An International Collaborative Study on Surgical Education for Quality Improvement (ASSURED): A Project by the 2017 International Society of Surgery (ISS/SIC) Travel Scholars International Working Group

Background: There is a huge difference in the standard of surgical training in different countries around the world. The disparity is more obvious in the various models of surgical training in low- and middle-income countries (LMICs) compared to high-income countries. Although the global training model of surgeons is evolving from an apprenticeship model to a competency-based model with additional training using simulation, the training of surgeons in LMICs still lacks a standard pathway of training.

Methods: This is a qualitative, descriptive, and collaborative study conducted in six LMICs across Asia, Africa, and South America. The data were collected on the status of surgical education in these countries as per the guidelines designed for the ASSURED project along with plans for quality improvement in surgical education in these countries.

Results: The training model in these selected LMICs appears to be a hybrid of the standard models of surgical training. The training models were tailored to the country’s need, but many fail to meet international standards. There are many areas identified that can be addressed in order to improve the quality of surgical education in these countries.

Conclusions: Many areas need to be improved for a better quality of surgical training in LMICs. There is a need of financial, technical, and research support for the improvement in these models of surgical education in LMICs.

Implementing antimicrobial stewardship to reduce surgical site infections: Experience and challenges from two tertiary-care hospitals in Mumbai, India.

Surgical site infections (SSIs) contribute significantly to post-surgical morbidity globally. Antimicrobial stewardship programmes (ASPs) are essential to reduce SSI rates and to curb antimicrobial resistance, especially in low-and-middle-income countries. This prospective study aimed to show the reproducibility of ASP implementation and SSI prevention measures in a semi-private institution with high perioperative prophylactic antimicrobial consumption beyond guidelines. The prevalence of SSIs in clean surgeries was analysed in a government hospital adhering to SSI prevention guidelines including antimicrobial prophylaxis (phase 1; n = 335) and in a surgical department unit of a semi-private hospital where the same guidelines were subsequently implemented (phase 2; n = 235). SSI rates were compared to check the hypothesis that ASPs and infection control policies are reproducible with similar SSI rates. Moreover, antimicrobial prophylaxis costs were compared between units with and without guideline adherence. Among a total of 570 clean surgeries analysed, SSI rates were similar in both phases (6.0% vs. 5.1%; P = 0.659). SSI rates were higher in patients aged >50 years in both phases (P = 0.0009 and 0.045), whilst there was no difference in SSI rates between diabetics and non-diabetics (P = 0.475 and 0.835). The cost of antimicrobial prophylaxis was lower in the guideline-oriented group (US$0.42 vs US$9 per patient; P = 0.0042). Implementing SSI prevention guidelines, including proper antimicrobial prophylaxis, is feasible and reproducible among different hospital settings, leading to a significant decrease in prophylaxis costs. SSI rates do not differ following the same international standards.

Masquerades less known: Case report of benign hair follicle tumors

Benign eyelid tumors derived from hair follicles are rare and frequently misdiagnosed as basal-cell carcinoma when evaluation is based on clinical evidence alone. The discrepancy between the clinical aspect and the histological diagnosis can be as high as 30-40%, even for experienced clinicians. Unfortunately, this masquerade is not only clinical but also histological. Patients may be subjected to unnecessarily extensive surgery. We present a case report of three patients clinically diagnosed as malignancy but histopathologically proven as benign hair follicle tumors.

The clinical efficacy of using autologous platelet-rich plasma in total hip arthroplasty: A retrospective comparative study

This study evaluated whether intra-articular platelet-rich plasma (PRP) might prevent postoperative bleeding in total hip arthroplasty (THA).In this study, 260 hips that underwent THA were evaluated randomly by paramedical staffs, 130 of which involved the intraoperative use of PRP, and 130 of which served as control group. Postoperative blood loss (drain bag volume), estimated blood loss, and change in hemoglobin (Hb) at day 1, 2, 4, and 7 were analyzed, respectively.PRP-treated group had a significant decrease in mean postoperative blood loss (92.6 ± 168.2 mL) compared to control group (682.3 ± 185.5 mL, P < .01). The mean postoperative estimated blood loss (526.1 ± 236.1 mL) in the PRP-treated group was significantly less than that in the control group (629.2.2 ± 142.3 mL, P < .01). There was a statistically significant difference in Hb value (mg/dL) at day 1, 2, 4, and 7 (-1.35 vs -1.98, -1.59 vs -2.52, -1.96 vs -2.82, and -1.76 vs -2.47, P < .05).We found a significant reduction in postoperative blood loss (drain bag volume), estimated blood loss, and change in Hb after the use of autologous platelet gel in patients of THA, and PRP appears to be effective in reducing postoperative bleeding in THA.

Lung squamous cell carcinoma with solitary ocular metastasis and its successful treatment with thoracic surgery and chemotherapy: an interesting and rare case report

The incidence of ocular metastasis from lung cancer is reported to be 0.1-7%, with adenocarcinoma and small cell lung cancer accounting for the highest proportions of these cases. The majority of cases involves metastasis to more than one other distal organ in addition to the eye. Here, we report for the first time, a case of lung squamous cell carcinoma with solitary symptomatic ocular metastasis as the initial manifestation that was managed by a multidisciplinary treatment (MDT).
A woman presented at the ophthalmology department of hospital with a 1-week history of left eye pain and blurred vision. Systemic examination led to the diagnosis of central lung cancer in the right lower lobe with ocular metastasis. After consultations with an MDT, including specialists from the surgery, internal medicine, ophthalmology, radiotherapy and imaging departments, the patient underwent surgery and chemotherapy. Her eye symptoms disappeared, and the ocular lesion was well controlled without any specific ocular treatment. The patient demonstrated a prolonged progression-free survival.
This is the first report of a rare case with solitary ocular metastasis as the initial manifestation of lung squamous cell carcinoma. This rare patient was treated based on evidence-based medicine, indicating the importance of cooperation within an MDT. The successful treatment of this case was reported as a new therapeutic reference for clinicians who encounter similar cases in the future.

Cataract surgery in diabetes mellitus: A systematic review

India is considered the diabetes capital of the world, and a significant proportion of patients undergoing cataract surgery are diabetic. Considering this, we reviewed the principles and guidelines of managing cataract in patients with diabetes. The preoperative, intraoperative, and postoperative factors are of paramount importance in the management of diabetic cataract patients. Particularly, the early recognition and treatment of diabetic retinopathy or maculopathy before cataract surgery influence the final visual outcome and play a major role in perioperative decision-making. Better understanding of various factors responsible for favorable outcome of cataract surgery in diabetic patients may guide us in better overalll management of these patients and optimizing the results.

Preliminary radiological result after establishment of hospital-based trauma registry in level-1 trauma hospital in developing country setting, prospective cohort study.

Injuries are the second most common cause of disability, the fifth most common cause of healthy years of life lost per 1000 people and unfortunately 90% of mortality takes place in low-to middle-income countries. Trauma registries guide policymakers and health care providers in decision making in terms of resource allocation as well as enhancing trauma care outcomes. Furthermore data from these registries inform policy makers to decrease the rate of death and disability occurring as a result of injuries. We present our experience in setting up an orthopedic trauma registry and the first short term follow-up of radiological outcomes.

Our study is a non-funded, non-commercial, prospective cohort study that was registered at Research Registry. The primary objectives of our study included assessing pattern of injuries in patients with upper and lower limb skeletal trauma presenting to our tertiary care academic university hospital and their respective outcomes. Data was collected by the musculoskeletal service line team members supervised by an experienced research associate and trauma consultants. The work has been reported in line with the STROCSS criteria.

A total of 177 patients were included in this analysis, of whom 101 (57.1%) patients had lower limb fractures, 64(36.1%) patients ad upper limb fractures and 12 (6.8%) patients had both upper and lower limbs involved. A total of 189 upper and lower limb fracture cases were recorded. 176 patients (93.1%) underwent surgeries and 13(6.9%) were managed nonoperatively. Roentgenographic outcomes were assessed using radiological criteria for each bone fractured.

Establishing a trauma registry assists in identification of the pattern of injuries presenting to the hospital which helps in priority setting, care management and planning. This continuous audit of outcomes in turn, plays a significant role in quality improvement.

Demand and capacity to integrate pelvic organ prolapse and genital fistula services in low-resource settings.

There is a need for expanded access to safe surgical care in low- and middle-income countries (LMICs) as illustrated by the report of the 2015 Lancet Commission on Global Surgery. Packages of closely-related surgical procedures may create platforms of capacity that maximize impact in LMIC. Pelvic organ prolapse (POP) and genital fistula care provide an example. Although POP affects many more women in LMICs than fistula, donor support for fistula treatment in LMICs has been underway for decades, whereas treatment for POP is usually limited to hysterectomy-based surgical treatment, occurring with little to no donor support. This capacity-building discrepancy has resulted in POP care that is often non-adherent to international standards and in non-integration of POP and fistula services, despite clear areas of similarity and overlap. The objective of this study was to assess the feasibility and potential value of integrating POP services at fistula centers.

Fistula repair sites supported by the Fistula Care Plus project were surveyed on current demand for and capacity to provide POP, in addition to perceptions about integrating POP and fistula repair services.

Respondents from 26 hospitals in sub-Saharan Africa and South Asia completed the survey. Most fistula centers (92%) reported demand for POP services, but many cannot meet this demand. Responses indicated a wide variation in assessment and grading practices for POP; approaches to lower urinary tract symptom evaluation; and surgical skills with regard to compartment-based POP, and urinary and rectal incontinence. Fistula surgeons identified integration synergies but also potential conflicts.

Integration of genital fistula and POP services may enhance the quality of POP care while increasing the sustainability of fistula care.

Diagnosis and management of 365 ureteric injuries following obstetric and gynecologic surgery in resource-limited settings.

Ureteric injuries are among the most serious complications of pelvic surgery. The incidence in low-resource settings is not well documented.This retrospective review analyzes a cohort of 365 ureteric injuries with ureterovaginal fistulas in 353 women following obstetric and gynecologic operations in 11 countries in Africa and Asia, all low-resource settings. The patients with ureteric injury were stratified into three groups according to the initial surgery: (a) obstetric operations, (b) gynecologic operations, and (c) vesicovaginal fistula (VVF) repairs.The 365 ureteric injuries in this series comprise 246 (67.4%) after obstetric procedures, 65 (17.8%) after gynecologic procedures, and 54 (14.8%) after repair of obstetric fistulas. Demographic characteristics show clear differences between women with iatrogenic injuries and women with obstetric fistulas. The study describes abdominal ureter reimplantation and other treatment procedures. Overall surgical results were good: 92.9% of women were cured (326/351), 5.4% were healed with some residual incontinence (19/351), and six failed (1.7%).Ureteric injuries after obstetric and gynecologic operations are not uncommon. Unlike in high-resource contexts, in low-resource settings obstetric procedures are most often associated with urogenital fistula. Despite resource limitations, diagnosis and treatment of ureteric injuries is possible, with good success rates. Training must emphasize optimal surgical techniques and different approaches to assisted vaginal delivery.

Developmental disabilities among children younger than 5 years in 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.

The Sustainable Development Goals (SDGs) mandate systematic monitoring of the health and wellbeing of all children to achieve optimal early childhood development. However, global epidemiological data on children with developmental disabilities are scarce. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 provides a comprehensive assessment of prevalence and years lived with disability (YLDs) for development disabilities among children younger than 5 years in 195 countries and territories from 1990 to 2016.We estimated prevalence and YLDs for epilepsy, intellectual disability, hearing loss, vision loss, autism spectrum disorder, and attention deficit hyperactivity disorder. YLDs were estimated as the product of the prevalence estimate and the disability weight for each mutually exclusive disorder, corrected for comorbidity. We used DisMod-MR 2.1, a Bayesian meta-regression tool, on a pool of primary data derived from systematic reviews of the literature, health surveys, hospital and claims databases, cohort studies, and disease-specific registries.Globally, 52·9 million (95% uncertainty interval [UI] 48·7-57·3; or 8·4% [7·7-9·1]) children younger than 5 years (54% males) had developmental disabilities in 2016 compared with 53·0 million (49·0-57·1; or 8·9% [8·2-9·5]) in 1990. About 95% of these children lived in low-income and middle-income countries. YLDs among these children increased from 3·8 million (95% UI 2·8-4·9) in 1990 to 3·9 million (2·9-5·2) in 2016. These disabilities accounted for 13·3% of the 29·3 million YLDs for all health conditions among children younger than 5 years in 2016. Vision loss was the most prevalent disability, followed by hearing loss, intellectual disability, and autism spectrum disorder. However, intellectual disability was the largest contributor to YLDs in both 1990 and 2016. Although the prevalence of developmental disabilities among children younger than 5 years decreased in all countries (except for North America) between 1990 and 2016, the number of children with developmental disabilities increased significantly in sub-Saharan Africa (71·3%) and in North Africa and the Middle East (7·6%). South Asia had the highest prevalence of children with developmental disabilities in 2016 and North America had the lowest.The global burden of developmental disabilities has not significantly improved since 1990, suggesting inadequate global attention on the developmental potential of children who survived childhood as a result of child survival programmes, particularly in sub-Saharan Africa and south Asia. The SDGs provide a framework for policy and action to address the needs of children with or at risk of developmental disabilities, particularly in resource-poor countries.The Bill & Melinda Gates Foundation.