Epidemiological Characteristics, Ventilator Management, and Clinical Outcome in Patients Receiving Invasive Ventilation in Intensive Care Units from 10 Asian Middle-Income Countries (PRoVENT-iMiC): An International, Multicenter, Prospective Study

Epidemiology, ventilator management, and outcome in patients receiving invasive ventilation in intensive care units (ICUs) in middle-income countries are largely unknown. PRactice of VENTilation in Middle-income Countries is an international multicenter 4-week observational study of invasively ventilated adult patients in 54 ICUs from 10 Asian countries conducted in 2017/18. Study outcomes included major ventilator settings (including tidal volume [V T ] and positive end-expiratory pressure [PEEP]); the proportion of patients at risk for acute respiratory distress syndrome (ARDS), according to the lung injury prediction score (LIPS), or with ARDS; the incidence of pulmonary complications; and ICU mortality. In 1,315 patients included, median V T was similar in patients with LIPS < 4 and patients with LIPS ≥ 4, but lower in patients with ARDS (7.90 [6.8–8.9], 8.0 [6.8–9.2], and 7.0 [5.8–8.4] mL/kg Predicted body weight; P = 0.0001). Median PEEP was similar in patients with LIPS < 4 and LIPS ≥ 4, but higher in patients with ARDS (five [5–7], five [5–8], and 10 [5–12] cmH2O; P < 0.0001). The proportions of patients with LIPS ≥ 4 or with ARDS were 68% (95% CI: 66–71) and 7% (95% CI: 6–8), respectively. Pulmonary complications increased stepwise from patients with LIPS < 4 to patients with LIPS ≥ 4 and patients with ARDS (19%, 21%, and 38% respectively; P = 0.0002), with a similar trend in ICU mortality (17%, 34%, and 45% respectively; P < 0.0001). The capacity of the LIPS to predict development of ARDS was poor (ROC AUC of 0.62, 95% CI: 0.54–0.70). In Asian middle-income countries, where two-thirds of ventilated patients are at risk for ARDS according to the LIPS and pulmonary complications are frequent, setting of V T is globally in line with current recommendations.

Death of 43 Indonesian women with ovarian cancer: A case series

Background: Ovarian cancer is a gynecological cancer with a higher mortality than other gynecological cancers.

Case report: There were 43 cases of Indonesian women who died of ovarian cancer in 2015-2017. Patients were first diagnosed at the age of 40-59 years (65.11%), of which had normal BMI (62.72%) and mostly in stage III (39.53%). The histology was 88.3% epithelial ovarian cancer with the most subtypes of mucinous carcinoma (25.5%). The majority were referral patients (62.7%), but due to its malignancy, many died before receiving ovarian cancer treatment (40.74%). Of the 43 patients, 17 patients received chemotherapy, and 10 patients received a combination of surgical therapy and chemotherapy. Most of the deaths were caused by primary disease (69.77%). Patients with stages III and IV, as well as patients receiving surgery or chemotherapy alone had shorter survival times.

Conclusion: Most ovarian cancer patients are first diagnosed at stage III with the mucinous carcinoma subtype. Most deaths are caused by primary ovarian cancer. The therapy that provides the longest survival is a combination of surgery and chemotherapy.

Neurosurgery at the epicenter of the COVID-19 pandemic in Indonesia: experience from a Surabaya academic tertiary hospital

OBJECTIVE
Global outbreak of the novel coronavirus disease 2019 (COVID-19) has forced healthcare systems worldwide to reshape their facilities and protocols. Although not considered the frontline specialty in managing COVID-19 patients, neurosurgical service and training were also significantly affected. This article focuses on the impact of the COVID-19 outbreak at a low- and/or middle-income country (LMIC) academic tertiary referral hospital, the university and hospital policies and actions for the neurosurgical service and training program during the outbreak, and the contingency plan for future reference on preparedness for service and education.

METHODS
The authors collected data from several official databases, including the Indonesian Ministry of Health database, East Java provincial government database, hospital database, and neurosurgery operative case log. Policies and regulations information was obtained from stakeholders, including the Indonesian Society of Neurological Surgeons, the hospital board of directors, and the dean’s office.

RESULTS
The curve of confirmed COVID-19 cases in Indonesia had not flattened by the 2nd week of June 2020. Surabaya, the second-largest city in Indonesia, became the epicenter of the COVID-19 outbreak in Indonesia. The neurosurgical service experienced a significant drop in cases (50% of cases from normal days) along all lines (outpatient clinic, emergency room, and surgical ward). Despite a strict preadmission screening, postoperative COVID-19 infection cases were detected during the treatment course of neurosurgical patients, and those with a positive COVID-19 infection had a high mortality rate. The reduction in the overall number of cases treated in the neurosurgical service had an impact on the educational and training program. The digital environment found popularity in the educational term; however, digital resources could not replace direct exposure to real patients. The education stakeholders adjusted the undergraduate students’ clinical postings and residents’ working schemes for safety reasons.

CONCLUSIONS
The neurosurgery service at an academic tertiary referral hospital in an LMIC experienced a significant reduction in cases. The university and program directors had to adapt to an off-campus and off-hospital policy for neurosurgical residents and undergraduate students. The hospital instituted a reorganization of residents for service. The digital environment found popularity during the outbreak to support the educational process.

Global neurosurgery, Bangladesh and COVID-19 era

Background. COVID-19 has become an alarming pandemic for our earth. It has created panic not only in China but also in developing countries like Bangladesh. Bangladesh has adequate confinements to constrain the spread of the infection and in this circumstance, overall healthcare workers including neurosurgeons are confronting a ton of difficulties. The purpose of this paper is to depict the proficiency of Global neurosurgery in this COVID-19 time.

Method. Global neurosurgery offers the chance of fusing the best proof-based guidelines of care. This paper demonstrated that, in low to middle-income countries, Global medical procedure has been received to address the issues of residents who lack critical surgical care.

Results. Inappropriate and insufficient asset allotment has been a significant obstacle for the health system for decently giving security to the patients. The fundamental training process has been genuinely hampered in the current circumstance. Worldwide health activities have set to an alternate centre and Global neurosurgery as an assurance is slowed down.

Conclusion. This paper recommended that Global neurosurgical activities need to come forward and increase the workforce to emphasize surgical service.

Does in-hospital trauma mortality in urban Indian academic centres differ between “office-hours” and “after-hours”?

Introduction
Trauma services within hospitals may vary considerably at different times across a 24 h period. The variable services may negatively affect the outcome of trauma victims. The current investigation aims to study the effect of arrival time of major trauma patients on mortality and morbidity.

Method
Retrospective analysis of the Australia-India Trauma Systems Collaboration (AITSC) registry established in four public university teaching centres in India Based on hospital arrival time, patients were grouped into “Office-hours” and “After-hours”. Outcome parameters were compared between the above groups.

Results
5536 (68.4%) patients presented “after-hours” (AO) and 2561 (31.6%) during “office-hours” (OH). The in-hospital mortality for “after-hours” and “office-hours” presentations were 12.1% and 11.6% respectively. On unadjusted analysis, there was no statistical difference in the odds of survival for OH versus AH presentations. (OR,1.05, 95% CI 0.9‐1.2). Adjusting for potential prognostic factors (injury severity, presence of shock on arrival, referral status, sex, or extremes of age), there was no statistically significant odds of survival for OH versus AH presentations (OR,1.02, 95%CI 0.9–1.2).ICU length of stay and duration of mechanical ventilation was longer in the AH group.

Conclusion
The in-hospital mortality did not differ between trauma patients who arrived during “after-hours” compared to ‘“office-hours”.

Change in the spectrum of orthopedic trauma: Effects of COVID-19 pandemic in a developing nation during the upsurge; a cross-sectional study

Background: The COVID-19 pandemic has caused a great impact on orthopedic surgery with a significant curtailment in elective surgeries which is the major bread and butter for orthopedic surgeons. It was also observed that the spectrum of orthopedic trauma injuries has shifted from more severe and frequent road traffic accidents (high energy trauma) to general, low energy house-hold injuries like low energy fractures in the elderly, pediatric fractures, house-hold sharp cut injuries and nail bed lacerations. The aim of this study is to appraise the effect of the COVID-19 pandemic on orthopedic surgical practice, both inpatient and outpatient facility.

Materials and methods: This is a retrospective cross sectional study conducted in a tertiary care teaching hospital. We collected data of patients admitted from February 1, 2020 to 30th April 2020 in the orthopedic service line using non-probability consecutive sampling. This study population was divided into pre-COVID and COVID eras (6 weeks each). The data included patient demographic parameters like age, gender and site of injury, mechanism of injury, diagnosis and procedure performed and carrying out of COVID-19 Polymerase Chain Reaction (PCR) test in the COVID-era.

Results: We observed that outpatient clinical volume decreased by 75% in COVID era. Fifty percent of surgical procedures decreased in COVID era as compared to pre-COVID era. Trauma procedures reduced by 40% in COVID era. Most common mechanism of injury was household injuries like low energy falls. A significant reduction in elective surgeries by 67% was observed in the COVID era.

Conclusion: The impact of COVID-19 pandemic has significantly changed the spectrum of orthopedic injury. More household injuries have occurred and are anticipated due to the ongoing effects of lockdown.

Addressing the Burden of Antimicrobial Resistance in Vietnamese Hospitals

Hospital acquired infections (HAIs), especially ventilator associated respiratory infection (VARI) cause significant morbidity and mortality, and disproportionally so in low and middle-income countries (LMICs), including Vietnam, where infection control in hospitals is often neglected. The management of HAIs in these settings is challenging because of the high proportions of antimicrobial drug resistance and limitations of laboratory diagnostics, financial and human resources in terms of knowledge and skills for antimicrobial stewardship and infection prevention and control.
Because resistance is driven by use of antimicrobials, my thesis started with a question on use and cost of antimicrobials in public hospitals in the country followed by a detailed
assessment of use and cost of antimicrobials in the management of ventilator associated respiratory infections (VARI). I obtained detailed bids from hospitals and provincial departments of health representing 28.7% (1.68 / 5.85 billion US$) of the total hospital medication budget in Vietnam. Antimicrobials represented 28.6% of these costs.

Antimicrobials were stratified using the Access, Watch, Reserve (AWaRe) groups proposed by WHO in 2017. I showed that the most commonly used antimicrobials across sites were second generation cephalosporins (20.3% of total procured defined daily dose, DDD) followed by combinations of penicillins and beta-lactamase inhibitors (18.4% of total procured DDD). The most expensive antimicrobials are the last resort antimicrobials, which can considerably increase the cost of treatment for patients with HAIs caused by multidrug resistant pathogens in critical care units in Vietnam. In recognition of this problem, I estimated the excess cost of management of VARI using a costing model study. At the current incidence rate of 21.7 episodes per 1000 ventilation-days, I estimated there were 34,428 episodes of VARI nationally, associated with a direct cost of more than US$ 40 million per year. Our studies showed the need for an affordable and scalable intervention in critical care units to reduce the burden of VARI and provide cost savings for national health expenditure.

My studies also showed that antimicrobial costs are a major component of the excess cost of VARI management in Vietnam (51.1%) and that a one day reduction in the duration of antimicrobial therapy can save US$ 1.72 million. Therefore, my thesis has focused on interventions to prevent VARI and to shorten antimicrobial therapy. In recognition of human resources constraints in Vietnam, including for microbiology diagnostics and critical care nursing, I have studied automatic technology and equipment, including matrix assisted
laser desorption ionization-time of flight mass spectrometry (MALDITOF-MS) for rapid identification of pathogens and continuous automatic cuff pressure control device to prevent VARI. To examine effectiveness of these intervention, I conducted 2 randomised controlled trials to evaluate the clinical effectiveness of matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDITOF-MS) in optimizing antimicrobial therapy and to evaluate the effectiveness of continuous cuff pressure control in preventing VARI. For the latter, pending unblinding and final results I describe the implementation of the trial and report the incidence of hospital acquired bloodstream infection during this trial.

A diagnostic randomised controlled trial (RCT) was conducted to evaluate the impact of MALDITOF-MS versus conventional diagnostics in improving antimicrobial use in patients with confirmed infection. Although MALDITOF-MS provided more rapid identification of invasive bacterial and fungal pathogens than conventional microbiology, the proportion of patients on optimal therapy at 24 or 48 hours after growth of specimen did not increase. These findings showed that without human resources and an effective antimicrobial stewardship programme, technology alone cannot provide a solution for antimicrobial overuse in hospitals in LMICs.

A randomized controlled clinical trial was conducted to evaluate the effectiveness of
continuous cuff pressure control versus daily manual cuff measurement (VARI-prevent). In this study I recruited and followed-up 597 adult patients who were admitted to ICUs and
were intubated within 48 hours of admission. The patients were randomised to receive either continuous or manual cuff pressure measurement and control and were followed for occurrence of VARI during ICU stay and up to 90 days after randomisation. The study has completed recruitment and follow-up and final analysis is ongoing. The overall rate of VARI and VAP in eligible patients was 23.7% (140/591) and 17.3% (102/591) respectively. The data from this trial (VARI-prevent) was analysed to estimate the incidence density rate of hospital acquired bloodstream infection (HABSI) in 3 ICUs in Vietnam for the first time. The most common pathogens causing HABSI were Klebsiella pneumoniae followed by Pseudomonas aeruginosa, Acinetobacter baumannii and Coagulase-Negative staphylococci. Polymicrobial culture results were reported in 6.8% (3/44) patients with culture confirmed HABSI. The rate of HABSI and central line associated BSI (CLABSI) were 7.4% (44/591) and 9.3% (31/333), respectively. The incidence density rate of HABSI and CLABSI were 3.76 per 1000 patients-days and 8.43 per 1000 catheter-days, respectively. This suggests that the implementation of infection prevention and control bundle including catheter care is important to reduce the high incidence of HABSI in Vietnam. The findings in my thesis are relevant to healthcare professionals and policy stakeholders. It demonstrates the magnitude of HAI burden and creates awareness of potential beneficial interventions. Results of my trials will be helpful to inform decisions to establish the antimicrobial stewardship programmes and infection prevention and control bundles to improve patients’ outcomes.

Barriers and facilitators of laparoscopic surgical training in rural north-east India: a qualitative study

Introduction:
Laparoscopic surgery has advantages for treating many abdominal surgical conditions, but its use in low and middle-income countries (LMICs) is limited by many factors, including a lack of training opportunities. The aim of this study was to explore the training experiences of surgeons in rural north-east India to highlight the barriers and facilitators to laparoscopic surgery.

Methods:
Eleven surgeons with experience in laparoscopy in rural north-east India were recruited using purposive and convenience sampling. Ethical approval was obtained from the Institutional Ethics Committee, Maulana Azad Medical College, New Delhi, India and the Leeds Institute of Health Sciences Research Ethics Sub-Committee, West Yorkshire, England. Consenting participants took part in semi-structured interviews, either between May 20 and 25, 2019 in rural north-east India or via Skype or at the University of Leeds in June 2019. Interviews were audio-recorded and transcribed and thematic content analysis performed.

Results:
Exposure to laparoscopy during postgraduate training was common, but training experiences were inconsistent and informal. Alternative training opportunities are limited by availability and cost. There is high demand for a structured curriculum, incorporating formal assessment and credentialing, to include observation and assistance in live surgery and laparoscopic simulation.

Conclusions:
Laparoscopic training experiences are highly variable, with limited training resources and lack of a curriculum. Poor accessibility is consistent with that recorded in literature. Current recommendations include government support and funding to guide development of a standardized curriculum and widen access to training programs for surgeons in rural settings.

Traumatic Brain Injury in Mumbai: A Survey of Providers along the Care Continuum

Introduction:
Traumatic brain injury (TBI) represents a significant burden of a global disease, especially in low- and middle-income countries (LMICs) such as India. Efforts to curb the impact of TBI require an appreciation of local factors related to this disease and its treatment.

Methods:
Semi-structured qualitative interviews were administered to paramedics, anesthesiologists, general surgeons, and neurosurgeons in locations throughout Mumbai from April to May 2018. A thematic analysis with an iterative coding was used to analyze the data. The primary objective was to identify provider-perceived themes related to TBI care in Mumbai.

Results:
A total of 50 participants were interviewed, including 17 paramedics, 15 anesthesiologists, 9 general surgeons, and 9 neurosurgeons who were involved in caring for TBI patients. The majority of physicians interviewed discussed their experiences in public sector hospitals (82%), while 12% discussed private sector hospitals and 6% discussed both. Four major themes emerged: Workforce, equipment, financing care, and the family and public role. These themes were often discussed in the context of their effects on increasing or decreasing complications and delays. Participants developed adaptations when managing shortcomings in these thematic areas. These adaptations included teamwork during workforce shortages and resource allocation when equipment was limited among others.

Conclusions:
Workforce, equipment, financing care, and the family and public role were identified as major themes in the care for TBI in Mumbai. These thematic elements provide a framework to evaluate and improve care along the care spectrum for TBI. Similar frameworks should be adapted to local contexts in urbanizing cities in LMICs.

Letter to Editor: “Artificial Intelligence, Machine Learning, Deep Learning and Big Data Analytics for Resource Optimization in Surgery”

Dear Editor,

Health care delivery in the pandemic is heavily disrupted. There are high stakes and economic implications are huge especially in more vulnerable low and middle-income group countries (LMICs). It is even more imperative now that we optimize our resources. Artificial intelligence (AI) and its exploits should now be requisitioned. Two subsets of AI are machine learning (ML) which in turn enables deep learning (DL). Big data are analyzed [1]. Such tasks are complex and will require yeoman efforts both on the parts individuals and governments. The respective state and central governments will provide regulatory sanctions. Preparations into big data analysis, machine learning leading to deep learning is likely to save resources. The current pandemic has amply shown this and should prompt us to invest in AI. Efforts and investment in deep learning should be translational in resource allocation and resource triage even during normal settings.