Breast Cancer in Asia: Incidence, Mortality, Early Detection, Mammography Programmes, and Risk-based Screening Initiatives

Close to half (45.4%) of 2.3 million breast cancers (BC) diagnosed in 2020 were from Asia. While the burden of breast cancer has been examined on the level of broad geographic regions, literature on more in-depth coverage of the individual countries and subregions of the Asian continent is lacking. This review examines the breast cancer burden in 47 Asian countries. Breast cancer screening guidelines and risk-based screening initiatives are discussed.

Nonphysician Sedation Providers in Africa: What Counts and What Is Being Counted?

“Not everything that can be counted counts, and not everything that counts can be counted.” – WB Cameron, Informal Sociology: A Casual Introduction to Sociological Thinking, 1963.

Does your anesthesia providers’ level of training impact your outcomes? This question has been widely evaluated and debated in the perioperative literature. With increasing demand for surgical and procedural services facilitated by anesthesia care globally, an answer will continue to be sought. Van der Merwe et al1 in their article “Postoperative outcomes associated with procedural sedation conducted by physician and non-physician anesthesia providers: findings from the prospective, observational African Surgical Outcomes Study (ASOS)” published in this month’s Anesthesia & Analgesia, have added to this discussion, with a secondary analysis of data from the African Surgical Outcomes Study (ASOS). Although their study provides some interesting insights into the outcomes of procedural sedation across the continent, our opinion is that the question remains largely unanswered.

To date, most of the literature evaluating the association between anesthesia care provider type and outcomes has focused on anesthesia care in highly developed health care systems. Questions have focused on task-shifting, where the responsibility for tasks is shifted from a more highly trained health care provider to health workers with shorter training and fewer qualifications, and task-sharing, where both levels of providers perform the task and may even work closely together. Examples include family doctors in Canada providing unsupervised anesthesia care in community hospitals after adding an additional year of training in anesthesia to their family medicine residency program; certified registered nurse anesthetists (CRNAs), practicing independently in many US states; and French anesthesiologists supervising nurse anesthetists with a 1:2 ratio. Ultimately, the hope is that by shifting/sharing tasks, access to care will improve with less-resource input and with similar (or in the case of task-sharing) even safer outcomes.2

Countries with a gross national income per capita of <$12,696 US dollars (USDs) are often (problematically) lumped together as low- and middle-income countries (LMICs)3 regardless of the profound diversity in this categorization, which contains around 85% of the world’s population.4 There is a critical shortage in human resources for health (HRH) globally, particularly in anesthesia. However, HRH are one of the most complex parts of health systems, with huge international variation in terms of numbers of health care workers, their training, their point of entry into training, their scope of practice, interprofessionalism, resilience, burnout, and retention of health care workers within the system.5–7 Developing a deep understanding of how to most effectively and efficiently provide safe anesthesia care is an urgent priority in improving global surgical outcomes; however, nuances in context make generalizations problematic.

Ven der Merwe et al1 aimed to evaluate this question by comparing patient outcomes when procedural sedation was delivered by nonphysician versus physician anesthesia providers. The primary data source, the ASOS, is a landmark study, where investigators collected a large amount of data (11,422 patients) over a relatively short amount of time, with good coverage of a broad geographic area.8 Its largely descriptive statistical analysis has been highly informative of perioperative outcomes in Africa, which appear to be much worse than previously published global data. In contrast, the Van der Merwe et al1 study is a small subset of the primary data (336 patients, ~3% of the full cohort), with a more complex comparative statistical analysis, with the authors concluding that receipt of sedation from a nonphysician provider was significantly associated with increased odds of severe complications. While these results must be interpreted with great caution (as we will outline below), the findings raise important questions about perioperative health care systems in Africa.

Evaluation of an Artificial Intelligence System for Retinopathy of Prematurity Screening in Nepal and Mongolia

Objective
The purpose of this study is to evaluate the performance of a deep learning algorithm for retinopathy of prematurity (ROP) screening in Nepal and Mongolia.

Design
This was a retrospective analysis of prospectively collected clinical data.

Subjects
Clinical information and fundus images were obtained from infants in two ROP screening programs in Nepal and Mongolia.

Methods
Fundus images were obtained using the Forus 3nethra neo in Nepal and RetCam® Portable in Mongolia. The overall severity of ROP was determined from the medical record using the International Classification of ROP (ICROP). The presence of plus disease was independently determined in each image using a reference standard diagnosis. The Imaging and Informatics for ROP (i-ROP) deep learning (DL) algorithm, which was trained on images from the RetCam® was used to classify plus disease, as well as assign a vascular severity score (VSS) from 1-9.

Main outcome measures
The main outcome measures were area under the receiver operating characteristic (AUC-ROC) and area under the precision recall curve (AUC-PR) for the presence of plus disease or type 1 ROP, and association between VSS and ICROP disease category.

Results
The prevalence of type 1 ROP was found to be higher in Mongolia (14.0%) than in Nepal (2.2%, p < 0.001) in these data sets. In Mongolia (Retcam images), the AUC-ROC for exam-level plus disease detection was 0.968 and AUC-PR was 0.823. In Nepal (Forus images), the AUC-ROC for exam-level plus disease detection was 0.999 and AUC-PR was 0.993. The ROP vascular severity score was associated with ICROP classification in both datasets (p < 0.001). At the population level, the median [interquartile range] VSS was found to be higher in Mongolia (2.7 [1.3–5.4]) as compared to Nepal (1.9 [1.2–3.4], p < 0.001). Conclusions These data provide preliminary evidence of the effectiveness of the i-ROP DL algorithm for ROP screening in neonatal populations in Nepal and Mongolia, using multiple camera systems, and provide useful data for consideration in future clinical implementation of AI-based ROP screening in low- and middle-income countries.

The Progress of Global Antimicrobial Resistance Governance and Its Implication to China: A Review

China has great potential for engaging in global actions on antimicrobial resistance (AMR) control. This study aims to summarize the process of global AMR governance and provide relevant policy recommendations on how China could take more initiative in the global AMR governance. We searched for academic articles and official document published or issued before December 2020 in e-journal databases, official websites of major organizations, and the relevant national ministries. This review revealed that global action on AMR control has experienced three stages: (1) The beginning stage (1980s and 1990s) when actions were mainly sponsored by high-income countries and AMR surveillance was focused on hospitals; (2) The rapid development stage (2000–2010) when global AMR governance began to concentrate on joint actions in multi-sectors, and developing countries were gradually involved in global actions; (3) The comprehensive stage (2011 to present) when global actions on AMR have covered various fields in different countries. China’s AMR governance has fallen behind at the beginning but recently began to catch up with the global trend. The central government should take a far-fetched view, act decisively and positively towards the global efforts of addressing AMR to play a more active and greater role on the international stage. View Full-Text

Global Neurosurgery – The Problem and Solution -The Asian Perspective

The world of Neurosurgery has witnessed a quantum jump in the last few decades. However, this progress has reaped benefits for patients’ income countries; the preventable deaths due to surgical deficit are as high as 47 million annually (1). Given this uneven balance of facilities in the health sector, the WHO has agreed to resolve the issues by participating in worldwide governing bodies of neurosurgery faculties in the individual country. The former president of the world bank was quoted that “surgery is an indivisible, indispensable part of health care and progress towards universal health coverag

Global Surgery indicators and pediatric hydrocephalus: a multicenter cross-country comparative study building the case for health systems strengthening

Purpose: The aim of this study is to compare specific three-institution, cross-country data that are relevant to the Global Surgery indicators and the functioning of health systems.

Methods: We retrospectively reviewed clinical and socioeconomic characteristics of pediatric patients who underwent CSF diversion surgery for hydrocephalus in three different centers: University of Tsukuba Hospital in Ibaraki, Japan (HIC), Jose R. Reyes Memorial Medical Center in Manila, Philippines (LMIC), and the Federal Neurosurgical Center in Novosibirsk, Russia (UMIC). The outcomes of interest were timing of CSF diversion surgery and mortality. Statistical tests included descriptive statistics, Cox proportional hazards model, and logistic regression. Nation-level data were also obtained to provide the relevant socioeconomic contexts in discussing the results.

Results: In total, 159 children were included—13 from Japan, 99 from the Philippines, and 47 from the Russian Federation. The median time to surgery at the specific neurosurgical centers were 6 days in the Philippines and 1 day in both Japan and Russia. For the cohort from the Philippines, non-poor patients were more likely to receive CSF diversion surgery at an earlier time (HR=4.74, 95%CI 2.34–9.61, p<0.001). In the same center, those with infantile or post-hemorrhagic hydrocephalus (HR=3.72, 95%CI 1.70–8.15, p=0.001) were more likely to receive CSF diversion earlier compared to those with congenital hydrocephalus, and those with post-infectious (HR=0.39, 95%CI 0.22–0.70, p=0.002) or myelomeningocele-associated hydrocephalus (HR=0.46, 95%CI 0.22–0.95, p=0.037) were less likely to undergo surgery at an earlier time. For Russia, older patients were more likely to receive or require early CSF diversion (HR=1.07, 95%CI 1.01–1.14, p=0.035). EVD insertion was found to be associated with mortality (cOR 14.45, 95% CI 1.28–162.97, p = 0.031).

Conclusion: In this study, Filipino children underwent late time-interval of CSF diversion surgery and had mortality differences compared to their Japanese and Russian counterparts. These disparities may reflect on the functioning of the respective country’s health systems.

Expert commentary on the challenges and opportunities for surgical site infection prevention through implementation of evidence-based guidelines in the Asia–Pacific Region

Introduction
Surgical site infections (SSIs) are a significant source of morbidity and mortality in the Asia–Pacific region (APAC), adversely impacting patient quality of life, fiscal productivity and placing a major economic burden on the country’s healthcare system. This commentary reports the findings of a two-day meeting that was held in Singapore on July 30–31, 2019, where a series of consensus recommendations were developed by an expert panel composed of infection control, surgical and quality experts from APAC nations in an effort to develop an evidence-based pathway to improving surgical patient outcomes in APAC.

Methods
The expert panel conducted a literature review targeting four sentinel areas within the APAC region: national and societal guidelines, implementation strategies, postoperative surveillance and clinical outcomes. The panel formulated a series of key questions regarding APAC-specific challenges and opportunities for SSI prevention.

Results
The expert panel identified several challenges for mitigating SSIs in APAC; (a) constraints on human resources, (b) lack of adequate policies and procedures, (c) lack of a strong safety culture, (d) limitation in funding resources, (e) environmental and geographic challenges, (f) cultural diversity, (g) poor patient awareness and (h) limitation in self-responsibility. Corrective strategies for guideline implementation in APAC were proposed that included: (a) institutional ownership of infection prevention strategies, (b) perform baseline assessments, (c) review evidence-based practices within the local context, (d) develop a plan for guideline implementation, (e) assess outcome and stakeholder feedback, and (f) ensure long-term sustainability.

Conclusions
Reducing the risk of SSIs in APAC region will require: (a) ongoing consultation and collaboration among stakeholders with a high level of clinical staff engagement and (b) a strong institutional and national commitment to alleviate the burden of SSIs by embracing a safety culture and accountability.

Andersen’s utilization model for cataract surgical rate and empirical evidence from economically-developing areas

Abstract
Background
Un-operated cataract is the leading cause of vision loss worldwide, responsible for 33% of visual impairment, and half of global blindness. The study aimed to build a fast evaluation method utilizing Andersen’s utilization framework and identify predictors of cataract surgical rate in sub-Saharan Africa and China.

Methods
The study was a cross-over ecological epidemiology study with a total of 19 countries in sub-Saharan Africa, and 31 provinces in China. Information was extracted from public data and published studies. Linear regression and structural equation modeling with Bootstrap were used to analyze predictors of CSR and their pathways to impact in sub-Saharan Africa and China separately.

Results
Cataract surgical resources in sub-Saharan Africa were linearly correlated with CSR (β = 0.74, 95% CI: 0.09, 0.91), while GDP/P didn’t impact cataract surgical resources (β = 0.29, 95% CI: − 0.12, 0.75). In China, residents’ average ability to pay was confirmed as the mediator between GDP/P and CSR (p = 0.32, RMSEA = 0.07; βCSR-paying = 0.77, 95% CI: 0.25, 0.90; βpaying-GDP/P = 0.89, 95% CI: 0.82, 0.93).

Conclusions
In sub-Saharan Africa, CSR is determined by health care provision. Local economic development may not directly influence CSR. Therefore, international assistance aimed to providing free cataract surgery directly is crucial. In China, CSR is determined principally by health care demand (ability to pay). To increase CSR in underserved areas of China, ability to pay must be enhanced through social insurance, and reduced surgical fees.

Epidemiological Characteristics, Ventilator Management, and Clinical Outcome in Patients Receiving Invasive Ventilation in Intensive Care Units from 10 Asian Middle-Income Countries (PRoVENT-iMiC): An International, Multicenter, Prospective Study

Epidemiology, ventilator management, and outcome in patients receiving invasive ventilation in intensive care units (ICUs) in middle-income countries are largely unknown. PRactice of VENTilation in Middle-income Countries is an international multicenter 4-week observational study of invasively ventilated adult patients in 54 ICUs from 10 Asian countries conducted in 2017/18. Study outcomes included major ventilator settings (including tidal volume [V T ] and positive end-expiratory pressure [PEEP]); the proportion of patients at risk for acute respiratory distress syndrome (ARDS), according to the lung injury prediction score (LIPS), or with ARDS; the incidence of pulmonary complications; and ICU mortality. In 1,315 patients included, median V T was similar in patients with LIPS < 4 and patients with LIPS ≥ 4, but lower in patients with ARDS (7.90 [6.8–8.9], 8.0 [6.8–9.2], and 7.0 [5.8–8.4] mL/kg Predicted body weight; P = 0.0001). Median PEEP was similar in patients with LIPS < 4 and LIPS ≥ 4, but higher in patients with ARDS (five [5–7], five [5–8], and 10 [5–12] cmH2O; P < 0.0001). The proportions of patients with LIPS ≥ 4 or with ARDS were 68% (95% CI: 66–71) and 7% (95% CI: 6–8), respectively. Pulmonary complications increased stepwise from patients with LIPS < 4 to patients with LIPS ≥ 4 and patients with ARDS (19%, 21%, and 38% respectively; P = 0.0002), with a similar trend in ICU mortality (17%, 34%, and 45% respectively; P < 0.0001). The capacity of the LIPS to predict development of ARDS was poor (ROC AUC of 0.62, 95% CI: 0.54–0.70). In Asian middle-income countries, where two-thirds of ventilated patients are at risk for ARDS according to the LIPS and pulmonary complications are frequent, setting of V T is globally in line with current recommendations.

Which Surgical Operations Should be Performed in District Hospitals in East, Central and Southern Africa? Results of a Survey of Regional Clinicians

Background
In East, Central and Southern Africa (ECSA), district hospitals (DH) are the main source of surgical care for 80% of the population. DHs in Africa must provide basic life-saving procedures, but the extent to which they can offer other general and emergency surgery is debated. Our paper contributes to this debate through analysis and discussion of regional surgical care providers’ perspectives.

Methods
We conducted a survey at the College of Surgeons of East, Central and Southern Africa Conference in Kigali in December 2018. The survey presented the participants with 59 surgical and anaesthesia procedures and asked them if they thought the procedure should be done in a district level hospital in their region. We then measured the level of positive agreement (LPA) for each procedure and conducted sub-analysis by cadre and level of experience.

Results
We had 100 respondents of which 94 were from ECSA. Eighteen procedures had an LPA of 80% or above, among which appendicectomy (98%), caesarean section (97%) and spinal anaesthesia (97%). Twenty-one procedures had an LPA between 31 and 79%. The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. Twenty procedures had an LPA below 30% among which paediatric anaesthesia and surgery.

Conclusion
Our study offers the perspectives of almost 100 surgical care providers from ECSA on which surgical and anaesthesia procedures should be provided in district hospitals. This might help in planning surgical care training and delivery in these hospitals.