The evaluation of a surgical task-sharing program in South Sudan

Background: Five billion people lack timely, affordable, and safe surgical services. Sub-Saharan Africa (SSA) is the region with the scarcest access to surgical care. The surgical workforce is crucial in closing this gap. In SSA, South Sudan has one of the lowest surgical workforce density. Task-sharing being a cost-effective training method, in 2019, the University of British Columbia collaborated with Médecins Sans Frontières to create the Essential Surgical Skills program and launched it in South Sudan. This study aims to evaluate this pilot program. Methods: This is a mixed-method prospective cohort study. Quantitative data include pre- and post-training outputs (number and types of surgeries, complication, re-operation, and mortality) and surgical proficiency of the trainees (quiz, Entrustable Professional Activity (EPA), and logbook data), and online survey for trainers. Semi-structured interviews were performed with trainees at the program completion. Results: Since July 2019, trainees performed 385 operations. The most common procedures were skin graft (14.8%), abscess drainage (9.61%), wound debridement and transverse laparotomy (7.79% each). 172 EPAs have been completed, out of which 136 (79%) showed that the trainee could independently perform the procedure. During the training, the operating room and surgical ward mortality remained similar to the pre-training phase. Furthermore, the surgical morbidity decreased from 25% to less than 5%. The pass rate for all quizzes was 100%. Interviews and survey showed that trainees’ surgical knowledge, interprofessional teamwork, trainers’ global insight on surgical training in Low- and Middle-Income Countries (LMICs), and patient care has improved. Also, the program empowered trainees, developed career path, and local acceptance and retention. The modules were relevant to community needs. Conclusions: This study casts light on the feasibility of training surgeons through a virtual platform in under-resourced regions. The COVID-19 global pandemic highlighted the need to make LMICs independent from fly-in trainers and traditional apprenticeship. Knowledge translation of this training platform’s evaluation will hopefully inform Ministries of Health and their partners to develop their National Surgical, Obstetric and Anesthesia Plans (NSOAPs). Furthermore, thanks to its scalability, both across levels of training and geography, it paves the way for virtual surgical education everywhere in the world.

Organized breast cancer screening not only reduces mortality from breast cancer but also significantly decreases disability-adjusted life years: analysis of the Global Burden of Disease Study and screening programme availability in 130 countries

Multiple studies over the past 4 decades have shown the significant benefit of breast cancer screening (BCS) in reducing mortality rates from breast cancer (BC). However, significant debate exists about the role of BCS in this regard, with some studies also showing no benefit in terms of mortality along with issues such as overdiagnosis, health care utilisation costs, psychological distress or overtreatment. To date, no BCS study has focused on disability. Hence the aim of this study is to evaluate the relative contribution of BCS approaches to age-standardized mortality and disability-adjusted life years (DALYs) rates along with other related risk factors, from a country-level perspective.

Patients and methods
This study created a country-dataset by merging information from the Global Burden of Disease study regarding female age-standardized BC mortality, DALYs rates and other risk factors with the BCS programme availability at the national or regional level (versus no or only pilot such programme), BCS type (mammography, digital screening, breast self-examination and clinical breast examination) and other BCS-related information among 130 countries. Mixed-effect multilevel regression models were run to examine the associations of interest.

Results
The most important factor predictive of lower mortality was the more advanced type of BCS programme availability [mammography: −4.16, 95% CI −6.76 to −1.55; digital mammography/ultrasound: −3.64, 95% CI −6.59 to −0.70] when compared with self- or clinical breast examinations. High levels of low-density lipoprotein cholesterol (LDL-c) and smoking were also related to higher mortality and DALYs from BC. In terms of BC DALYs, BCS had a 21.9 to 22.3-fold increase in the magnitude of effect compared with that in terms of mortality. Data on mortality and DALYs in relation to BCS programmes were also calculated for high-, middle- and low-income countries.

Conclusions
These data further support the positive effects of BCS in relation to age-standardized BC mortality rates, and for the first time show the impact of BCS on DALYs too. Additional factors, such as diabetes, high levels of LDL-c or smoking seemed to be related to BC mortality and disability, and could be considered as additional components of possible interventions to be used alongside BCS to optimize the BCS benefit on patients.

The characteristics and outcomes of trauma admissions to an adult general surgery ward in a tertiary teaching hospital

Background
Traumatic injuries are proportionally higher in low- and middle-income countries (LMICs) than high-income counties. Data on trauma epidemiology and patients’ outcomes are limited in LMICs.

Methods
A retrospective review of medical records was performed for trauma admissions to the Princess Marina Hospital general surgical (GS) wards from August 2017 to July 2018. Data on demographics, mechanisms of injury, body parts injured, Revised Trauma Score, surgical procedures, hospital stay, and outcomes were analysed.

Results
During the study period, 2610 patients were admitted to GS wards, 1307 were emergency admissions. Trauma contributed 22.1% (576) of the total and 44.1% of the emergency admissions. Among the trauma admissions, 79.3% (457) were male. The median[interquartile range(IQR)](range) age in years was 30[24–40](13–97). The main mechanisms of injury were interpersonal violence (IPV), 53.1% and road traffic crashes (RTCs), 23.1%. More females than males suffered animal bites (5.9% vs. 0.9%), and burns (8.4% vs. 4.2%), while more males than females were affected by IPV (57.8% vs. 35.3%) and self-harm (5.5% vs. 3.4%). Multiple body parts were injured in 6.6%, mainly by RTCs. Interpersonal violence (IPV) and RTCs resulted in significant numbers of head and neck injuries, 57.3% and 22.2% respectively. More females than males had multiple body-parts injury 34.5% vs. 18.5%. Revised Trauma Score (RTS) of ≤11 was recorded in IPV, 38.4% and RTCs, 33.6%. Surgical procedures were performed on 44.4% patients. The most common surgical procedures were laparotomy (27.8%), insertion of chest tube (27.8%), and craniotomy/burr hole(25.1%). Complications were recorded in 10.1% of the patients(58) including 39 deaths, 6.8% of the 576.

Conclusion
Trauma contributed significantly to the total GS and emergency admissions. The most common mechanism of injury was IPV with head and neck the most frequently injured body part. Further studies on IPV and trauma admissions involving paediatric and orthopaedic patients are warranted.

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

Gaps in surgical competencies of general surgeons deployed on humanitarian missions in disaster settings

Introduction:As the access to surgery differs geographically, its disparity is even more pronounced in disaster settings. With the increasing interest of surgeons from high-income countries (HIC) to respond to these surgical disparities, non-governmental organizations (NGOs) often send teams of health practitioners to provide healthcare aid to the most unstable regions of the world. However, surgeons participating in these missions rarely get the medical training necessary to face the large scope of procedures they can encounter in humanitarian settings. This research aims to create a framework of the necessary skills needed for surgeons to provide proper surgical care in disaster settings.Methodology:This is a descriptive qualitative study to outline the differences between the surgical procedures general surgeons in HICs are being trained on during their surgical training with the surgical procedures required in disaster settings. After identifying the main surgical procedures general surgeons are expected to be trained on before their deployment to a disaster setting in an LMICs, a survey was sent to participants to assess their competency level in these procedures and the likelihood of them performing these procedures in their home country compared to on the mission.Results:Participants indicated the high frequency of performing several surgical procedures from different surgical specialties on humanitarian missions. The most common of these procedures are cesarean section, fracture reduction, skeletal retraction, wound debridement, burn dressing, application of skin and graft, and performing emergency laparotomies. However, only wound debridement and emergency laparotomy were performed more than 10-20 times/ year by the participants in their daily practice in the past 5 years. The rest of the procedures in this list were never performed by the participants in their daily practice. Obstetrical and orthopedic procedures are amongst the most common procedures a general surgeon must perform when deployed on a mission in a disaster setting. However, they are rarely, if ever, performed by the surgeons in their daily practice. Looking at the requirements to complete general surgery training in most HICs, it is clear that the focus has shifted to training in advanced procedures and away from surgical training in other specialty procedures such as obstetrics, plastic surgery, orthopedic, and neurosurgery. Discussion:This study proves the perception that there is a gap in the training of surgeons who engage in health missions abroad compared to the scope of practice expected of them during these missions. This gap is more present in subspecialties such as obstetrics, orthopedics, urology, and neurosurgery. This shows the importance of surgeons who participate in these missions to have broad-based training that includes the most encountered surgical procedures in disaster settings. Acquiring skills in these life-saving procedures before being deployed on a surgical mission will improve the mortality and morbidity outcomes of these missions and create an ethical space where surgeons from high-income countries only perform procedures they have been adequately trained on

Financial toxicity due to breast cancer treatment in low- and middle-income countries: evidence from Vietnam

Background
This study examined the financial toxicity faced by breast cancer (BC) patients in Vietnam and the factors associated with the risk and degree of that toxicity.

Methods
A total of 309 BC patients/survivors completed an online survey (n=209) or a face-to-face interview (n=100) at two tertiary hospitals. Descriptive statistics and χ2 tests were used to identify and analyse the forms and degree of financial toxicity faced by BC patients/survivors. A Cragg hurdle model assessed variation in risk and the degree of financial toxicity due to treatment.

Results
41% of respondents faced financial toxicity due to BC treatment costs. The mean amount of money that exceeded BC patients/survivors’ ability to pay was 153 million Vietnamese Dong (VND) ($6602) and ranged from 2.42 million VND to 1358 million VND ($104–58,413). A diagnosis at stage II or III of BC was associated with 16.0 and 18.0 million VND (~$690–777) more in the degree of financial toxicity compared with patients who were diagnosed at stage 0/I, respectively. Being retired or married or having full (100%) health insurance was associated with a decrease in the degree of financial toxicity.

Conclusions
A significant proportion of Vietnamese BC patients/survivors face serious financial toxicity due to BC treatment costs. There is a need to consider the introduction of measures that would attenuate this hardship and promote uptake of screening for the reduction in financial toxicity as well as the health gains it may achieve through earlier detection of cancer.

Fears and barriers: problems in breast cancer diagnosis and treatment in Pakistan

Background
Women in Pakistan lack appropriate awareness about diagnosis and treatment for breast cancer due to a range of multifaceted barriers. There is a dearth of literature examining the socio-cultural factors that inhibit women from breast cancer screening, diagnosis and treatment in Punjab, Pakistan. Addressing this gap, this qualitative study sought to identify and explore the barriers that hinder women from seeking timely screening and treatment.

Methods
In this process 45 women (age = 18–50 years) with breast cancer were purposively sampled and interviewed from the Punjab Institute of Nuclear Medicine (PINUM) hospital, Faisalabad, Pakistan.

Results
An inductive approach was used to analyze the data which resulted in the emergence of eight subthemes under the umbrella of three major themes that delineate individual, socio-cultural and structural barriers to seek screening and treatment of breast cancer in Punjab. Individual barriers included lack of awareness, hesitance in accepting social support, and spiritual healing. The identified socio-cultural factors included feminine sensitivity, stigmatization, and aversion to male doctors. Lack of financial resources and apathetic medical services were structural barriers that hinder screening and treatment.

Conclusions
These barriers can be addressed through raising awareness and community mobilization about breast-self exam and treatment. The healthcare system should also pay attention to socio-psychological and cultural factors impeding women’s access to available health facilities.

Barriers to training in laparoscopic surgery in low- and middle-income countries: A systematic review

Laparoscopic surgery has the potential to improve care in resource-deprived low- and-middle-income countries (LMICs). This study aims to analyse the barriers to training in laparoscopic surgery in LMICs. Medline, Embase, Global Health and Web of Science were searched using ‘LMIC’, ‘Laparoscopy’ and ‘Training’. Two researchers screened results with mutual agreement. Included papers were in English, focused on abdominal laparoscopy and training in LMICs. PRISMA guidelines were followed; 2992 records were screened, and 86 full-text articles reviewed to give 26 key papers. Thematic grouping identified seven key barriers: funding; availability and maintenance of equipment; local access to experienced laparoscopic trainers; stakeholder dynamics; lack of knowledge on effective training curricula; surgical departmental structure and practical opportunities for trainees. In low-resource settings, technological advances may offer low-cost solutions in the successful implementation of laparoscopic training and improve access to surgical care.

Measuring barriers to fistula care: investigating composite measures for targeted fistula programming in Nigeria and Uganda

Background
Accessing surgical repair poses challenges to women living with female genital fistula who experience intersectional vulnerabilities including poverty, gender, stigma and geography. Barriers to fistula care have been described qualitatively in several low- and middle-income countries, but limited effort has been made to quantify these factors. This study aimed to develop and validate composite measures to assess barriers to accessing fistula repair in Nigeria and Uganda.

Methods
This quantitative study built on qualitative findings to content validate composite measures and investigates post-repair client surveys conducted at tertiary hospitals in Northern and Southern Nigeria and Central Uganda asking women about the degree to which a range of barriers affected their access. An iterative scale development approach included exploratory and confirmatory factor analyses of two samples (n = 315 and n = 142, respectively) using STATA 13 software. Reliability, goodness-of-fit, and convergent and predictive validity were assessed.

Results
A preliminary 43-item list demonstrated face and content validity, triangulated with qualitative data collected prior to and concurrently with survey data. The iterative item reduction approach resulted in the validation of a set of composite measures, including two indices and three sub-scales. These include a Financial/Transport Inaccessibility Index (6 items) and a multidimensional Barriers to Fistula Care Index of 17 items comprised of three latent sub-scales: Limited awareness (4 items), Social abandonment (6 items), and Internalized stigma (7 items). Factor analyses resulted in favorable psychometric properties and good reliability across measures (ordinal thetas: 0.70–0.91). Higher levels of barriers to fistula care are associated with a woman living with fistula for longer periods of time, with age and geographic settings as potential confounders.

Conclusions
This set of composite measures that quantitatively captures barriers to fistula care can be used separately or together in research and programming in low- and middle-income countries.

Concurrent manifestations of Horner’s syndrome and esophageal metastasis of breast cancer: case report of a young woman after a period of non-adherence to treatment: a case report

Background
Esophageal involvement and Horner’s syndrome are rare manifestations of breast cancer distant metastases that can pose a significant challenge in diagnosis and treatment. In addition to the more aggressive behavior of breast cancer diagnosed in young women, non-adherence to treatment is associated with increased risk of distant metastasis.

Case presentation
A 36-year-old Javanese woman presented to our institution with dysphagia, hoarseness, and frequent hiccups. In the 6 weeks prior to the current admission, the patient also reported tingling in the neck and shoulder, anhidrosis in the left hemifacial region, and drooping of the upper left eyelid. She was previously managed as tuberculoid laryngitis. Plain X-rays showed burst fractures of the cervical vertebrae and slight pleural effusion. Laryngoscopy revealed bowing of the vocal cords and liquid residue in the vallecula that was reduced upon chin tuck. Esophageal metastasis was confirmed with endoscopy showing thickening of the wall and positive cytology swab with ductal malignant cells. The patient had a history of breast cancer with a period of loss to follow-up of 4 years.

Conclusions
Physicians should consider potential distant metastasis of breast cancer to the esophagus and sympathetic nervous system of the neck particularly in a high-risk woman with presentation of dysphagia and manifestations of Horner’s syndrome.