Affording Unavoidable Emergency Surgical Care – The Lived Experiences and Payment Coping Strategies of Households in Ibadan Metropolis, Southwestern Nigeria

Background
Pre-payment and risk pooling schemes, central to the idea of universal health coverage, should protect households from catastrophic health expenditure and impoverishment; particularly when emergency care is required. Inadequate financial protection consequent on surgical emergencies occurs despite the existence of risk-pooling schemes. This study documented the experiences and coping strategies of slum and non-slum dwellers in a southwestern metropolis of Nigeria who had undergone emergency surgery.
Methods
In-depth interviews were conducted with 31 participants (13 slums dwellers, 18 non-slum dwellers) who had recently paid for emergency surgical care in Ibadan. Patients who had experienced catastrophic health expenditure from the use of emergency surgical care were identified and people who paid for the care were purposively selected for the interviews. Using an in-depth interview guide, information on the experiences and overall coping strategies during and after the hospitalization was collected. Data were analyzed inductively using the thematic approach.
Results
The mean age of the 31 participants (consisting of 7 men and 24 women) was 31 ± 5.6years. Apathy to savings limited the preparation for unplanned healthcare needs. Choice of hospital was determined by word of mouth, perceptions of good quality or prompt care and availability of staff. Social networks were relied on widely as a coping mechanism before and during the admission. Patients that were unable to pay experienced poor and humiliating treatment (in severe cases, incarceration). Inability to afford care was exacerbated by double billing and extraneous charges. It was opined that health care should be more affordable for all and that the current National Health Insurance Scheme, that was operating sub-optimally, should be strengthened appropriately for all to benefit.
Conclusion
The study highlights households’ poor attitude to health-related savings and pre-payment into a social solidarity fund to cover the costs of emergency surgical care. It also highlights the factors influencing costs of emergency surgical care and the role of social networks in mitigating the high costs of care. Improving financial protection from emergency surgical care would entail promoting a positive attitude to health-related savings, social solidarity and extending the benefits of social health insurance.

Postoperative analgesic effect of intrathecal dexmedetomidine on bupivacaine subarachnoid block for open reduction and internal fixation of femoral fractures

Background
One of the drawbacks of subarachnoid block is the short duration of analgesia particularly when adjuvants are not added to local anesthetics agent used. However, dexmedetomidine an α2-adrenergic agent has been found to possess analgesic effect.
Aims
This study seeks to determine the analgesic efficacy of intrathecal 7.5 μg of dexmedetomidine and its side effects when used for open reduction and internal fixation (ORIF) of femoral fractures.
Methodology
It is a prospective randomized, double-blinded study that was carried out in a Nnamdi Azikiwe University Teaching Hospital, Nnewi in Nigeria. Seventy American Society of Anesthesiologists I or II patients were randomized into two groups of 35 each to receive 3 ml of 0.5% hyperbaric bupivacaine combined with either 7.5 μg of dexmedetomidine in 0.3 ml of normal saline (Group D) or 0.3 ml of normal saline alone (Group S). Patient’s outcome measures noted (time to first request of analgesia, proportion of patients with pain score <4 postoperatively using numerical rating scale [NRS], and total analgesic consumed in 24 h.).
Results
The patients in Group D had a longer time to first request of analgesia, larger proportion of patients with pain score 0.05). However, the patient satisfaction was better in Group D.
Conclusion
The addition of 7.5 μg of dexmedetomidine to bupivacaine for subarachnoid block in the management of femoral fractures using ORIF provided better anesthetic profile, particularly prolonged duration of postoperative analgesia without significant side effects.

Postoperative Pain Management in Emergency Surgeries: A One-year Survey on Perception and Satisfaction among Surgical Patients

Background
Postoperative pain varies from an individual to individual. It also varies with types and extent of surgery. In general, postoperative pain is inadequately managed in most centers worldwide, especially in developing countries. Therefore, this study presents the perception and satisfaction of postoperative pain management in emergency surgeries.
Methods
A 1-year prospective study of the 891 patients who underwent emergency general surgeries at Ahmadu Bello University Teaching Hospital, from January to December 2018 is hereby presented. Pain scores and patient’s satisfaction toward postoperative pain management were considered at 8 and 24 h postoperatively through a predesigned questionnaire. Numeric Pain Rating Scale was used to determine pain intensity and the level of satisfaction following postoperative pain management. Student’s t-test was used to compare the pain scores and patient’s level of satisfaction of the postoperative pain management.
Results
A total of 891 patients were recruited for this study, with a mean age of 36.4 ± 8.9 years with a male-to-female ratio of 1.3:1. Postoperative pain management satisfaction score for patients (98%) who had pain 8-h postoperative period was 4.8 ± 1.6. Similarly, 96.4% of the patients who had pain 24 h postoperatively scored 2.8 ± 1.7. Majority of the patients 481 (54%) were of the American Society of Anesthesiologist physical Class II. Most of the patients underwent general surgery using the technique of general anesthesia.
Conclusion
This study indicated that the perception and level of patient’s satisfaction regarding postoperative pain management are inadequate. The health professionals and policy makers should be aware that postoperative pain management is suboptimal, as patients still have severe postoperative pain. Therefore, the need for improved postoperative pain management.

Perioperative Management of Gastrointestinal Surgery in a Resource-Limited Hospital in Niger: Cross-sectional Study

Background
Perioperative management in digestive surgery is a challenge in sub-Saharan Africa. Objective: To describe the process and outcomes of perioperative management in gastrointestinal surgery.
Materials and methods
This was a single center cross-sectional study over a 4-month period from June 1 to September 30, 2017, in a Nigerien hospital (West Africa). This study included caregivers and patients operated on gastrointestinal surgery.
Results
We collected data for 56 caregivers and 253 patients underwent gastrointestinal surgery. The average age of caregivers was 38.6 ± 8.7. The median length of professional practice was 9 years. Almost 52% of caregivers (n = 29) did not know the standards of perioperative care. The median age of patients was 24 years, and male gender constituted 70% of cases (n = 177) with a sex ratio of 2.32. Patients came from rural areas in 78.2% (n = 198). Emergency surgery accounted for 60% (n = 152). The most surgical procedure was digestive ostomies performed in 28.9% (n = 73), followed by hernia repair and appendectomy in 24.5% (n = 62) and 13.9% (n = 35) respectively. The postoperative course was complicated in 28.1% (n = 71) among which 13 deaths. In the group of caregivers, the poor practice of perioperative management was associated with poor professional qualification, insufficient equipment, insufficient motivation (p < 0.05). The ASA3&ASA4 score, undernutrition, emergency surgery, poor postoperative monitoring, and poor psychological preparation were associated with complicated postoperative outcomes (p < 0.05).
Conclusion
The inadequacy of the technical platform and the lack of continuous training for healthcare staff represented the main dysfunctions of our hospital. The risk factors for complications found in this study need appropriate perioperative management to improve prognosis in gastrointestinal surgery.

Prophylactic surgical drainage is associated with increased infection following intramedullary nailing of diaphyseal long bone fractures: A prospective cohort study in Nigeria

Introduction: Prophylactic surgical drains are commonly used in Nigeria following intramedullary nailing (IMN) of long bone diaphyseal fractures. However, evidence in the literature suggests that drains do not confer any benefit and predispose clean wounds to infection. This study compares outcomes between patients treated with and without prophylactic surgical drainage following diaphyseal long bone fractures treated with IMN. Methods: A prospective cohort study with randomization was conducted at a tertiary referral center in Enugu, Nigeria. Investigators included skeletally mature patients with diaphyseal long bone (femur, tibia, humerus) fractures treated with SIGN IMN. Patients followed-up at 5, 14, and 30 days post-operatively. The primary outcome was surgical site infection (SSI) rate. Secondary outcomes included post-operative pain at 6 and 12 h, need for blood transfusion, wound characteristics (swelling, ecchymosis, and gaping), need for dressing changes, and length of hospital stay. Results: Of the enrolled patients, 76 (96%) of 79 completed 30-day follow-up. SSI rate was associated with patients who received a prophylactic drain versus those who did not (23.7% vs. 10.5%, p = 0.007). There were no significant differences in transfusion need (p = 0.22), wound swelling (p = 0.74), wound ecchymosis (p = 1.00), wound gaping (p = 1.00), dressing change need (p = 0.31), post-operative pain at 6 h (p = 0.25) or 12 h (p = 0.57), or length of stay (p = 0.95). Discussion: Surgical drain placement following IMN of diaphyseal long bone fractures is associated with a significantly higher risk of SSI. Reducing surgical drain use following orthopaedic injuries in lower resource settings may translate to reduced infection rates.

Not just numbers: beyond counting caesarean deliveries to understanding their determinants in Ghana using a population based cross-sectional study

Background
The increasing rate of caesarean deliveries (CD) has become a serious concern for public health experts globally. Despite this health concern, research on factors associated CD in many low- and -middle countries like Ghana is sparse. This study, therefore, assessed the prevalence and determinants of CD among child-bearing women aged 15–49  in Ghana.

Methods
The study used data from the 2014 Ghana Demographic and Health Survey. The analysis was limited to mothers (n = 2742) aged 15–49 , who had given birth in health facilities 5 years preceding the survey. Association between CD and its determinants was assessed by calculating adjusted odds ratios (AOR) with their respective 95% confidence intervals using a binary logistic regression.

Results
The percentage of mothers who delivered their babies through caesarean section (CS) was 18.5%. Using multivariable logistic regression, the results showed that women aged 45–49 (AOR = 10.5; 95% CI: 3.0–37.4), and women from a household that are headed by a female (AOR = 1.3; 95% CI = 1.1–1.7) had higher odds to deliver through CS. Women from the Upper East (AOR =0.4; 95% CI = 0.2–0.7) and Upper West (AOR = 0.4; 95% CI = 0.2–0.8) regions had lower odds to deliver their children through CS. Women with parity 4 or more (AOR = 0.3; 95% CI = 0.2–0.5) had lower odds of CD compared to those with parity 1. Women with female babies had lower odds (AOR = 0.8; CI = 0.7–0.9) of delivering them through CS compared to those with male children.

Conclusion
The percentage of women delivering babies through the CS in Ghana is high. The high rates of CD noted do not essentially indicate good quality care or services. Hence, health facilities offering this medical protocol need to adopt comprehensive and strict measures to ensure detailed medical justifications by doctors for performing these caesarean surgeries.

Outcome of Esotropia Surgery in 2 Tertiary Hospitals in Cameroon

Purpose: To evaluate the ocular alignment following esotropia surgery in our setting.
Patients and methods: We conducted a cross sectional descriptive study which spanned 19 years, from October 1999 to September 2018 at the Douala General Hospital and the Yaoundé Central Hospital. Complete medical records of patients who underwent surgery for esotropia during the study period were included. Data collected included age at diagnosis, sex, age of onset of esotropia, age at surgery, refractive error, type of surgery performed, pre and post-operative angle of deviation. The outcome was considered good when the postoperative angle was ≤10 prism diopters (PD).
Results: Four hundred and ninety patients with primary esotropia were seen during the study period. Only 155 returned for follow-up after wearing the full cycloplegic correction for a minimum period of 3 months. Accommodative esotropia was found in 32 cases (20.6%). Among the 123 cases requiring surgery, 63 cases underwent surgery (51.2%). Fifty-nine complete records were included (59.3% females and 40.7% males). The mean age at the time of diagnosis was 6.5 ± 6.1 years and the mean age at the time of surgery was 8.7 ± 6.1 years. The mean preoperative angle at distance was 42.8 ±10.8 PD. The outcome was good in 91.5% of cases. No factor influenced the outcome of surgery.
Conclusion: The outcome of esotropia surgery was good in this study. This could serve to increase patient motivation to accept surgery in our setting.

Epidemiology and Perioperative Mortality of Exploratory Laparotomy in Rural Ghana

Background:
Perioperative mortality rate (POMR) has been identified as an important measure of access to safe surgical and anesthesia care in global surgery. There has been limited study on this measure in rural Ghana. In order to identify areas for future quality improvement efforts, we aimed to assess the epidemiology of exploratory laparotomy and to investigate POMR as a benchmark quality measure.

Methods:
Surgical records were reviewed at a regional referral hospital in Eastern Region, Ghana to identify cases of exploratory laparotomy from July 2017 through June 2018. Patient demographics, health information, and outcomes data were collected. Logistic regression was used to identify predictors of perioperative mortality.

Findings:
The study included operations for 286 adult and 60 pediatric patients. Only 60% of patients were covered by National Health Insurance (NHI). The overall POMR was 11.5% (12.6% adults; 6.7% pediatric). Sixty percent of mortalities were referrals from outside hospitals and the mortality rate for referrals was 13.5%. Odds of mortality was 13 times greater with perforated peptic ulcer disease (OR = 13.1, p = 0.025) and 12 times greater with trauma (OR = 11.7, p = 0.042) when compared to the most common operation. Female sex (OR = 0.3, p = 0.016) and NHI (OR = 0.4, p = 0.031) were protective variables. Individuals 60 years and older (OR = 3.3, p = 0.016) had higher mortality.

Conclusion:
POMR can be an important outcome and quality indicator for rural populations. Interventions aimed at decreasing emergent hernia repair, preventing perforation of peptic ulcer disease, improving rural infrastructure for response to major trauma, and increasing NHI coverage may improve POMR in rural Ghana.

Improving capacity and access to neurosurgery in sub-Saharan Africa using a twinning paradigm pioneered by the Swedish African Neurosurgical Collaboration

Background: The unmet need for neurosurgery in sub-Saharan Africa is staggering. Resolving this requires strategies that synergize salient local resources with tailored foreign help. This study is a trial of a twinning model adopted by the Swedish African Neurosurgical Collaboration (SANC).

Methods: A multi-step neurosurgical twinning technique, International Neurosurgical Twinning Modeled for Africa (INTIMA), developed through a collaboration between African and Swedish neurosurgical teams was adopted for a neurosurgical mission in March 2019. The pioneering steps are evaluated together with data of treated patients prospectively acquired using SPSS Chicago Inc., Version 23. Associations were analyzed using chi-square tests, while inferences were evaluated at 95% level of significance.

Results: The SANC global neurosurgery mission targeted microsurgical brain tumor resection. Fifty-five patients were operated on during the mission and subsequent 3 months. Patients’ ages ranged from 3 months to 69 years with a mean of 30.6 ± 2.1 years 95% CL. Seven cases were performed during the first mission, while 48 were performed after the mission. Compared to 3 months before SANC when only 9 brain tumors were resected, more tumors were resected (n = 25) within the 3 consecutive months from the mission (X2 = 14.2, DF = 1, P = 0.000). Thirty-day mortality following tumor resection was also lower, X2 = 4.8, DF = 1, P = 0.028.

Conclusion: Improvements in capacity and short-term outcome define our initial pioneering application of a neurosurgical twinning paradigm pioneered by SANC.

Outcome of management of gastroschisis: comparison of improvised surgical silo and extended right hemicolectomy

Gastroschisis is onea of the major abdominal wall defects encountered commonly in pediatric surgery. Whereas complete reduction and abdominal closure is achieved easily sometimes, a daunting situation arises when the eviscerated bowel loops and other viscera cannot be returned immediately into the abdominal cavity. This situation is a major contributor to the outcome of the treatment of gastroschisis in our region. In our efforts to improve our outcome, we have adopted the technique of extended right hemicolectomy for cases where complete reduction and primary abdominal wall closure is otherwise not possible. This study compared the management outcome of gastroschisis using our improvised silo, and performing an extended right hemicolectomy.

Results
Thirty-nine cases were analyzed. Simple closure could not be achieved in 28 cases. In the absence of standard silos, improvised ones were constructed from the amniotic membrane (3 cases), urine bag (4 cases), and latex gloves (9 cases) giving a total of 16 cases managed with silos. Extended right hemicolectomy was performed in 12 cases.

Conclusions
Given the peculiarities of circumstances in our region regarding human and material resources in the care of gastroschisis patients, an extended right hemicolectomy, to make it possible to close the abdomen primarily in gastroschisis is a more viable option than the use of improvised silo.