Burn Admissions Across Low- and Middle-income Countries: A Repeated Cross-sectional Survey

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43–79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.

Drug shortages in low- and middle-income countries: Colombia as a case study

Background
Drug shortages are a global problem. Analyzing shortages worldwide is important to identify possible relationships between drug shortages across countries, determine strategies that reduce drug shortages, and reduce the inequality in access to medicines between countries. In contrast to well-documented shortages in high-income countries, there are few studies that consider low- and middle-income economies. We evaluate drug shortages in one middle-income country, Colombia.

Methods
We collected data from INVIMA, the institution responsible for managing medicine shortage alerts in Colombia. We classified the data using the Anatomical Therapeutic Chemical (ATC) classification system and analyzed them using descriptive statistics. We considered a study period from 2015 to 2021 (vital medicines) and from 2010 to 2020 (non-vital medicines).

Results
In total, 173 unique ATC codes were in shortage. These included antidotes, alimentary tract and metabolism products, anesthetics, cardiac stimulants and antithrombotic agents. The major causes were manufacturing problems and few suppliers. Drug shortages substantially increased from 2020 to May 2021 due to the COVID-19 pandemic. Among resolved shortages, the average duration was 1.6 years with a standard deviation of 1.9 years. The longest, naloxone tablets, were in shortage for almost 10 years.

Conclusions
Drug shortages are a persistent problem in Colombia. Government institutions have made progress in implementing systems and procedures to report them. However, the approaches implemented need to be maintained and refined. This study lays the groundwork for the analysis of drug shortages in other LMICs. We highlight the necessity of addressing drug shortages in their global context and reducing the inequality in access to medicines between countries.

Implementing a Neurotrauma Registry in Latin America and the Caribbean

Background Traumatic brain injury (TBI) has a disproportionately greater impact in low- and middle-income countries (LMICs). One strategy to reduce the burden of disease in LMICs is through the implementation of a trauma registry that standardizes the assessment of each patient’s management of care.

Objective This study aims to ascertain the interest of Latin America and the Caribbean (LAC) nations in establishing a shared neurotrauma registry in the regional block, based on an existing framework for collaboration.

Methods A descriptive review was performed regarding the interests of LAC nations in implementing a shared neurotrauma registry in their region. We convened a meeting with seven Caribbean and five Latin American nations.

Results One hundred percent (n = 12) of the LAC representatives including neurosurgeons, neurointensivists, ministers of health, and chief medical officers/emergency medical technicians (EMTs) agreed to adopt the registry for tracking the burden of TBI and associated pathologies within the region.

Conclusion The implementation of a neurotrauma registry can benefit the region through a shared database to track disease, improve outcomes, build research, and ultimately influence policy

Difficulties in the Management of Placenta Accreta Spectrum in Hospitals with Limited Resources

Objective Placenta accreta spectrum (PAS) is a serious diseases, and the recommendation is that the treatment is conducted in centers of excellence. Such hospitals are not easy to find in low- and middle-income countries. We seek to describe the process of prenatal diagnosis, surgical management, and postnatal histological analysis in a low-income country referral hospital with limited resources.

Methods A descriptive, retrospective study was carried out including patients with a pre- or intraoperative diagnosis of PAS. The clinical results of the patients were studied as well as the results of the prenatal ultrasound and the correlation with the postnatal pathological diagnosis.

Results In total, 129 patients were included. Forty-eight of them had a prenatal PAS ultrasound diagnosis (37.2%). In the remaining 81 (62.8%), the diagnosis was intraoperative.

Although hysterectomy was performed in all cases, one-third of the patients (31%) did not have a histological study of the uterus. In 40% of the patients who had a histological study, PAS was not reported by the pathologist.

Conclusion The frequency of prenatal diagnosis and the availability of postnatal histological studies were very low in the studied population. Surgical skill, favored by a high flow of patients, is an important factor to avoid complications in settings with limited resources.

Evaluation of Computed Tomography Scoring Systems in the Prediction of Short-Term Mortality in Traumatic Brain Injury Patients from a Low- to Middle-Income Country

The present study aims to evaluate the accuracy of the prognostic discrimination and prediction of the short-term mortality of the Marshall computed tomography (CT) classification and Rotterdam and Helsinki CT scores in a cohort of TBI patients from a low- to middle-income country. This is a post hoc analysis of a previously conducted prospective cohort study conducted in a university-associated, tertiary-level hospital that serves a population of >12 million in Brazil. Marshall CT class, Rotterdam and Helsinki scores, and their components were evaluated in the prediction of 14-day and in-hospital mortality using Nagelkerk’s pseudo-R2 and area under the receiver operating characteristic curve. Multi-variate regression was performed using known outcome predictors (age, Glasgow Coma Scale, pupil response, hypoxia, hypotension, and hemoglobin values) to evaluate the increase in variance explained when adding each of the CT classification systems. Four hundred forty-seven patients were included. Mean age of the patient cohort was 40 (standard deviation, 17.83) years, and 85.5% were male. Marshall CT class was the least accurate model, showing pseudo-R2 values equal to 0.122 for 14-day mortality and 0.057 for in-hospital mortality, whereas Rotterdam CT scores were 0.245 and 0.194 and Helsinki CT scores were 0.264 and 0.229. The AUC confirms the best prediction of the Rotterdam and Helsinki CT scores regarding the Marshall CT class, which presented greater discriminative ability. When associated with known outcome predictors, Marshall CT class and Rotterdam and Helsinki CT scores showed an increase in the explained variance of 2%, 13.4%, and 21.6%, respectively. In this study, Rotterdam and Helsinki scores were more accurate models in predicting short-term mortality. The study denotes a contribution to the process of external validation of the scores and may collaborate with the best risk stratification for patients with this important pathology.

“My Body, My Rhythm, My Voice”: a community dance pilot intervention engaging breast cancer survivors in physical activity in a middle-income country

Background: Interventions to promote physical activity among women breast cancer survivors (BCS) in low to middle-income countries are limited. We assessed the acceptability and preliminary effectiveness of a theory-driven group dance intervention for BCS delivered in Bogotá, Colombia.

Methods: We conducted a quasi-experimental study employing a mixed-methods approach to assess the 8-week, 3 times/week group dance intervention. The effect of the intervention on participants’ physical activity levels (measured by accelerometry), motivation to engage in physical activity, and quality of life were evaluated using Generalized Estimating Equations analysis. The qualitative method included semi-structured interviews thematically analyzed to evaluate program acceptability.

Results: Sixty-four BCS were allocated to the intervention (N=31) or the control groups (N=33). In the intervention arm, 84% attended ≥60% of sessions. We found increases on average minutes of moderate-to-vigorous physical activity per day (intervention: +8.99 vs control: -3.7 min; p = 0.01), and in ratings of motivation (intervention change score= 0.45, vs. control change score= -0.05; p = 0.01). BCS reported improvements in perceived behavioral capabilities to be active, captured through the interviews.

Conclusions: The high attendance, behavioral changes, and successful delivery indicate the potential effectiveness, feasibility, and scalability of the intervention for BCS in Colombia.

Trial registration: Clinical trials NCT05252780, registered on Dec 7th, 2021 – Retrospectively registered Unique protocol ID: P20CA217199-9492018.

Lessons learned during the COVID-19 pandemic using virtual basic laparoscopic training in Santa Cruz de la Sierra, Bolivia: effects on confidence, knowledge, and skill

Background
An international surgical team implemented a virtual basic laparoscopic surgery course for Bolivian general and pediatric surgeons and residents during the COVID-19 pandemic. This simulation course aimed to enhance training in a lower-resource environment despite the challenges of decreased operative volume and lack of in-person instruction.

Methods
The course was developed by surgeons from Bolivian and U.S.-based institutions and offered twice between July-December 2020. Didactic content and skill techniques were taught via weekly live videoconferences. Additional mentorship was provided through small group sessions. Participants were evaluated by pre- and post-course tests of didactic content as well as by video task review.

Results
Of the 24 enrolled participants, 13 were practicing surgeons and 10 were surgery residents (one unspecified). Fifty percent (n = 12) indicated “almost never” performing laparoscopic surgeries pre-course. Confidence significantly increased for five laparoscopic tasks. Test scores also increased significantly (68.2% ± 12.5%, n = 21; vs 76.6% ± 12.6%, n = 19; p = 0.040). While challenges impeded objective evaluation for the first course iteration, adjustments permitted video scoring in the second iteration. This group demonstrated significant improvements in precision cutting (11.6% ± 16.7%, n = 9; vs 62.5% ± 18.6%, n = 6; p < 0.001), intracorporeal knot tying (36.4% ± 38.1%, n = 9; vs 79.2% ± 17.2%, n = 7; p = 0.012), and combined skill (40.3% ± 17.7%; n = 8 vs 77.2% ± 13.6%, n = 4; p = 0.042). Collectively, combined skill scores improved by 66.3% ± 10.4%.

Conclusion
Virtual international collaboration can improve confidence, knowledge, and basic laparoscopic skills, even in resource-limited settings during a global pandemic. Future efforts should focus on standardizing resources for participants and enhancing access to live feedback resources between classes.

A granular analysis of service delivery for surgical system strengthening: Application of the Lancet indicators for policy development in Colombia

Background
The Lancet Commission on Global Surgery (LCoGS) surgical indicators have given the surgical community metrics for objectively characterizing the disparity in access to surgical healthcare. However, aggregate national statistics lack sufficient specificity to inform strengthening plans at the community level. We performed a second-stage analysis of Colombian surgical system service delivery to inform the development of resource- and context-sensitive interventions to inform a revision of the Decennial Public Health Plan for access inequity resolution.

Methods
Data from the year 2016 to inform total operative volume (TOV) and 30-day non-risk adjusted peri-operative mortality (POMR) were collected from the Colombian national health information system. TOV and POMR were sub-characterized by demographics, urgency, service line, disease pathology and facility location.

Findings
In 2016, aggregate national mortality was 0·87%, while mortality attributable to elective and emergency surgery was 0·73% and 1·30%, respectively. The elderly experienced a 5·6-fold higher mortality, with 4·2% undergoing an operation within 30 days of dying. Individuals undergoing hepatobiliary, thoracic, cardiac, and neurosurgical operations experienced the highest mortality rates while obstetrics, general surgery, orthopaedics, and urology performed the largest procedure volume. Finally, analysis of operation and service line specific POMR reveals opportunities for improvement.

Interpretation
This granular second-stage analysis provides actionable data which is fundamental to the development of resource and context-sensitive interventions to address gaps and inequities in surgical system service delivery. Furthermore, this analysis validates the modeling underlying development of the LCoGS indicators. These data will inform the assessment of implementation priorities and revision of the Colombian Decennial Public Health Plan

Global Surgery at the National Landscape: Perspectives after the XXXIV Brazilian Congress of Surgery

The XXXIV Brazilian Congress of Surgery included Global Surgery for the first time in its scientific program. Global Surgery is any action in research, clinical practice, and policy-making that aims to improve access and quality of care in surgical specialties. In 2015, The Lancet Commission on Global Surgery highlighted that five billion people lack safe, timely, and affordable surgical care. Even more critical, nine of ten people cannot access essential surgical care in low and middle-income countries, where a third of the worldwide population resides, and only 6% of global surgical procedures are performed. Although Brazilian researchers and institutions have been contributing to lay the movement’s foundations since 2014, Global Surgery remains a barely debated subject in the country. It is urgent to expand the field and break paradigms regarding the surgeons’ role in public health in Brazil. Accomplishing these standards requires a joint effort to strategically allocate resources and identify collaboration opportunities, including those from medical societies and regulatory bodies. As members of the International Student Surgical Network of Brazil – a nonprofit organization by and for students, residents, and young physicians focused on Global Surgery – we review why investing in surgery is cost-effective to strengthen health systems, reduce morbimortality, and lead to economic development. Additionally, we highlight and propose key recommendations to foster the field at the national level.

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.