A step-based protocol approach is proposed by this study to aid the implementation of patient education digital interventions. Conclusion: The implementation of this tool is feasible and presents patients with easier access to appropriate and engaging information, allowing better surgical preparation and recovery. It can be offered online, allowing it to be sustainable while creating the foundations for a modern patient education culture in LMICs

Progress and challenges in potential access to oral health primary care services in Brazil: A population-based panel study with latent transition analysis

Objective
Compared indicators of potential access to oral health services sought in two cycles of the Program for Improvement of Access and Quality of Primary Care (PMAQ-AB), verifying whether the program generated changes in access to oral health services.

Methods
Transitional analysis of latent classes was used to analyze two cross-sections of the external evaluation of the PMAQ-AB (Cycle I: 2011–2012 and Cycle II: 2013–2014), identifying completeness classes for a structure and work process related to oral health. Consider three indicators of structure (presence of a dental surgeon, existence of a dental office and operating at minimum hours) and five of the work process (scheduling every day of the week, home visits, basic dental procedures, scheduling for spontaneous demand and continuation of treatment). Choropleth maps and hotspots were made.

Results
The proportion of elements that had one or more dentist (CD), dental office and operated at minimum hours varied from 65.56% to 67.13 between the two cycles of the PMAQ-AB. The number of teams that made appointments every day of the week increased 8.7% and those that made home visits varied from 44.51% to 52.88%. The reduction in the number of teams that reported guaranteeing the agenda for accommodating spontaneous demand, varying from 62.41% to 60.11% and in the continuity of treatment, varying from 63.41% to 61.11%. For the structure of health requirements, the predominant completeness profile was “Best completeness” in both cycles, comprising 71.0% of the sets at time 1 and 67.0% at time 2. The proportion of teams with “Best completeness” increased by 89.1%, the one with “Worst completeness” increased by 20%, while those with “Average completeness” decreased by 66.3%.

Conclusion
We identified positive changes in the indicators of potential access to oral health services, expanding the users’ ability to use them. However, some access attributes remain unsatisfactory, with organizational barriers persisting.

Prostate Cancer Survival and Mortality according to a 13-year retrospective cohort study in Brazil: Competing-Risk Analysis

Objective: To analyze cancer-specific mortality (CSM) and other-cause mortality (OCM) among patients with prostate cancer that initiated treatment in the Brazilian Unified Health System (SUS), between 2002 and 2010, in Brazil.

Methods: Retrospective observational study that used the National Oncological Database, which was developed by record-linkage techniques used to integrate data from SUS Information Systems, namely: Outpatient (SIA-SUS), Hospital (SIH-SUS), and Mortality (SIM-SUS). Cancer-specific and other-cause survival probabilities were estimated by the time elapsed between the date of the first treatment until the patients’ deaths or the end of the study, from 2002 until 2015. The Fine-Gray model for competing risk was used to estimate factors associated with patients’ risk of death.

Results: Of the 112,856 studied patients, the average age was 70.5 years, 21% died due to prostate cancer, and 25% due to other causes. Specific survival in 160 months was 75%, and other-cause survival was 67%. For CSM, the main factors associated with patients’ risk of death were: stage IV (AHR = 2.91; 95%CI 2.73 – 3.11), systemic treatment (AHR = 2.10; 95%CI 2.00 – 2.22), and combined surgery (AHR = 2.30, 95%CI 2.18 – 2.42). As for OCM, the main factors associated with patients’ risk of death were age and comorbidities.

Conclusion: The analyzed patients with prostate cancer were older and died mainly from other causes, probably due to the presence of comorbidities associated with the tumor.

Functional recovery time after facial fractures: characteristics and associated factors in a sample of patients from southern Brazil

Understanding the cause, severity, and elapsed time for the restoration of the functions of maxillofacial injuries can contribute to the establishment of clinical priorities aiming at effective treatment and further prevention of facial trauma. The objective of this study was to understand the factors associated with the restoration of mastication, ocular, and nasal functions in the face of trauma victims, estimating their recovery time after surgical treatment. We analyzed 114 medical records of patients treated at the Hospital Montenegro, who attended follow-up consultations for up to 180 days. For analysis of the recovery time, we performed survival analysis, followed by COX analysis. We observed that half of the patients recovered their functions within 20 days. The average time for recovery from trauma in the zygomatic-orbital-malar-nasal complex was 11 days, and in the maxillary-mandibular complex, 21 days (HR: 1.5 [0.99 2.3], p = 0.055). Although functional reestablishment has reached high rates after the surgical approach, it is necessary to analyze the failing cases, as well as the economic impacts and the prevention strategies associated with facial trauma, to improve the service to the population.

Use of simulators in video laparoscopic surgery in medical training: a prospective court study with medicine academic at a university in Southern Brazil

Introduction: the onset of minimally invasive surgery, such as laparoscopic surgery, was accompanied by an increased frequency of complications, many of which were life-threatening. With the objective of minimizing morbidity and mortality and accelerating the learning curve, video laparoscopic surgery simulators were developed to improve the psychomotor skills required for these procedures.

Objective: to compare the performance of second year medical students of the Lutheran University of Brazil, in simulated videolaparoscopic surgeries performed at the Realistic Simulation Center of the Faculty of Health Sciences of Porto Alegre.

Method: prospective cohort study with 16 medical students with no prior experience in video-surgery simulation. The students performed simulated exercises and were evaluated regarding Coordination, Navigation by Instrument and Time in the accomplishment of the procedures.

Results: the sample consisted of 69% women and 31% men with a mean age of 23.2 years. The students obtained better results in the second simulation application. The skill in Navigation by Instrument task was the one that showed the best evolution in the studied group. The Total Time in the accomplishment of the procedures was the parameter with greater difference between the successive simulations.

Conclusion: medical students presented a significant improvement in their performance with the repetition of the simulation exercises, demonstrating that the Laparoscopic Surgery Simulators are a promising tool in medical training and development of surgical skills.

Fall in organ donations and transplants in Ceará in the COVID-19 pandemic: a descriptive study, April – June 2020

Objective: To describe organ donations and transplants in Ceará state, Brazil, following the declaration of the COVID-19 pandemic.

Methods: This was a descriptive study using data from the Brazilian Organ Transplantation Association. The number of donors and transplants from April to June 2020 was compared to the same period in 2019 and to the first quarter of 2020.

Results: In the first half of 2020, the state registered 72 effective donors, just 17 (23.6%) of whom related to the second quarter. Of the 352 transplants in the first half of 2020, 37 (10.7%) were performed in the second quarter. Compared with the period from April to June 2019, there was a reduction of 67.9% and 89.3% in the number of donors and transplants, respectively, in the same period of 2020.

Conclusion: The number of donors and transplants in Ceará showed an important fall in the three months following the declaration of the COVID-19 pandemic, especially for kidney, heart and cornea transplants

Assessment of diagnostics capacity in hospitals providing surgical care in two Latin American states

Background
Diagnostic services are an essential component of high-quality surgical, anesthesia and obstetric (SAO) care. Efforts to scale up SAO care in Latin America have often overlooked diagnostics capacity. This study aims to analyze the capacity of diagnostic services, including radiology, pathology, and laboratory medicine, in hospitals providing SAO care in the states of Chiapas, Mexico and Amazonas, Brazil.

Methods
A stratified cross-sectional evaluation of diagnostic capacity in hospitals performing surgery in Chiapas and Amazonas was performed using the Surgical Assessment Tool (SAT). National data sources were queried for indicators of diagnostics capacity in terms of workforce, infrastructure and diagnosis utilization. Fisher’s exact tests and chi-square tests were used to compare categorical variables between the private and public sector in Chiapas while descriptive statistics are used to compare Amazonas and Chiapas.

Findings
In Chiapas, 53% (n = 17) of public and 34% (n = 20) of private hospitals providing SAO care were assessed. More private hospitals than public hospitals could always provide x-rays (35% vs 23.5%) and ultrasound (85% vs 47.1%). However neither sector could consistently perform basic laboratory testing such as complete blood counts (70.6% public, 65% private). In Amazonas, 30% (n = 18) of rural hospitals were surveyed. Most had functioning x-ray machine (77.8%) and ultrasound (55.6%). The majority of hospitals could provide complete blood count (66.7%) but only one hospital (5.6%) could always perform an infectious panel. Both Chiapas and Amazonas had dramatically fewer diagnostic practitioners per capita in each state compared to the national average capacity.

Interpretation
Facilities providing SAO care in low-resource states in Mexico and Brazil often lack functioning diagnostics services and workforce. Scale-up of diagnostic services is essential to improve SAO care and should occur with emphasis on equitable and adequate resource allocation.