Strategies for Improving Quality and Safety in Global Health: Lessons From Nontechnical Skills for Surgery Implementation in Rwanda

In 2015 the Lancet Commission on Global Surgery published its report “Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development,”1 helping to galvanize a global movement to increase access to safe, timely, and affordable surgical and anesthesia care with an emphasis on equity. A goal of the movement is to enable the benefits of these efforts to be reaped most by impoverished and marginalized populations. The authors laid out 5 key messages, including the great number of operations required annually (approximately 143 million), especially among the poorest third of the world’s population, which receives only 6% of the operations. The commission called on nations to track and report on 6 metrics related to surgical care. Two of these metrics—surgeon, anesthetist, and obstetric (SAO) density (the number of specialist surgical, anesthetic, and obstetric providers per 100,000 population) and surgical volume (number of operations performed in operating rooms annually per 100,000 population)—are measurements …

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.

We Asked the Experts: The Role of Rural Hospitals in Achieving Equitable Surgical Access in Low-Resourced Settings

Strengthening and defining the role of rural hospitals within a surgical ecosystem is essential to improving quality and timely surgical access for rural people in low and middle-income countries (LMICs). Regional hospitals are the cornerstone of LMIC rural surgical care but have insufficient human resources and infrastructure that limit the surgical care they can provide. District hospitals are most accessible for many rural patients but also have limited surgical capacity. In order to surgical access for rural people, both regional and district hospital surgical services must be strengthened. A strong relationship between regional and district hospitals through a hub and spoke model is needed. Regional hospital surgeons can support training and supervision for and referrals from district hospitals. Telemedicine can play a key role to leapfrog physical barriers and surgical specialist shortages. The changing demographics of surgical disease will continue to worsen the strain on tertiary hospitals where most subspecialists in LMICs work. The fewer rural patients who need to travel to urban referral and tertiary facilities for problems that can be managed at lower-level facilities, the better access to timely surgical care for all.

Breast Cancer in the Gaza Strip: The impact of the medical permit regime on public health

For the last 14 years, the Gaza Strip has been subject to an illegal blockade imposed by the Israeli and Egyptian governments. This severe restriction on movement prevents Gazans from accessing critical resources and makes access to health care, even for the most severely ill patients, contingent on a convoluted permit system run by the Israeli military. Consequences of the permit system include major delays in treatment and adverse health outcomes. My thesis explores the impact of the permit system on health outcomes for breast cancer patients in Gaza and offers recommendations for improving public health via community-based and political initiatives

Surgical Management and Outcomes of Wilms Tumor in Rwanda: A Retrospective Study of Patients Operated on at the University Teaching Hospital of Kigali-Rwanda

BACKGROUND: Wilms tumor is the most common renal tumor in children and accounts for 6-8% of all childhood malignancies and has a variable survival rate worldwide. The aim of this study was to describe the surgical management and outcomes of care for Wilms tumor patients operated at the University Teaching Hospital of Kigali (CHUK).
METHODS: This is a retrospective chart review conducted at CHUK in Rwanda. It includes all children who had a confirmed Wilms tumor diagnosis operated from July 2012 to June 2016. Patient’s demographics, staging, surgical management, and outcomes were analyzed.
RESULTS: A total of 58 patients diagnosed with Wilms tumor were identified. 52.6% were female. The median age was four years, interquartile range (IQR): 1-10 years. The majority of the children were stage II (39.7%) and the minority being stage V (5.2%). Treatment offered was in accordance with the Societe Internationale d’ Oncologie Pediatrique (SIOP) protocol; 91.2% of patients received four weeks of preoperative chemotherapy and a median of 15 weeks postoperative chemotherapy (IQR: 8,26). The resection rate was 100% for those with unilateral tumors. The spillage rate was 15.8%. At the time of the study, the mortality rate was 19.3%, recurrence was 7%, and 12.3% were lost to follow-up.
CONCLUSION: The introduction of a single national protocol for treating Wilms tumor in Rwanda with a dedicated management team, including the surgical and pediatric oncology services, has led to early outcomes approaching the ones in high-income countries, but efforts also need to include earlier detection of this tumor.

Epidemiology and Anatomic Distribution of Colorectal Cancer in South Africa

Background: Colorectal cancer (CRC) is the 5th most common cancer in subSaharan Africa (SSA) and the 3rd most common cancer in Southern Africa. CRC characteristics in SSA, including anatomic distribution, are not well described. Objective: To describe patient characteristics and anatomic location of colorectal adenocarcinoma (CRC-AC) in South Africa. Design: This was a retrospective study of CRC using the South African National Cancer Registry from 2006-2011. Main Outcome Measures: Patient age, gender, racial/ethnic group, province, histology type, and tumour location. Results: 6146 patients were included in the analysis. Among patients with adenocarcinomas, the median age of presentation was 60 (interquartile range, 49-70) years. 1372 (25%) of patients were < 50 years and 2870 (52%) were male. There were 5498 (89%) cases of adenocarcinoma (AC). 1277 (26%) CRC-AC were right colonic lesions, 1214 (25%) were left colonic lesions, and 2404 (49%) lesions were located in the rectum. Patients ≥ 50 years at presentation (OR=1.29. p< 0.001) and from Limpopo province (OR=1.46, p=0.029) were more likely to have left colonic and rectal adenocarcinoma on multivariate analysis. Patients who were black (OR=1.67, p< 0.001), had right colonic lesions (OR=1.25, p=0.007), and were from Mpumalanga (OR=1.67, p=0.007), Limpopo (OR=1.60, p=0.002), or Northwest (OR=1.76, p=0.001), were significantly associated with early onset adenocarcinoma. Conclusion: CRC-AC in South Africa presents at an earlier age than in HICs, such as the US. Early-onset CRC is higher in black South Africans who live in Mpumalanga, Limpopo, and Northwest in comparison with other provinces. The majority of colorectal cancer were leftsided and rectal; thus screening flexible sigmoidoscopy should be considered. Further studies on the age-specific incidence and the genetics and epigenetics of CRC-AC in South Africa are needed.

Healthcare-associated infections and antimicrobial use in surgical wards of a large urban central hospital in Blantyre, Malawi: a point prevalence survey

Background
There are limited data on healthcare-associated infections (HAI) from African countries like Malawi.

Aim
We undertook a point prevalence survey of HAI and antimicrobial use in the surgery department of Queen Elizabeth Central Hospital (QECH) in Malawi and ascertained the associated risk factors for HAI.

Methods
A cross-sectional point prevalence survey (PPS) was carried out in the surgery department of QECH. The European Centre for Disease Prevention and Control PPS protocol version 5.3 was adapted to our setting and used as a data collection tool.

Findings
105 patients were included in the analysis; median age was 34 (IQR: 24–47) years and 55.2% patients were male. Point prevalence of HAI was 11.4% (n=12/105) (95% CI: 6.0%–19.1%), including four surgical site infections, four urinary tract infections, three bloodstream infections and one bone/joint infection. We identified the following risk factors for HAI; length-of-stay between 8 and 14 days (OR=14.4, 95% CI: 1.65–124.7, p=0.0143), presence of indwelling urinary catheter (OR=8.3, 95% CI: 2.24–30.70, p=0.003) and history of surgery in the past 30 days (OR=5.11, 95% CI: 1.46–17.83, p=0.011). 29/105 patients (27.6%) were prescribed antimicrobials, most commonly the 3rd-generation cephalosporin, ceftriaxone (n=15).

Conclusion
The prevalence rates of HAI and antimicrobial use in surgery wards at QECH are relatively high. Hospital infection prevention and control measures need to be strengthened to reduce the burden of HAI at QECH.

Feasibility and diagnostic accuracy of Telephone Administration of an adapted wound heaLing QuestiONnaire for assessment for surgical site infection following abdominal surgery in low and middle-income countries (TALON): protocol for a study within a trial (SWAT)

Background
Surgical site infection is the most common complication of abdominal surgery, with a global impact on patients and health systems. There are no tools to identify wound infection that are validated for use in the global setting. The overall aim of the study described in this protocol is to evaluate the feasibility and validity of a remote, digital pathway for wound assessment after hospital discharge for patients in low- and middle-income countries (LMICs).

Methods
A multi-centre, international, mixed-methods study within a trial, conducted in two stages (TALON-1 and TALON-2). TALON-1 will adapt and translate a universal reporter outcome measurement tool (Bluebelle Wound Healing Questionnaire, WHQ) for use in global surgical research (SWAT store registration: 126) that can be delivered over the telephone. TALON-2 will evaluate a remote wound assessment pathway (including trial retention) and validate the diagnostic accuracy of this adapted WHQ through a prospective cohort study embedded within two global surgery trials. Embedded community engagement and involvement activities will be used to optimise delivery and ensure culturally attuned conduct. TALON-1 and TALON-2 are designed and will be reported in accordance with best practice guidelines for adaptation and validation of outcome measures, and diagnostic test accuracy studies.

Discussion
Methods to identify surgical site infection after surgery for patients after hospital discharge have the potential to improve patient safety, trial retention, and research efficiency. TALON represents a large, pragmatic, international study co-designed and delivered with LMIC researchers and patients to address an important research gap in global surgery trial methodology.

Level of knowledge and practice of female healthcare providers about early detection methods of breast cancer at Debre Tabor Comprehensive Specialised Hospital: a cross-sectional study

Background: Despite the higher mortality rate of breast cancer in low and middle-income countries, the practice of early detection methods is low and the majority of the patients presenting at an advanced stage of the disease need palliative care with low survival rates. Although healthcare providers are the key for practicing early detection methods of breast cancer for themselves and their clients, little is known about their knowledge and practice of early detection methods of breast cancer in Northcentral Ethiopia.

Methods: An institution-based cross-sectional study was conducted among female healthcare providers at Debre Tabor Comprehensive Specialised Hospital. Data were collected using a structured self-administered questionnaire. The data were analysed using SPSS version 23. Descriptive statistics were used to describe the socio-demographic information of participants. Binary and multivariable logistic regression with adjusted odds ratio (AOR) and 95% confidence interval (CI) was used to identify factors associated with the outcome variable. Statistical significance was declared at p 2 years (AOR = 3.2; 95% CI: 1.72, 5.29), history of any breast problem (AOR = 1.4; 95% CI: 1.02, 2.37), family history of breast cancer (AOR = 4.0; 95% CI: 2.58, 15.84), having good knowledge (AOR = 2.9; 95% CI: 1.3, 6.52) and history of comorbidities (AOR = 1.09; 95% CI: 1.09, 3.59) were the factors associated with the practice of breast self-examination.

Conclusion: Our study found that the knowledge and practice of breast cancer early detection methods was low in the study setting. Only less than half of female healthcare providers practiced regular breast self-examination, which suggests the need to provide training for healthcare providers to fill the gap and to promote early detection of breast cancer cases.

Prevalence and Mortality of Triple-Negative Breast Cancer in West Africa: Biologic and Sociocultural Factors

Key Objective
Triple-negative breast cancer (TNBC) is a malignant breast cancer, lacking targeted therapy, which would benefit from further research to understand its nature and the observed variation in its malignancy between women of differing ancestries. This large-scale systematic literature review examines the current and emerging biologic and nonbiologic factors, which have been shown to influence TNBC disease outcomes among indigenous West African (WA) females while discussing some prospective steps that could be adopted by health care systems for the reduction of this burden.

Knowledge Generated
WA women are the most burdened populations in relation to TNBC. Biologic and economic factors have been shown to significantly influence the TNBC disease outcomes. Women’s education initiatives, specialist training, and accessible health care are needed in WA countries.

Relevance
The determination of WA-specific biologic, cultural, and socioeconomic TNBC factors could align efforts in developing treatment options and physician recommendations to cancer-burdened women.