The Rise of Inflow Cisternostomy in Resource-Limited Settings: Rationale, Limitations, and Future Challenges

Low- and middle-income countries (LMICs) bear most of the global burden of traumatic brain injury (TBI), but they lack the resources to address this public health crisis. For TBI guidelines and innovations to be effective, they must consider the context in LMICs; keeping this in mind, this article will focus on the history, pathophysiology, practice, evidence, and implications of cisternostomy. In this narrative review, the author discusses the history, pathophysiology, practice, evidence, and implications of cisternostomy. Cisternostomy for the management of TBI is an innovation developed in LMICs, primarily for LMICs. Its practice is based on the cerebrospinal fluid shift edema theory that attributes injury to increased pressure within the subarachnoid space due to subarachnoid hemorrhage and subsequent dysfunction of glymphatic drainage. Early reports of the technique report significant improvements in the Glasgow Outcome Scale, lower mortality rates, and shorter intensive care unit durations. Most reports are single-center studies with small sample sizes, and the technique requires experience and skill. These limitations have led to criticisms and slow adoption of the technique. Further research is needed to establish the effect of cisternostomy on TBI outcomes.

Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies

Secondary peritonitis and intra-abdominal sepsis are a global health problem. The life-threatening systemic insult that results from intra-abdominal sepsis has been extensively studied and remains somewhat poorly understood. While local surgical therapy for perforation of the abdominal viscera is an age-old therapy, systemic therapies to control the subsequent systemic inflammatory response are scarce. Advancements in critical care have led to improved outcomes in secondary peritonitis. The understanding of the effect of secondary peritonitis on the human microbiome is an evolving field and has yielded potential therapeutic targets. This review of secondary peritonitis discusses the history, classification, pathophysiology, diagnosis, treatment, and future directions of the management of secondary peritonitis. Ongoing clinical studies in the treatment of secondary peritonitis and the open abdomen are discussed

Point-of-Care Ultrasound: Applications in Low- and Middle-Income Countries

Purpose of Review
This review highlights the applications of point-of-care ultrasound in low- and middle-income countries and shows the diversity of ultrasound in the diagnosis and management of patients.

Recent Findings
There is a paucity of data on point-of-care ultrasound in anesthesiology in low- and middle-income countries. However, research has shown that point-of-care ultrasound can effectively help manage infectious diseases, as well as abdominal and pulmonary pathologies.

Summary
Point-of-care ultrasound is a low-cost imaging modality that can be used for the diagnosis and management of diseases that affect low- and middle-income countries. There is limited data on the use of ultrasound in anesthesiology, which provides clinicians and researchers opportunity to study its use during the perioperative period.

Double standards in healthcare innovations: the case of mosquito net mesh for hernia repair

With over two decades of evidence available including from randomised clinical trials, we explore whether the use of low-cost mosquito net mesh for inguinal hernia repair, common practice only in low-income and middle-income countries, represents a double standard in surgical care. We explore the clinical evidence, biomechanical properties and sterilisation requirements for mosquito net mesh for hernia repair and discuss the rationale for its use routinely in all settings, including in high-income settings. Considering that mosquito net mesh is as effective and safe as commercial mesh, and also with features that more closely resemble normal abdominal wall tissue, there is a strong case for its use in all settings, not just low-income and middle-income countries. In the healthcare sector specifically, either innovations should be acceptable for all contexts, or none at all. If such a double standard exists and worse, persists, it raises serious questions about the ethics of promoting healthcare innovations in some but not all contexts in terms of risks to health outcomes, equitable access, and barriers to learning.

A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes

Background
Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation.

Main body
We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as “in-hospital mortality” as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure.

Conclusion
The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.

Global prevalence of traumatic non-fatal limb amputation

Background:
Reliable information on both global need for prosthetic services and the current prosthetist workforce is limited. Global burden of disease estimates can provide valuable insight into amputation prevalence due to traumatic causes and global prosthetists needed to treat traumatic amputations.

Objectives:
This study was conducted to quantify and interpret patterns in global distribution and prevalence of traumatic limb amputation by cause, region, and age within the context of prosthetic rehabilitation, prosthetist need, and prosthetist education.

Study design:
A secondary database descriptive study.

Methods:
Amputation prevalence and prevalence rate per 100,000 due to trauma were estimated using the 2017 global burden of disease results. Global burden of disease estimation utilizes a Bayesian metaregression and best available data to estimate the prevalence of diseases and injuries, such as amputation.

Results:
In 2017, 57.7 million people were living with limb amputation due to traumatic causes worldwide. Leading traumatic causes of limb amputation were falls (36.2%), road injuries (15.7%), other transportation injuries (11.2%), and mechanical forces (10.4%). The highest number of prevalent traumatic amputations was in East Asia and South Asia followed by Western Europe, North Africa, and the Middle East, high-income North America and Eastern Europe. Based on these prevalence estimates, approximately 75,850 prosthetists are needed globally to treat people with traumatic amputations.

Conclusion:
Amputation prevalence estimates and patterns can inform prosthetic service provision, education and planning.

The landscape of academic global surgery: a rapid review

Interest in academic global surgery, which comprises clinical, educational, and research collaborations to improve surgical care between academic surgeons in high-income countries and low- and middle-income countries (LMICs) and their corresponding academic institutions, has grown over the years. However, there is no collective knowledge of academic global surgery. Thus, this review aims to understand the current landscape of academic global surgery and discuss future directions. A rapid review, a streamlined approach, was conducted to identify and summarize emerging studies systematically. The keywords applied in the search strategy were “global surgery” and “academic programs”. The total number of retrieved articles in PubMed was 390, and after the investigation, 20 articles were extensively reviewed for the result section. According to the results, this study provided findings regarding: (I) perceptions of residents, faculty, and surgical program directors toward academic global surgery programs, (II) key program characteristics of implemented academic global surgery programs, and (III) evaluation results of available academic global surgery programs. We also drew lessons and challenges for a useful guide for future academic global surgery research and the development of optimal educational programs. This review identified a small but rich set of information on academic global surgery. Further research and discussion are needed on how to successfully incorporate the academic global surgery program into medical institutions

Virtual learning in global surgery: current strategies and adaptation for the COVID-19 pandemic

Modern surgical education has shifted to include technology as an integral component of training programs. The onset of the COVID-19 pandemic highlights the need to identify currently training modalities in global surgery and to delineate how these can be best used given the shift of global surgical training to the virtual setting. Here, we conducted a rapid review of the MEDLINE database examining the current status of training modalities in global surgical training programs and presented a case study of a virtual learning course on providing safe surgical care in the time of a pandemic. Our rapid review identified 285 publications, of which 101 were included in our analysis. Most articles describe training in high income country environments (87%, 88/101). The principal training modality described is apprenticeship (46%, 46/101), followed by simulation training (37%, 37/101), and virtual learning strategies (14%, 14/101). Our focused case study describes a virtual course entitled “Safe Surgical Care: Strategies During Pandemics,” created at the University of British Columbia by E.J., published 1-month postdeclaration of the pandemic. This multimodal course was rolled-out over a 5-week period and had significant engagement on an international level, with 1944 participants from 105 countries. With in-person training decreased as a result of the pandemic, virtual reality, virtual simulation, and telementoring may serve to bridge this gap. We propose that virtual learning strategies be integrated into global surgical training through the pursuit of increased accessibility, incorporation of telementoring, and inclusion in national health policy.

The ethical development and sustainability of trauma registries in low- and middle-income countries

Trauma registries are an anonymized, systematic, prospective data banks for trauma patients that may include details on demographics, injury details, hospital processes, and outcomes. They are an important component of trauma care systems and a tool for improving outcomes in trauma. Given the high rates of morbidity and mortality from trauma in low- and middle-income countries (LMICs), the implementation of trauma registries in LMICs is a growing area of interest; however, while many pilot trauma registries have been demonstrated to be feasible in LMICs, very few are sustainable in the long term. In this thesis, a trauma registry established in 2017 in Mbarara Regional Referral Hospital (MRRH), Uganda is examined. Since the establishment of this registry, data for over 3000 trauma patients has been collected, however, the registry faces questions of how to achieve long-term viability without the financial support of external partnerships. The aim of this thesis is therefore to evaluate several aspects of sustainability of trauma registries for low-income settings. First, the ethical importance of sustainability in global surgery was established through a scoping review on the literature on the ethics of global surgery. A grounded theory content analysis was completed to identify themes and gaps in the existing literature. Four major ethical domains in global surgery were identified: clinical care and delivery; education and exchange of trainees; research, monitoring, and evaluation; and engagement in collaborations and partnerships. While the literature on ethics in global surgery was sparse, mostly in the form of commentaries or editorials, and largely published by authors in high-income countries (HICs), the importance of including LMIC authors in the conversation on ethics in global surgery and the value of building sustainable collaborations and partnerships were key findings of this scoping review. Next, a literature review of considerations for the implementation of ethical and sustainable trauma registries in LMICs was completed. A number of practical challenges were identified for the development of trauma registries in LMICs and included funding sources, personnel requirements, technology access, and quality assurance mechanisms. Ethical considerations for trauma registry development were also identified, and included concerns of patient confidentiality, informed consent, and sustaining the registry. Strategies for these ethical and practical considerations for trauma registry development in LMICs are discussed, and opportunities for future research opportunities are explored. The widespread nature and accessibility of mobile phones in most low- and middle-income countries, including Uganda, makes the use of mobile phone technology in health a potential avenue for inexpensive health care innovation. A mobile application trauma registry was designed and implemented to minimize workload and contribute to sustainability of the registry. Healthcare workers involved in trauma then completed a validated questionnaire known as the Unified Theory of Acceptance and Use of Technology (UTAUT) for evaluating the usability of the mobile application trauma registry and predicting future use behaviours. Healthcare workers scored the mobile application highly, indicating a high potential for ongoing use. The UTAUT was also identified as a method for other trauma registries to predict future use and opportunities for sustainability. Finally, a potential means of financial self-sustainability for trauma registries in low-income countries was evaluated. In many public hospitals in low-income settings, government funding for patients seen is dependent on documentation of those patients. This study evaluated the improvements to patient documentation following the implementation of a trauma registry and concurrent patient registration system at MRRH. A significant improvement in patient documentation was found, with a 20-fold increase in trauma patients documented following the implementation of patient registration and a trauma registry. This more accurate documentation could then be used to apply for increased government funding for trauma patients and for sustaining the trauma registry in the long-term. The concurrent implementation of a patient registration system with a trauma registry therefore could be an avenue for financial viability for other trauma registries in low-income contexts. Taken together, these studies represent a compelling picture for the ethical imperative to develop sustainable trauma registries in LMICs and some of the strategies that may be undertaken to achieve this. By combining these techniques, we hope to achieve a sustainable, long-term trauma registry at MRRH that can serve as a model for other trauma registries in LMICs going forward.

Hospitals’ responsibility in response to the threat of infectious disease outbreak in the context of the coronavirus disease 2019 (COVID-19) pandemic: Implications for low- and middle-income countries

The WHO declared the coronavirus disease 2019 (COVID-19) outbreak as a public health emergency of international concern on January 30, 2020, and then a pandemic on March 11, 2020. COVID-19 affected over 200 countries and territories worldwide, with 25,541,380 confirmed cases and 852,000 deaths associated with COVID-19 globally, as of September 1, 2020.

While facing such a public health emergency, hospitals were on the front line to deliver health care and psychological services. The early detection, diagnosis, reporting, isolation, and clinical management of patients during a public health emergency required the extensive involvement of hospitals in all aspects. The response capacity of hospitals directly determined the outcomes of the prevention and control of an outbreak.

The COVID-19 pandemic has affected almost all nations and territories regardless of their development level or geographic location, although suitable risk mitigation measures differ between developing and developed countries. In low- and middle-income countries (LMICs), the consequences of the pandemic could be more complicated because incidence and mortality might be associated more with a fragile health care system and shortage of related resources. As evidenced by the situation in Bangladesh, India, Kenya, South Africa, and other LMICs, socioeconomic status (SES) disparity was a major factor in the spread of disease, potentially leading to alarmingly insufficient preparedness and responses in dealing with the COVID-19 pandemic.4 Conversely, the pandemic might also bring more unpredictable socioeconomic and long-term impacts in LMICs, and those with lower SES fare worse in these situations.

This review aimed to summarize the responsibilities of and measures taken by hospitals in combatting the COVID-19 outbreak. Our findings are hoped to provide experiences, as well as lessons and potential implications for LMICs.