Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019

Health-care needs change throughout the life course. It is thus crucial to assess whether health systems provide access to quality health care for all ages. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019), we measured the Healthcare Access and Quality (HAQ) Index overall and for select age groups in 204 locations from 1990 to 2019.

We distinguished the overall HAQ Index (ages 0–74 years) from scores for select age groups: the young (ages 0–14 years), working (ages 15–64 years), and post-working (ages 65–74 years) groups. For GBD 2019, HAQ Index construction methods were updated to use the arithmetic mean of scaled mortality-to-incidence ratios (MIRs) and risk-standardised death rates (RSDRs) for 32 causes of death that should not occur in the presence of timely, quality health care. Across locations and years, MIRs and RSDRs were scaled from 0 (worst) to 100 (best) separately, putting the HAQ Index on a different relative scale for each age group. We estimated absolute convergence for each group on the basis of whether the HAQ Index grew faster in absolute terms between 1990 and 2019 in countries with lower 1990 HAQ Index scores than countries with higher 1990 HAQ Index scores and by Socio-demographic Index (SDI) quintile. SDI is a summary metric of overall development.

Between 1990 and 2019, the HAQ Index increased overall (by 19·6 points, 95% uncertainty interval 17·9–21·3), as well as among the young (22·5, 19·9–24·7), working (17·2, 15·2–19·1), and post-working (15·1, 13·2–17·0) age groups. Large differences in HAQ Index scores were present across SDI levels in 2019, with the overall index ranging from 30·7 (28·6–33·0) on average in low-SDI countries to 83·4 (82·4–84·3) on average in high-SDI countries. Similarly large ranges between low-SDI and high-SDI countries, respectively, were estimated in the HAQ Index for the young (40·4–89·0), working (33·8–82·8), and post-working (30·4–79·1) groups. Absolute convergence in HAQ Index was estimated in the young group only. In contrast, divergence was estimated among the working and post-working groups, driven by slow progress in low-SDI countries.

Although major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young.

Bill & Melinda Gates Foundation.

The Role and Duty of Global Surgery in Increasing Sustainability and Improving Patient Care in Low and Middle-Income Countries

Global health is one of the most pressing issues facing the 21st century. Surgery is a resource and energy-intensive healthcare activity which produces overwhelming quantities of waste. Using the 5Rs (Reduce, Reuse, Recycle, Rethink, and Research) provides the global surgical community with the pillars of sustainability to develop strategies that are scalable and transferable in both low and middle-income countries and their high-income counterparts.

Reducing energy consumption is necessary to achieving net zero emissions in the provision of essential healthcare. Simple, easily transferrable, high-income country (HIC) technologies can greatly reduce energy demands in low-income countries. Reusing appropriately sterilized equipment and reprocessing surgical devices leads to a reduction of costs and a significant reduction of unnecessary potentially hazardous waste. Recycling through official government-facilitated means reduces ‘informal recycling’ schemes, and the spread of communicable diseases whilst expectantly reducing the release of carcinogens and atmospheric greenhouse gases. Rethinking local surgical innovation and providing an ecosystem that is both ethical and sustainable, is not only beneficial from a medical perspective but allows local financial investment and feeds back into local economies. Finally, research output from low-income countries is minimal compared to the global academic output. Research from low and middle-income countries must equal research from high-income countries, thereby producing fruitful partnerships. With adequate international collaboration and awareness of the lack of necessary surgical interventions in low and middle-income countries (LMICs), global surgery has the potential to reduce the impact of surgical practice on the environment, without compromising patient safety or quality of care.

Global neurosurgery over a 60-year period: Conceptual foundations, time reference, emerging Co-ordinates and prospects for collaborative interventions in low and middle income countries

We evaluated salient initiatives invested in global neurosurgery over a 60-year period,

Research question
What are the Phases, Achievements, Challenges, and Lessons of Global Neurosurgery.

A 60-year retrospective study from 1960 to 2020 analyzing the major phases, lessons, and progress notes. We reviewed the foundational need questions and innovated tools used to answer them.

Three phases defining our study period were identified. In the early phase, birthing academic units and the onset of individual volunteerism were dominant concepts. The 2nd phase is summarized by the rise of volunteerism and surgical camps.

The third phase is heralded by advocacy and strategies for achieving care equity. The defining moment is the Lancet commission for global surgery summit in 2015. Lessons include the need for evaluation of the resources of recipient and donor locations using novel global surgery tools.

Global neurosurgery over the 60-year study period is summarized by indelible touchstones of personal and group efforts as well as triumphs derived from innovations in the face of formidable challenges.

The Efficacy of Honey Compared to Silver Sulfadiazine for Burn Wound Dressing in Superficial and Partial Thickness Burns—A Systematic Review and Meta-Analysis

Burn dressings play a vital role in protecting the patient from infection and aiding in the wound healing process. At present, the best burn wound dressing remains unknown. This study aimed to assess the efficacy of honey versus silver sulfadiazine dressing (SSD) for the treatment of superficial and partial thickness burns. We performed a systematic review and meta-analysis using the PubMed, MEDLINE and Embase databases to find relevant randomised control trials (RCTs) for inclusion. The outcomes measures included complete burn wound healing time, the proportion of wounds rendered sterile and subjective pain relief associated with the respective dressing type. This review was completed in line with PRISMA guidelines and has been registered with PROSPERO (Study ID: CRD42022337433). All studies in the English language that assessed honey versus SSD for patients with superficial or partial thickness burns were included. Quality and risk of bias assessments were performed using the Cochrane RoB2 tool. Seven studies were identified: totalling a population of 582 patients. From three studies, meta-analysis showed no significant difference in complete wound healing time (p = 0.06). Meta-analysis from five studies highlighted an overall significant difference favouring honey dressing in the proportion of wounds rendered sterile at day 7 post-injury (OR 10.80; 95% CI [5.76, 20.26]; p < 0.00001; I2 = 88%). We conclude that honey dressings may be as or more effective than SSD in the treatment of superficial and partial thickness burn injuries. However, due to the low quality of available studies in this field, further research is necessary to establish the optimum burn dressing. Ideally, this should be conducted in the form of prospective three-arm RCTs in accordance with the CONSORT statement.

Outcomes of Children With Low-Grade Gliomas in Low- and Middle-Income Countries: A Systematic Review

Pediatric CNS tumors are increasingly a priority, particularly with the WHO designation of low-grade glioma (LGG) as one of six index childhood cancers. There are currently limited data on outcomes of pediatric patients with LGGs in low- and middle-income countries (LMICs).

To better understand the outcomes of LGGs in LMICs, this systematic review interrogated nine literature databases.

The search identified 14,977 publications. Sixteen studies from 19 countries met the selection criteria and were included for data abstraction and analysis. Eleven studies (69%) were retrospective reviews from single institutions, and one (6%) captured institutional data prospectively. The studies captured a total of 957 patients with a median of 49 patients per study. Seven (44%) of the studies described the treatment modalities used. Of 373 patients for whom there was information, 173 (46%) had a gross total or near total resection, 109 (29%) had a subtotal resection, and 91 (24%) had only a biopsy performed. Seven studies, with a total of 476 patients, described the frequency of use of radiotherapy and/or chemotherapy in the cohorts: 83 of these patients received radiotherapy and 76 received chemotherapy. The 5-year overall survival ranged from 69.2% to 93.5%, although lower survival rates were reported at earlier time points. We identified limitations in the published studies with respect to the cohort sizes and methodologies.

The included studies reported survival rates frequently exceeding 80%, although the ultimate number of studies was limited, pointing to the paucity of studies describing the outcomes of children with LGGs in LMICs. This study underscores the need for more robust data on outcomes in pediatric LGG.

Neurotrauma clinicians’ perspectives on the contextual challenges associated with traumatic brain injury follow up in low-income and middle-income countries: A reflexive thematic analysis

Traumatic brain injury (TBI) is a major global health issue, but low- and middle-income countries (LMICs) face the greatest burden. Significant differences in neurotrauma outcomes are recognised between LMICs and high-income countries. However, outcome data is not consistently nor reliably recorded in either setting, thus the true burden of TBI cannot be accurately quantified.

To explore the specific contextual challenges of, and possible solutions to improve, long-term follow-up following TBI in low-resource settings.

A cross-sectional, pragmatic qualitative study, that considered knowledge subjective and reality multiple (i.e. situated within the naturalistic paradigm). Data collection utilised semi-structured interviews, by videoconference and asynchronous e-mail. Data were analysed using Braun and Clarke’s six-stage Reflexive Thematic Analysis.

18 neurosurgeons from 13 countries participated in this study, and data analysis gave rise to five themes: Clinical Context: What must we understand?; Perspectives and Definitions: What are we talking about?; Ownership and Beneficiaries: Why do we do it?; Lost to Follow-up: Who misses out and why?; Processes and Procedures: What do we do, or what might we do?

The collection of long-term outcome data plays an imperative role in reducing the global burden of neurotrauma. Therefore, this was an exploratory study that examined the contextual challenges associated with long-term follow-up in LMICs. Where technology can contribute to improved neurotrauma surveillance and remote assessment, these must be implemented in a manner that improves patient outcomes, reduces clinical burden on physicians, and does not surpass the comprehension, capabilities, or financial means of the end user. Future research is recommended to investigate patient and family perspectives, the impact on clinical care teams, and the full economic implications of new technologies for follow-up.

Crohn’s Disease Among the Poorest Billion: Burden of Crohn’s Disease in Low- and Lower-Middle-Income Countries

To establish the epidemiology and patterns of care of Crohn’s Disease in low- and lower-middle-income countries.

A cross-sectional survey of gastroenterology providers in countries where the world’s poorest billion live was conducted to learn more about the state of diagnostic and treatment capacity for Crohn’s. Quantitative data were analyzed in R and Excel.

A total of 46 survey responses from 15 countries were received, giving a response rate of 54.8%. All responses collected were from providers practicing in Africa and South Asia. The mean number of patients with Crohn’s cared for in the last year was 89.5 overall but ranged from 0 reported at one facility in Rwanda to 1000 reported at two different facilities in India. Overall, Crohn’s disease made up 20.6% of the inflammatory bowel disease diagnoses reported by survey respondents, with Africa exhibiting a larger proportion of Crohn’s compared to ulcerative colitis than Asia. Most providers reported that patients with Crohn’s have symptoms for 6–24 months prior to diagnosis and that 26–50% of their patients live in rural areas. The most reported diagnostic challenges are differentiating between Crohn’s and intestinal tuberculosis, poor disease awareness, and lack of trained pathologists. The most widely reported challenge in managing Crohn’s disease is patients’ inability to afford biologics, reported by 65% of providers.

Our study suggests there may be a greater burden of Crohn’s disease in low- and lower-middle-income countries than is indicated in prior literature. Respondents reported many challenges in diagnosing and treating Crohn’s disease.

Cost of open access publishing in otolaryngology-head and neck surgery

Open access (OA) publishing makes research more accessible but is associated with steep article processing charges (APCs). The study objective was to characterize the APCs of OA publishing in otolaryngology-head and neck surgery (OHNS) journals.

We conducted a cross-sectional analysis of published policies of 110 OHNS journals collated from three databases. The primary outcomes were the publishing model, APC for original research, and APC waiver policy.

We identified 110 OHNS journals (57 fully OA, 47 hybrid, 2 subscription-only, 4 unknown model). After excluding 12 journals (2 subscription-only, 4 unknown model, 5 OA with unspecified APCs, and 1 OA that accepts publications only from society members), we analyzed 98 journals, 23 of which did not charge APCs. Among 75 journals with nonzero APCs, the mean and median APCs were $2452 and $2900 (interquartile range: $1082–3520). Twenty-five journals (33.3%) offered APC subsidies for authors in low- and middle-income countries (LMICs) and/or on a case-by-case basis. Eighty-five and 25 journals were based in high-income countries (HICs) and LMICs, respectively. The mean APC was higher among HIC journals than LMIC journals ($2606 vs. $958, p < 0.001).

APCs range from tens to thousands of dollars with limited waivers for authors in LMICs.

Second- and Third-Tier Therapies for Severe Traumatic Brain Injury

Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.

Abdominal Packing for Obstetric Surgical Uncontrollable Hemorrhage

Postpartum hemorrhage (PPH), which makes up the bulk of the 14 million occurrences of obstetric hemorrhage that happen yearly, is the most prevalent type. Obstetric emergencies must be promptly identified and treated because most PPH-related deaths occur within four hours of delivery and even after hysterectomy. This literature study tries to elucidate abdominal packing in reducing obstetrical bleeding in greater detail. Pads or roller gauze (sterile pads bound by suture threads, wrapped in a sterile bag, or stacked gauze) and balloon pack (Foley catheter or Bakri balloon), and abdominal packs retrieved within 24-48 hours, are two categories of abdominal packing techniques for controlling bleeding after hysterectomy. Due to its ease of use, minimal risk of complications, and usefulness in environments with limited resources, abdominal packing continues to be a valuable technique in the arsenal of the modern obstetrician.