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1. Women neurosurgeons around the world: a systematic review

Journal of Neurosurgery


Authors: Tina Lulla, Rosemary T. Behmer Hansen, Cynthia A. Smith, Nicole A. Silva, Nitesh V. Patel, Anil Nanda
Region / country: Global
Speciality: Neurosurgery, Other

OBJECTIVE
Gender disparities in neurosurgery have persisted even as the number of female medical students in many countries has risen. An understanding of the current gender distribution of neurosurgeons around the world and the possible factors contributing to country-specific gender disparities is an important step in improving gender equity in the field.

METHODS
The authors performed a systematic review of studies pertaining to women in neurosurgery. Papers listed in PubMed in the English language were collected. A modified grounded theory approach was utilized to systematically identify and code factors noted to contribute to gender disparities in neurosurgery. Statistical analysis was performed with IBM SPSS Statistics for Windows.

RESULTS
The authors identified 39 studies describing the density of women neurosurgeons in particular regions, 18 of which documented the proportion of practicing female neurosurgeons in a single or in multiple countries. The majority of these studies were published within the last 5 years. Eight factors contributing to gender disparity were identified, including conference representation, the proverbial glass ceiling, lifestyle, mentoring, discrimination, interest, salary, and physical burden.

CONCLUSIONS
The topic of women in neurosurgery has received considerable global scholarly attention. The worldwide proportion of female neurosurgeons varies by region and country. Mentorship was the most frequently cited factor contributing to noted gender differences, with lifestyle, the glass ceiling, and discrimination also frequently mentioned. Future studies are necessary to assess the influence of country-specific sociopolitical factors that push and pull individuals of all backgrounds to enter this field.


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2. Investing in the future: a call for strategies to empower and expand representation of women in neurosurgery worldwide

Journal of Neurosurgery


Authors: Samantha J. Sadler, Ho Kei Yuki Ip, Eliana Kim, Claire Karekezi, Faith C. Robertson
Region / country: Global
Speciality: Neurosurgery, Other

As progress is gradually being made toward increased representation and retention of women in neurosurgery, the neurosurgical community should elevate effective efforts that may be driving positive change. Here, the authors describe explicit efforts by the neurosurgery community to empower and expand representation of women in neurosurgery, among which they identified four themes: 1) formal mentorship channels; 2) scholarships and awards; 3) training and exposure opportunities; and 4) infrastructural approaches. Ultimately, a data-driven approach is needed to improve representation and empowerment of women in neurosurgery and to best direct the neurosurgical community’s efforts across the globe.

ABBREVIATIONS AANS = American Association of Neurological Surgeons; CNS = Congress of Neurological Surgeons; COSECSA = College of Surgeons of East, Central and Southern Africa; FIENS = Foundation for International Education in Neurological Surgery; LMIC = low- and middle-income country; WINS = Women in Neurosurgery; WiSA = Women in Surgery Africa.


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3. Imaging: towards a global solution to overcome the cancer pandemic

The lancet oncology


Authors: Isabelle Borget, Nathalie Lassau, Corinne Balleyguier, Aurélie Bardet, Fabrice Barlesi
Region / country: Global
Speciality: Health policy, Surgical oncology

In The Lancet Oncology, Hedvig Hricak and colleagues present a wide and rich review of cancer imaging in low-income and middle-income countries (LMICs).1 This Lancet Oncology Commission on medical imaging and nuclear medicine includes an inventory of resources, identification of needs, and a tightly argued call to action.
The UN has defined global health and access to care as a target for sustainable development.2 In the meantime, the burden of cancer is increasing worldwide and is higher in LMICs than in high-income countries (HICs), with these countries experiencing a greater share of global cancer deaths (57·3% for Asia and 7·3% for Africa) than the share of global cancer incidence (48·4% and 5·8%, respectively).3, 4 However, the proportional level of care for cancer remains low in LMICs.
To provide insights on access to imaging, the IMAGINE (the International Atomic Energy Agency Medical imAGIng and Nuclear mEdicine) global resources database was developed. It has allowed demonstration of high disparities between countries and a paucity of imaging resources in LMICs with, for example, one CT scanner for 1 694 000 people in LMICs versus one for 25 000 people in HICs.
Because insufficient or no access to imaging causes delays in diagnosis, cancer survival in LMICs is still worse than in wealthier countries: more people are diagnosed in LMICs when their cancer has already spread and more people receive less intensive or effective treatment than in HICs. Hence, imaging is an essential step towards staging and better cancer care. Surgical, chemotherapy, and radiotherapy management cannot be optimised without an appropriate imaging plan. Like previous studies,5, 6 the present analysis reveals the potential benefits of scaling up imaging modalities in cancer management by improving 5-year survival.
Hricak and colleagues show the synergy between imaging, treatment, and quality of care for cancer management, and the individual effects are not additive.3, 7 Their microsimulation model demonstrated that simultaneous expansion of imaging, treatment, and quality of care would avert 9 549 500 deaths worldwide between 2020 and 2030, but four times fewer deaths (2 463 500) would be averted with the scale-up of imaging alone. Earlier diagnosis and optimal staging of cancer are efficient8 because treatment for earlier cancer stages is more effective and less costly than treatment for advanced or metastatic disease.
Hricak and colleagues advocate for an integrated cancer care management approach to avoid fragmented or incomplete delivery of care. The provision of affordable and comprehensive cancer care, including imaging, in LMICs will be most effectively and efficiently accomplished with a coordinated and global coalition (involving governments, civil society, patients, health-care professionals, professional associations, researchers, funders, international agencies, private sector, and innovators) to scale up targeted and strategic investments.
Now is the right time for LMICs to increase their use of medical imaging and nuclear medicine.


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4. Predictors of Five-Year Overall Survival in Women Treated for Cervical Cancer at the Kenyatta National Hospital in 2008

College of Health Sciences (COHES)


Authors: Damar Auma Osok
Region / country: Eastern Africa – Kenya
Speciality: Obstetrics and Gynaecology, Surgical oncology

Cervical cancer is the fourth most commonly diagnosed and the fourth leading cause of cancer death among women worldwide. In many low- and middle-income countries (LMICs) including Kenya cervical cancer remains the leading cause of cancer death among women. This situation is due to the fact that despite the existence of effective preventive and early detection programs, lack of implementation in LMICs leads many women suffering from the disease to premature death. This study was aimed at estimating the five-year overall survival rates for women with cervical cancer in Kenya. To achieve this, the study employed a retrospective cohort design where medical records of all patients who commenced treatment for cervical cancer in 2008 were reviewed retrospectively over a period of five years from 2008- 2013. Data analysis involved the use of Stata v14.2 to generate descriptive statistics and conduct survival analysis. The five-year overall survival estimate for women with cervical cancer at Kenyatta National Hospital (KNH) in 2008 was found to be 59%. Stage of disease at diagnosis, type of treatment received and whether or not treatment was initiated and completed are the three factors revealed to have the strongest influence on patient survival. Occupation which was used as a proxy for socio-economic status (SES) did not reflect the financial burden imposed on patients seeking treatment. However, the loss to follow up was significantly high at a rate of 82.3%; with no deaths observed after the first year, the overall survival estimate is only accurate over the first year. The results of this study provided insight on the relationship between various socio-demographic and clinical factors and patient outcomes of cervical cancer treatments at KNH. Moreover, it highlighted the ongoing health system challenges surrounding provision of and access to cancer treatment. The results will inform policy makers and health service providers on the quality and accessibility of available cervical cancer treatments as delivered within our healthcare setting


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5. Cardiovascular disease risk profile and management practices in 45 low-income and middle-income countries: A cross-sectional study of nationally representative individual-level survey data

PLOS MEDICINE


Authors: David Peiris ,Arpita Ghosh,Jennifer Manne-Goehler,Lindsay M. Jaacks,Michaela Theilmann,Maja E. Marcus,Zhaxybay Zhumadilov,Lindiwe Tsabedze,Adil Supiyev,Bahendeka K. Silver,Abla M. Sibai,Bolormaa Norov,Mary T. Mayige,Joao S. Martins,Nuno Lunet,Demetre Labadarios,Jutta M. A. Jorgensen,Corine Houehanou,David Guwatudde,Mongal S. Gurung,Albertino Damasceno,Krishna K. Aryal,Glennis Andall-Brereton,Kokou Agoudavi,Briar McKenzie,Jacqui Webster,Rifat Atun,Till Bärnighausen,Sebastian Vollmer,Justine I. Davies ,Pascal Geldsetzer
Region / country: Global
Speciality: Cardiothoracic surgery

Background
Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population’s median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines.

Methods and findings
We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%–4.2%) and 1.6% (1.3%–2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%–37.2%) for males and 41.6% (23.9%–53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%–58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis.

Conclusions
This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.


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6. Clavien–Dindo classification of post-operative complications in a South African setting

wits journal of clinical medicine


Authors: Maeyane Stephens Moeng, Anna Sparaco, Irma Mare, Veneshree Naidoo, Boitumelo Phakathi, Eloise Juliet Miller, Thomas Kekgatleope Marumo, Uzayr Khan, Taalib Monareng, Thifhelimbilu Emmanuel Luvhengo
Region / country: Southern Africa – South Africa
Speciality: General surgery

Background: Clavien-Dindo (CD) classification is used to standardize the reporting of post-operative complications. The aim of the study was to report our initial experience following the adoption of the use of CD classification for reporting of post-operative complications across surgical specialities. Methods: An audit of prospectively collected data, from records of patients aged 18 years and older who had surgery, was conducted. Data collected included patients’ demographics, acuity of operations, types of surgery, recorded post-operative complications and assigned CD class. Categorical variables were summarized using frequency and percentages. The mean with standard deviation (SD) was used for the aggregation of continuous data. χ2-test or Fisher’s exact test was used to compare categorical findings. The strength of associations was measured using Cramer’s V and the φ coeficient. Data analysis was carried out using the SAS version 9.4 for Windows. The level of significance was set at a P value below 0.05. Results: A total of 3399 surgical procedures were performed, of which 1700 (50.0%) were emergencies. The mean (± SD) age of operated patients was 44.3 (±16.7) years. eThre were 11.2% post-operative complications of which 65.8% were directly related to surgical procedures. Approximately 48.1% of the complications were infections. The CD classicfiation was applied to the complications, of which 31.6% were categorized as Grade I and 26.3% as Grade IIIb. There was a significant but weak association between reported complication types and surgical specialty (P < 0.0001; Cramer's V = 0.25), and between the reported grade of complications and surgical specialty (P < 0.0001; Cramer's V = 0.21). Overall mortality was 7.7%. Conclusions: The CD classification was adopted by all specialties studied. The rate of post-operative complications was 11%, the majority of which were infections. Reported grades of complications were influenced by surgical specialty. A high number of Grade IIIb complications were recorded than have been previously reported.


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7. Management of major obstetric hemorrhage prior to peripartum hysterectomy and outcomes across nine European countries

Acta Obstetricia et Gynecologica Scandinavica


Authors: Athanasios F. Kallianidis, Alice Maraschini , Jakub Danis , Lotte B. Colmorn , Catherine Deneux‐ Tharaux, Serena Donati , Mika Gissler, Maija Jakobsson, Marian Knight, Alexandra Kristufkova, Pelle G. Lindqvist , Griet Vandenberghe , Thomas van den Akker
Region / country: Northern Europe, Southern Europe, Western Europe – Belgium, Denmark, Finland, France, Italy, Slovak Republic (Slovakia), Sweden, United Kingdom
Speciality: Obstetrics and Gynaecology

Introduction
Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong suspicion of placenta accreta spectrum (PAS), where it may be anticipated before cesarean section. The aim of this study was to compare management strategies in the case of obstetric hemorrhage leading to hysterectomy, between nine European countries participating in the International Network of Obstetric Survey Systems (INOSS), and to describe pooled maternal and neonatal outcomes following peripartum hysterectomy.

Material and methods
We merged data from nine nationwide or multi‐regional obstetric surveillance studies performed in Belgium, Denmark, Finland, France, Italy, the Netherlands, Slovakia, Sweden and the UK collected between 2004 and 2016. Hysterectomies performed from 22 gestational weeks up to 48 h postpartum due to obstetric hemorrhage were included. Stratifying women with and without PAS, procedures performed in the management of obstetric hemorrhage prior to hysterectomy between countries were counted and compared. Prevalence of maternal mortality, complications after hysterectomy and neonatal adverse events (stillbirth or neonatal mortality) were calculated.

Results
A total of 1302 women with peripartum hysterectomy were included. In women without PAS who had major obstetric hemorrhage leading to hysterectomy, uterotonics administration was lowest in Slovakia (48/73, 66%) and highest in Denmark (25/27, 93%), intrauterine balloon use was lowest in Slovakia (1/72, 1%) and highest in Denmark (11/27, 41%), and interventional radiology varied between 0/27 in Denmark and Slovakia to 11/59 (79%) in Belgium. In women with PAS, uterotonics administration was lowest in Finland (5/16, 31%) and highest in the UK (84/103, 82%), intrauterine balloon use varied between 0/14 in Belgium and Slovakia to 29/103 (28%) in the UK. Interventional radiology was lowest in Denmark (0/16) and highest in Finland (9/15, 60%). Maternal mortality occurred in 14/1226 (1%), the most common complications were hematologic (95/1202, 8%) and respiratory (81/1101, 7%). Adverse neonatal events were observed in 79/1259 (6%) births.

Conclusions
Management of obstetric hemorrhage in women who eventually underwent peripartum hysterectomy varied greatly between these nine European countries. This potentially life‐saving procedure is associated with substantial adverse maternal and neonatal outcome.


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8. Epidemiology of Traumatic Brain Injury in Georgia: A Prospective Hospital-Based Study

Dovepress


Authors: Eka Burkadze, Ketevan Axobadze, Nino Chkhaberidze,Nino Chikhladze, Madalina Adina Coman, Diana Dulf, Corinne Peek-Asa
Region / country: Eastern Europe, Western Asia – Georgia
Speciality: Neurosurgery, Trauma surgery

Purpose: Traumatic brain injury (TBI) is one of the major causes of morbidity and mortality worldwide, disproportionally affecting low- and middle-income countries (LMICs). Epidemiological characteristics of TBI at a national level are absent for most LMICs including Georgia. This study aimed to establish the registries and assess causes and outcomes in TBI patients presenting to two major trauma hospitals in the capital city –Tbilisi.
Patients and Methods: The prospective observational study was conducted at Acad. O. Gudushauri National Medical Center and M. Iashvili Children’s Central Hospital from March, 1 through August, 31, 2019. Patients of all age groups admitted to one of the study hospitals with a TBI diagnosis were eligible for participation. Collected data were uploaded using the electronic data collection tool –REDCap, analyzed through SPSS software and evaluated to provide detailed information on TBI-related variables and outcomes using descriptive statistics.
Results: Overall, 542 hospitalized patients were enrolled during the study period, about 63% were male and the average age was 17.7. The main causes of TBI were falls (58%) and struck by or against an object (22%). The 97% suffered from mild TBI (GCS 13– 15). Over 23% of patients arrived at the hospital more than 1 hour after injury and 25% after more than 4-hours post-injury. Moderate and severe TBI were associated with an increased hospital length of stay. Mortality rate of severe TBI was 54%.
Conclusion: This study provides important information on the major epidemiological characteristics of TBI in Georgia, which should be considered for setting priorities for injury management


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9. Mapping Global Neurosurgery Research Collaboratives: A Social Network Analysis of the 50 Most Cited Global Neurosurgery Articles

Neurosurgery Open


Authors: Ulrick Sidney Kanmounye, Lorraine Arabang Sebopelo, Chiuyu Keke, Yvan Zolo, Wah Praise Senyuy, Genevieve Endalle, Régis Takoukam, Dawin Sichimba, Stéphane Nguembu, Nathalie Ghomsi
Region / country: Global
Speciality: Neurosurgery

Social network analysis of bibliometric data evaluates the relationships between the articles, authors, and themes of a research niche. The network can be visualized as maps composed of nodes and links. This study aimed to identify and evaluate the relationships between articles, authors, and keywords in global neurosurgery. The authors searched global neurosurgery articles on the Web of Science database from inception to June 18, 2020. The 50 most cited articles were selected and their metadata (document coupling, co-authorship, and co-occurrence) was exported. The metadata were analyzed and visualized with VOSViewer (Centre for Science and Technology Studies, Leiden University, The Netherlands). The articles were published between 1995 and 2020 and they had a median of 4.0 (interquartile range [IQR] = 5.0) citations. There were 5 clusters in the document coupling and 10 clusters in the co-authorship analysis. A total of 229 authors contributed to the articles and Kee B. Park contributed the most to articles (14 publications). Backward citation analysis was organized into 4 clusters and co-occurrence analysis into 7 clusters. The most common themes were pediatric neurosurgery, neurotrauma, and health system strengthening. The authors identified trends, contributors, and themes of highly cited global neurosurgery research. These findings can help establish collaborations and set the agenda in global neurosurgery research.


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10. Inequity in paediatric oncology in South Africa – The neuroblastoma case study

South African Journal of Oncology


Authors: Jaques van Heerden, Tonya Esterhuizen, Mariana Kruger
Region / country: Southern Africa – South Africa
Speciality: Neurosurgery, Paediatric surgery, Surgical oncology

Background: The South African Constitution affords everyone the right to access healthcare services, but in children the care must ensure survival.

Aim: This study aimed to determine whether there was access to equitable paediatric oncology services for the management of neuroblastoma in South Africa.

Setting: Paediatric oncology services in South Africa between 2000 to 2014.

Methods: A literature review was carried out, focussing on access to healthcare in South Africa for children with neuroblastoma. Services were classified in accordance with the International Society of Paediatric Oncology resource settings for neuroblastoma diagnosis. Supplementary data from a retrospective study of the management of neuroblastoma in South Africa were evaluated.

Results: The neuroblastoma care services in South Africa were not uniformly resourced and accessible across the provinces. Two provinces (2/9 provinces) had excellent healthcare services that included access to transplant facilities, whilst three (3/9 provinces) had no services. Traveling distances to healthcare services pose major challenges, whilst number of medical staff providing oncology care were unequally distributed. The Constitution did not define basic healthcare for children, nor did the National Cancer Control plan acknowledge childhood cancer as a defined entity without provision until 2022.

Conclusion: Children diagnosed with neuroblastoma do not have equitable access to healthcare as stated in the South African Constitution. The case of neuroblastoma highlights the inequitable access to childhood care as a whole in South Africa. As the health of children is a national priority, it is therefore necessary to sensitise policymakers to the needs of children with cancer.


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11. Abdominal vascular injuries- what general/ trauma surgeons should know

journal of the pakistan medical association


Authors: Zia Ur Rehman
Region / country: Global
Speciality: General surgery, Trauma surgery

Abdominal vascular injuries are the common cause of death after abdominal trauma. These are challenging injuries to manage due to severe haemodynamic instability, associated injuries and difficulty in accessing and controlling these vessels. Early control of bleeding can decrease the mortality in these patients. Abdominal vasculature is divided in four zones and each zone need different operative strategy for exposure. Principles of proximal and distal control are followed before exploring any haematoma. Endovascular interventions (angioembolization, stent-graft) have shown improved outcomes in patients with blunt abdominal trauma. Resuscitative Endovascular Balloon Occlusion of Aorta is minimal invasive method of achieving aortic occlusion and acts as bridge for definitive intervention or surgery. Updated knowledge is necessary for all those directly involved in managing these patients. The current review discusses relevant anatomy, principles, different surgical approaches and endovascular techniques to deal these injuries.


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12. Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study

journal of the Association of Anaesthetists


Authors: GlobalSurg Collaborative
Region / country: Global
Speciality: Cardiothoracic surgery, Emergency surgery, ENT surgery, General surgery, Maxillofacial and oral surgery, Neurosurgery, Obstetrics and Gynaecology, Paediatric surgery, Plastic surgery, Surgical Education, Surgical oncology, Trauma and orthopaedic surgery, Trauma surgery, Urology surgery, Vascular surgery

Peri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3–4.8), 3.9 (2.6–5.1) and 3.6 (2.0–5.2), respectively). Surgery performed ≥ 7 weeks after SARS‐CoV‐2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9–2.1)). After a ≥ 7 week delay in undertaking surgery following SARS‐CoV‐2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2–8.7) vs. 2.4% (95%CI 1.4–3.4) vs. 1.3% (95%CI 0.6–2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS‐CoV‐2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay


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13. Personal protective equipment for reducing the risk of COVID-19 infection among healthcare workers involved in emergency trauma surgery during the pandemic: an umbrella review protocol

BMJ Open


Authors: Dylan P Griswold, Andres Gempeler, Angelos G Kolias,Peter J Hutchinson,Andres M Rubiano
Region / country: Global
Speciality: Trauma surgery

Introduction
Many healthcare facilities in low-income and middle-income countries are inadequately resourced and may lack optimal organisation and governance, especially concerning surgical health systems. COVID-19 has the potential to decimate these already strained surgical healthcare services unless health systems take stringent measures to protect healthcare workers (HCWs) from viral exposure and ensure the continuity of specialised care for patients. The objective of this broad evidence synthesis is to identify and summarise the available literature regarding the efficacy of different personal protective equipment (PPE) in reducing the risk of COVID-19 infection in health personnel caring for patients undergoing trauma surgery in low-resource environments.

Methods
We will conduct several searches in the L·OVE (Living OVerview of Evidence) platform for COVID-19, a system that performs automated regular searches in PubMed, Embase, Cochrane Central Register of Controlled Trials and over 30 other sources. The search results will be presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. This review will preferentially consider systematic reviews of experimental and quasi-experimental studies, as well as individual studies of such designs, evaluating the effect of different PPE on the risk of COVID-19 infection in HCWs involved in emergency trauma surgery. Critical appraisal of eligible studies for methodological quality will be conducted. Data will be extracted using the standardised data extraction tool in Covidence. Studies will, when possible, be pooled in a statistical meta-analysis using JBI SUMARI. The Grading of Recommendations, Assessment, Development and Evaluation approach for grading the certainty of evidence will be followed and a summary of findings will be created.

Ethics and dissemination
Ethical approval is not required for this review. The plan for dissemination is to publish review findings in a peer-reviewed journal and present findings at high-level conferences that engage the most pertinent stakeholders.


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14. Task-shifting eye care to ophthalmic community health officers (OCHO) in Sierra Leone: A qualitative study

journal of global health


Authors: Vladimir Pente , Stevens Bechange , Emma Jolley , Patrick Tobi, Anne Roca , Anna Ruddock , Nancy Smart , Kolawole Ogundimu, Matthew Vandy, Elena Schmidt
Region / country: Western Africa – Sierra Leone
Speciality: Ophthalmology

Background :Preventing visual impairment due to avoidable causes has been a long-standing global priority. Of all blindness in Sierra Leone, 91.5% is estimated to be avoidable and 58.2% treatable, however, there are only 6 ophthalmologists for the whole country. Task-shifting has been suggested as a strategy to address this issue and a training intervention was developed to create a cadre of community-based staff known as Ophthalmic Community Health Officers (OCHOs). This qualitative study aimed to explore the experiences of OCHOs, their relationship with other eye health workers, and how they interact with the wider health system, in order to provide recommendations for the design and delivery of future task-shifting strategies.
Methods Between April and May 2018, we conducted semi-structured interviews with 42 participants including: OCHOs (n=13), traditional ophthalmic staff (n=17)
and other stakeholders from the districts (n=6), training institution staff (n=4) and MOH headquarters (n=2). We identified participants using purposive sampling. Interviews were audio-recorded, transcribed, and thematically analysed. We draw largely on in-depth interviews but complement the analysis with evidence from a
document review.
Results In Sierra Leone, the roll-out of the OCHO programme presented a mixed picture. OCHOs participating in the study expressed a strong commitment to their new role. However, policy changes proposed to clearly demarcate roles and responsibilities and institutionalise the cadre in the civil service were not implemented, resulting in the posting of some staff at an inappropriate level, dissatisfaction with the OCHO certification, and lack of opportunities for advancement and training. These challenges reflect structural weaknesses in the health system that undermine a cohesive implementation of eye health initiatives at the primary health care level in Sierra Leone.
Conclusions: Task-shifting has the potential to improve provision in under-resourced specialities such as eye health. However, the success of this approach will be contingent upon the development of a robust and supportive health policy environment


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15. Genitourinary reconstructive surgery curriculum and postgraduate training program development in the Caribbean

Société Internationale d’Urologie


Authors: Jessica DeLong, Ramon Virasoro
Region / country: Caribbean
Speciality: Urology surgery

Objectives: To describe the development of a genitourinary reconstructive fellowship curriculum and the establishment of the first genitourinary reconstructive and pelvic floor postgraduate training program in the Caribbean.

Methods: In an effort to respond to the need for specialty-trained reconstructive urologists in the Dominican Republic, we developed an18-month fellowship program to train local surgeons. The process began with creation of a curriculum and partnership with in-country physicians, societies, hospitals, and government officials. We sought accreditation via a well-established local university, and fellowship candidates were selected. A database was maintained to track outcomes. Subjective and objective reviews were performed of the fellows.

Results: The first fellow graduated in 2018, the second in 2020, and the third is currently in training. The curriculum was created and implemented. The fellowship has been successfully integrated into the health system, and the fellows performed 199 and 235 cases, respectively, during the program, completing all rotations successfully. They have been appointed to the national health system. Both graduates are now docents in the program and in the public system. Additional staff including radiologists, radiology technicians, nurses, urology residents (both Dominican and American), urology attendings, operating room staff, and anesthesia residents were trained as a result of the program.

Conclusions: To our knowledge, this is the first fellowship of its kind in the Caribbean. A novel curriculum was created and implemented, and the first 2 fellows have successfully completed all rotations. This training model may be transferable to additional sites.


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16. Pathways to care: a case study of traffic injury in Vietnam

BMC Public Health


Authors: Thanh Tam Tran, Adrian Sleigh , Cathy Banwell
Region / country: South-eastern Asia – Vietnam
Speciality: Emergency surgery, Trauma surgery

Background
Traffic injuries place a significant burden on mortality, morbidity and health services worldwide. Qualitative factors are important determinants of health but they are often ignored in the study of injury and corresponding development of prehospital Emergency Medical Services (EMS), especially in developing country settings. Here we report our research on sociocultural factors shaping pathways to hospital care for those injured on the roads and streets of Vietnam.

Methods
Qualitative fieldwork on pathways to emergency care of traffic injury was carried out from March to August 2016 in four hospitals in Vietnam, two in Ho Chi Minh City and two in Hanoi. Forty-eight traffic injured patients and their families were interviewed at length using a semi-structured topic guide regarding their journey to the hospital, help received, personal beliefs and other matters that they thought important. Transcribed interviews were analysed thematically guided by the three-delay model of emergency care.

Results
Seeking care was the first delay and reflected concerns over money and possessions. The family was central for transporting and caring for the patient but their late arrival prolonged time spent at the scene. Reaching care was the second delay and detours to inappropriate primary care services had postponed the eventual trip to the hospital. Ambulance services were misunderstood and believed to be suboptimal, making taxis the preferred form of transport. Receiving care at the hospital was the third delay and both patients and families distrusted service quality. Request to transfer to other hospitals often created more conflict. Overall, sociocultural beliefs of groups of people were very influential.

Conclusions
Analysis using the three-delay model for road traffic injury in Vietnam has revealed important barriers to emergency care. Hospital care needs to improve to enhance patient experiences and trust. Socioculture affects each of the three delays and needs to inform thinking of future developments of the EMS system, especially for countries with limited resources.


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17. Silver linings: a qualitative study of desirable changes to cancer care during the COVID-19 pandemic

ecancer medical science


Authors: Dorothy Lombe, Richard Sullivan, Carlo Caduff, Zipporah Ali, Nirmala Bhoo-Pathy, Jim Cleary, Matt Jalink, Tomohiro Matsuda, Deborah Mukherji, Diana Sarfati, Verna Vanderpuye, Aasim Yusuf ,Christopher Booth
Region / country: Global – Canada, Colombia, Ghana, India, Japan, Lebanon, Malaysia, New Zealand, Turkey, United Kingdom, Zambia
Speciality: Surgical oncology

Introduction: Public health emergencies and crises such as the current COVID-19 pandemic can accelerate innovation and place renewed focus on the value of health interventions. Capturing important lessons learnt, both positive and negative, is vital. We aimed to document the perceived positive changes (silver linings) in cancer care that emerged during the COVID-19 pandemic and identify challenges that may limit their long-term adoption.

Methods: This study employed a qualitative design. Semi-structured interviews (n = 20) were conducted with key opinion leaders from 14 countries. The participants were predominantly members of the International COVID-19 and Cancer Taskforce, who convened in March 2020 to address delivery of cancer care in the context of the pandemic. The Framework Method was employed to analyse the positive changes of the pandemic with corresponding challenges to their maintenance post-pandemic.

Results: Ten themes of positive changes were identified which included: value in cancer care, digital communication, convenience, inclusivity and cooperation, decentralisation of cancer care, acceleration of policy change, human interactions, hygiene practices, health awareness and promotion and systems improvement. Impediments to the scale-up of these positive changes included resource disparities and variation in legal frameworks across regions. Barriers were largely attributed to behaviours and attitudes of stakeholders.

Conclusion: The COVID-19 pandemic has led to important value-based innovations and changes for better cancer care across different health systems. The challenges to maintaining/implementing these changes vary by setting. Efforts are needed to implement improved elements of care that evolved during the pandemic.


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18. The Out-of-Pocket Cost Burden of Cancer Care—A Systematic Literature Review

Current Oncology


Authors: Nicolas Iragorri ,Claire de Oliveira ,Natalie Fitzgerald ,Beverley Essue
Region / country: Global – Canada, United Kingdom, United States of America
Speciality: Surgical oncology

Background: Out-of-pocket costs pose a substantial economic burden to cancer patients and their families. The purpose of this study was to evaluate the literature on out-of-pocket costs of cancer care. Methods: A systematic literature review was conducted to identify studies that estimated the out-of-pocket cost burden faced by cancer patients and their caregivers. The average monthly out-of-pocket costs per patient were reported/estimated and converted to 2018 USD. Costs were reported as medical and non-medical costs and were reported across countries or country income levels by cancer site, where possible, and category. The out-of-pocket burden was estimated as the average proportion of income spent as non-reimbursable costs. Results: Among all cancers, adult patients and caregivers in the U.S. spent between USD 180 and USD 2600 per month, compared to USD 15–400 in Canada, USD 4–609 in Western Europe, and USD 58–438 in Australia. Patients with breast or colorectal cancer spent around USD 200 per month, while pediatric cancer patients spent USD 800. Patients spent USD 288 per month on cancer medications in the U.S. and USD 40 in other high-income countries (HICs). The average costs for medical consultations and in-hospital care were estimated between USD 40–71 in HICs. Cancer patients and caregivers spent 42% and 16% of their annual income on out-of-pocket expenses in low- and middle-income countries and HICs, respectively. Conclusions: We found evidence that cancer is associated with high out-of-pocket costs. Healthcare systems have an opportunity to improve the coverage of medical and non-medical costs for cancer patients to help alleviate this burden and ensure equitable access to care


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19. Ultrasound-Guided Transthoracic Mediastinal Biopsy: A Safe Technique for Tissue Diagnosis in Middle- and Low-Income Countries

cureus


Authors: Muhammad Kashif Shazlee, Muhammad Ali, Muhammad Saad Ahmed, Junaid Iqbal, Jaideep Darira, Muhammad Qasim Naeem
Region / country: Southern Asia – Pakistan
Speciality: Cardiothoracic surgery, Other, Surgical oncology

Background and objectives
The high cost of video-assisted transthoracic procedures precludes their use in the diagnostics of mediastinal masses in low- and middle-income countries (LMICs). This study aims to assess the technical success rate and diagnostic yield of ultrasound-guided transthoracic mediastinal biopsies at a tertiary care hospital.

Methods
This descriptive cross-sectional study was conducted in patients presenting with mediastinal masses referred to radiology services at Dr. Ziauddin University Hospital. Karachi, Pakistan. Ultrasonography was performed using Toshiba Xario 200 & Aplio 500 using convex and linear probes accordingly. Biopsy was performed using a combination of 18G semiautomatic trucut and 17G co-axial needles. Complications and overall diagnostic yields were determined.

Results
In all 70 patients referred, the procedure was completed successfully with an overall procedural yield of 95.7%. Inconclusive biopsies due to inadequate specimen were seen in two (4.2%) patients. No post-procedure major complication or mortality was observed. Minor complications were seen in three (4.2%) out of 70, including hematoma (<3 cm) in one patient and small pneumomediastinum in two patients.

Conclusion
Ultrasound-guided transthoracic mediastinal biopsy may be the pragmatic technique of choice in LMICs for the diagnosis of mediastinal masses as they provide real-time visualization and is cost-effective and safe


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20. Progress and challenges in potential access to oral health primary care services in Brazil: A population-based panel study with latent transition analysis

PLOS ONE


Authors: Ana Graziela Araujo Ribeiro ,Rafiza Félix Marão Martins,João Ricardo Nickenig Vissoci,Núbia Cristina da Silva,Thiago Augusto Hernandes Rocha,Rejane Christine de Sousa Queiroz,Aline Sampieri Tonello,Catherine A. Staton,Luiz Augusto Facchini,Erika Bárbara Abreu Fonseca Thomaz
Region / country: South America – Brazil
Speciality: Maxillofacial and oral surgery

Objective
Compared indicators of potential access to oral health services sought in two cycles of the Program for Improvement of Access and Quality of Primary Care (PMAQ-AB), verifying whether the program generated changes in access to oral health services.

Methods
Transitional analysis of latent classes was used to analyze two cross-sections of the external evaluation of the PMAQ-AB (Cycle I: 2011–2012 and Cycle II: 2013–2014), identifying completeness classes for a structure and work process related to oral health. Consider three indicators of structure (presence of a dental surgeon, existence of a dental office and operating at minimum hours) and five of the work process (scheduling every day of the week, home visits, basic dental procedures, scheduling for spontaneous demand and continuation of treatment). Choropleth maps and hotspots were made.

Results
The proportion of elements that had one or more dentist (CD), dental office and operated at minimum hours varied from 65.56% to 67.13 between the two cycles of the PMAQ-AB. The number of teams that made appointments every day of the week increased 8.7% and those that made home visits varied from 44.51% to 52.88%. The reduction in the number of teams that reported guaranteeing the agenda for accommodating spontaneous demand, varying from 62.41% to 60.11% and in the continuity of treatment, varying from 63.41% to 61.11%. For the structure of health requirements, the predominant completeness profile was “Best completeness” in both cycles, comprising 71.0% of the sets at time 1 and 67.0% at time 2. The proportion of teams with “Best completeness” increased by 89.1%, the one with “Worst completeness” increased by 20%, while those with “Average completeness” decreased by 66.3%.

Conclusion
We identified positive changes in the indicators of potential access to oral health services, expanding the users’ ability to use them. However, some access attributes remain unsatisfactory, with organizational barriers persisting.


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21. Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study

BMJ Quality and Safety


Authors: Morgane Clarke, Chiara Pittalis, Eric Borgstein, Leon Bijlmakers, Mweene Cheelo, Martilord Ifeanyichi, Gerald Mwapasa, Adinan Juma, Henk Broekhuizen, Grace Drury, Chris Lavy, John Kachimba, Nyengo Mkandawire, Kondo Chilonga, Ruairí Brugha, Jakub Gajewski
Region / country: Eastern Africa, Southern Africa – Malawi, Tanzania, Zambia
Speciality: General surgery

Background In low-income and middle-income countries, an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable. Poor quality of care also leads to inefficient use of human, material and financial resources for health. Improving outcomes and mitigating the risk of adverse events require effective monitoring and quality control systems.

Aim To assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia.

Methods A mixed-methods cross-sectional study of 75 DHs: Malawi (22), Tanzania (30) and Zambia (23). This included a questionnaire, interviews and visual inspection of operating theatre (OT) registers. Data were collected on monitoring and quality systems for surgical activity, processes and outcomes, as well as perceived barriers.

Results 53% (n=40/75) of DHs use more than one OT register to record surgical operations. With the exception of standardised printed OT registers in Zambia, the register format (often handwritten books) and type of data collected varied between DHs. Monthly reports were seldom analysed by surgical teams. Less than 30% of all surveyed DHs used surgical safety checklists (n=22/75), and <15% (n=11/75) performed surgical audits. 73% (n=22/30) of DHs in Tanzania and less than half of DHs in Malawi (n=11/22) and Zambia (n=10/23) conducted surgical case reviews. Reports of surgical morbidity and mortality were compiled in 65% (n=15/23) of Zambian DHs, and in less than one-third of DHs in Tanzania (n=9/30) and Malawi (n=4/22). Reported barriers to monitoring and quality systems included an absence of formalised guidelines, continuous training opportunities as well as inadequate accountability mechanisms.

Conclusions Surgical monitoring and quality control systems were not standard among sampled DHs. Improvements are needed in standardisation of quality measures used; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.


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22. Barriers to access and utilization of healthcare by children with neurological impairments and disability in low-and middle-income countries: a systematic review

Wellcome Open Research


Authors: Lucy W. Mwangi , Jonathan A. Abuga, Emma Cottrell, Symon M. Kariuki , Samson M. Kinyanjui, Charles RJC. Newton
Region / country: Global
Speciality: Neurosurgery, Paediatric surgery

Background: Neurological impairments (NI) and disability are common among survivors of childhood mortality in low-and middle-income countries (LMICs). We conducted a systematic review to examine the barriers limiting access and utilization of biomedical care by children and adolescents with NI in LMICs.
Methods: We searched PubMed, Latin America and Caribbean Health Sciences Literature, Global Index Medicus, and Google Scholar for studies published between 01/01/1990 and 14/11/2019 to identify relevant studies. We included all reports on barriers limiting access and utilization of preventive, curative, and rehabilitative care for children aged 0-19 years with NI in five domains: epilepsy, and cognitive, auditory, visual, and motor function impairment. Data from primary studies were synthesized using both qualitative and quantitative approaches, and we report a synthesized analysis of the barriers identified in the primary studies.
Results: Our literature searches identified 3,074 reports of which 16 were included in the final analysis. Fourteen studies (87.5%) originated from rural settings in sub-Saharan Africa (SSA). Factors limiting access and utilization of healthcare services in >50% of the studies were: financial constraints (N=15, 93.8%), geographical inaccessibility (N=11, 68.8%), inadequate healthcare resources (N=11, 68.8%), inadequate education/awareness (N=9, 56.3%), and prohibitive culture/beliefs (N=9, 56.3%). Factors reported in <50% of the studies related to the attitude of the patient, health worker, or society (N=7, 43.8%), poor doctor-patient communication (N=5, 31.3%), physical inaccessibility (N=3, 18.8%), and a lack of confidentiality for personal information (N=2, 12.5%). Very few reports were identified from outside Africa preventing a statistical analysis by continent and economic level.
Conclusions: Financial constraints, geographic inaccessibility, and inadequate healthcare resources were the most common barriers limiting access and utilization of healthcare services by children with NI in LMICs.
PROSPERO registration: CRD42020165296 (28/04/2020)


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23. Healthcare providers experiences of using uterine balloon tamponade (UBT) devices for the treatment of post-partum haemorrhage: A meta-synthesis of qualitative studies

PLOS ONE


Authors: Kenneth Finlayson ,Joshua P. Vogel ,Fernando Althabe ,Mariana Widmer ,Olufemi T. Oladapo
Region / country: Global
Speciality: Emergency surgery, Obstetrics and Gynaecology

Background
Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and severe morbidity globally. When PPH cannot be controlled using standard medical treatments, uterine balloon tamponade (UBT) may be used to arrest bleeding. While UBT is used by healthcare providers in hospital settings internationally, their views and experiences have not been systematically explored. The aim of this review is to identify, appraise and synthesize available evidence about the views and experiences of healthcare providers using UBT to treat PPH.

Methods
Using a pre-determined search strategy, we searched MEDLINE, CINAHL, PsycINFO, EMBASE, LILACS, AJOL, and reference lists of eligible studies published 1996–2019, reporting qualitative data on the views and experiences of health professionals using UBT to treat PPH. Author findings were extracted and synthesised using techniques derived from thematic synthesis and confidence in the findings was assessed using GRADE-CERQual.

Results
Out of 89 studies we identified 5 that met our inclusion criteria. The studies were conducted in five low- and middle-income countries (LMICs) in Africa and reported on the use of simple UBT devices for the treatment of PPH. A variety of cadres (including midwives, medical officers and clinical officers) had experience with using UBTs and found them to be effective, convenient, easy to assemble and relatively inexpensive. Providers also suggested regular, hands-on training was necessary to maintain skills and highlighted the importance of community engagement in successful implementation.

Conclusions
Providers felt that administration of a simple UBT device offered a practical and cost-effective approach to the treatment of uncontrolled PPH, especially in contexts where uterotonics were ineffective or unavailable or where access to surgery was not possible. The findings are limited by the relatively small number of studies contributing to the review and further research in other contexts is required to address wider acceptability and feasibility issues


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24. Decompressive craniotomy: an international survey of practice

Acta Neurochirurgical


Authors: Midhun Mohan, Hugo Layard Horsfall, Davi Jorge Fontoura Solla, Faith C. Robertson, Amos O. Adeleye, Tsegazeab Laeke Teklemariam, Muhammad Mukhtar Khan, Franco Servadei, Tariq Khan, Claire Karekezi, Andres M. Rubiano, Peter J. Hutchinson, Wellingson Silva Paiva, Angelos G. Kolias & B. Indira Devi on behalf of the NIHR Global Health Research Group on Neurotrauma
Region / country: Global
Speciality: Neurosurgery, Trauma surgery

Background
Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide.

Method
A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019.

Results
We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC.

Conclusion
Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial.


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25. Assessment of Patient Safety Culture Among Doctors, Nurses, and Midwives in a Public Hospital in Afghanistan

Risk Management and Healthcare Policy


Authors: Jabarkhil AQ, Tabatabaee SS, Jamali J, Moghri J
Region / country: Central Asia, Southern Asia – Afghanistan
Speciality: Health policy

Introduction: The first step to improve the safety of patients in hospitals is to evaluate safety culture. Therefore, the patient safety culture in doctors, nurses and midwives should be reviewed regularly. The aim of the study was to determine the current state of patient safety culture among physicians, nurses and midwives at the Estiqlal Hospital in Kabul to promote an effective safety culture.
Methods: This cross-sectional descriptive study was conducted from January to March 2020 among doctors, nurses, and midwives at the Esteqlal Specialized Hospital in Kabul. In that study, the data were collected through a survey of hospital. Among the 267 employees invited to participate, 267 (100%) completed the surveys. Descriptive statistics have been used to adjust frequency distribution tables and inferential statistics to identify differences in variable relationships. The independent sample T-test and one-way ‘ANOVA ‘ were used to check variations between groups, and SPSS version 25 was used for data analysis.
Results: The findings of this study have shown that organizational learning and non-punitive response to errors have had the highest and lowest scores. Eight out of 12 dimensions of patient safety culture scored lower. Four dimensions of patient safety culture scored the highest. Overall, patient safety culture dimensions were low and poor (44%). This means the patient safety culture at the hospital was poor.
Conclusion: The safety culture of the patients at the hospital was inappropriate, particularly in the eight dimensions of the patient safety culture, immediate intervention was necessary. The study emphasizes the creation of a desirable organizational climate, the need for staff involvement in various levels of decision-making, the creation of a culture of error reporting and recognizing the causing factors, and promoting a patient safety culture.


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26. Understanding the implementation (including women’s use) of maternity waiting homes in low-income and middle-income countries: a realist synthesis protocol

BMJ Open


Authors: Daphne N McRae, Anayda Portela, Tamara Waldron, Nicole Bergen, Nazeem Muhajarine
Region / country: Global
Speciality: Health policy, Obstetrics and Gynaecology

Introduction
Maternity waiting homes in low-income and middle-income countries provide accommodation near health facilities for pregnant women close to the time of birth to promote facility-based birth and birth with a skilled professional and to enable timely access to emergency obstetric services when needed. To date, no studies have provided a systematic, comprehensive synthesis explaining facilitators and barriers to successful maternity waiting home implementation and whether and how implementation strategies and recommendations vary by context. This synthesis will systematically consolidate the evidence, answering the question, ‘How, why, for whom, and in what context are maternity waiting homes successfully implemented in low-income and middle-income countries?’.

Methods and analysis
Methods include standard steps for realist synthesis: determining the scope of the review, searching for evidence, appraising and extracting data, synthesising and analysing the data and developing recommendations for dissemination. Steps are iterative, repeating until theoretical saturation is achieved. Searching will be conducted in 13 electronic databases with results managed in Eppi-Reviewer V.4. There will be no language, study-type or document-type restrictions. Items documented prior to 1990 will be excluded. To ensure our initial and revised programme theories accurately reflect the experiences and knowledge of key stakeholders, most notably the beneficiaries, interviews will be conducted with maternity waiting home users/nonusers, healthcare staff, policymakers and programme designers. All data will be analysed using context–mechanism–outcome configurations, refined and synthesised to produce a final programme theory.

Ethics and dissemination
Ethics approval for the project will be obtained from the Mozambican National Bioethical Commission, Jimma University College of Health Sciences Institutional Review Board and the University of Saskatchewan Bioethical Research Ethics Board. To ensure results of the evaluation are available for uptake by a wide range of stakeholders, dissemination will include peer-reviewed journal publication, a plain-language brief, and conference presentations to stakeholders’ practice audiences.


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27. Primary care and pulmonary physicians’ knowledge and practice concerning screening for lung cancer in Lebanon, a middle‐income country

cancer medicine


Authors: Imad Bou Akl , Nathalie K. Zgheib , Maroun Matar, Deborah Mukherji , Marco Bardus , Rihab Nasr
Region / country: Middle East – Lebanon
Speciality: Cardiothoracic surgery, Surgical oncology

Background
Screening for lung cancer with low‐dose computed tomography (LDCT) was shown to reduce lung cancer incidence and overall mortality, and it has been recently included in international guidelines. Despite the rising burden of lung cancer in low and middle‐income countries (LMICs) such as Lebanon, little is known about what primary care physicians or pulmonologists know and think about LDCT as a screening procedure for lung cancer, and if they recommend it.

Objectives
Evaluate the knowledge about LDCT and implementation of international guidelines for lung cancer screening among Lebanese primary care physicians (PCPs) and pulmonary specialists.

Methodology
PCPs and PUs based in Lebanon were surveyed concerning knowledge and practices related to lung cancer screening by self‐administered paper questionnaires.

Results
73.8% of PCPs and 60.7% of pulmonary specialists recognized LDCT as an effective tool for lung cancer screening, with 63.6% of PCPs and 71% of pulmonary specialists having used it for screening. However, only 23.4% of PCPs and 14.5% of pulmonary specialists recognized the eligibility criteria for screening. Chest X‐ray was recognized as ineffective by only 55.8% of PCPs and 40.7% of pulmonary specialists; indeed, 30.2% of PCPs and 46% of pulmonary specialists continue using it for screening. The majority have initiated a discussion about the risks and benefits of lung cancer screening.

Conclusion
PCPs and pulmonary specialists are initiating discussions and ordering LDCT for lung cancer screening. However, a significant proportion of both specialties are still using a non‐recommended screening tool (chest x‐ray); only few PCPs and pulmonary specialists recognized the population at risk for which screening is recommended. Targeted provider education is needed to close the knowledge gap and promote proper implementation of guidelines for lung cancer screening.


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28. Respiratory complications after surgery in Vietnam: National estimates of the economic burden

The Lancet Regional Health – Western Pacific


Authors: Bui MyHanh ,Khuong Quynh Long , Le Phuong Anh , Doan Quoc Hungab ,Duong Tuan Duce, Pham Thanh, Vietf Tran Tien Hung, Nguyen Hong Ha, Tran Binh Giang ,Duong Duc Hungh ,Hoang Gia Duh,Dao XuanThanh ,Le QuangCuong
Region / country: South-eastern Asia – Vietnam
Speciality: Critical care, Health policy, Other

Background
Estimating the cost of postoperative respiratory complications is crucial in developing appropriate strategies to mitigate the global and national economic burden. However, systematic analysis of the economic burden in low- and middle-income countries is lacking.

Methods
We used the nationwide database of the Vietnam Social Insurance agency and extracted data from January 2017 to September 2018. The data contain 1 241 893 surgical patients undergoing one of seven types of surgery. Propensity score matching method was used to match cases with and without complications. We used generalized gamma regressions to estimate the direct medical costs; logistic regressions to evaluate the impact of postoperative respiratory complications on re-hospitalization and outpatient visits.

Findings
Postoperative respiratory complications increased the odds of re-hospitalization and outpatient visits by 3·49 times (95% CI: 3·35–3·64) and 1·39 times (95% CI: 1·34–1·45) among surgical patients, respectively. The mean incremental cost associated with postoperative respiratory complications occurring within 30 days of the index admission was 1053·3 USD (95% CI: 940·7–1165·8) per procedure, which was equivalent to 41% of the GDP per capita of Vietnam in 2018. We estimated the national annual incremental cost due to respiratory complications occurring within 30 days after surgery was 13·87 million USD. Pneumonia contributed the greatest part of the annual cost burden of postoperative respiratory complications.

Interpretation
The economic burden of postoperative respiratory complications is substantial at both individual and national levels. Postoperative respiratory complications also increase the odds of re-hospitalization and outpatient visits and increase the length of hospital stay among surgical patients.


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29. Global Epidemiology of End-Stage Kidney Disease and Disparities in Kidney Replacement Therapy

American Journal of Nephrology


Authors: Thurlow J.S. , · Joshi M.a,b , Yan G.c , Norris K.C.d , Agodoa L.Y.e , Yuan C.M.a,b · Nee R.
Region / country: Global
Speciality: Urology surgery

Background: The global epidemiology of end-stage kidney disease (ESKD) reflects each nation’s unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs). Summary: From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.


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30. Assessment of clinical and radiographic outcomes following retrograde versus antegrade nailing of infraisthmic femoral shaft fractures without the use of intraoperative fluoroscopy in Tanzania

OTA International


Authors: von Kaeppler Ericka P., Donnelley Claire A. , Roberts Heather J., Eliezer Edmund N, Haonga Billy T, Morshed Saam , Shearer David
Region / country: Eastern Africa – Tanzania
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Objectives:
To compare clinical and radiographic outcomes following antegrade versus retrograde intramedullary nailing of infraisthmic femoral shaft fractures.

Design:
Secondary analysis of prospective cohort study.

Setting:
Tertiary hospital in Tanzania.

Participants:
Adult patients with infraisthmic diaphyseal femur fractures.

Intervention:
Antegrade or retrograde SIGN intramedullary nail.

Outcomes:
Health-related quality of life (HRQOL), radiographic healing, knee range of motion, pain, and alignment (defined as less than or equal to 5 degrees of angular deformity in both coronal and sagittal planes) assessed at 6, 12, 24, and 52 weeks postoperatively.

Results:
Of 160 included patients, 141 (88.1%) had 1-year follow-up and were included in analyses: 42 (29.8%) antegrade, 99 (70.2%) retrograde. Antegrade-nailed patients had more loss of coronal alignment (P = .026), but less knee pain at 6 months (P = .017) and increased knee flexion at 6 weeks (P = .021). There were no significant differences in reoperations, HRQOL, hip pain, knee extension, radiographic healing, or sagittal alignment.

Conclusions:
Antegrade nailing of infraisthmic femur fractures had higher incidence of alignment loss, but no detectable differences in HRQOL, pain, radiographic healing, or reoperation. Retrograde nailing was associated with increased knee pain and decreased knee range of motion at early time points, but this dissipated by 1 year. To our knowledge, this is the first study to prospectively compare outcomes over 1 year in patients treated with antegrade versus retrograde SIGN intramedullary nailing of infraisthmic femur fractures.


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31. Demystifying the potential of Global surgery for Public health

OSF PrePrints


Authors: Parth Patel, Usman Garba Kurmi, Hadiza Abubakar Balkore, Dattatreya Mukherjee
Region / country: Global
Speciality: Health policy

Remarkable gains have been made in global health in the last 25 years, and surgical care is an integral component of healthcare systems for countries at all levels of development. Global surgery, which global surgery, which comprises clinical, educational, and research collaborations to improve surgical care between academic surgeons in high-income countries and low-and middle-income countries (LMICs) and their affiliated academic institutions, has grown significantly. Global surgery may resonate most with those in low-or-middle-income countries (LCMICs),where basic surgery needs are rarely met, and even the most trivial resource may be hard to obtain on a permanent or reliable basis. Therefore, considering this, this article provides an overview on various factors defining the interface between surgery and public health at a global level and discuss future directions.


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32. Assessing the Indirect Effects of COVID-19 on Healthcare Delivery, Utilization, and Health Outcomes: A Scoping Review

European Journal of Public Health


Authors: Charlotte M Roy, E Brennan Bollman, Laura M Carson, Alexander J Northrop, Elizabeth F Jackson, Rachel T Moresky
Region / country: Global
Speciality: Health policy

Background
The COVID-19 pandemic and global efforts to contain its spread, such as stay-at-home orders and transportation shutdowns, have created new barriers to accessing healthcare, resulting in changes in service delivery and utilization globally. The purpose of this study is to provide an overview of the literature published thus far on the indirect health effects of COVID-19 and to explore the data sources and methodologies being used to assess indirect health effects.

Methods
A scoping review of peer-reviewed literature using three search engines was performed.

Results
One hundred and seventy studies were included in the final analysis. Nearly half (46.5%) of included studies focused on cardiovascular health outcomes. The main methodologies used were observational analytic and surveys. Data was drawn from individual health facilities, multicentre networks, regional registries, and national health information systems. Most studies were conducted in high-income countries with only 35.4% of studies representing low- and middle-income countries.

Conclusion
Healthcare utilization for non-COVID-19 conditions has decreased almost universally, across both high- and lower-income countries. The pandemic’s impact on non-COVID-19 health outcomes, particularly for chronic diseases, may take years to fully manifest and should be a topic of ongoing study. Future research should be tied to system improvement and the promotion of health equity, with researchers identifying potentially actionable findings for national, regional, and local health leadership. Public health professionals must also seek to address the disparity in published data from LMICs as compared to high-income countries.


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33. The injustice of unfit clinical practice guidelines in low-resource realities

the lancet global health


Authors: Nanna Maaløe, Anna Marie RønneØrtved, Jane Brandt Sørensen, Brenda Sequeira Dmello, Prof Thomasvan den Akker, Monica Lauridsen Kujabi, Prof Hussein Kidanto, Tarek Meguid , Prof Ib Christian Bygbjerg , Prof Jos van Roosmalen ,Dan Wolf Meyrowitsch , Natasha Housseine
Region / country: Global
Speciality: Health policy

To end the international crisis of preventable deaths in low-income and middle-income countries, evidence-informed and cost-efficient health care is urgently needed, and contextualised clinical practice guidelines are pivotal. However, as exposed by indirect consequences of poorly adapted COVID-19 guidelines, fundamental gaps continue to be reported between international recommendations and realistic best practice. To address this long-standing injustice of leaving health providers without useful guidance, we draw on examples from maternal health and the COVID-19 pandemic. We propose a framework for how global guideline developers can more effectively stratify recommendations for low-resource settings and account for predictable contextual barriers of implementation (eg, human resources) as well as gains and losses (eg, cost-efficiency). Such development of more realistic clinical practice guidelines at the global level will pave the way for simpler and achievable adaptation at local levels. We also urge the development and adaptation of high-quality clinical practice guidelines at national and subnational levels in low-income and middle-income countries through co-creation with end-users, and we encourage global sharing of these experiences.


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34. Construction and Performance Testing of a Fast-Assembly COVID-19 (FALCON) Emergency Ventilator in a Model of Normal and Low-Pulmonary Compliance Conditions

Front. Physiology


Authors: Luke A. White, Ryan P. Mackay, Giovanni F. Solitro, Steven A. Conrad, J. Steven Alexander
Region / country: Global
Speciality: Critical care, Other

Introduction: The COVID-19 pandemic has revealed an immense, unmet and international need for available ventilators. Both clinical and engineering groups around the globe have responded through the development of “homemade” or do-it-yourself (DIY) ventilators. Several designs have been prototyped, tested, and shared over the internet. However, many open source DIY ventilators require extensive familiarity with microcontroller programming and electronics assembly, which many healthcare providers may lack. In light of this, we designed and bench tested a low-cost, pressure-controlled mechanical ventilator that is “plug and play” by design, where no end-user microcontroller programming is required. This Fast-AssembLy COVID-Nineteen (FALCON) emergency prototype ventilator can be rapidly assembled and could be readily modified and improved upon to potentially provide a ventilatory option when no other is present, especially in low- and middle-income countries.

Hypothesis: We anticipated that a minimal component prototype ventilator could be easily assembled that could reproduce pressure/flow waveforms and tidal volumes similar to a hospital grade ventilator (Engström CarestationTM).

Materials and Methods: We benched-tested our prototype ventilator using an artificial test lung under 36 test conditions with varying respiratory rates, peak inspiratory pressures (PIP), positive end expiratory pressures (PEEP), and artificial lung compliances. Pressure and flow waveforms were recorded, and tidal volumes calculated with prototype ventilator performance compared to a hospital-grade ventilator (Engström CarestationTM) under identical test conditions.

Results: Pressure and flow waveforms produced by the prototype ventilator were highly similar to the CarestationTM. The ventilator generated consistent PIP/PEEP, with tidal volume ranges similar to the CarestationTM. The FALCON prototype was tested continuously for a 5-day period without failure or significant changes in delivered PIP/PEEP.

Conclusion: The FALCON prototype ventilator is an inexpensive and easily-assembled “plug and play” emergency ventilator design. The FALCON ventilator is currently a non-certified prototype that, following further appropriate validation and testing, might eventually be used as a life-saving emergency device in extraordinary circumstances when more sophisticated forms of ventilation are unavailable.


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35. Knowledge of, and complicance to infection prevention and control among nurses in the northern regional hospital

UDSspace


Authors: Mohammed Mutaru Tahiru
Region / country: Western Africa – Ghana
Speciality: Health policy

Introduction: Hospital-acquired infections (HAIs) also known as a nosocomial infection is associated with increased morbidity and mortality among hospitalized clients and predisposes health care workers (HCWs) to an increased risk of infections. Therefore, an effective Infection Prevention and Control (IPC) programme is fundamental to quality health care. This study looked at the knowledge of and compliance with infection prevention and control among Nurses at the Northern Regional Hospital Tamale, Ghana. The goal of this study was to assess the knowledge level and compliance with infection prevention and control practices among Nurses in the Northern Regional hospital Tamale, Ghana. Methodology: The study adopted a facility-based descriptive cross-sectional study. Data were collected from 268 staff nurses at Central Hospital, Tamale. A mixed-method was employed and using Self- administered questionnaire and key informant interview guide. Data were collected and entered into IBM SPSS V. 21 for analysis. Results: At the Northern Regional Hospital majority (60.5%) of the respondents had high IPC knowledge, 25.8% had moderate IPC knowledge level and only 13.8% had low IPC knowledge level. The findings on IPC compliance revealed that majority (77.6%) of the respondents had a low IPC compliance level, 19.8% had a moderate IPC compliance level and only 2.6% had a high IPC compliance level. Conclusion: Although the study revealed that most of the respondents had good knowledge of the IPC. However, compliance with IPC guidelines was still very low in the hospital. It was observed from the study that, the hospital has limited access to IPC training manuals couple with inadequate IPC materials such as Hand hygiene materials and Personnel protective equipment (PPEs). The Ghana Health Service in collaboration with the Ministry of Health should intensify monitoring and supervision at all levels of service delivery points to ensure health care providers compiles with IPC standard protocols. The Ghana Health Service, Ministry of Health and Development Partners should ensure IPC materials are in constant supply and made available to all health care service points. The Hospital should regularly conduct refresher training on current IPC standards and ensure compliance through effective monitoring. Health staff should make conscious efforts to protect themselves and clients against infections by ensuring that IPC standards and protocols are strictly followed in the discharge of their duties.


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36. Assessment of Laparoscopic Instrument Reprocessing in Rural India: A Mixed Methods Study

Research Square


Authors: Daniel Robertson, Jesudian Gnanaraj , Linda Wauben, Jan Huijs, Vasanth Mark Samuel, Jenny Dankelman , Tim Horeman-Franse
Region / country: Southern Asia – India
Speciality: General surgery, Health policy

Background
Laparoscopy is a minimally-invasive surgical procedure that uses long slender instruments that require much smaller incisions than conventional surgery. This leads to faster recovery times, fewer infections and shorter hospital stays. For these reasons, laparoscopy could be particularly advantageous to patients in low to middle income countries (LMICs). Unfortunately, sterile processing departments in LMIC hospitals are faced with limited access to equipment and trained staff and poses an obstacle to safe surgical care. The reprocessing of laparoscopic devices requires specialised equipment and training. Therefore, when LMIC hospitals invest in laparoscopy, an update of the standard operating procedure in sterile processing is required. Currently, it is unclear whether LMIC hospitals, that already perform laparoscopy, have managed to introduce updated reprocessing methods that minimally invasive equipment requires. The aim of this study was to identify the laparoscopic sterile reprocessing procedures in rural India and to test the effectiveness of the sterilisation equipment.
Methods
We assessed laparoscopic instrument sterilisation capacity in four rural hospitals in different states in India using a mixed-methods approach. As the main form of data collection, we developed a standardised observational checklist based on reprocessing guidelines from several sources. Steam autoclave performance was measured by monitoring the autoclave cycles in two hospitals. Finally, the findings from the checklist data were supported by an interview survey with surgeons and nurses.
Results
The checklist data revealed the reprocessing methods the hospitals used in the reprocessing of laparoscopic instruments. It showed that the standard operating procedures had not been updated since the introduction of laparoscopy and the same reprocessing methods for regular surgical instruments were still applied. The interviews conrmed that staff had not received additional training and that they were unaware of the hazardous effects of reprocessing detergents and disinfectants.
Conclusion
As laparoscopy is becoming more prevalent in LMICs, updated policy is needed to incorporate minimally invasive instrument reprocessing in medical practitioner and staff training programs. While reprocessing standards improve, it is essential to develop instruments and reprocessing equipment that is
more suitable for resource-constrained rural surgical environments.


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37. SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

British Journal of Surgery


Authors: COVIDSurg Collaborative
Region / country: Global
Speciality: Health policy

Background
Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling.

Methods
The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty.

Results
NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year.

Conclusion
As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.


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38. Prevention of road traffic collisions and associated neurotrauma in Colombia: An exploratory qualitative study

PLOS ONE


Authors: Santhani M. Selveindran ,Gurusinghe D. N. Samarutilake ,David Santiago Vera ,Carol Brayne,Christine Hill,Angelos Kolias,Alexis J. Joannides,Peter J. A. Hutchinson,Andres M. Rubiano
Region / country: South America – Colombia
Speciality: Emergency surgery, Neurosurgery, Trauma surgery

Introduction
Neurotrauma is an important but preventable cause of death and disability worldwide, with the majority being associated with road traffic collisions (RTCs). The greatest burden is seen in low -and middle- income countries (LMICs) where variations in the environment, infrastructure, population and habits can challenge the success of conventional preventative approaches. It is therefore necessary to understand local perspectives to allow for the development and implementation of context-specific strategies which are effective and sustainable.

Methods
This study took place in Colombia where qualitative data collection was carried out with ten key informants between October and November 2019. Semi-structured interviews were conducted and explored perceptions on RTCs and neurotrauma, preventative strategies and interventions, and the role of research in prevention. Interview transcripts were analysed by thematic analysis using a framework approach.

Results
Participants’ confirmed that RTCs are a significant problem in Colombia with neurotrauma as an important outcome. Human and organisational factors were identified as key causes of the high rates of RTCs. Participants described the current local preventative strategies, but were quick to discuss limitations and challenges to their success. Key barriers reported were poor attitudes and knowledge, particularly in the community. Suggestions were provided on ways to improve prevention through better education and awareness, stricter enforcement and new policies on prevention, proper budgeting and resource allocation, as well as through collaboration and changes in attitudes and leadership. Participants identified four key research areas they felt would influence prevention of RTCs and associated neurotrauma: causes of RTCs; consequences and impact of RTCs; public involvement in research; improving prevention.

Conclusion
RTCs are a major problem in Colombia despite the current preventative strategies and interventions. Findings from this study have a potential to influence policy, practice and research by illustrating different solutions to the challenges surrounding prevention and by highlighting areas for further research.


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39. Smartphone Medical App Use and Associated Factors Among Physicians at Referral Hospitals in Amhara Region, North Ethiopia, in 2019: Cross-sectional Study

JMIR Mhealth Uhealth


Authors: Gizaw Hailiye Teferi, Binyam Cheklu Tilahun , Habtamu Alganeh Guadie , Ashenafi Tazebew Amare
Region / country: Eastern Africa – Ethiopia
Speciality: Health policy, Other

Background:
Information in health care is rapidly expanding and is updated very regularly, especially with the increasing use of technology in the sector. Due to this, health care providers require timely access to the latest scientific evidence anywhere. Smartphone medical apps are tools to access the latest reputable scientific evidence in the discipline. In addition, smartphone medical apps could lead to improved decision making, reduced numbers of medical errors, and improved communication between hospital medical staff.

Objective:
The aim of this study was to assess smartphone medical app use and associated factors among physicians working at referral hospitals of the Amhara region, Ethiopia.

Methods:
An institution-based cross-sectional study design was conducted among physicians working at 5 referral hospitals in the Amhara region, Ethiopia, from February 5 to May 27, 2019. A simple random sampling method was used to select 423 physicians. A self-administered questionnaire was used to collect the data and analyzed using SPSS, version 21 (IBM Corp). Binary and multivariable logistic regression analysis was performed to assess factors associated with smartphone medical app use among physicians. A value of P<.05, corresponding to a 95% CI, was considered statistically significant. The validity of the questionnaire was determined based on the view of experts and the reliability of it obtained by calculating the value of Cronbach alpha (α=.78)

Results:
In this study, most of the 417 respondents (375, 89.9%) had medical apps installed on their smartphones. Of those 375 respondents, 264 (70.4%) had used medical apps during clinical practice. The medical apps most commonly used by the respondents were UpToDate, Medscape, MedCalc, and Doximity. According to multivariable logistic regression analysis, attitude (adjusted odds ratio [AOR] 1.64, 95% CI 1.05-2.55), internet access (AOR 2.82, 95% CI 1.75-4.54), computer training (AOR 1.71, 95% CI 1.09-2.67), perceived usefulness of the app (AOR 1.64, 95% CI 1.05-2.54), information technology support staff (AOR 2.363, 95% CI 1.5-3.08), and technical skill (AOR 2.52, 95% CI 1.50-4.25) were significantly associated with smartphone medical app use.

Conclusions:
Most respondents have a smartphone medical app and have used it in clinical practice. Attitude, internet access, computer training, perceived usefulness of the app, information technology support staff, and technical skill are the most notable factors that are associated with smartphone medical app use by physicians.


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40. A broken bone no longer a burden to carry: a destination in sight

African Journal of Current Medical Research


Authors: Saabea Owusu Konadu,Dominic Konadu Yeboah, Gilda Opoku, Obed Nyarko Ofori
Region / country: Western Africa – Ghana
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Worldwide the third leading cause of death among persons under 40 years is attributed to trauma(1). In Ghana road traffic accidents have a case fatality rate of about 17%(3). Over the years with interventions and policies by AO Alliance the burden and morbidity following trauma especially road traffic accidents have reduced; with a destination in sight where a broken bone is no longer a burden to carry.


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41. District hospital surgical capacity in Western Cape Province, South Africa: A cross-sectional survey

the south african medical journal


Authors: P Naidu, K M Chu
Region / country: Southern Africa – South Africa
Speciality: General surgery, Health policy

Background. The role of the district hospital (DH) in surgical care has been undervalued. However, decentralised surgical services at DHs have been identified as a key component of universal health coverage. Surgical capacity at DHs in Western Cape (WC) Province, South Africa, has not been described.

Objectives. To describe DH surgical capacity in WC and identify barriers to scaling up surgical capacity at these facilities.

Methods. This was a cross-sectional survey of 33 DHs using the World Health Organization surgical situational analysis tool administered to hospital staff from June to December 2019. The survey addressed the following domains: general services and financing; service delivery and surgical volume; surgical workforce; hospital and operating theatre (OT) infrastructure, equipment and medication; and barriers to scaling up surgical care.

Results. Seven of 33 DHs (21%) did not have a functional OT. Of the 28 World Bank DH procedures, small WC DHs performed up to 22 (79%) and medium/large DHs up to 26 (93%). Only medium/large DHs performed all three bellwether procedures. Five DHs (15%) had a full-time surgeon, anaesthetist or obstetrician (SAO). Of DHs without any SAO specialists, 14 (50%) had family physicians (FPs). These DHs performed more operative procedures than those without FPs (p=0.005). Lack of finances dedicated for surgical care and lack of surgical providers were the most reported barriers to providing and expanding surgical services.

Conclusions. WC DH surgical capacity varied by hospital size. However, FPs could play an essential role in surgery at DHs with appropriate training, oversight and support from SAO specialists. Strategies to scale up surgical capacity include dedicated financial and human resources.


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42. Development of an Interactive Global Surgery Course for Interdisciplinary Learners

annals of golbal health


Authors: Tamara N. Fitzgerald , Nyagetuba J. K. Muma, John A. Gallis, Grey Reavis, Alvan Ukachukwu, Emily R. Smith, Osondu Ogbuoji, Henry E. Rice
Region / country: Global
Speciality: Surgical Education

Introduction: Global surgical care is increasingly recognized in the global health agenda and requires multidisciplinary engagement. Despite high interest among medical students, residents and other learners, many surgical faculty and health experts remain uniformed about global surgical care.

Methods: We have operated an interdisciplinary graduate-level course in Global Surgical Care based on didactics and interactive group learning. Students completed a pre- and post-course survey regarding their learning experiences and results were analyzed using the Wilcoxon signed-rank test.

Results: Fourteen students completed the pre-course survey, and 11 completed the post-course survey. Eleven students (79%) were enrolled in a Master’s degree program in global health, with eight students (57%) planning to attend medical school. The median ranking of surgery on the global health agenda was fifth at the beginning of the course and third at the conclusion (p = 0.11). Non-infectious disease priorities tended to stay the same or increase in rank from pre- to post-course. Infectious disease priorities tended to decrease in rank (HIV/AIDS, p = 0.07; malaria, p = 0.02; neglected infectious disease, p = 0.3). Students reported that their understanding of global health (p = 0.03), global surgery (p = 0.001) and challenges faced by the underserved (p = 0.03) improved during the course. When asked if surgery was an indispensable part of healthcare, before the course 64% of students strongly agreed, while after the course 91% of students strongly agreed (p = 0.3). Students reported that the interactive nature of the course strengthened their skills in collaborative problem-solving.

Conclusions: We describe an interdisciplinary global surgery course that integrates didactics with team-based projects. Students appeared to learn core topics and held a different view of global surgery after the course. Similar courses in global surgery can educate clinicians and other stakeholders about strategies for building healthy surgical systems worldwide.


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43. Improving Neurosurgery education using Social-Media Case-based discussions: A Pilot Study

World Neurosurgery: X


Authors: Nicola Newall, Brandon G. Smith, Oliver Burton,Aswin Char , Angelos G. Kolias, Peter J. Hutchinson, Alex Alamri, Chris Uff
Region / country: Global
Speciality: Neurosurgery, Surgical Education

In recent years, there has been a shift towards a more generalised undergraduate medical curriculum in the United Kingdom (UK). This has meant there is less exposure to a number of specialities, including neurosurgery. As a result, some specialities have developed speciality-specific core curricula to ensure accurate,
standardised teaching occurs. However, at present, there are no national guidelines for undergraduate neurosurgery teaching, albeit with some recommendations from the Royal College of Surgeons and the Association of Surgeons in Training.A growing body of literature has highlighted the disparities in neurosurgical teaching between medical schools. A UK survey examining the current teaching practice found that in some institutions neurosurgery was not taught as part of the curriculum, and in others not all students received formal teaching. Significant variations in the content were also reported and teaching was often undertaken by non-specialist clinicians. With the UK moving towards more streamlined residency programmes through nationalised selection into specialties in 2005, postgraduate experience in neurosurgery has also dwindled; this experience would previously have been invaluable for doctors subsequently moving into other specialties.


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44. Epidemiologic Pattern of Cancer in Kathmandu Valley, Nepal: Findings of Population-Based Cancer Registry, 2018

JCO Global Oncology


Authors: Ranjeeta Subedi , Meghnath Dhimal , Atul Budukh ,Sandhya Chapagain, Pradeep Gyawali, Bishal Gyawali , Uma Dahal, Rajesh Dikshit, and Anjani Kumar Jha
Region / country: Southern Asia – Nepal
Speciality: Surgical oncology

PURPOSE
Although cancer is an important and growing public health issue in Nepal, the country lacked any population-based cancer registry (PBCR) until 2018. In this study, we describe the establishment of the PBCR for the first time in Nepal and use the registry data to understand incidence, mortality, and patterns of cancer in the Kathmandu Valley (consisting of Kathmandu, Lalitpur, and Bhaktapur districts), which comprises 10.5% of the estimated 29 million population of Nepal in 2018.

MATERIALS AND METHODS
The PBCR collects information from facilities and communities through the active process. The facilities include cancer or general hospitals, pathology laboratories, hospice, and Ayurvedic centers. In the communities, the field enumerators or female community health volunteers collected the data from the households. In addition, the Social Security and Nursing Division under the Department of Health Services, which provides subsidy for cancer treatment of underprivileged patients, was another major source of data. The collected data were verified for residence, accuracy, and completeness and then entered and analyzed using CanReg5 software.

RESULTS
In the Kathmandu Valley, the PBCR registered 2,156 new cancer cases with overall age-adjusted incidence rate for all cancers of 95.7 per 100,000 population (95.3 for males and 98.1 for females). The age-adjusted mortality rate for males was 36.3 (n = 365) and for females 27.0 (n = 305) per 100,000 population. We found that the commonest cancers in males were lung and stomach, whereas in females, they were breast and lung cancer. Gallbladder cancer was among the top five common cancers in both sex.

CONCLUSION
These findings provide a milestone to understand the cancer burden in the country for the first time using the PBCR and will be helpful to develop and prioritize cancer control strategies.


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45. New Frontiers for Fairer Breast Cancer Care in a Globalized World

Eur J Breast Health


Authors: Didier Verhoeven , Claudia Allemani , Cary Kaufman , Sabine Siesling , Manuela Joore , Etienne Brain , Mauricio Magalhães Costa
Region / country: Global
Speciality: General surgery, Surgical oncology

In early 2020, the book “Breast cancer: Global Quality Care” was published by Oxford University Press. In the year since then, publications, interviews (by ecancer), presentations, webinars, and virtual congress have been organized to disseminate further the main message of the project: “A call for Fairer Breast Cancer Care for all Women in a Globalized World.” Special attention is paid to increasing the “value-based healthcare” putting the patient in the center of the care pathway and sharing information on high-quality integrated breast cancer care. Specific recommendations are made considering the local resource facilities. The multidisciplinary breast conference is considered “the jewel in the crown” of the integrated practice unit, connecting multiple specializations and functions concerned with patients with breast cancer. Management and coordination of medical expertise, facilities, and their interfaces are highly recommended. The participation of two world-leading cancer research programs, the CONCORD program and Breast Health Global Initiative, in this project has been particularly important. The project is continuously under review with feedback from the faculty. The future plan is to arrive at an openaccess publication that is freely available to all interested people. This project is designed to help ease the burden and suffering of women with breast cancer
across the globe


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46. Regional anesthesia educational material utilization varies by World Bank income category: A mobile health application data study

plos one


Authors: Vanessa Moll, Edward R. Mariano, Jamie M. Kitzman,Vikas N. O’Reilly-Shah ,Craig S. Jabaley
Region / country: Global
Speciality: Anaesthesia, Health policy, Surgical Education

Introduction
Regional anesthesia offers an alternative to general anesthesia and may be advantageous in low resource environments. There is a paucity of data regarding the practice of regional anesthesia in low- and middle-income countries. Using access data from a free Android app with curated regional anesthesia learning modules, we aimed to estimate global interest in regional anesthesia and potential applications to clinical practice stratified by World Bank income level.

Methods
We retrospectively analyzed data collected from the free Android app “Anesthesiologist” from December 2015 to April 2020. The app performs basic anesthetic calculations and provides links to videos on performing 12 different nerve blocks. Users of the app were classified on the basis of whether or not they had accessed the links. Nerve blocks were also classified according to major use (surgical block, postoperative pain adjunct, rescue block).

Results
Practitioners in low- and middle-income countries accessed the app more frequently than in high-income countries as measured by clicks. Users from low- and middle-income countries focused mainly on surgical blocks: ankle, axillary, infraclavicular, interscalene, and supraclavicular blocks. In high-income countries, more users viewed postoperative pain blocks: adductor canal, popliteal, femoral, and transverse abdominis plane blocks. Utilization of the app was constant over time with a general decline with the start of the COVID-19 pandemic.

Conclusion
The use of an in app survey and analytics can help identify gaps and opportunities for regional anesthesia techniques and practices. This is especially impactful in limited-resource areas, such as lower-income environments and can lead to targeted educational initiatives.


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47. Trends and patterns of antibiotic prescribing at orthopedic inpatient departments of two private-sector hospitals in Central India: A 10-year observational study

journal plos one


Authors: Kristina Skender,Vivek Singh,Cecilia Stalsby-Lundborg,Megha Sharma
Region / country: Southern Asia – India
Speciality: Other, Trauma and orthopaedic surgery

Background
Frequent antibiotic prescribing in departments with high infection risk like orthopedics prominently contributes to the global increase of antibiotic resistance. However, few studies present antibiotic prescribing patterns and trends among orthopedic inpatients.

Aim
To compare and present the patterns and trends of antibiotic prescription over 10 years for orthopedic inpatients in a teaching (TH) and a non-teaching hospital (NTH) in Central India.

Methods
Data from orthopedic inpatients (TH-6446; NTH-4397) were collected using a prospective cross-sectional study design. Patterns were compared based on the indications and corresponding antibiotic treatments, mean Defined Daily Doses (DDD)/1000 patient-days, adherence to the National List of Essential Medicines India (NLEMI) and the World Health Organization Model List of Essential Medicines (WHOMLEM). Antibiotic prescriptions were analyzed separately for the operated and the non-operated inpatients. Linear regression was used to analyze the time trends of antibiotic prescribing; in total through DDD/1000 patient-days and by antibiotic groups.

Results
Third generation cephalosporins were the most prescribed antibiotic class (TH-39%; NTH-65%) and fractures were the most common indications (TH-48%; NTH-48%). Majority of the operated inpatients (TH-99%; NTH-97%) were prescribed pre-operative prophylactic antibiotics. The non-operated inpatients were also prescribed antibiotics (TH-40%; NTH-75%), although few of them had infectious diagnoses (TH-8%; NTH-14%). Adherence to the NLEMI was lower (TH-31%; NTH-34%) than adherence to the WHOMLEM (TH-65%; NTH-62%) in both hospitals. Mean DDD/1000 patient-days was 16 times higher in the TH (2658) compared to the NTH (162). Total antibiotic prescribing increased over 10 years (TH-β = 3.23; NTH-β = 1.02).

Conclusion
Substantial number of inpatients were prescribed antibiotics without clear infectious indications. Adherence to the NLEMI and the WHOMLEM was low in both hospitals. Antibiotic use increased in both hospitals over 10 years and was higher in the TH than in the NTH. The need for developing and implementing local antibiotic prescribing guidelines is emphasized.


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48. How do caregivers of children with congenital heart diseases access and navigate the healthcare system in Ethiopia?

BMC Health Services Research


Authors: Sugy Choi, Heesu Shin, Jongho Heo, Etsegenet Gedlu, Berhanu Nega, Tamirat Moges, Abebe Bezabih, Jayoung Park & Woong-Han Kim
Region / country: Eastern Africa – Ethiopia
Speciality: Cardiothoracic surgery, Paediatric surgery

Background
Surgery can correct congenital heart defects, but disease management in low- and middle-income countries can be challenging and complex due to a lack of referral system, financial resources, human resources, and infrastructure for surgical and post-operative care. This study investigates the experiences of caregivers of children with CHD accessing the health care system and pediatric cardiac surgery.

Methods
A qualitative study was conducted at a teaching hospital in Ethiopia. We conducted semi-structured interviews with 13 caregivers of 10 patients with CHD who underwent cardiac surgery. We additionally conducted chart reviews for triangulation and verification. Interviews were conducted in Amharic and then translated into English. Data were analyzed according to the principles of interpretive thematic analysis, informed by the candidacy framework.

Results
The following four observations emerged from the interviews: (a) most patients were diagnosed with CHD at birth if they were born at a health care facility, but for those born at home, CHD was discovered much later (b) many patients experienced misdiagnoses before seeking care at a large hospital, (c) after diagnosis, patients were waiting for the surgery for more than a year, (d) caregivers felt anxious and optimistic once they were able to schedule the surgical date. During the care-seeking journey, caregivers encountered financial constraints, struggled in a fragmented delivery system, and experienced poor service quality.

Conclusions
Delayed access to care was largely due to the lack of early CHD recognition and financial hardships, related to the inefficient and disorganized health care system. Fee waivers were available to assist low-income children in gaining access to health services or medications, but application information was not readily available. Indirect costs like long-distance travel contributed to this challenge. Overall, improvements must be made for district-level screening and the health care workforce.


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49. Perception and Attitude of Surgical Trainees in Nigeria to Trauma Care

Surgery Research and Practice


Authors: Onyedika Okoye , Emmanuel Ameh, and Emmanuel Ojo
Region / country: Western Africa – Nigeria
Speciality: Critical care, Emergency surgery, Surgical Education, Trauma surgery

Background. Trauma is still the leading cause of death in individuals between the ages of 1 and 44 years. Establishment of good trauma centres and systems has been shown to have a significant positive impact on outcomes. Surgical specialties, particularly trauma, are becoming less attractive in different parts of the world for a variety of reasons. Aim.  The aim of this study is to ascertain the perception and attitude of future surgeons towards trauma care in Nigeria. Materials and methods. This is a cross-sectional study using a pretested, structured, paper-based questionnaire which was administered to consecutive surgical trainees at the annual revision course of West African College of Surgeons. Data were analyzed using SPSS version 12, and results are presented in tables and figures. Results. One hundred and fifty-seven questionnaires were adequately completed with a male-to-female ratio of 18 : 1 and median age of 30 years. There is a general agreement among the respondents that trauma incidence in Nigeria is high or very high. While about 70% of the respondents believe that the Nigerian trauma system is poorly planned, about 19% think it is nonexistent. 81 (53.7%) agree or strongly agree that managing trauma patients is too stressful. A good number, 116 (74.4%), strongly agree that having a separate dedicated trauma unit will improve care and outcome. While 82% of the surgical trainees support post fellowship training in trauma, only 62.2% will like to have the training. There is no significant difference between the proportion of males and females who would like to have the training. Conclusion. Surgical trainees in Nigeria have good perception and positive attitude towards trauma care. Primary prevention measures must be emphasized during surgical trainees’ training in trauma.


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50. Shared learning in and beyond the COVID-19 pandemic

European Journal of Cardio-Thoracic Surgery


Authors: Ramanish Ravishankar, Najah A Adreak, Dominique Vervoort
Region / country: Global
Speciality: Cardiothoracic surgery, Health policy

The COVID-19 pandemic has cost the lives of over 1.5 million people to date and resulted in severe surgical backlogs up to tens of millions of surgeries worldwide [1]. Steinmaurer and Bley [2] appropriately question whether the transformability of cardiac surgery in high-income country epicentres of the COVID-19 pandemic can lead to changes elsewhere in the world. Six billion people lack access to safe, timely and affordable cardiac surgical care when needed, and this pandemic has only aggravated disparities in access to care [3, 4]. As countries have adapted and vaccines are on the horizon, it is paramount to think above and beyond what we have learned in our specialty during these challenging times and recognize the sustained disparities across the globe.

These disparities can be further explored by assessing service provision and workforce capacity in low- and middle-income countries (LMICs). This is especially prominent in low-income countries, where 0.04 cardiac surgeons are available per million population compared to 7.15 in high-income countries [4]. The loss of even 1 surgeon can lead to disastrous consequences in service provision. Now, travel restrictions imposed due to the pandemic have substantially increased these discrepancies. LMIC centres acting as regional hubs, often offering free or subsidized surgery, have experienced significant volume reductions while adapting to COVID-19 responses [4]. The pandemic also affected visiting teams, who have been unable to reach regions where local capacity is scant. These issues signpost the need for urgent solutions.

The pandemic has emphasized the importance of a global health view for cardiac surgery. Mutual learning can act as a vector for exponential change and improvement in meeting these disparities. George et al. [5] have described multiple strategies used in the New-York Presbyterian Hospital within their cardiac surgical service such as split ventilation and using additional operating room space for intensive care beds. Such innovations may be utilized to increase the long-term cardiac surgical capacity in LMICs in intensive care units, which can be rate-limiting factors when deciding to take on new patients. In addition, personal protective equipment may be preserved by reducing the number of personnel scrubbed in and switching between operations [5]. This was mirrored in Boston Children’s Hospital, where do-it-yourself elastomeric respirators were developed as a result of N95 shortages [6]. With such low-cost options being successfully incorporated into high-performance units, these examples highlight the importance of shared learning and its symbiotic relationship.

The COVID-19 era has facilitated change in clinical practice to reach a new normal, but with recent developments of imminent vaccine rollout, there is hope for resolving the challenges presented to us both in the short and long terms. With high-income countries dictating and dominating vaccine distribution, we can expect a significant hiatus before adequate herd immunity can be established in LMICs. As a result of these economic imbalances, cardiovascular care disparities will continue to pose a substantial burden. It is our moral responsibility to recognize the privileged position we inhabit and use the experiences from this pandemic to fuel shared learning and bilateral partnerships.


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51. Postpartum infection, pain and experiences with care among women treated for postpartum hemorrhage in three African countries: A cohort study of women managed with and without condom-catheter uterine balloon tamponade

PLOS ONE


Authors: Holly A. Anger, Jill Durocher, Rasha Dabash, Nevine Hassanein, Sam Ononge, Gillian Burkhardt, Laura J. Frye, Ayisha Diop, Seynabou Bop Moctar Beye Diop, Emad Darwish, Mohamed Cherine Ramadan, Juliana Kayaga, Dyanna Charles, Alioune Gaye, Melody Eckardt, Beverly Winikof
Region / country: Eastern Africa, Northern Africa, Western Africa – Egypt, Senegal, Uganda
Speciality: Anaesthesia, Obstetrics and Gynaecology

Abstract
Objective
We aimed to determine the risk of postpartum infection and increased pain associated with use of condom-catheter uterine balloon tamponade (UBT) among women diagnosed with postpartum hemorrhage (PPH) in three low- and middle-income countries (LMICs). We also sought women’s opinions on their overall experience of PPH care.

Methods
This prospective cohort study compared women diagnosed with PPH who received and did not receive UBT (UBT group and no-UBT group, respectively) at 18 secondary level hospitals in Uganda, Egypt, and Senegal that participated in a stepped wedge, cluster-randomized trial assessing UBT introduction. Key outcomes were reported pain (on a scale 0–10) in the immediate postpartum period and receipt of antibiotics within four weeks postpartum (a proxy for postpartum infection). Outcomes related to satisfaction with care and aspects women liked most and least about PPH care were also reported.

Results
Among women diagnosed with PPH, 58 were in the UBT group and 2188 in the no-UBT group. Self-reported, post-discharge antibiotic use within four weeks postpartum was similar in the UBT (3/58, 5.6%) and no-UBT groups (100/2188, 4.6%, risk ratio = 1.22, 95% confidence interval [CI]: 0.45–3.35). A high postpartum pain score of 8–10 was more common among women in the UBT group (17/46, 37.0%) than in the no-UBT group (360/1805, 19.9%, relative risk ratio = 3.64, 95% CI:1.30–10.16). Most women were satisfied with their care (1935/2325, 83.2%). When asked what they liked least about care, the most common responses were that medications (580/1511, 38.4%) and medical supplies (503/1511, 33.3%) were unavailable.

Conclusion
UBT did not increase the risk of postpartum infection among this population. Women who receive UBT may experience higher degrees of pain compared to women who do not receive UBT. Women’s satisfaction with their care and stockouts of medications and other supplies deserve greater attention when introducing new technologies like UBT.


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52. Starting and Operating a Public Cardiac Catheterization Laboratory in a Low Resource Setting: The Eight-Year Story of the Uganda Heart Institute Catheter Laboratory

Global Heart Journal


Authors: Joselyn Rwebembera , Twalib Aliku, James Kayima, Sulaiman Lubega, Elias Sebatta, Brian Kiggundu, Daudi Kirenzi, Wilson Nyakoojo, Charles Mondo, Krishna Kumar, Kanishka Ratnayaka, Shakeel Qureshi, Sanjay Daluvoy, Peter Lwabi, John Omagino, Craig Sable, Chris Longenecker, Dan Simon, Marco Costa, Emmy Okello
Region / country: Eastern Africa – Uganda
Speciality: Cardiothoracic surgery, Vascular surgery

Abstract
Background: Low- and-middle-income-countries (LMICs) currently bear 80% of the world’s cardiovascular disease (CVD) mortality burden. The same countries are underequipped to handle the disease burden due to critical shortage of resources. Functional cardiac catheterization laboratories (cath labs) are central in the diagnosis and management of CVDs. Yet, most LMICs, including Uganda, fall remarkably below the minimum recommended standards of cath lab:population ratio due to a host of factors including the start-up and recurring costs.

Objectives: To review the performance, challenges and solutions employed, lessons learned, and projections for the future for a single cath lab that has been serving the Ugandan population of 40 million people in the past eight years.

Methods: A retrospective review of the Uganda Heart Institute cath lab clinical database from 15 February 2012 to 31 December 2019 was performed.

Results: In the initial two years, this cath lab was dependent on skills transfer camps by visiting expert teams, but currently, Ugandan resident specialists independently operate this lab. 3,542 adult and pediatric procedures were conducted in 8 years, including coronary angiograms and percutaneous coronary interventions, device implantations, valvuloplasties, and cardiac defect closures, among others. There was a consistent expansion of the spectrum of procedures conducted in this cath lab each year. The initial lack of technical expertise and sourcing for equipment, as well as the continual need for sundries present(ed) major roadblocks. Government support and leveraging existing multi-level collaborations has provided a platform for several solutions. Sustainability of cath lab services remains a significant challenge especially in relation to the high cost of sundries and other consumables amidst a limited budget.

Conclusion: A practical example of how centers in LMIC can set up and sustain a public cardiac catheterization laboratory is presented. Government support, research, and training collaborations, if present, become invaluable leverage opportunities.


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53. The cost of inpatient burn management in Nepal

Burns


Authors: Ak Narayan Poudela, Patricia Pricebc, Julia Lowina, Rojina Shilpakard, Kiran Nakarmie, Tom Potokar
Region / country: Southern Asia – Nepal
Speciality: Plastic surgery, Trauma surgery

Abstract
Introduction
The management of burns is costly and complex with inpatient burns accounting for a high proportion of the costs associated with burn care. We conducted a study to estimate the cost of inpatient burn management in Nepal. Our objectives were to identify the resource and cost components of the inpatient burn care pathways and to estimate direct and overhead costs in two specialist burn units in tertiary hospitals in Nepal.

Methods
We conducted fieldwork at two tertiary hospitals to identify the cost of burns management in a specialist setting. Data were collected through semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs) with burn experts; unit cost data was collected from hospital finance departments, laboratories and pharmacies. The study focused on acute inpatient burn cases admitted to specialist burn centres within a hospital-setting.

Results
Experts divided inpatient burn care pathways into three categories: superficial partial-thickness burns (SPT), mixed depth partial-thickness burns (MDPT) and full thickness burns (FT). These pathways were confirmed in the FGDs. A ‘typical’ burns patient was identified for each pathway. Total resource use and total direct costs along with overhead costs were estimated for acute inpatient burn patients. The average per patient pathway costs were estimated at NRs 102,194 (US$ 896.4), NRs 196,666 (US$ 1725), NRs 481,951 (US$ 4,227.6) for SPT, MDPT and FT patients respectively. The largest cost contributors were surgery, dressings and bed charges respectively.

Conclusion
This study is a first step towards a comprehensive estimate of the costs of severe burns in Nepal.


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54. A study protocol for a Pilot Masked, Randomized Controlled Trial Evaluating Locally-applied Gentamicin versus Saline in Open Tibia Fractures (pGO-Tibia) in Dar es Salaam, Tanzania

Pilot and Feasibility Studies


Authors: Ericka P. von Kaeppler, Claire Donnelley, Syed H. Ali, Heather J. Roberts, John M. Ibrahim, Hao-Hua Wu, Edmund N. Eliezer, Travis C. Porco, Billy T. Haonga, Saam Morshed & David W. Shearer , Claire Donnelley, Syed H. Ali, Heather J. Roberts, John M. Ibrahim, Hao-Hua Wu, Edmund N. Eliezer, Travis C. Porco, Billy T. Haonga, Saam Morshed, David W. Shearer
Region / country: Eastern Africa – Tanzania
Speciality: Trauma and orthopaedic surgery

Abstract
Background
Open tibia fractures are a major source of disability in low- and middle-income countries (LMICs) due to the high incidence of complications, particularly infection and chronic osteomyelitis. One proposed adjunctive measure to reduce infection is prophylactic local antibiotic delivery, which can achieve much higher concentrations at the surgical site than can safely be achieved with systemic administration. Animal studies and retrospective clinical studies support the use of gentamicin for this purpose, but no high-quality clinical trials have been conducted to date in high- or low-income settings.

Methods
We describe a protocol for a pilot study conducted in Dar es Salaam, Tanzania, to assess the feasibility of a single-center masked randomized controlled trial to compare the efficacy of locally applied gentamicin to placebo for the prevention of fracture-related infection in open tibial shaft fractures.

Discussion
The results of this study will inform the design and feasibility of a definitive trial to address the use of local gentamicin in open tibial fractures. If proven effective, local gentamicin would be a low-cost strategy to reduce complications and disability from open tibial fractures that could impact care in both high- and low-income countries.


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55. Cervical cancer in Sub‐Saharan Africa: a multinational population‐based cohort study on patterns and guideline adherence of care

The Oncologist


Authors: Mirko Griesel, Tobias P Seraphin, Nikolaus CS Mezger, Lucia Hämmerl, Jana Feuchtner, Walburga Yvonne Joko‐Fru, Mazvita Sengayi‐Muchengeti, Biying Liu, Samukeliso Vuma, Anne Korir, Gladys C Chesumbai, Sarah Nambooze, Cesaltina F Lorenzoni, Marie‐Thérèse Akele‐Akpo, Amalado Ayemou, Cheick B Traoré, Tigeneh Wondemagegnehu, Andreas Wienke, Christoph Thomssen, Donald M Parkin, Ahmedin Jemal, Eva J Kantelhardt
Region / country: Central Africa, Eastern Africa, Southern Africa, Western Africa – Benin, Ethiopia, Ivory Coast, Mali, Mozambique, Uganda, Zimbabwe
Speciality: Obstetrics and Gynaecology, Surgical oncology

Abstract
Background
Cervical cancer (CC) is the most common female cancer in many countries of sub‐Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival (OS).

Methods
Our observational study covered nine population‐based cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44‐125 patients diagnosed 2010‐2016 were selected in each. Cancer‐directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (USA) Guidelines.

Results
Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline‐adherent, 2.4% with minor and 8.2% major deviations. CDT was not documented or without curative potential in 22%; 15.7% were diagnosed FIGO IV disease. Adherence was not assessed in 46.9% (no stage or follow‐up documented 11.9%) or records not traced (35.1%). The largest share of guideline‐adherent CDT was observed in Nairobi (49%), the smallest in Maputo (4%). In FIGO I‐III patients (n=190), minor and major guideline deviations were associated with impaired OS: hazard rate ratio (HRR) 1.73, 95% confidence interval (CI) 0.36‐8.37; and HRR 1.97, CI 0.59‐6.56 respectively. CDT without curative potential (HRR 3.88, CI 1.19‐12.71) and no CDT (HRR 9.43, CI 3.03‐29.33) showed substantially worse survival.

Conclusion
We found only one in six cervical cancer patients in SSA received CDT with curative potential. At least one‐fifth and possibly up to two thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of man


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56. The Preparing Residents for International Medical Experiences (PRIME) Simulation Workshop: Equipping Surgery and Anesthesia Trainees for International Rotations

The Journal of Teaching and Learning Resources


Authors: J. Matthew Kynes, Rondi Kauffmann, Camila B. Walters, Christopher Sizemore, MD, Arna Banerjee
Region / country: Global
Speciality: Anaesthesia, Obstetrics and Gynaecology, Surgical Education

Abstract
Introduction: Although global health training expands clinical and sociocultural expertise for graduate medical trainees and is increasingly in demand, evidence-based courses are limited. To improve self-assessed competence for clinical scenarios encountered during international rotations, we developed and assessed a simulation-based workshop called Preparing Residents for International Medical Experiences. Methods: High-fidelity simulation activities for anesthesiology, surgery, and OB/GYN trainees involved three scenarios. The first was a mass casualty in a low-resource setting requiring distribution of human and material resources. In the second, learners managed a septic operative patient and coordinated postoperative care without an ICU bed available. The final scenario had learners evaluate a non-English-speaking patient with pre-eclampsia. We paired simulation with small-group discussion to address socio-behavioural factors, stress, and teaching skills. Participants evaluated the quality of the teaching provided. In addition, we measured anesthesiology trainees’ self-assessed competence before and after the workshop. Results: The workshop included 23 learners over two iterations. Fifteen trainees (65%) completed the course evaluation, 93% of whom strongly agreed that the training met the stated objectives. Thirteen out of 15 (87%) anesthesiology trainees completed the competence survey. After the training, more trainees indicated confidence in providing clinical care with indirect supervision or independently. Mean self-assessed competency scores on a scale of 1–5 increased for all areas, with a mean competency increase of 0.3 (95% CI, 0.2–0.5). Discussion: Including simulation in a pretravel workshop can improve trainees’ self-assessed competence for a variety of scenarios involving clinical care in limited-resource settings


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57. Evaluating mechanism and severity of injuries among trauma patients admitted at Sina Hospital, the National Trauma Registry of Iran

Chinese Journal of Traumatology


Authors: Mina Saeednejad, Mohammadreza Zafarghandi, Narjes KhaliliVali Baigi, Moein Khormali, Zahra Ghodsi, Mahdi Sharif-Alhoseini, Gerard M. O’Reilly, Khatereh Naghdi, Melika Khaleghi-Nekou, Seyed mohammad Piri, Vafa Rahimi-Movaghar, Somayeh Bahrami, Marjan Laal, Mahdi Mohammadzadeh, Esmaeil Fakharian, Habibollah Pirnejad, Hamid Pahlavanhosseini, Payman SalamatiHomayounSadeghi-Bazargani
Region / country: Middle East – Iran
Speciality: Emergency surgery, Trauma and orthopaedic surgery, Trauma surgery

Abstract
Purpose
Injuries are one of the leading causes of death and lead to a high social and financial burden. Injury patterns can vary significantly among different age groups and body regions. This study aimed to evaluate the relationship between mechanism of injury, patient comorbidities and severity of injuries.

Methods
The study included trauma patients from July 2016 to June 2018, who were admitted to Sina Hospital, Tehran, Iran, for 2 years. The inclusion criteria were all injured patients who had at least one of the following: hospital length of stay more than 24 h, death in hospital, and transfer from the intensive care unit of another hospital. Data collection was performed using the National Trauma Registry of Iran (NTRI) minimum dataset.

Results
The most common injury mechanism was road traffic injuries (49.0%), followed by falls (25.5%). The mean age of those who fell was significantly higher in comparison with other mechanisms (p < 0.001). Severe extremity injuries occurred more often in the fall group than in the vehicle collision group (69.0% vs. 43.5%, p < 0.001). Moreover, cases of severe multiple trauma were higher amongst vehicle collisions than injuries caused by falls (27.8% vs. 12.9%, p = 0.003).

Conclusion
Comparing falls with motor vehicle collisions, patients who fell were older and sustained more extremity injuries. Patients injured by motor vehicle collision were more likely to have sustained multiple trauma than those presenting with falls. Recognition of the relationship between mechanisms and consequences of injuries may lead to more effective interventions.


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58. Financial toxicity of cancer care in low and middle-income countries: a systematic review and meta-analysis

Research Square


Authors: Andrew Donkor, Vivian Della Atuwo-Ampoh, Frederick Yakanu, Eric Torgbenu, Edward Kwabena Ameyaw, Doris Kitson-Mills, Verna Vanderpuye, Kofi Adesi Kyei, Samuel Anim-Sampong, Omar Khader, Jamal Khader
Region / country: Global
Speciality: Surgical oncology

Abstract
Introduction: The costs associated with cancer diagnosis, treatment and care present enormous financial toxicity. However, evidence of financial toxicity associated with cancer in low and middle-income countries (LMICs) is scarce.

Aim: To identify the extent of cancer-related financial toxicity and how it has been measured in LMICs.

Methods: Four electronic databases were searched to identify studies of any design that reported financial toxicity among cancer patients in LMICs. Random-effects meta-analysis was used to derive the pooled prevalence of financial toxicity. Sub-group analyses were performed according to: costs; and determinants of financial toxicity.

Results: A total of 31 studies were included in this systematic review and meta-analysis. The pooled prevalence of financial toxicity was 56.96% [95% CI, 30.51, 106.32]. In sub-group meta-analyses, the financial toxicity was higher among cancer patients with household size of more than four (1.17% [95% CI, 1.03, 1.32]; p = 0.02; I2 = 0%), multiple cycles of chemotherapy (1.94% [95% CI, 1.00, 3.75]; p = 0.05; I2 = 43%) and private health facilities (2.87% [95% CI, 1.89, 4.35]; p < 0.00001; I2 = 26%). Mean medical costs per cancer patients were $2,740.18 [95% CI, $1,953.62, $3,526.74]. The ratio of cost of care to gross domestic product (GDP) per capita varied considerably across the LMICs included in this review, which ranged from 0.06 in Vietnam to 327.65 in Ethiopia.

Conclusions: This study indicates that cancer diagnosis, treatment and care impose high financial toxicity on cancer patients in LMICs. Further rigorous research on cancer-related financial toxicity is needed.


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59. Cardiac anesthesiologist and the global capacity building to tackle rheumatic valvular heart disease

Journal of Cardiothoracic and Vascular Anesthesia


Authors: Deepak K. Tempe
Region / country: Global
Speciality: Anaesthesia, Cardiothoracic surgery

Rheumatic heart disease (RHD) is considered the neglected disease of the tropics and is endemic in several low- and middle-income countries (LMIC). 1 It still is an important cause of preventable morbidity and mortality associated with cardiovascular disease among children and young adults. The disease has seen a sharp decrease in most high-income countries (HIC) and primarily, the LMICs of Asia and Africa face the brunt of RHD, which also imposes huge economic burden. 2 In addition, RHD is also a significant cause of maternal mortality. 3 For precise understanding of the burden of RHD, it needs to be appreciated that LMICs are more populous (more than 5 times that of HICs) and that RHD remains the single most common cardiovascular disease in young adult and adolescent patients in need of heart surgery. 4 Furthermore, LMICs provide very different levels of cardiac surgical services for their population. There has been an impressive significant growth in the cardiac surgical capacity in middle-income countries, even so, there is a wide gap between patients in need of intervention / surgery and those who actually receive it. In addition, the diversity of health care facilities in these countries has led to availability of state-of-the art facilities to a select few (affluent) with majority (poor and under-privileged) having to rely on the overwhelmed public hospitals. The situation in the low-income countries is even worse.


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60. Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others?

BMJ Quality & Safety


Authors: Shehnaz Alidina , Pritha Chatterjee , Noor Zanial, Sakshie Sanjay Alreja, Rebecca Balira, David Barash, Edwin Ernest, Geofrey Charles Giiti, Erastus Maina, Adelina Mazhiqi, Rahma Mushi, Cheri Reynolds, Meaghan Sydlowski, Florian Tinuga, Sarah Maongezi, John G Meara , Ntuli A Kapologwe, Erin Barringer, Monica Cainer, Isabelle Citron, Amanda DiMeo, Laura Fitzgerald, Hiba Ghandour, Magdalena Gruendl, Augustino Hellar, Desmond T Jumbam, Adam Katoto, Lauren Kelly, Steve Kisakye, Salome Kuchukhidze, Tenzing N Lama, Gopal Menon, Stella Mshana, Chase Reynolds, Hannington Segirinya, Dorcas Simba, Victoria Smith, Steven J Staffa , Christopher Strader, Leopold Tibyehabwa, Alena Troxel, John Varallo, Taylor Wurdeman, David Zurakowski
Region / country: Global
Speciality: Health policy

Abstract
Background Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania’s Lake Zone to distil implementation lessons for low-resource settings.

Methods We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers.

Results Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum.

Conclusion Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.


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61. Predicting mortality in adults with suspected infection in a Rwandan hospital: an evaluation of the adapted MEWS, qSOFA and UVA scores

BMJ Open


Authors: Amanda Klinger , Ariel Mueller , Tori Sutherland , Christophe Mpirimbanyi , Elie Nziyomaze , Jean-Paul Niyomugabo , Zack Niyonsenga , Jennifer Rickard , Daniel S Talmor, Elisabeth Riviello
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Critical care

Rationale: Mortality prediction scores are increasingly being evaluated in low and middle income countries (LMICs) for research comparisons, quality improvement and clinical decision-making. The modified early warning score (MEWS), quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA), and Universal Vital Assessment (UVA) score use variables that are feasible to obtain, and have demonstrated potential to predict mortality in LMIC cohorts.

Objective: To determine the predictive capacity of adapted MEWS, qSOFA and UVA in a Rwandan hospital.

Design, setting, participants and outcome measures: We prospectively collected data on all adult patients admitted to a tertiary hospital in Rwanda with suspected infection over 7 months. We calculated an adapted MEWS, qSOFA and UVA score for each participant. The predictive capacity of each score was assessed including sensitivity, specificity, positive and negative predictive value, OR, area under the receiver operating curve (AUROC) and performance by underlying risk quartile.

Results: We screened 19 178 patient days, and enrolled 647 unique patients. Median age was 35 years, and in-hospital mortality was 18.1%. The proportion of data missing for each variable ranged from 0% to 11.7%. The sensitivities and specificities of the scores were: adapted MEWS >4, 50.4% and 74.9%, respectively; qSOFA >2, 24.8% and 90.4%, respectively; and UVA >4, 28.2% and 91.1%, respectively. The scores as continuous variables demonstrated the following AUROCs: adapted MEWS 0.69 (95% CI 0.64 to 0.74), qSOFA 0.65 (95% CI 0.60 to 0.70), and UVA 0.71 (95% CI 0.66 to 0.76); there was no statistically significant difference between the discriminative capacities of the scores.

Conclusion: Three scores demonstrated a modest ability to predict mortality in a prospective study of inpatients with suspected infection at a Rwandan tertiary hospital. Careful consideration must be given to their adequacy before using them in research comparisons, quality improvement or clinical decision-making.


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62. Surgical and Trauma Capacity Assessment in Rural Haryana, India

Annals of Global Health


Authors: Manisha B Bhatia , Srivarshini C Mohan , Kevin J Blair , Marissa A Boeck , Ashish Bhalla , Sristi Sharma , Irene Helenowski , Leah C Tatebe , Benedict C Nwomeh , Mamta Swaroop
Region / country: Southern Asia – India
Speciality: Health policy, Trauma surgery

Background: Trauma is a major global health problem and majority of the deaths occur in low- and middle-income countries (LMICs), at even higher rates in the rural areas. The three-delay model assesses three different delays in accessing healthcare and can be applied to improve surgical and trauma healthcare delivery. Prior to implementing change, the capacities of the rural India healthcare system need to be identified.

Objective: The object of this study was to estimate surgical and trauma care capacities of government health facilities in rural Nanakpur, Haryana, India using the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT) tools.

Methods: The PIPES and INTACT tools were administered at eight government health facilities serving the population of Nanakpur in June 2015. Data analysis was performed per tool subsection, and an overall score was calculated. Higher PIPES or INTACT indices correspond to greater surgical or trauma care capacity, respectively.

Findings: Surgical and trauma care capacities increased with higher levels of care. The median PIPES score was significantly higher for tertiary facilities than primary and secondary facilities [13.8 (IQR 9.5, 18.2) vs. 4.7 (IQR 3.9, 6.2), p = 0.03]. The lower-level facilities were mainly lacking in personnel and procedures.

Conclusions: Surgical and trauma care capacities at healthcare facilities in Haryana, India demonstrate a shortage of surgical resources at lower-level centers. Specifically, the Primary Health Centers were not operating at full capacity. These results can inform resource allocation, including increasing education, across different facility levels in rural India.


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63. Pregnancy Associated Breast Cancer (PABC): Report from a gestational cancer registry from a tertiary cancer care centre, India

The Breast


Authors: Jyoti bajpai, Vijay Simha, T.S. Shylasree, Rajeev Sarin, Reema Pathak, Palak Popat, Smruti Mokal, Sonal Dandekar, Jaya Ghosh, Neeta Nair, Seema Gulia, Sushmita Rath, Shalaka Joshi,Tabassum Wadasadawala, Tanuja Sheth, Vani Parmar, R.A. Badwe, Sudeep Gupta
Region / country: Southern Asia – India
Speciality: General surgery, Obstetrics and Gynaecology, Plastic surgery, Surgical oncology

Background
Pregnancy associated breast cancer (PABC) is a rare entity and defined as breast cancer diagnosed during pregnancy or one-year post-partum. There is sparse data especially from low and middle-income countries (LMIC) and merits exploration.

Methods
The study (2013 -2020) evaluated demographics, treatment patterns and outcomes of PABC.

Results
There were 104 patients, median age of 31 years; 43 (41%) had triple-negative disease, 31(29.8%) had hormone-receptor (HR) positive and HER2 negative, 14 (13.5%) had HER2-positive and HR negative and 16(15.4%) had triple positive disease. 101(97%) had IDC grade III tumors and 74% had delayed diagnosis. 72% presented with early stage (24, EBC) or locally advanced breast cancer (53, LABC) and received either neoadjuvant (n=49) or adjuvant (n=26) chemotherapy and surgery. Trastuzumab, tamoxifen, and radiotherapy were administered post-delivery. At a median follow up of 27 (IQR:19-35) months, the estimated 3-year event-free survival (EFS) for EBC and LABC was 82% (95% CI: 65.2 – 100) and 56% (95% CI: 42 – 75.6%) and for metastatic 24% (95% CI: 10.1% – 58.5%) respectively.

Of the 104 patients, 34 were diagnosed antepartum (AP) and 15 had termination, 2 had preterm and 16 had full-term deliveries(FTDs). Among postpartum cohort (n=70), 2 had termination, 1 had preterm, 67 had FTDs. 83(including 17 from AP) children from both cohorts were experiencing normal milestones.

Conclusion
Data from the first Indian PABC registry showed that the majority had delayed diagnosis and aggressive features(TNBC, higher grade). Treatment was feasible in majority and stage matched outcomes were comparable to non-PABCs.


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64. Understanding the role of lady health workers in improving access to eye health services in rural Pakistan – findings from a qualitative study

Archives of Public Health volume


Authors: Stevens Bechange, Elena Schmidt, Anna Ruddock, Itfaq Khaliq Khan, Munazza Gillani, Anne Roca, Imran Nazir, Robina Iqbal, Sandeep Buttan, Muhammed Bilal, Leena Ahmed & Emma Jolley
Region / country: Southern Asia – Pakistan
Speciality: Health policy, Ophthalmology

Background
In 1994, the Lady Health Workers (LHWs) Programme was established in Pakistan to increase access to essential primary care services and support health systems at the household and community levels. In Khyber Pakhtunkhwa (KPK) province in northern Pakistan, eye care is among the many unmet needs that LHWs were trained to address, including screening and referral of people with eye conditions to health facilities. However, despite an increase in referrals by LHWs, compliance with referrals in KPK has been very low. We explored the role of LHWs in patient referral and the barriers to patient compliance with referrals.

Methods
Qualitative methodology was adopted. Between April and June 2019, we conducted eight focus group discussions and nine in-depth interviews with 73 participants including patients, LHWs and their supervisors, district managers and other stakeholders. Data were analysed thematically using NVivo software version 12.

Results
LHWs have a broad understanding of basic health care and are responsible for a wide range of activities at the community level. LHWs felt that the training in primary eye care had equipped them with the skills to identify and refer eye patients. However, they reported that access to care was hampered when referred patients reached hospitals, where disorganised services and poor quality of care discouraged uptake of referrals. LHWs felt that this had a negative impact on their credibility and on the trust and respect they received from the community, which, coupled with low eye health awareness, influenced patients’ decisions about whether to comply with a referral. There was a lack of trust in the health care services provided by public sector hospitals. Poverty, deep-rooted gender inequities and transportation were the other reported main drivers of non-adherence to referrals.

Conclusions
Results from this study have shown that the training of LHWs in eye care was well received. However, training alone is not enough and does not result in improved access for patients to specialist services if other parts of the health system are not strengthened. Pathways for referrals should be agreed and explicitly communicated to both the health care providers and the patients.


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65. Understanding health-seeking and adherence to treatment by patients with esophageal cancer at the Uganda cancer Institute: a qualitative study

BMC Health Services Research volume


Authors: Nakimuli Esther, Ssentongo Julius & Mwaka Amos Deogratius
Region / country: Eastern Africa – Uganda
Speciality: General surgery, Surgical oncology

Background
In the low- and middle-income countries, most patients with esophageal cancer present with advanced stage disease and experience poor survival. There is inadequate understanding of the factors that influence decisions to and actual health-seeking, and adherence to treatment regimens among esophageal cancer patients in Uganda, yet this knowledge is critical in informing interventions to promote prompt health-seeking, diagnosis at early stage and access to appropriate cancer therapy to improve survival. We explored health-seeking experiences and adherence to treatment among esophageal cancer patients attending the Uganda Cancer Institute.

Methods
We conducted an interview based qualitative study at the Uganda Cancer Institute (UCI). Participants included patients with established histology diagnosis of esophageal cancer and healthcare professionals involved in the care of these patients. We used purposive sampling approach to select study participants. In-depth and key informant interviews were used in data collection. Data collection was conducted till point of data saturation was reached. Thematic content analysis approach was used in data analyses and interpretations. Themes and subthemes were identified deductively.

Results
Sixteen patients and 17 healthcare professionals were included in the study. Delayed health-seeking and poor adherence to treatment were related to (i) emotional and psychosocial factors including stress of cancer diagnosis, stigma related to esophageal cancer symptoms, and fear of loss of jobs and livelihood, (ii) limited knowledge and recognition of esophageal cancer symptoms by both patients and primary healthcare professionals, and (iii) limited access to specialized cancer care, mainly because of long distance to the facility and associated high transport cost. Patients were generally enthused with patient – provider relationships at the UCI. While inadequate communication and some degree of incivility were reported, majority of patients thought the healthcare professionals were empathetic and supportive.

Conclusion
Health system and individual patient factors influence health-seeking for symptoms of esophageal cancer and adherence to treatment schedule for the disease. Interventions to improve access to and acceptability of esophageal cancer services, as well as increase public awareness of esophageal cancer risk factors and symptoms could lead to earlier diagnosis and potentially better survival from the disease in Uganda.


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66. Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others?

BMJ Quality & Safety


Authors: Shehnaz Alidina , Pritha Chatterjee , Noor Zanial, Sakshie Sanjay Alreja, Rebecca Balira, David Barash, Edwin Ernest, Geofrey Charles Giiti, Erastus Maina, Adelina Mazhiqi, Rahma Mushi, Cheri Reynolds, Meaghan Sydlowski, Florian Tinuga, Sarah Maongezi, John G Meara , Ntuli A Kapologwe, Erin Barringer, Monica Cainer, Isabelle Citron, Amanda DiMeo, Laura Fitzgerald, Hiba Ghandour, Magdalena Gruendl, Augustino Hellar, Desmond T Jumbam, Adam Katoto, Lauren Kelly, Steve Kisakye, Salome Kuchukhidze, Tenzing N Lama, Gopal Menon, Stella Mshana, Chase Reynolds, Hannington Segirinya, Dorcas Simba, Victoria Smith, Steven J Staffa , Christopher Strader, Leopold Tibyehabwa, Alena Troxel, John Varallo, Taylor Wurdeman, David Zurakowski
Region / country: Global
Speciality: Health policy

Abstract
Background Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania’s Lake Zone to distil implementation lessons for low-resource settings.

Methods We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers.

Results Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum.

Conclusion Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.


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67. Peer-led surgery education: A model for a surgery interest group

Journal Of Pakistan Medical Association


Authors: Muhammad Ali, Sardar Shahmir, Babar Chauhan, Ayesha Noor, Sadaf Khan, Syed Ather Enam
Region / country: Southern Asia – Pakistan
Speciality: Surgical Education

Abstract
We present a systematic, sustainable, student-led model for a Surgery Interest Group in a low and middle-income country setting to encourage other medical students to establish similar groups in their institutions. Our model was developed at the Aga Khan University Medical College, Karachi, and is comprised of medical students, teaching associates, residents, faculty and alumni. The group focuses on connecting medical students with an interest in surgery with opportunities to help them match in surgery training programs. The opportunities include, but are not limited to, skill development, personal development, mentorship and research. Our model has shown growth and expansion over the last four years, and can be successfully replicated in medical colleges across similar settings.


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68. Telementoring, Surgery training, Rural surgery, Breast cancer

Journal Of Pakistan Medical Association


Authors: Fatima Mubarik, Hania Shahzad, Syeda Sakina Abidi, Sana Zeeshan, Lubna Vohra, Sadaf Khan, Abida Khalil Sattar
Region / country: Southern Asia – Pakistan
Speciality: Plastic surgery, Surgical Education, Surgical oncology

Abstract
Telementorship allows an expert surgeon to mentor another surgeon through an advanced procedure from a remote location via 2-way audio-visual communication. The current article was planned to review the existing literature and evaluate the utility of telementorship regarding educating rural surgeons in Pakistan about multidisciplinary breast cancer care. Publications from 2016 to 2020 were searched on PubMed and GoogleScholar and 10 most recent publications were selected. Review of literature revealed that even though telementorship in this context might be comparable to onsite mentorship, multiple concerns need to be addressed before its implementation. These include lack of concrete evidence regarding its effectiveness, legal, security and financial issues. Thus, a pilot project evaluating the efficacy of telementorship needs to be conducted for rural breast surgeons working in Pakistan. If these studies show promise and an affordable, convenient and effective method of telementorship is devised, then it may become the future of breast surgery training in far-flung regions of Pakistan.


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69. Surgical and Trauma Capacity Assessment in Rural Haryana, India

Annals of Global Health


Authors: Manisha B. Bhatia , Srivarshini C. Mohan, Kevin J. Blair, Marissa A. Boeck, Ashish Bhalla, Sristi Sharma, Irene Helenowski, Leah C. Tatebe, Benedict C. Nwomeh, Mamta Swaroop
Region / country: Southern Asia – India
Speciality: Health policy, Trauma surgery

Abstract
Background: Trauma is a major global health problem and majority of the deaths occur in low- and middle-income countries (LMICs), at even higher rates in the rural areas. The three-delay model assesses three different delays in accessing healthcare and can be applied to improve surgical and trauma healthcare delivery. Prior to implementing change, the capacities of the rural India healthcare system need to be identified.

Objective: The object of this study was to estimate surgical and trauma care capacities of government health facilities in rural Nanakpur, Haryana, India using the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT) tools.

Methods: The PIPES and INTACT tools were administered at eight government health facilities serving the population of Nanakpur in June 2015. Data analysis was performed per tool subsection, and an overall score was calculated. Higher PIPES or INTACT indices correspond to greater surgical or trauma care capacity, respectively.

Findings: Surgical and trauma care capacities increased with higher levels of care. The median PIPES score was significantly higher for tertiary facilities than primary and secondary facilities [13.8 (IQR 9.5, 18.2) vs. 4.7 (IQR 3.9, 6.2), p = 0.03]. The lower-level facilities were mainly lacking in personnel and procedures.

Conclusions: Surgical and trauma care capacities at healthcare facilities in Haryana, India demonstrate a shortage of surgical resources at lower-level centers. Specifically, the Primary Health Centers were not operating at full capacity. These results can inform resource allocation, including increasing education, across different facility levels in rural India.


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70. World Health Assembly 73: A Step Forward for Global Surgery

Annals of Global Health


Authors: Gabrielle L. Cahill, Makela C. Stankey , Craig D. McClain, Kee B. Park
Region / country: Global
Speciality: Health policy

Abstract
Member States at this year’s World Health Assembly 73 (WHA73), held virtually for the first time due to the COVID-19 pandemic, passed multiple resolutions that must be considered when framing efforts to strengthen surgical systems. Surgery has been a relatively neglected field in the global health landscape due to its nature as a crosscutting treatment rather than focusing on a specific disease or demographic. However, in recent years, access to essential and emergency surgical, obstetric, and anesthesia care has gained increasing recognition as a vital aspect of global health. The WHA73 Resolutions concern specific conditions, as has been characteristic of global health practice, yet proper care for each highlighted disease is inextricably linked to surgical care. Global surgery advocates must recognize how surgical system strengthening aligns with these strategic priorities in order to ensure that surgical care continues to be integrated into efforts to decrease global health disparities.


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71. Health System Factors That Influence Treatment Delay in Women With Breast Cancer in Sub-saharan Africa: A Systematic Review

Research square


Authors: Gloria Gbenonsi, Mouna Boucham, Zakaria Belrhiti, Chakib Nejjari, Inge Huybrechts, Mohamed Khalis
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: General surgery, Plastic surgery, Surgical oncology

Abstract
Background
Breast cancer patients in sub-Saharan Africa experience long delays between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing delay in treatment has not been widely investigated. This review aimed to identify existing information on health system factors that influence treatment delays in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.
Methods
PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyse (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program quality-assessment tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.
Results
From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence treatment delay in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.
Conclusion
The present review shows that treatment delay among women with breast cancer in sub-Saharan Africa is influenced by many related health system factors. Policymakers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region


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72. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020

The Lancet Global Health


Authors: Prof Matthew J Burton, PhD Jacqueline Ramke, PhD Ana Patricia Marques, PhD Prof Rupert R A Bourne, MD Rupert R A Bourne Affiliations Vision and Eye Research Institute, Anglia Ruskin University, Cambridge, UK Department of Ophthalmology, Cambridge University Hospitals, Cambridge, UK Search for articles by this author Prof Nathan Congdon, MD Iain Jones, MSc Brandon A M Ah Tong, BSocSci Simon Arunga, PhD Damodar Bachani, MD Covadonga Bascaran, MSc Andrew Bastawrous, PhD Prof Karl Blanchet, PhD Tasanee Braithwaite, DM John C Buchan, MD Prof John Cairns, MPhil Anasaini Cama, MPH Margarida Chagunda, MSc Chimgee Chuluunkhuu, MD Andrew Cooper, PhD Jessica Crofts-Lawrence, MSt William H Dean, PhD Prof Alastair K Denniston, PhD Joshua R Ehrlich, MD Paul M Emerson, PhD Jennifer R Evans, PhD Prof Kevin D Frick, PhD Prof David S Friedman, PhD João M Furtado, PhD Michael M Gichangi, MMed Stephen Gichuhi, PhD Suzanne S Gilbert, PhD Reeta Gurung, MD Esmael Habtamu, PhD Peter Holland, MSc Prof Jost B Jonas, PhD Prof Pearse A Keane, MD Prof Lisa Keay, PhD Rohit C Khanna, MPH Prof Peng Tee Khaw, PhD Prof Hannah Kuper, ScD Fatima Kyari, PhD Prof Van C Lansingh, PhD Islay Mactaggart, PhD Milka M Mafwiri, MMed Prof Wanjiku Mathenge, PhD Ian McCormick, MSc Priya Morjaria, PhD Lizette Mowatt, FRCOphth Debbie Muirhead, MSc Prof Gudlavalleti V S Murthy, MD Nyawira Mwangi, PhD Daksha B Patel, MD Prof Tunde Peto, PhD Babar M Qureshi, MD Prof Solange R Salomão, PhD Virginia Sarah, BA Bernadetha R Shilio, MMed Anthony W Solomon, PhD Bonnielin K Swenor, PhD Prof Hugh R Taylor, FRANZCO Prof Ningli Wang, PhD Aubrey Webson, DBA Prof Sheila K West, PhD Prof Tien Yin Wong, MD Richard Wormald, MSc Sumrana Yasmin, MSc Mayinuer Yusufu, MTI Juan Carlos Silva, MD Prof Serge Resnikoff, PhD Thulasiraj Ravilla, MBA Prof Clare E Gilbert, MD Prof Allen Foster, FRCOphth Prof Hannah B Faal, FRCOphth
Region / country: Global
Speciality: Ophthalmology

Eye health and vision have widespread and profound implications for many aspects of life, health, sustainable development, and the economy. Yet nowadays, many people, families, and populations continue to suffer the consequences of poor access to high-quality, affordable eye care, leading to vision impairment and blindness.
In 2020, an estimated 596 million people had distance vision impairment worldwide, of whom 43 million were blind. Another 510 million people had uncorrected near vision impairment, simply because of not having reading spectacles. A large proportion of those affected (90%), live in low-income and middle-income countries (LMICs). However, encouragingly, more than 90% of people with vision impairment have a preventable or treatable cause with existing highly cost-effective interventions. Eye conditions affect all stages of life, with young children and older people being particularly affected. Crucially, women, rural populations, and ethnic minority groups are more likely to have vision impairment, and this pervasive inequality needs to be addressed. By 2050, population ageing, growth, and urbanisation might lead to an estimated 895 million people with distance vision impairment, of whom 61 million will be blind. Action to prioritise eye health is needed now.
This Commission defines eye health as maximised vision, ocular health, and functional ability, thereby contributing to overall health and wellbeing, social inclusion, and quality of life. Eye health is essential to achieve many of the Sustainable Development Goals (SDGs). Poor eye health and impaired vision have a negative effect on quality of life and restrict equitable access to and achievement in education and the workplace. Vision loss has substantial financial implications for affected individuals, families, and communities. Although high-quality data for global economic estimates are scarce, particularly for LMICs, conservative assessments based on the latest prevalence figures for 2020 suggest that annual global productivity loss from vision impairment is approximately US$410·7 billion purchasing power parity. Vision impairment reduces mobility, affects mental wellbeing, exacerbates risk of dementia, increases likelihood of falls and road traffic crashes, increases the need for social care, and ultimately leads to higher mortality rates.
By contrast, vision facilitates many daily life activities, enables better educational outcomes, and increases work productivity, reducing inequality. An increasing amount of evidence shows the potential for vision to advance the SDGs, by contributing towards poverty reduction, zero hunger, good health and wellbeing, quality education, gender equality, and decent work. Eye health is a global public priority, transforming lives in both poor and wealthy communities. Therefore, eye health needs to be reframed as a development as well as a health issue and given greater prominence within the global development and health agendas.
Vision loss has many causes that require promotional, preventive, treatment, and rehabilitative interventions. Cataract, uncorrected refractive error, glaucoma, age-related macular degeneration, and diabetic retinopathy are responsible for most global vision impairment. Research has identified treatments to reduce or eliminate blindness from all these conditions; the priority is to deliver treatments where they are most needed. Proven eye care interventions, such as cataract surgery and spectacle provision, are among the most cost-effective in all of health care. Greater financial investment is needed so that millions of people living with unnecessary vision impairment and blindness can benefit from these interventions.
Lessons from the past three decades give hope that this challenge can be met. Between 1990 and 2020, the age-standardised global prevalence of blindness fell by 28·5%. Since the 1990s, prevalence of major infectious causes of blindness—onchocerciasis and trachoma—have declined substantially. Hope remains that by 2030, the transmission of onchocerciasis will be interrupted, and trachoma will be eliminated as a public health problem in every country worldwide. However, the ageing population has led to a higher crude prevalence of age-related causes of blindness, and thus an increased total number of people with blindness in some regions.


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73. Association between vision impairment and mortality: a systematic review and meta-analysis

The Lancet Global Health


Authors: Joshua R Ehrlich, Jacqueline Ramke, David Macleod, Helen Burn, Chan Ning Lee, Justine Zhang, William Waldock, Bonnielin K Swenor, jIris Gordon, Nathan Congdon, Matthew Burton, JenniferEvans
Region / country: Global
Speciality: Ophthalmology

Background
The number of individuals with vision impairment worldwide is increasing because of an ageing population. We aimed to systematically identify studies describing the association between vision impairment and mortality, and to assess the association between vision impairment and all-cause mortality.

Methods
For this systematic review and meta-analysis, we searched MEDLINE (Ovid), Embase, and Global Health database on Feb 1, 2020, for studies published in English between database inception and Feb 1, 2020. We included prospective and retrospective cohort studies that measured the association between vision impairment and all-cause mortality in people aged 40 years or older who were followed up for 1 year or more. In a protocol amendment, we also included randomised controlled trials that met the same criteria as for cohort studies, in which the association between visual impairment and mortality was independent of the study intervention. Studies that did not report age-adjusted mortality data, or that focused only on populations with specific health conditions were excluded. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. We graded the overall certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations framework. We did a random-effects meta-analysis to calculate pooled maximally adjusted hazard ratios (HRs) for all-cause mortality for individuals with a visual acuity of <6/12 versus those with ≥6/12; <6/18 versus those with ≥6/18; <6/60 versus those with ≥6/18; and <6/60 versus those with ≥6/60.

Findings
Our searches identified 3845 articles, of which 28 studies, representing 30 cohorts (446 088 participants) from 12 countries, were included in the systematic review. The meta-analysis included 17 studies, representing 18 cohorts (47 998 participants). There was variability in the methods used to assess and report vision impairment. Pooled HRs for all-cause mortality were 1·29 (95% CI 1·20–1·39) for visual acuity <6/12 versus ≥6/12, with low heterogeneity between studies (n=15; τ2=0·01, I2=31·46%); 1·43 (1·22–1·68) for visual acuity <6/18 versus ≥6/18, with low heterogeneity between studies (n=2; τ2=0·0, I2=0·0%); 1·89 (1·45–2·47) for visual acuity <6/60 versus ≥6/18 (n=1); and 1·02 (0·79–1·32) for visual acuity <6/60 versus ≥6/60 (n=2; τ2=0·02, I2=25·04%). Three studies received an assessment of low risk of bias across all six domains, and six studies had a high risk of bias in one or more domains. Effect sizes were greater for studies that used best-corrected visual acuity compared with those that used presenting visual acuity as the vision assessment method (p=0·0055), but the effect sizes did not vary in terms of risk of bias, study design, or participant-level factors (ie, age). We judged the evidence to be of moderate certainty.

Interpretation
The hazard for all-cause mortality was higher in people with vision impairment compared with those that had normal vision or mild vision impairment, and the magnitude of this effect increased with more severe vision impairment. These findings have implications for promoting healthy longevity and achieving the Sustainable Development Goals.

Funding
Wellcome Trust, Commonwealth Scholarship Commission, National Institutes of Health, Research to Prevent Blindness, the Queen Elizabeth Diamond Jubilee Trust, Moorfields Eye Charity, National Institute for Health Research, Moorfields Biomedical Research Centre, Sightsavers, the Fred Hollows Foundation, the Seva Foundation, the British Council for the Prevention of Blindness, and Christian Blind Mission.


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74. Magnitude, Pattern and Management Outcome of Intestinal Obstruction among Non-Traumatic Acute Abdomen Surgical Admissions in Arba Minch General Hospital, Southern Ethiopia

Research Square


Authors: Mulatie Atalay, Abinet Gebremickael, Solomon Demissie, Yonas Derso
Region / country: Eastern Africa – Ethiopia
Speciality: Emergency surgery, General surgery

Abstract
Background: Intestinal obstruction is defined as a blockage or partial blockage of the passage of the intestinal contents. It is a potentially risky surgical emergency associated with high morbidity and mortality. Its pattern differs from country to country and even from place to place within a country. Therefore, this study aimed to find out the magnitude, pattern and management outcome of intestinal obstruction in Arba Minch General Hospital.

Methods: A retrospective Cross-Sectional study was conducted in Arba Minch General hospital from January 09, 2015, to November 09, 2018. The data collection period was from December 15, 2018, to February 09, 2019. Simple random technique was applied to select 801 study participants. Then, the required data entered into Epi Info version 7.2.1.0 and exported to the statistical package for the social sciences software package version 20 for analysis.

Result: This study revealed that the overall magnitude of intestinal obstruction was 40.60% with 95% CI (34.95 – 45.95). The magnitude of unfavorable management outcomes and deaths during the study period were 22.3% with 95% CI (18.00-27.00) and 7.1 % with 95% CI (4.00-10.00) respectively. Small bowel volvulus, sigmoid volvulus and adhesion (bands) accounted for 45.30%, 21.35% and 11.97% of all patterns of intestinal obstructions respectively. Dehydration (p<0.001), persistent tachycardia (p<0.001) and perforated bowl (p<0.001) were highly significantly associated with the management outcome of intestinal obstruction.

Conclusion and recommendation: Intestinal obstruction was the most common among all acute abdomen cases and its management outcome highly associated with dehydration. Early resuscitation is recommended to decrease unfavorable management outcomes.


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75. Andersen’s utilization model for cataract surgical rate and empirical evidence from economically-developing areas

BMC Ophthalmology


Authors: Senlin Lin, Yingyan Ma, Zhiyuan Hou, Nathan Congdon, Lina Lu, Haidong Zou
Region / country: Central Africa, Eastern Africa, Eastern Asia, Northern Africa, Southern Africa, Western Africa
Speciality: Ophthalmology

Abstract
Background
Un-operated cataract is the leading cause of vision loss worldwide, responsible for 33% of visual impairment, and half of global blindness. The study aimed to build a fast evaluation method utilizing Andersen’s utilization framework and identify predictors of cataract surgical rate in sub-Saharan Africa and China.

Methods
The study was a cross-over ecological epidemiology study with a total of 19 countries in sub-Saharan Africa, and 31 provinces in China. Information was extracted from public data and published studies. Linear regression and structural equation modeling with Bootstrap were used to analyze predictors of CSR and their pathways to impact in sub-Saharan Africa and China separately.

Results
Cataract surgical resources in sub-Saharan Africa were linearly correlated with CSR (β = 0.74, 95% CI: 0.09, 0.91), while GDP/P didn’t impact cataract surgical resources (β = 0.29, 95% CI: − 0.12, 0.75). In China, residents’ average ability to pay was confirmed as the mediator between GDP/P and CSR (p = 0.32, RMSEA = 0.07; βCSR-paying = 0.77, 95% CI: 0.25, 0.90; βpaying-GDP/P = 0.89, 95% CI: 0.82, 0.93).

Conclusions
In sub-Saharan Africa, CSR is determined by health care provision. Local economic development may not directly influence CSR. Therefore, international assistance aimed to providing free cataract surgery directly is crucial. In China, CSR is determined principally by health care demand (ability to pay). To increase CSR in underserved areas of China, ability to pay must be enhanced through social insurance, and reduced surgical fees.


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76. Associations of On-arrival Vital Signs with 24-hour In-hospital Mortality in Adult Trauma Patients Admitted to Four Public University Hospitals in Urban India: A Prospective Multi-Centre Cohort Study

Injury


Authors: Bhakti Sarang, Prashant Bhandarkar, Nakul Raykar, Gerard M O Reilly, Kapil Dev Sonim, Martin Gerdin Warnberg, Monty Khajanchiap, Satish Dharapg, Peter Cameronhi, Teresa Howard, Anita Gadgila, Bhavesh Jarwanin, Monali Mohana, Sanjeev Bhoir, Nobhojit Royast
Region / country: Southern Asia – India
Speciality: Trauma surgery

Abstract
Introduction: In India, more than a million people die annually due to injuries. Identifying the patients at risk of early mortality (within 24 hour of hospital arrival) is essential for triage. A bilateral Government Australia-India Trauma System Collaboration generated a trauma registry in the context of India, which yielded a cohort of trauma patients for systematic observation and interventions. The aim of this study was to determine the independent association of on-arrival vital signs and Glasgow Coma Score (GCS) with 24-hour mortality among adult trauma patients admitted at four university public hospitals in urban India.

Methods: We performed an analysis of a prospective multicentre observational study of trauma patients across four urban public university hospitals in India, between April 2016 and February 2018. The primary outcome was 24-hour in-hospital mortality. We used logistic regression to determine mutually independent associations of the vital signs and GCS with 24-hour mortality.

Results: A total of 7497 adult patients (18 years and above) were included. The 24-hour mortality was 1.9%. In univariable logistic regression, Glasgow Coma Score (GCS) and the vital signs systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and peripheral capillary oxygen saturation (SpO2) had statistically significant associations with 24-hour mortality. These relationships held in multivariable analysis with hypotension (SBP100bpm) and bradycardia (HR<60bpm), hypoxia (SpO220brpm) and severe (3-8) and moderate (9-12) GCS having strong association with 24-hour mortality. Notably, the patients with missing values for SBP, HR and RR also demonstrated higher odds of 24-hour mortality. The Injury Severity Scores (ISS) did not corelate with 24-hour mortality.

Conclusion: The routinely measured GCS and vital signs including SBP, HR, SpO2 and RR are independently associated with 24-hour in-hospital mortality in the context of university hospitals of urban India. These easily measured parameters in the emergency setting may help improve decision-making and guide further management in the trauma victims. A poor short-term prognosis was also observed in patients in whom these physiological variables were not recorded.


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77. Magnitude of Multidrug Resistance among Bacterial Isolates from Surgical Site Infections in Two National Referral Hospitals in Asmara, Eritrea

International Journal of Microbiology


Authors: Eyob Yohannes Garoy, Yacob Berhane Gebreab, Oliver Okoth Achila, Nobiel Tecklebrhan, Hermon Michael Tsegai, Alex Zecarias Hailu, Abrehet Marikos Buthuamlak, Tewelde Ghide Asfaga, Mohammed Elfatih Hamida
Region / country: Eastern Africa – Eritrea
Speciality: General surgery, Other

Abstract
Background. The World Health Organization has emphasized the importance of understanding the epidemiology of MDR organisms from a local standpoint. Here, we report on a spectrum of bacteria associated with surgical site infections in two referral hospitals in Eritrea and the associated antibiotic susceptibility patterns. Methods. This survey was conducted between February and June 2017. A total of 83 patients receiving treatment for various surgical conditions were included. Swabs from infected surgical sites were collected using Levine technique and processed using standard microbiological procedures. In vitro antimicrobial susceptibility testing was performed on Mueller–Hinton Agar by the Kirby-Bauer disk diffusion method following Clinical and Laboratory Standards Institute guidelines. The data were analyzed using SPSS version 20. Results. A total of 116 isolates were recovered from 83 patients. In total, 67 (58%) and 49 (42%) of the isolates were Gram-positive and Gram-negative bacteria, respectively. The most common isolates included Citrobacter spp., Klebsiella spp., Escherichia coli, Proteus spp., Pseudomonas aeruginosa, Salmonella spp., Enterobacter spp., and Acinetobacter spp. In contrast, Staphylococcus aureus, CONS, and Streptococcus viridians were the predominant Gram-positive isolates. All the Staphylococcus aureus isolates were resistant to penicillin. MRSA phenotype was observed in 70% of the isolates. Vancomycin, clindamycin, and erythromycin resistance were observed in 60%, 25%, and 25% of the isolates, respectively. Furthermore, a high proportion (91%) of the Gram-negative bacteria were resistant to ampicillin and 100% of the Pseudomonas aeruginosa and Escherichia coli isolates were resistant to >5 of the tested antibiotics. The two Acinetobacter isolates were resistant to >7 antimicrobial agents. We also noted that 4 (60%) of the Klebsiella isolates were resistant to >5 antimicrobial agents. Possible pan-drug-resistant (PDR) strains were also isolated. Conclusion. Due to the high frequency of MDR isolates reported in this study, the development and implementation of suitable infection control policies and guidelines is imperative.


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78. Return to work in survivors of primary brain Tumours treated with intensity modulated radiotherapy

Cancer Treatment and Research Communications


Authors: Mohammed A.R.Basalathullah, Monica Malik, Deepthi Valiyaveettil, Nadendla Beulah, Elizabeth Syed, Fayaz Ahmed
Region / country: Southern Asia – India
Speciality: Neurosurgery

Mini
Primary Brain Tumour survivors usually have significant morbidity, especially cognitive and neurological dysfunction. Return to pre-diagnosis work can be an important QoL indicator and outcomes measure in these patients. We did a retrospective study to assess return to work amongst the patients who underwent radiotherapy at our centre.

Background
Primary brain tumour (PBT) survivors have a high burden of morbidity. Return to work (RTW) is an important survivorship parameter and outcomes measure in these patients, especially in developing countries. This study was done to assess RTW after radiotherapy, reasons for no RTW, and relationship of RTW with treatment and patient factors.

Patients and Methods
A single centre study was done amongst PBT patients. Baseline and treatment details, education, employment was assessed. RTW assessed as: time to RTW, full/ part-time, reasons for no RTW and RTW at 6 months post-therapy, and last follow up.

Results
67 PBT patients with a median age of 42 years were assessed. Most common diagnosis was low grade glioma. Over 66% patients were illiterate, and 62% had semi-skilled and unskilled jobs, mostly agriculture. About 64.4% patients returned to employment in a median time of 3 months. At 6 months post-treatment 58.2% had a job, with only 42% working full-time. ‘Limb weakness’ (21.4%), followed by ‘loss of job/ no job’ (16.7%), ‘fatigue’/ ‘tiredness’ (14.3%), ‘poor vision/ diminished vision’ (11.9%) were the common reasons for no RTW. The factors found to be significantly associated with return to work were younger age (p = 0.042), male sex (0.013), the absence of complications during radiotherapy (p = 0.049), part time job prior to diagnosis (p = 0.047), and early return to work after RT (p < 0.001).

Conclusion
Studies are needed to identify the barriers in re- employment and steps to overcome them in cancer patients


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79. Neglected tropical diseases activities in Africa in the COVID-19 era: the need for a “hybrid” approach in COVID-endemic times

Infectious Diseases of Poverty


Authors: David Molyneux, Simon Bush, Ron Bannerman, Philip Downs, Joy Shu’aibu, Pelagie Boko-Collins, Ioasia Radvan, Leah Wohlgemuth & Chris Boyton
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Health policy, Other

With the coronavirus disease 2019 (COVID-19) pandemic showing no signs of abating, resuming neglected tropical disease (NTD) activities, particularly mass drug administration (MDA), is vital. Failure to resume activities will not only enhance the risk of NTD transmission, but will fail to leverage behaviour change messaging on the importance of hand and face washing and improved sanitation—a common strategy for several NTDs that also reduces the risk of COVID-19 spread. This so-called “hybrid approach” will demonstrate best practices for mitigating the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by incorporating physical distancing, use of masks, and frequent hand-washing in the delivery of medicines to endemic communities and support action against the transmission of the virus through water, sanitation and hygiene interventions promoted by NTD programmes. Unless MDA and morbidity management activities resume, achievement of NTD targets as projected in the WHO/NTD Roadmap (2021–2030) will be deferred, the aspirational goal of NTD programmes to enhance universal health coverage jeopardised and the call to ‘leave no one behind’ a hollow one. We outline what implementing this hybrid approach, which aims to strengthen health systems, and facilitate integration and cross-sector collaboration, can achieve based on work undertaken in several African countries.


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80. Implementation Science Protocol for a participatory, theory-informed implementation research programme in the context of health system strengthening in sub-Saharan Africa (ASSET-ImplementER)

BMJ Journals


Authors: Nadine Seward, Jamie Murdoch, Charlotte Hanlon, Ricardo Araya, Wei Gao, Richard Harding, Crick Lund, Saba Hinrichs-Krapels, Rosie Mayston, Muralikrishnan R. Kartha, Martin Prince, Jane Sandall, Graham Thornicroft, Ruth Verhey, Nick Sevdalis
Region / country: Central Africa, Eastern Africa, Southern Africa, Western Africa – Ethiopia, Sierra Leone, South Africa, Zimbabwe
Speciality: Health policy

Background ASSET (Health System Strengthening in Sub-Saharan Africa) is a health system strengthening (HSS) programme that aims to develop and evaluate effective and sustainable solutions that support high-quality care that involve eight work packages across four sub-Saharan African countries. Here we present the protocol for the implementation science (IS) theme within ASSET that aims to (1) understand what HSS interventions work, for whom and how; and (2) how implementation science methodologies can be adapted to improve the design and evaluation of HSS interventions within resource-poor contexts.

Pre-implementation phase The IS theme, jointly with ASSET work-packages, applies IS determinant frameworks to identify factors that influence the effectiveness of delivering evidence-informed care. Determinants are used to select a set of HSS interventions for further evaluation, where work packages also theorise selective mechanisms to achieve the expected outcomes.

Piloting phase and rolling implementation phase Work-packages pilot the HSS interventions. An iterative process then begins involving evaluation, refection and adaptation. Throughout this phase, IS determinant frameworks are applied to monitor and identify barriers and enablers to implementation in a series of workshops, surveys and interviews. Selective mechanisms of action are also investigated. In a final workshop, ASSET teams come together, to reflect and explore the utility of the selected IS methods and provide suggestions for future use.

Structured templates are used to organise and analyse common and heterogeneous patterns across work-packages. Qualitative data are analysed using thematic analysis and quantitative data is analysed using means and proportions.

Conclusions We use a novel combination of implementation science methods at a programmatic level to facilitate comparisons of determinants and mechanisms that influence the effectiveness of HSS interventions in achieving implementation outcomes across different contexts. The study will also contribute conceptual development and clarification at the underdeveloped interface of implementation science, HSS and global health.


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81. Epidemiological trends in community acquired acute Kidney Injury in Pakistan: 25 years Experience from a Tertiary Care Renal Unit

Pakistan Journal of Medical Sciences


Authors: Rubina Naqvi
Region / country: Southern Asia – Pakistan
Speciality: General surgery, Urology surgery

Background: Epidemiological studies of community acquired acute kidney injury (AKI) are sparse especially from South Asia and none has published from Pakistan. Reported incidences from different countries vary with use of different criteria of defining AKI. There is also variation found in different class of income countries, hospital based versus community based AKI.

Methods: The current study was carried out in all adult AKI patients developing community acquired AKI and coming to a tertiary care renal institution from January 1990 to December 2014. This is a retrospective data collection from patient’s records and AKI was defined according to KDIGO guidelines. Trends among different groups which are classified in medical, obstetrical and surgical were observed and presented.

Results: In medical AKI there has been found a rise in toxic rhabdomyolysis, vivax malaria and dengue infection during later part of study. In obstetrical AKI observed continuous rise in numbers contributing to total AKI during these years. Surgical AKI included obstructed cases during initial ten years and only surgical trauma during later 15 years. Older age on presentation in medical AKI, and thrombocytopenia, deranged coagulation, deranged liver function, hyperkalemia, requirement of mechanical ventilation and multi organ failure in all groups remained predictors of higher mortality.

Conclusion: From Pakistan epidemiology for community acquired AKI has never been published on a large scale and this study would remain source of great information in this regard over coming years.


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82. A Situational Analysis of the Specialist Anaesthesia Workforce of East, Central and Southern Africa

Research


Authors: Juventine Asingei, Eric O’Flynn, Diarmuid O’Donovan, Sophia Masuka, Doreen Mashava, Faith Akello, Mpoki Ulisubisya
Region / country: Central Africa, Eastern Africa, Southern Africa
Speciality: Anaesthesia

Background: An accurate account of the distribution of qualied anaesthesiologists in East, Central and Southern Africa has been lacking with most of the current publications being estimates of headline gures. As university training programmes, and more recently the College of Anaesthesiologists of East, Central and Southern Africa (CANECSA), work to scale up the anaesthesiology workforce, it is crucial to understand the scope of the need by carrying out an extensive survey. This is key to informing policymakers and stakeholders for tackling the problem of human resources for anaesthesia.

Methods: The anaesthesiologist distribution in the eight CANECSA member countries was determined using a combination existing databases and collection of new data from sources such as CANECSA records, national medical council registers, national anaesthesiology society records, as well as data validation through direct and indirect contact with the anaesthesiologists. Data collation and analysis was performed using Microsoft Excel Spreadsheets and SPSS by assessing relevant frequencies and crosstabulations. Data was stored in a cloud-based database managed by CANECSA.

Results: 411 qualified anaesthesiologists were identied within the CANECSA member countries, a rate of 0.21 anaesthesiologists per 100,000 population compared to 333 (0.17 anaesthesiologists per 100,000 population) reported by the World Federation of Societies of Anaesthesiology (WFSA) in 2015/2016. Newly quantified details on the distribution of anesthesiologists in the region include: the majority (89.5%) of anaesthesiologists perform clinical work and most (69.3%) are based in the main commercial cities of their countries of practice; only about one third (35.5%) are female; the majority are employed by government institutions (61.6%) and medical-training institutions (59.4%); and almost half (49.2%) of anaesthesiologists whose age was recorded ranged from 30 to 39 years.

Conclusion: The numbers of anaesthesiologists in CANECSA member countries are still far below all international recommendations constituting only about 5% of the minimum recommended figures for LMICs. Anaesthesiologist are highly concentrated in the major cities of the region, with few in provincial and rural areas. Nonetheless, all trends suggest huge opportunities for advancing training of more
anaesthesiologists through collaborative efforts.


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83. Amid COVID-19 pandemic, are non-COVID patients left in the lurch?

Pakistan Journal of Medical Sciences


Authors: Laima Alam, Syed Kumail Hasan Kazmi, Mafaza Alam, Varqa Faraid
Region / country: Southern Asia – Pakistan
Speciality: Health policy, Other

Objectives: 1) To explore the possible impact of the pandemic on the health seeking behavior of the patients, 2) To explore the relation of socio-demographics on the utility of health-care facilities.

Methods: This cross-sectional study was conducted by enrolling all patients ≥15 years of age presenting to the Out-Patient-Department of three main public-hospitals after obtaining ethical committee approval. A questionnaire with validated Urdu translation was filled by each participant that included socio-demographic data, pre-Covid and Covid-19 era health seeking behaviors and the impact of the pandemic on the utilization of healthcare facilities. Data was analyzed using SPSS V.19.

Results: A total of 393 patients were enrolled with a male preponderance (72%) and a median age range of 31-45 years. Fifty-eight percent of the study population was unemployed and 47.3% were seeking follow up care. The frequency of ER and multiple (>4 times) OPD visits were significantly decreased in the Covid-19 times whereas, the laboratory and radiology services were largely unaffected. A significant number of patients were not satisfied with the current healthcare facilities that was seen irrespective of the socio-demographic status. Emergency Room and radiology services were largely unaffected whereas, elective procedures and laboratory facilities were reported to be severely affected or delayed in relation to socio-demographic variables.

Conclusions: Healthcare inequalities have widened and depression has shown a sharp rise during this pandemic. The over-burdened healthcare facilities at the verge of collapse may miss out on the chronic non-Covid patients which would ultimately lead to increased morbidity and mortality.


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

International Journal of Surgery Case Reports


Authors: Pungky Mulawardhana, Poedjo Hartono , Hari Nugroho , Atika Ayuningtyas
Region / country: South-eastern Asia – Indonesia
Speciality: Obstetrics and Gynaecology, Surgical oncology

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.


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85. Placental pathology and maternal factors associated with stillbirth: An institutional based case-control study in Northern Tanzania

PLOS One


Authors: Godwin Lema,Alex Mremi ,Patrick Amsi, Jeremia J. Pyuza,Julius P. Alloyce,Bariki Mchome,Pendo Mlay
Region / country: Eastern Africa – Tanzania
Speciality: Obstetrics and Gynaecology

Objective
To determine the placental pathologies and maternal factors associated with stillbirth at Kilimanjaro Christian Medical Centre, a tertiary referral hospital in Northern Tanzania.

Methods
A 1:2 unmatched case-control study was carried out among deliveries over an 8-month period. Stillbirths were a case group and live births were the control group. Respective placentas of the newborns from both groups were histopathologically analyzed. Maternal information was collected via chart review. Mean and standard deviation were used to summarize the numerical variables while frequency and percentage were used to summarize categorical variables. Crude and adjusted logistic regressions were done to test the association between each variable and the risk of stillbirth.

Results
A total of 2305 women delivered during the study period. Their mean age was 30 ± 5.9 years. Of all deliveries, 2207 (95.8%) were live births while 98 (4.2%) were stillbirths. Of these, 96 stillbirths (cases) and 192 live births (controls) were enrolled. The average gestational age for the enrolled cases was 33.8 ±3.2 weeks while that of the controls was 36.3±3.6 weeks, (p-value 0.244). Of all stillbirths, nearly two thirds 61(63.5%) were males while the females were 35(36.5%). Of the stillbirth, 41were fresh stillbirths while 55 were macerated. The risk of stillbirth was significantly associated with lower maternal education [aOR (95% CI): 5.22(2.01–13.58)], history of stillbirth [aOR (95%CI): 3.17(1.20–8.36)], lower number of antenatal visits [aOR (95%CI): 6.68(2.71–16.48), pre/eclampsia [aOR (95%CI): 4.06(2.03–8.13)], and ante partum haemorrhage [OR (95%CI): 2.39(1.04–5.53)]. Placental pathology associated with stillbirth included utero-placental vascular pathology and acute chorioamnionitis.

Conclusions
Educating the mothers on the importance of regular antenatal clinic attendance, monitoring and managing maternal conditions during antenatal periods should be emphasized. Placentas from stillbirths should be histo-pathologically evaluated to better understand the possible aetiology of stillbirths.


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86. The Rise of Inflow Cisternostomy in Resource-Limited Settings: Rationale, Limitations, and Future Challenges

Emergency Medicine International


Authors: Ulrick Sidney Kanmounye
Region / country: Global
Speciality: Neurosurgery, Trauma and orthopaedic surgery, Trauma surgery

Low- and middle-income countries (LMICs) bear most of the global burden of traumatic brain injury (TBI), but they lack the resources to address this public health crisis. For TBI guidelines and innovations to be effective, they must consider the context in LMICs; keeping this in mind, this article will focus on the history, pathophysiology, practice, evidence, and implications of cisternostomy. In this narrative review, the author discusses the history, pathophysiology, practice, evidence, and implications of cisternostomy. Cisternostomy for the management of TBI is an innovation developed in LMICs, primarily for LMICs. Its practice is based on the cerebrospinal fluid shift edema theory that attributes injury to increased pressure within the subarachnoid space due to subarachnoid hemorrhage and subsequent dysfunction of glymphatic drainage. Early reports of the technique report significant improvements in the Glasgow Outcome Scale, lower mortality rates, and shorter intensive care unit durations. Most reports are single-center studies with small sample sizes, and the technique requires experience and skill. These limitations have led to criticisms and slow adoption of the technique. Further research is needed to establish the effect of cisternostomy on TBI outcomes.


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87. A Consensus Statement for Trauma Surgery Capacity Building in Latin America

World Journal of Emergency Surgery


Authors: Mohini Dasari, Erica D. Johnson, Jorge H. Montenegro, Dylan Griswold, Maria Fernanda Jiménez, Juan Carlos Puyana, Andres M. Rubiano
Region / country: South America
Speciality: Trauma surgery

Background: Trauma is a significant public health problem in Latin America (L.A.), contributing to substantial death and disability in the region. Several LA countries have implemented trauma registries and injury surveillance systems. However, the region lacks an integrated trauma system. The consensus conference’s goal was to integrate existing L.A. trauma data collection efforts into a regional trauma program and encourage the use of the data to inform health policy.

Methods: We created a consensus group of 25 experts in trauma and emergency care with previous data collection and injury surveillance experience in the L.A. region. Experts participated in a consensus conference to discuss the state of trauma data collection in L.A. We utilized the Delphi method to build consensus around strategic steps for trauma data management in the region. Consensus was defined as the agreement of ≥ 70% among the expert panel.

Results: The consensus conference determined that action was necessary from academic bodies, scientific societies, and ministries of health to encourage a culture of collection and use of health data in trauma. The panel developed a set of recommendations for these groups to encourage the development and use of robust trauma information systems in L.A. Consensus was achieved in one Delphi round.

Conclusions: The expert group successfully reached a consensus on recommendations to key stakeholders in trauma information systems in L.A. These recommendations may be used to encourage capacity-building in trauma research and trauma health policy in the region


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88. Feasibility and integration of an intensive emergency pediatric care curriculum in Armenia

International Journal of Emergency Medicine


Authors: Baghdassarian Aline, Best Al M, Virabyan Anushavan, Alexanian Claire, Shekherdimian Shant, Sally A. Santen, Hambartzum Simonyan
Region / country: Western Asia – Armenia
Speciality: Emergency surgery, Paediatric surgery

Background: Emergency pediatric care curriculum (EPCC) was developed to address the need for pediatric rapid assessment and resuscitation skills among out-of-hospital emergency providers in Armenia. This study was designed to evaluate the effectiveness of EPCC in increasing physicians’ knowledge when instruction transitioned to local
instructors. We hypothesize that (1) EPCC will have a positive impact on post-test knowledge, (2) this effect will be maintained when local trainers teach the course, and (3) curriculum will satisfy participants.

Methods: This is a quasi-experimental, pre-test/post-test study over a 4-year period from October 2014‑November 2017. Train-the-trainer model was used. Primary outcomes are immediate knowledge acquisition each year and comparison of knowledge acquisition between two cohorts based on North American vs local instructors.
Descriptive statistics was used to summarize results. Pre-post change and differences across years were analyzed using repeated measures mixed models.

Results: Test scores improved from pretest mean of 51% (95% CI 49.6 to 53.0%) to post-test mean of 78% (95% CI 77.0 to 79.6%, p < 0.001). Average increase from pre- to post-test each year was 27% (95% CI 25.3 to 28.7%). Improvement was sustained when local instructors taught the course (p = 0.74). There was no difference in
improvement when experience in critical care, EMS, and other specialties were compared (p = 0.23). Participants reported satisfaction and wanted the course repeated. In 2017, EPCC was integrated within the Emergency Medicine residency program in Armenia.

Discussion: This program was effective at impacting immediate knowledge as well as participant satisfaction and intentions to change practice. This knowledge acquisition and reported satisfaction remained constant even when the instruction was transitioned to the local instructors after 2 years. Through a partnership between the USA and
Armenia, we provided OH-EPs in Armenia with an intensive educational experience to attain knowledge and skills necessary to manage acutely ill or injured children in the out-of-hospital setting.

Conclusions: EPCC resulted in significant improvement in knowledge and was well received by participants. This is a viable and sustainable model to train providers who have otherwise not had formal education in this field


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89. Working title: high dose rate intra-cavitary brachytherapy with cobalt 60 source for locally advanced cervical cancer: the Zimbabwean experience

Infectious Agents and Cancer


Authors: Shirley Chibonda, Ntokozo Ndlovu, Nomsa Tsikai, Lameck Munangaidzwa, Sandra Ndarukwa, Albert Nyamhunga & Tinashe Mazhindu
Region / country: Southern Africa – Zimbabwe
Speciality: Obstetrics and Gynaecology, Surgical oncology

Background and purpose
Cervical cancer is the fourth commonest cancer in women in the world with the highest regional incidence and mortality seen in Southern, Eastern and Western Africa. It is the commonest cause of cancer morbidity and mortality among Zimbabwean women. Most patients present with locally advanced disease that is no longer amenable to surgery. Definitive concurrent chemoradiation (CCRT), which is the use of external beam radiotherapy (EBRT) and weekly cisplatin, includes use of intracavitary brachytherapy, as the standard treatment. In the setting of this study, cobalt-60 (Co60)-based high dose rate brachytherapy (HDR-BT) has been in use since 2013. This study sought to review practices pertaining to use of brachytherapy in Zimbabwe, including timing with external beam radiotherapy, adverse effects and patient outcomes.

Methods
A retrospective analysis of data from records of patients with histologically confirmed cervical cancer treated with HDR-BT at the main radiotherapy centre in Zimbabwe from January 2013 to December 2014 was done. Outcome measures were local control, overall survival as well as gastro-intestinal and genito-urinary toxicity.

Results
A total of 226 patients were treated with HDR-BT during the study period, with a 97% treatment completion rate. All patients received between 45-50Gy of pelvic EBRT. Seventy-four percent received concurrent platinum-based chemotherapy. In 52% of the patients, HDR-BT was started when they were still receiving EBRT. The commonest fractionation schedule used was the 7Gy × 3 fractions, once a week (87%). Clinical complete tumour response was achieved in 75% at 6 weeks post treatment, 23% had partial response. Follow-up rates at 1 year and 2 years were 40 and 19% respectively. Disease free survival at 1 year and 2 years was 94 and 95% respectively. Vaginal stenosis was the commonest toxicity recorded, high incidence noted with increasing age. Four patients developed vesico-vaginal fistulae and two patients had rectovaginal fistulae.

Conclusion
One hundred and seventeen patients patients started HDR-BT during EBRT course, with a treatment completion rate of 97%. The overall treatment duration was within 56 days in the majority of patients. Early local tumour control was similar for all the HDR-BT fractionation regimes used in the study, with a high rate (75%) of complete clinical response at 6 weeks post-treatment. Prospective studies to evaluate early and long-term outcomes of HDR-BT in our setting are recommended.


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90. Point-of-Care Ultrasound: Applications in Low- and Middle-Income Countries

Current Anesthesiology Reports


Authors: Timothy T. Tran, Maung Hlaing, Martin Krause
Region / country: Global
Speciality: Anaesthesia, General surgery, Health policy

Purpose of Review
This review highlights the applications of point-of-care ultrasound in low- and middle-income countries and shows the diversity of ultrasound in the diagnosis and management of patients.

Recent Findings
There is a paucity of data on point-of-care ultrasound in anesthesiology in low- and middle-income countries. However, research has shown that point-of-care ultrasound can effectively help manage infectious diseases, as well as abdominal and pulmonary pathologies.

Summary
Point-of-care ultrasound is a low-cost imaging modality that can be used for the diagnosis and management of diseases that affect low- and middle-income countries. There is limited data on the use of ultrasound in anesthesiology, which provides clinicians and researchers opportunity to study its use during the perioperative period.


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91. Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies

Scandinavian Journal of Surgery


Authors: T. W. Clements, C. G. Ball,M. Tolonen, A. W. Kirkpatrick
Region / country: Global
Speciality: General surgery

Secondary peritonitis and intra-abdominal sepsis are a global health problem. The life-threatening systemic insult that results from intra-abdominal sepsis has been extensively studied and remains somewhat poorly understood. While local surgical therapy for perforation of the abdominal viscera is an age-old therapy, systemic therapies to control the subsequent systemic inflammatory response are scarce. Advancements in critical care have led to improved outcomes in secondary peritonitis. The understanding of the effect of secondary peritonitis on the human microbiome is an evolving field and has yielded potential therapeutic targets. This review of secondary peritonitis discusses the history, classification, pathophysiology, diagnosis, treatment, and future directions of the management of secondary peritonitis. Ongoing clinical studies in the treatment of secondary peritonitis and the open abdomen are discussed


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92. Impact of Community-Based Clinical Breast Examinations in Botswana

JCO Global Oncology


Authors: Michael Dykstra, Brighid Malone, Onica Lekuntwane, Jason Efstathiou, Virginia Letsatsi, Shekinah Elmore, Cesar Castro, Neo Tapela, and Scott Dryden-Peterson
Region / country: Southern Africa – Botswana
Speciality: General surgery, Obstetrics and Gynaecology, Surgical oncology

PURPOSE
We evaluated a clinical breast examination (CBE) screening program to determine the prevalence of breast abnormalities, number examined per cancer diagnosis, and clinical resources required for these diagnoses in a middle-income African setting.

METHODS
We performed a retrospective review of a CBE screening program (2015-2018) by Journey of Hope Botswana, a Botswana-based nongovernmental organization (NGO). Symptomatic and asymptomatic women were invited to attend. Screening events were held in communities throughout rural and periurban Botswana, with CBEs performed by volunteer nurses. Individuals who screened positive were referred to a private tertiary facility and were followed by the NGO. Data were obtained from NGO records.

RESULTS
Of 6,120 screened women (50 men excluded), 452 (7.4%) presented with a symptom and 357 (5.83%) were referred for further evaluation; 257 ultrasounds, 100 fine-needle aspirations (FNAs), 58 mammograms, and 31 biopsies were performed. In total, 6,031 were exonerated from cancer, 78 were lost to follow-up (67 for ≤ 50 years and 11 for > 50 years), and 11 were diagnosed with cancer (five for 41-50 years and six for > 50 years, 10 presented with symptoms). Overall breast cancer prevalence was calculated to be 18/10,000 (95% CI, 8 to 29/10,000). The number of women examined per breast cancer diagnosis was 237 (95% CI, 126 to 1910) for women of age 41-50 years and 196 (95% CI, 109 to 977) for women of age > 50 years. Median time to diagnosis for all women was 17.5 [1 to 32.5] days. CBE-detected tumors were not different than tumors presenting through standard care.

CONCLUSION
In a previously unscreened population, yield from community-based CBE screening was high, particularly among symptomatic women, and required modest diagnostic resources. This strategy has potential to reduce breast cancer mortality.


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93. Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control

JCO Global Oncology


Authors: Minjoung Monica Koo, Karla Unger-Saldaña, Amos D. Mwaka, Marilys Corbex, Ophira Ginsburg, Fiona M. Walter MBBChir, Natalia Calanzani, Jennifer Moodley, Greg P. Rubin and Georgios Lyratzopoulos
Region / country: Global
Speciality: General surgery, Health policy, Surgical oncology

Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site–specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems’ capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.


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94. How do Supply- and Demand-side Interventions Influence Equity in Healthcare Utilisation? Evidence from Maternal Healthcare in Senegal

City Research Online


Authors: Divya Parmar and Aneesh Banerjee
Region / country: Western Africa – Senegal
Speciality: Health policy, Obstetrics and Gynaecology

The launch of the Millennium Development Goals in 2000, followed by the Sustainable Development Goals in 2015, and the increasing focus on achieving universal health coverage has led to numerous interventions on both supply- and demand-sides of health systems in low- and middle-income countries. While tremendous progress has been achieved, inequities in access to healthcare persist, leading to calls for a closer examination of the equity implications of these interventions. This paper examines the equity implications of two such interventions in the context of maternal healthcare in Senegal. The first intervention on the supply-side focuses on improving the availability of maternal health services while the second intervention, on the demand-side, abolished user fees for facility deliveries. Using three rounds of Demographic Health Surveys
covering the period 1992 to 2010 and employing three measures of socioeconomic status (SES) based on household wealth, mothers’ education and rural/urban residence – we find that although both interventions increase utilisation of maternal health services, the rich benefit more from the supply-side intervention, thereby increasing inequity, while the poor benefit more from the demand-side intervention i.e. reducing inequity. Both interventions positively influence facility deliveries in rural areas although the increase in facility deliveries after the demand-side intervention is more than the increase after the supply-side intervention. There is no significant difference in utilisation based on mothers’ education. Since people from different SES categories are likely to respond differently to interventions on the supply- and demand-side of the health system, policymakers involved in the design of health programmes should pay closer attention to concerns of inequity and elite capture that may unintentionally result from these interventions


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95. Broader health impacts of vertical responses to Covid-19 in low- and middle-income countries

Social Science in Humanitarian Action Platform


Authors: Tabitha Hrynick, Santiago Ripoll and Simone Carter
Region / country: Global
Speciality: Health policy, Other

The COVID-19 pandemic has undermined capacity and efforts to address other health needs that are just as pressing as the virus itself, particularly in low- and middle-income countries (LMICs). Pressure on governments to act on COVID-19 now to save “immediately identifiable lives” rather than “statistical lives at risk”1 has had and will continue to have harmful short- and long-term consequences for other areas of health. This paper reviews the effects of vertical responses to COVID-19 on health systems, services, and people’s access to and use of them in LMICs, where historic and ongoing under-investments heighten vulnerability to a multiplicity of health threats. We use the term ‘vertical response’ to describe decisions, measures and actions taken solely with the purpose of preventing and containing COVID-19, often without adequate consideration of how this affects the wider health system and pre-existing resource constraints. Through four main sections focused on 1) characterising vertical response, 2) the drivers of broader health impacts, 3) evidence of impacts, and finally 4) suggestions for mitigation, we provide insight for actors in government, agencies, organisations and communities to design and implement more proportionate, appropriate, comprehensive and socially just responses that address COVID-19 without compromising other aspects of health. Beyond immediate action, there is a need to re-evaluate priorities and approaches in global health, both in the context of COVID-19 and beyond. If the well-being of all people is truly valued, ‘whole of health’ approaches which account for health trade-offs of COVID-19 response in the short-term, and address the health needs of diverse populations in the medium- to long-term are crucial.


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96. Recommendations for the Management of COVID-19 in Low- and Middle-Income Countries

The American Society of Tropical Medicine and Hygiene


Authors: Arjen M. Dondorp, Alfred C. Papali and Marcus J. Schultz
Region / country: Global
Speciality: Critical care, Health policy

At the conclusion of its first year, the dynamics of the COVID-19 pandemic are still fluid. Today’s global and regional numbers on incidence and mortality are outdated just a few weeks later. Effective SARS-CoV-2 vaccines are becoming available, but the exact timeline of their availability, in particular in low- and middle-income countries (LMICs), is still unclear. What has become clear, albeit not completely understood, is that many poorer countries have been hit less by the pandemic than high-income countries (HICs), even when accounting for underreporting related to more limited testing capacity. Many LMICs need to be commended for their generally faster public health responses at much earlier stages in their epidemics than their HIC counterparts. Also, likely because of the relatively younger population in LMICs than HICs, the estimated COVID-19 infection/ fatality ratio is typically around two to three deaths per 1,000 infections in LMICs, contrasted to six to 10 deaths per 1,000 infections observed in HICs with older populations.


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97. Estimated Impact of the COVID-19 Economic Recession on Under-5 Mortality Rates for 129 Countries

The Lancet


Authors: Marcelo Cardona Cabrera , Joseph Millward , Katelyn Jison Yoo, Alison Gemmill , David M. Bishai
Region / country: Global
Speciality: Health policy, Paediatric surgery

Background: This study estimates the potential loss of life in children under five years old attributable to the economic recessions of 2020. Multiple prior studies have shown a strong and independent effect of GDP per capita on child mortality in developing countries after controlling for health system effects, demography, politics, environment, and literacy.

Methods: Data were retrieved from the World Bank World Development Indicators database and the United Nations World Populations Prospects estimates for the years 1990-2020 for 129 countries with GDP per capita below 12,375 US$ (defined as low, lower-middle, and upper-middle income countries; LMICs). We used a multi-level, mixed effects, multivariate model to estimate the adjusted relationship between GDP per capita and the under-5 mortality rate (U5MR) specific to each country. The model’s country-specific parameters were used to simulate the impact on U5MR due to reductions in GDP per capita of 5%, 10%, and 15%.

Findings: In a conservative scenario, a 5% reduction in GDP per capita in 2020 is estimated to cause an additional 282,996 deaths in children under 5 in one year compared to a baseline of no economic recession. Recessions at 10% and 15% lead to higher losses of under-5 lives, increasing to 585,802 and 911,026 additional deaths, respectively. We estimate that nearly half of all the potential under-5 lives lost from economic recessions in LMICs are estimated to occur in Sub-Saharan Africa.

Interpretation: In developing countries, under-5 mortality rates are closely tied to national income. We estimate that the recessions of 2020 will lead to around 300,000 deaths in the under-5 population. Our results do not take into account the irreparable effects of economic deprivation on child development. We expect to see similar trends of child mortality in the next few years in the absence of sufficient SARS-CoV-2 vaccination or herd immunity.


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98. Mortality during and following hospital admission among school-aged children: a cohort study

Wellcome Open Research


Authors: Moses M Ngari , Christina Obiero, Martha K Mwangome, Amek Nyaguara, Neema Mturi, Sheila Murunga, Mark Otiende, Per Ole Iversen, Gregory W Fegan, Judd L Walson, James A Berkley
Region / country: Eastern Africa – Kenya
Speciality: Health policy, Paediatric surgery

Background: Far less is known about the reasons for hospitalization or mortality during and after hospitalization among school-aged children than among under-fives in low- and middle-income countries. This study aimed to describe common types of illness causing hospitalisation; inpatient mortality and post-discharge mortality among school-age children at Kilifi County Hospital (KCH), Kenya.
Methods: A retrospective cohort study of children 5−12 years old admitted at KCH, 2007 to 2016, and resident within the Kilifi Health Demographic Surveillance System (KHDSS). Children discharged alive were followed up for one year by quarterly census. Outcomes were inpatient and one-year post-discharge mortality.
Results: We included 3,907 admissions among 3,196 children with a median age of 7 years 8 months (IQR 74−116 months). Severe anaemia (792, 20%), malaria (749, 19%), sickle cell disease (408, 10%), trauma (408, 10%), and severe pneumonia (340, 8.7%) were the commonest reasons for admission. Comorbidities included 623 (16%) with severe wasting, 386 (10%) with severe stunting, 90 (2.3%) with oedematous malnutrition and 194 (5.0%) with HIV infection. 132 (3.4%) children died during hospitalisation. Inpatient death was associated with signs of disease severity, age, bacteraemia, HIV infection and severe stunting. After discharge, 89/2,997 (3.0%) children died within one year during 2,853 child-years observed (31.2 deaths [95%CI, 25.3−38.4] per 1,000 child-years). 63/89 (71%) of post-discharge deaths occurred within three months and 45% of deaths occurred outside hospital. Post-discharge mortality was positively associated with weak pulse, tachypnoea, severe anaemia, HIV infection and severe wasting and negatively associated with malaria.
Conclusions: Reasons for admissions are markedly different from those reported in under-fives. There was significant post-discharge mortality, suggesting hospitalisation is a marker of risk in this population. Our findings inform guideline development to include risk stratification, targeted post-discharge care and facilitate access to healthcare to improve survival in the early months post-discharge in school-aged children.


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99. Prevalence, causes and impact of musculoskeletal impairment in Malawi: A national cluster randomized survey

plos Journals


Authors: Leonard Banza Ngoie ,Eva Dybvik,Geir Hallan,Jan-Erik Gjertsen,Nyengo Mkandawire,Carlos Varela,Sven Young
Region / country: Southern Africa – Malawi
Speciality: Health policy, Trauma and orthopaedic surgery

There is a lack of accurate information on the prevalence and causes of musculoskeletal impairment (MSI) in low income countries. The WHO prevalence estimate does not help plan services for specific national income levels or countries. The aim of this study was to find the prevalence, impact, causes and factors associated with musculoskeletal impairment in Malawi. We wished to undertake a national cluster randomized survey of musculoskeletal impairment in Malawi, one of the UN Least Developed Countries (LDC), that involved a reliable sampling methodology with a case definition and diagnostic criteria that could clearly be related to the classification system used in the WHO International Classification of Functioning, Disability and Health (ICF)

Methods
A sample size of 1,481 households was calculated using data from the latest national census and an expected prevalence based on similar surveys conducted in Rwanda and Cameroon. We randomly selected clusters across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the distribution of the population. In the field, randomization of households in a cluster was based on a ground bottle spin. All household members present were screened, and all MSI cases identified were examined in more detail by medical students under supervision, using a standardized interview and examination protocol. Data collection was carried out from 1st July to 30th August 2016. Extrapolation was done based on study size compared to the population of Malawi. MSI severity was classified using the parameters for the percentage of function outlined in the WHO International Classification of Functioning (ICF). A loss of function of 5–24% was mild, 25–49% was moderate and 50–90% was severe. The Malawian version of the EQ-5D-3L questionnaire was used, and EQ-5D index scores were calculated using population values from Zimbabwe, as a population value set for Malawi is not currently available. Chi-square test was used to test categorical variables. Odds ratio (OR) was calculated with a linear regression model adjusted for age, gender, location and education.

Results
A total of 8,801 individuals were enumerated in 1,481 households. Of the 8,548 participants that were screened and examined (response rate of 97.1%), 810 cases of MSI were diagnosed of which 18% (108) had mild, 54% (329) had moderate and 28% (167) had severe MSI as classified by ICF. There was an overall prevalence of MSI of 9.5% (CI 8.9–10.1). The prevalence of MSI increased with age, and was similar in men (9.3%) and women (9.6%). People without formal education were more likely to have MSI [13.3% (CI 11.8–14.8)] compared to those with formal education levels [8.9% (CI 8.1–9.7), p<0.001] for primary school and [5.9% (4.6–7.2), p<0.001] for secondary school. Overall, 33.2% of MSIs were due to congenital causes, 25.6% were neurological in origin, 19.2% due to acquired non-traumatic non-infective causes, 16.8% due to trauma and 5.2% due to infection. Extrapolation of these findings indicated that there are approximately one million cases of MSI in Malawi that need further treatment. MSI had a profound impact on quality of life. Analysis of disaggregated quality of life measures using EQ-5D showed clear correlation with the ICF class. A large proportion of patients with moderate and severe MSI were confined to bed, unable to wash or undress or unable to perform usual daily activities.

Conclusion
This study has uncovered a high prevalence of MSI in Malawi and its profound impact on a large proportion of the population. These findings suggest that MSI places a considerable strain on social and financial structures in this low-income country. The Quality of Life of those with severe MSI is considerably affected. The huge burden of musculoskeletal impairment in Malawi is mostly unattended, revealing an urgent need to scale up surgical and rehabilitation services in the country.


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100. Healthcare in transition in the Republic of Armenia: the evolution of emergency medical systems and directions forward

International Journal of Emergency Medicine


Authors: Sharon Chekijian, Nune Truzyan, Taguhi Stepanyan & Alexander Bazarchyan
Region / country: Western Asia – Armenia
Speciality: Emergency surgery, Health policy

Armenia, an ex-Soviet Republic in transition since independence in 1991, has made remarkable strides in development. The crisis of prioritization that has plagued many post-Soviet republics in transition has meant differential growth in varied sectors in Armenia. Emergency systems is one of the sectors which is neglected in the current drive to modernize. The legacy of the Soviet Semashko system has left a void in specialized care including emergency care. This manuscript is a descriptive overview of the current state of emergency care in Armenia using in-depth key informant interviews and review of published and unpublished internal United States Agency for International Development (USAID) and Ministry of Health (MOH) documents as well as data from the Yerevan Municipal Ambulance Service and international agencies. The Republic of Artsakh is briefly discussed.

The development of emergency care systems is an extremely efficient way to provide care across many different conditions in many age groups. Conditions such as traumatic injuries, heart attacks, cardiac arrest, stroke, and respiratory failure are very time-dependent. Armenia has a decent emergency infrastructure in place and has the benefit of an educated and skilled physician workforce. The missing piece of the puzzle appears to be investment in graduate and post-graduate education in emergency care and development of hospital-based emergency care for stabilization of stroke, myocardial infarction, trauma, and sepsis as well as other acute conditions


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101. Designing devices for global surgery: evaluation of participatory and frugal design methods

International Journal of surgery global health


Authors: Marriott Webb, Millie BEng ,Bridges Philippa , Aruparayil Noel ,Mishra Anurag ,Bains Lovenish , Hall Richard, Gnanaraj Jesudian ,Culmer Peter
Region / country: Global
Speciality: General surgery, Health policy, Other

Introduction:
Most people living in low- and middle-income countries have no access to surgical care. Equipping under-resourced health care contexts with appropriate surgical equipment is thus critical. “Global” technologies must be designed specifically for these contexts. But while models, approaches and methods have been developed for the design of equipment for global surgery, few studies describe their implementation or evaluate their adequacy for this purpose.

Methods:
A multidisciplinary team applied participatory and frugal design methods to design a surgical device for gasless laparoscopy. The team employed a formal roadmap, devised to guide the development of global surgical equipment, to structure the design process into phases. Phases 0–1 comprised primary research with surgeons working in low-resource settings and forming collaborative partnerships with key stakeholders. These participated in phases 2–3 through design workshops and video events. To conclude, surgical stakeholders (n=13) evaluated a high-fidelity prototype in a cadaveric study.

Results:
The resulting design, “RAIS” (Retractor for Abdominal Insufflation-less Surgery), received positive feedback from rural surgeons keen to embrace and champion innovation as a result of the close collaboration and participatory design methods employed. The roadmap provided a valuable means to structure the design process but this evaluation highlighted the need for further development to detail specific methodology. The project outcomes were used to develop recommendations for innovators designing global surgical equipment.

To inform early phases in the design roadmap, engaging a variety of stakeholders to provide regular input is crucial. Effective communication is vital to elucidate clear functional design requirements and hence reveal opportunities for frugal innovation. Finally, responsible innovation must be embedded within the process of designing devices for global surgery.

Conclusion:
A community-wide effort is required to formally evaluate and optimize processes for designing global surgical devices and hence accelerate adoption of frugal surgical technologies in low-resource settings.


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102. Challenges in Providing Surgical Procedures During the COVID-19 Pandemic: Qualitative Study Among Operating Department Practitioners in Pakistan

Research Square


Authors: Sara Rizvi Jafree, Ain ul Momina, Nudra Malik, Syed Ashgar Naqi, Florian Fischer
Region / country: Southern Asia – Pakistan
Speciality: Emergency surgery, Health policy

ackground: Operating Department Practitioners (ODPs) are neglected human resources for health with regard to both professional development and research for patient safety. The surgical theatre is associated with the highest mortality rates and with the onslaught of the COVID-19 pandemic. ODPs are key practitioners with respect to infection control during surgeries. Therefore, this study aims to describe challenges faced by ODPs. The secondary aim is to use empirical evidence to inform the public health sector management about both ODP professional development and improvement in surgical procedures, with a specific focus on pandemics.

Methods: A qualitative study has been conducted. Data collection was based on an interview guide with open-ended questions. Interviews with 39 ODPs in public sector teaching hospitals of Pakistan who have been working during the COVID-19 pandemic were part of the analysis. Content analysis was used to generate themes.

Results: Ten themes related to challenges faced by ODPs in delivering services during the pandemic for securing patient safety were identified: (i) Disparity in training for prevention of COVID-19; (ii) Shortcomings in COVID-19 testing; (iii) Supply shortages of personal protective equipment; (iv) Challenges in maintaining physical distance and prevention protocols; (v) Human resource shortages and role burden; (vi) Problems with hospital administration; (vii) Exclusion and hierarchy; (viii) Teamwork limitations and other communication issues; (ix) Error Management; and (x) Anxiety and fear.

Conclusions: The public health sector, in Pakistan and other developing regions, need to invest in the professional development of ODPs and improve resources and structures for surgical procedures, during pandemics and otherwise


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103. Trends in national and subnational wealth related inequalities in use of maternal health care services in Nepal: an analysis using demographic and health surveys (2001–2016)

BMC Public Health


Authors: Vishnu Prasad Sapkota, Umesh Prasad Bhusal & Kiran Acharya
Region / country: Southern Asia – Nepal
Speciality: Health policy, Obstetrics and Gynaecology

Background
Maternal health affects the lives of many women and children globally every year and it is one of the high priority programs of the Government of Nepal (GoN). Different evidence articulate that the equity gap in accessing and using maternal health services at national level is decreasing over 2001–2016. This study aimed to assess whether the equity gap in using maternal health services is also decreasing at subnational level over this period given the geography of Nepal has already been identified as one of the predictors of accessibility and utilization of maternal health services.

Methods
The study used wealth index scores for each household and calculated the concentration curves and indexes in their relative formulation, with no corrections. Concentration curve was used to identify whether socioeconomic inequality in maternity services exists and whether it was more pronounced at one point in time than another or in one province than another. The changes between 2001 and 2016 were also disaggregated across the provinces. Test of significance of changes in Concentration Index was performed by calculating pooled standard errors. We used R software for statistical analysis.

Results
The study observed a progressive and statistically significant decrease in concentration index for at least four antenatal care (ANC) visit and institutional delivery at national level over 2001–2016. The changes were not statistically significant for Cesarean Section delivery. Regarding inequality in four-ANC all provinces except Karnali showed significant decreases at least between 2011 and 2016. Similarly, all provinces, except Karnali, showed a statistically significant decrease in concentration index for institutional delivery between 2011 and 2016.

Conclusion
Despite appreciable progress at national level, the study found that the progress in reducing equity gap in use of maternal health services is not uniform across seven provinces. Tailored investment to address barriers in utilization of maternal health services across provinces is urgent to make further progress in achieving equitable distribution in use of maternal health services. There is an opportunity now that the country is federalized, and provincial governments can make a need-based improvement by addressing specific barriers.


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104. The influence of travel time to health facilities on stillbirths: A geospatial case-control analysis of facility-based data in Gombe, Nigeria

plos One


Authors: Oghenebrume Wariri, Egwu Onuwabuchi, Jacob Albin Korem Alhassan, Eseoghene Dase, Iliya Jalo, Christopher Hassan Laima, Halima Usman Farouk,Aliyu U. El-Nafaty, Uduak Okomo, Winfred Dotse-Gborgbortsi
Region / country: Western Africa – Nigeria
Speciality: Critical care, Health policy, Obstetrics and Gynaecology

Access to quality emergency obstetric and newborn care (EmONC); having a skilled attendant at birth (SBA); adequate antenatal care; and efficient referral systems are considered the most effective interventions in preventing stillbirths. We determined the influence of travel time from mother’s area of residence to a tertiary health facility where women sought care on the likelihood of delivering a stillbirth. We carried out a prospective matched case-control study between 1st January 2019 and 31st December 2019 at the Federal Teaching Hospital Gombe (FTHG), Nigeria. All women who experienced a stillbirth after hospital admission during the study period were included as cases while controls were consecutive age-matched (ratio 1:1) women who experienced a live birth. We modelled travel time to health facilities. To determine how travel time to the nearest health facility and the FTHG were predictive of the likelihood of stillbirths, we fitted a conditional logistic regression model. A total of 318 women, including 159 who had stillborn babies (cases) and 159 age-matched women who had live births (controls) were included. We did not observe any significant difference in the mean travel time to the nearest government health facility for women who had experienced a stillbirth compared to those who had a live birth [9.3 mins (SD 7.3, 11.2) vs 6.9 mins (SD 5.1, 8.7) respectively, p = 0.077]. However, women who experienced a stillbirth had twice the mean travel time of women who had a live birth (26.3 vs 14.5 mins) when measured from their area of residence to the FTHG where deliveries occurred. Women who lived farther than 60 minutes were 12 times more likely of having a stillborn [OR = 12 (1.8, 24.3), p = 0.011] compared to those who lived within 15 minutes travel time to the FTHG. We have shown for the first time, the influence of travel time to a major tertiary referral health facility on the occurrence of stillbirths in an urban city in, northeast Nigeria


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105. Estimation of the National Surgical Needs in India by Enumerating the Surgical Procedures in an Urban Community Under Universal Health Coverage

World Journal of Surgery


Authors: Prashant Bhandarkar , Anita Gadgil , Priti Patil , Monali Mohan , Nobhojit Roy
Region / country: Southern Asia – India
Speciality: Anaesthesia, General surgery, Obstetrics and Gynaecology, Ophthalmology, Trauma and orthopaedic surgery

Background
11% of the global burden of disease requires surgical care or anaesthesia management or both. Some studies have estimated this burden to be as high as 30%. The Lancet Commission for Global Surgery (LCoGS) estimated that 5000 surgeries are required to meet the surgical burden of disease for 100,000 people in LMICs. Studies from LMICs, estimating surgical burden based on enumeration of surgeries, are sparse.

Method
We performed this study in an urban population availing employees’ heath scheme in Mumbai, India. Surgical procedures performed in 2017 and 2018, under this free and equitable health scheme, were enumerated. We estimated the surgical needs for national population, based on age and sex distribution of surgeries and age standardization from our cohort.

Result
A total of 4642 surgeries were performed per year for a population of 88,273. Cataract (22.8%), Caesareans (3.8%), surgeries for fractures (3.27%) and hernia (2.86%) were the commonest surgeries. 44.2% of surgeries belonged to the essential surgeries. We estimated 3646 surgeries would be required per 100,000 Indian population per year. One-third of these surgeries would be needed for the age group 30–49 years, in the Indian population.

Conclusion
A total of 3646 surgeries were estimated annually to meet the surgical needs of Indian population as compared to the global estimate of 5000 surgeries per 100,000 people. Caesarean section, cataract, surgeries for fractures and hernia are the major contributors to the surgical needs. More enumeration-based studies are needed for better estimates from rural as well as other urban areas.


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106. Quality of Histopathological Reporting in Breast Cancer: Results From Four South African Breast Units

JCO Global Oncology


Authors: Armand Toma, Daniel O’Neil , Maureen Joffe , Oluwatosin Ayeni,Carolina Nel , Eunice van den Berg , Simon Nayler, Herbert Cubasch , Boitumelo Phakathi , Ines Buccimazza, Sharon Čačala, Paul Ruff, Shane Norris , and Sarah Nietz
Region / country: Southern Africa – South Africa
Speciality: General surgery, Surgical oncology

PURPOSE
High-quality histopathology reporting forms the basis for treatment decisions. The quality indicator for pathology reports from the European Society of Breast Cancer Specialists was applied to a cohort from four South African breast units.

METHODS
The study included 1,850 patients with invasive breast cancer and evaluated 1,850 core biopsies and 1,158 surgical specimen reports with cross-center comparisons. A core biopsy report required histologic type; tumor grade; and estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) status, with a confirmatory test for equivocal HER2 results. Ki-67 was regarded as optional. Pathologic stage, tumor size, lymphovascular invasion, and distance to nearest invasive margin were mandatory for surgical specimens. Specimen turnaround time (TAT) was added as a locally relevant indicator.

RESULTS
Seventy-five percent of core biopsy and 74.3% of surgical specimen reports were complete but showed large variability across study sites. The most common reason for an incomplete core biopsy report was missing tumor grade (17.9%). Half of the equivocal HER2 results lacked confirmatory testing (50.6%). Ki-67 was reported in 89.3%. For surgical specimens, the closest surgical margin was reported in 78.1% and lymphovascular invasion in 84.8% of patients. Mean TAT was 11.9 days (standard deviation [SD], 10.8 days) for core biopsies and 16.1 days (SD, 11.3) for surgical specimens.

CONCLUSION
Histopathology reporting is at a high level but can be improved, especially for tumor grade, HER2, and Ki-67, as is reporting of margins and lymphovascular invasion. A South African pathology consensus will reduce variability among laboratories. Routine use of standardized data sheets with synoptic reports and ongoing audits will improve completeness of reports over time.


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107. Intimate partner violence against adolescent girls and young women and its association with miscarriages, stillbirths and induced abortions in sub-Saharan Africa: Evidence from demographic and health surveys

SSM – Population Health


Authors: Bright Opoku Ahinkorah
Region / country: Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Obstetrics and Gynaecology

Intimate partner violence has been associated with numerous consequences for women, including pregnancy termination. This study aimed to examine the association between intimate partner violence and pregnancy termination among adolescent girls and young women in 25 sub-Saharan African countries. Data for this study was obtained from the demographic and health surveys of 25 countries in sub-Saharan Africa, published between 2010 and 2019. A total of 60,563 adolescent girls and young women were included in this study. Binary logistic regression models were used in analyzing the data and the results were presented as crude odds ratios (CORs) and adjusted odds ratios (AORs) at 95% confidence interval (CI). The prevalence of intimate partner violence and pregnancy termination among adolescent girls and young women in the 25 countries in sub-Saharan Africa were 19% and 10.1% respectively. In all these countries, the odds of pregnancy termination was higher among adolescent girls and young women who had ever experienced intimate partner violence, compared to those who had never experienced intimate partner violence [COR = 1.60, 95% CI = 1.51–1.71], and this persisted after controlling for confounders [AOR = 1.58, 95% CI = 1.48–1.68]. However, across countries, intimate partner violence had significant association with pregnancy termination among adolescent girls and young women in Angola, Chad, Congo DR and Gabon (Central Africa); Benin, Burkina Faso, Cote D’lvoire, Gambia and Mali (West Africa); Comoros, Rwanda and Uganda (East Africa); and Malawi and Zambia (Southern Africa). The findings imply that reducing pregnancy termination among adolescent girls and young women in sub-Saharan Africa depends on the elimination of intimate partner violence. Thus, policies and programmes aimed at reducing pregnancy termination among adolescent girls and young women in sub-Saharan Africa, should pay particular attention to those who have history of intimate partner violence.


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108. 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

The American Journal of Tropical Medicine and Hygiene


Authors: Luigi Pisani, Anna Geke Algera, Ary Serpa Neto, Areef Ahsan, Abigail Beane, Kaweesak Chittawatanarat, Abul Faiz, Rashan Haniffa, Seyed MohammadReza Hashemian, Madiha Hashmi, Hisham Ahmed Imad, Kanishka Indraratna, Shivakumar Iyer, Gyan Kayastha, Bhuvana Krishna, Tai Li Ling, Hassan Moosa, Behzad Nadjm, Rajyabardhan Pattnaik, Sriram Sampath, Louise Thwaites, Ni Ni Tun, Nor’azim Mohd Yunos, Salvatore Grasso, Frederique Paulus, Marcelo Gama de Abreu, Paolo Pelosi, Nick Day, Nick White, Arjen M. Dondorp, Marcus J. Schultz and for the PRoVENT-iMiC† investigators, MORU‡ and the PROVE Network
Region / country: Central Asia, Eastern Asia, South-eastern Asia, Southern Asia, Western Asia
Speciality: Critical care

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.


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109. “Hanging in a balance”: A qualitative study exploring clinicians’ experiences of providing care at the end of life in the burn unit

Palliative Medicine


Authors: Jonathan Bayuo, Katherine Bristowe, Richard Harding, Anita Eseenam Agbeko, Frances Kam Yuet Wong, Frank Bediako Agyei, Gabriel Allotey, Prince Kyei Baffour, Pius Agbenorku, Paa Ekow Hoyte-Williams, Ramatu Agambire
Region / country: Western Africa – Ghana
Speciality: Critical care, Trauma surgery

Background:
Although the culture in burns/critical care units is gradually evolving to support the delivery of palliative/end of life care, how clinicians experience the end of life phase in the burn unit remains minimally explored with a general lack of guidelines to support them.

Aim:
To explore the end of life care experiences of burn care staff and ascertain how their experiences can facilitate the development of clinical guidelines.

Design:
Interpretive-descriptive qualitative approach with a sequential two phased multiple data collection strategies was employed (face to face semi-structured in-depth interviews and follow-up consultative meeting). Thematic analysis was used to analyze the data.

Setting/participants:
The study was undertaken in a large teaching hospital in Ghana. Twenty burn care staff who had a minimum of 6 months working experience completed the interviews and 22 practitioners participated in the consultative meeting.

Results:
Experiences of burn care staff are complex with four themes emerging: (1) evaluating injury severity and prognostication, (2) nature of existing system of care, (3) perceived patient needs, and (4) considerations for palliative care in burns. Guidelines in this regard should focus on facilitating communication between the patient and family and staff, holistic symptom management at the end of life, and post-bereavement support for family members and burn care practitioners.

Conclusions:
The end of life period in the burn unit is poorly defined coupled with prognostic uncertainty. Collaborative model of practice and further training are required to support the integration of palliative care in the burn unit.


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110. Clinical quality and performance measurement in the prehospital emergency medical services in the low-to-middle income country setting

Karolinska Institutet


Authors: Ian Howard
Region / country: Southern Africa – South Africa
Speciality: Emergency surgery, Health policy

BACKGROUND
Measuring quality and safety in any healthcare setting however is highly contextual, and depends on the manner in which quality is defined or viewed within that setting. It is this contextual nature that has provoked significant debate and hindered efforts at developing formal standards or criteria for measuring quality and safety in healthcare, regardless of setting. Historically, performance within the Emergency Medical Services (EMS) delivering prehospital emergency care has been assessed primarily based on response times. While easy to measure and valued by the public, overall, response time targets are a poor predictor of quality of care and clinical outcomes.
AIM
The overall aim of the research was to develop a framework for clinical quality and performance-based assessment of prehospital emergency care for use in the South African EMS.
METHOD
The research was divided amongst four studies, with each study constituting one of the overall research objectives. Study I was a sequential explanatory mixed methods study with the aim of understanding the knowledge, attitudes and practices of clinical quality and performance assessment amongst South African EMS personnel. Part 1 consisted of a webbased cross-sectional survey, and Part 2 consisted of semi-structured telephonic interviews of select participants from Part 1 to explore the results of the survey. Descriptive statistics were carried out to summarise and present all survey items, and conventional content analysis employed to analyse the interview data. Study II utilised a three round modified Delphi study to identify, refine and review a list of appropriate quality indicators for potential use in the South African EMS setting. For Study III a novel quality indicator appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of their consensus application, and tested against the outcomes of Study II. Descriptive statistics were utilised to describe and summarize the categorical based appraisal data. Inter-rater reliability was calculated using percentage agreement and Gwet’s AC1. Correlation between the individual methods and the protocol was calculated using Spearman’s rank Correlation and z-test. Conventional content analysis was utilised to analyse the group discussions. Study IV utilised a multiple exploratory case study design to evaluate the current state of quality systems in the South African EMS. A formative assessment was conducted on the quality systems of four provincial EMS and one national private EMS, following which semi-structured interviews were conducted to further explore the results obtained from the formative assessment, supported by multiple
secondary data sources. Descriptive statistics were utilised to describe and summarize the formative assessment. Conventional content analysis was utilised to analyse the interview data and document analysis utilised to sort and analyse the supporting data
RESULTS
Despite relatively poor knowledge of organisational-specific quality systems, understanding of the core components and importance of quality systems was demonstrated. The role of these systems in the Low to Middle Income Country setting (LMICs) was supported by participants, where the importance of context, system transparency, reliability and validity were essential towards achieving ongoing success and utilisation. The role of leadership and communication towards the effective facilitation of such a system was equally identified. Participating services generally scored higher for structure and planning. Measurement and improvement were found to be more dependent on utilisation and perceived mandate. There was a relatively strong focus on clinical quality assessment within the private service, whereas in the provincial systems, measures were exclusively restricted to call times with little focus on clinical care. Staff engagement and programme evaluation were generally among the lowest scores. A multitude of contextual factors were identified that affected the effectiveness of quality systems, centred around leadership, vision and mission, and quality system infrastructure and capacity, guided by the need for comprehensive yet pragmatic strategic policies and standards. A total, 104 quality indicators reached consensus agreement including, 90 clinical QIs, across 15 subcategories, and 14 non-clinical QIs across two subcategories. Amongst the clinical category, airway management (n=13 QIs; 14%); out-of-hospital cardiac arrest (n=13 QIs; 14%); and acute coronary syndromes (n=11 QIs; 12%) made up the majority. Within the non-clinical category, adverse events made up the significant majority with nine QIs (64%). There was mixed inter-rater reliability of the individual methods. There was similarly poor to moderate correlation of the results obtained between the individual methods (Spearman’s rank correlation=0.42,p<0.001). From a series of 104 QIs, 11 were identified that were shared between the individual methods. A further 19 QIs were identified and not shared by each method, highlighting the benefits of a multimethod approach.
CONCLUSION
For the purposes of this study we focused on the technical competence aspect of quality, in developing our measurement framework. Towards this, we identified a significant number of QIs assessed to be valid and feasible for the South African prehospital emergency care setting. The majority of which are centred around clinically focused processes of care, measures that are lacking in current performance assessment in EMS in South Africa. However, we also discovered the importance and influencing role of the individual practitioners and quality system in which the QIs will be implemented, a point highlighted across all the methodologies and studies. Given the potential magnitude of this influence, it is of the utmost importance that any measurement framework examining technicalquality, have equal in-depth understanding of these factors in order to be successful.


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111. An evaluation of obstetric ultrasound education program in Nepal using the RE-AIM framework

BMC Medical Education


Authors: Jieun Kim, Prabin Raj Shakya, Sugy Choi, Joong Shin Park, Suman Raj Tamrakar, Jongho Heo & Woong-Han Kim
Region / country: Southern Asia – Nepal
Speciality: Obstetrics and Gynaecology, Surgical Education

Background
Nepal has a high prevalence of congenital anomaly contributing to high infant mortality. Ultrasound, an important tool to detect congenital anomalies and manage maternity-related risk factors, is not properly used in Nepal because Nepali doctors have limited opportunities for learning ultrasound techniques. Hence, we developed and implemented an ultrasound education program from 2016 to 2018. The objective of this study is to evaluate the education program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

Methods
We conducted a mixed-method study to evaluate each component of RE-AIM. The team collected quantitative data from administrative records, tests, surveys, and an online follow-up survey. Qualitative data were collected from individual in-depth interviews at least a year after the program. The proportions, means, and t-tests were used for quantitative data, and thematic coding for qualitative data.

Results
A total of 228 healthcare workers representing 27.3% of the districts of Nepal were reached from 2016 to 2018. The program improved participants’ knowledge (29.3, 8.7, and 23.8 increases out of 100, each year, p< 0.001, n=85) and self-confidence (0.6, 0.3, 1.3 increases out of 4.0, p< 0.01, n=111). The participants were highly satisfied with the program (4.2, 4.1, and 4.0 out of 5.0, n=162). Among the respondents of the online follow-up survey (n=28), 60.7% had used ultrasound in their daily practice after the education program, and a medical institution established an ultrasound training center. The absence of clear accreditation and practical guidelines in ultrasound use were presented as barriers for adoption and maintenance.

Conclusion
The program was successful in improving participant’s knowledge and self-confidence in ultrasound techniques and showed great potential for the adoption and maintenance of the techniques in their practice. Continuous implementation of the program and institutional policy changes to facilitate ultrasound use may increase the ultrasound use and improve ultrasound service quality in Nepal.


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112. Social media and global cardiovascular disparities

European Heart Journal – Digital Health


Authors: Alejandra Castro-Varela, Jessica G Y Luc, Dominique Vervoort
Region / country: Global
Speciality: Cardiothoracic surgery, Health policy

Social media have become pervasive in modern life, academic practice, and medicine, even more so in response to the COVID-19 pandemic. Ladeiras-Lopes et al.1 present a timely overview of social media in cardiovascular medicine, highlighting successes to date and opportunities to responsibly incorporate social media in clinicians’ and researchers’ toolbox. Indeed, the power and growth of social media cannot be disregarded. For professional platforms like Twitter, the reach of tweets can be as much as hundreds of thousands of unique users: a large and fast gain for minimal (280-character) effort. The potential of social media platforms has further been clear through its ability to foster social networks, remote mentorship, virtual journal clubs, post-publication peer review, and more.2 In today’s world, where virtual communication, education, and telemedicine are increasingly leveraged, opportunities arise to take existing social media tools beyond our immediate environments and seek to connect with and learn from peers and colleagues in low- and middle-income countries (LMICs) and remote areas.3

Disparities in cardiovascular medicine persist as 18 million people die each year from cardiovascular diseases, of which a vast majority takes place in LMICs.4 Six billion people lack access to safe, timely, and affordable cardiac surgical care,4 whereas little is known regarding the global distribution of non-surgical cardiac care providers. Nevertheless, many challenges, such as inefficient supply chains, limited training programmes, remote populations, lack of financial risk protection, and other barriers to care remain common across all cardiovascular disciplines. In addition, beyond health system disparities, language barriers contribute to the vast gap in country- or population-specific research in the global health and global surgery context. Moreover, this has commonly been skewed with anglophone predominance, requiring a paradigm shift to instill more equitable practices within today’s academic ecosystem.

Social media has shown vast potential in the realms of global health and global surgery, creating networks of clinicians, trainees, and researchers all the way to the last mile.5 While current social media engagement is focused largely on online dialogue, it is increasingly leveraged as a tool to foster global collaboration, community engagement, education, and awareness regarding global health issues.6 Importantly, social media have been used to facilitate telemedicine and teleconsult communication channels to gain expertise from colleagues remotely or to educate residents and fellows, especially in lower-resource or remote settings.7,8 The current pandemic further leverages such channels and networks to host virtual conferences and shift to virtual education, ranging from video-conference calls to online training modules and low-cost, low-to-high-fidelity virtual reality and simulators.3 Similar opportunities arise to utilize such networks, specifically with regards to social media, in the fields of global cardiology and global cardiac surgery.

Social media platforms aid in creating global networks that transcend borders and promote international collaboration. For example, the Global Cardiac Surgery Initiative brings together trainees and young surgeons in cardiac surgery from around the world to advance the field of global cardiac surgery, illustrating what can result from such networks in terms of mentorship, sponsorship, and support for trainees and early-career researchers.9 Education and research are no longer limited by distance or time zones, giving way to open-access information through low-cost or free-of-charge webinars and conferences. Experts in the field share evidence-based and experience-based education and advice, recordings of which are readily available for whenever needed. Cases, some one-of-a-kind as observed in the current pandemic, may be discussed among colleagues and how to best manage them considering available resources and training. Accordingly, social media facilitates virtual training, presenting a variety of topics directed to students, trainees, faculty, and even patients. Moreover, virtual coaching of the entire cardiac surgery team present in the operating room, including perfusionists, scrub technicians, and nurses, remains an area of opportunity to explore to truly leverage the heart team mentality at the core of our work and such online engagement.

During this pandemic, social media has proven to be an effective tool for rapidly disseminating novel information, guidelines, and recently published papers.10 This allows for global efforts to continue in a timely fashion despite known or unforeseen barriers, such as the COVID-19 pandemic. Therefore, recognizing and understanding such barriers constitutes an important aspect of global health. One may utilize such platforms to present ongoing projects and the difficulties they encounter along the way. Additionally, social media allows for increasing awareness regarding understudied and under-addressed topics, such as global cardiac surgery. It makes connecting and interacting with others dedicated to global health, as well as other medical and non-medical disciplines, amiable, and approachable. These are of importance to create a true interdisciplinary and intersectoral health system that aims to consider multiple points of views and cover all issues thoroughly, as opposed to conventional vertical-only global health interventions. It is time for governments, global organizations, and individuals to search for long-due solutions and implement radical changes, in which social media can be a fundamental tool. Global research collaborations allow for increased awareness of each countries’ disparities and ideas to dissipate them, as well as finding sponsor organizations and partners with similar goals, facilitating resource collection and allocation in a sustainable manner. Social media may provide an opportunity for generating international registries to better understand population-specific characteristics and differences in access to care. Finally, it serves as an invaluable tool to inspire and mentor trainees to pursue certain career options, at home and abroad. The impact on the formation of present and future cardiology and cardiac surgery leaders will continue to grant encouraging results, extending to all corners of the world.

Global cardiovascular disparities prevail and substantially impede progress towards the Sustainable Development Goals and countries’ paths towards universal health coverage. Social media is a tool that should be leveraged to foster awareness surrounding these global disparities and accelerate shared learning, network building, and knowledge generation and dissemination within global cardiovascular care.


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113. Conference equity in global health: a systematic review of factors impacting LMIC representation at global health conferences

BMJ Global Health


Authors: Lotta Velin, Jean-Wilguens Lartigue,Samantha Ann Johnson,Anudari Zorigtbaatar, Ulrick Sidney Kanmounye, Paul Truche, Michelle Nyah Joseph
Region / country: Global
Speciality: Health policy, Surgical Education

Introduction Global health conferences are important platforms for knowledge exchange, decision-making and personal and professional growth for attendees. Neocolonial patterns in global health at large and recent opinion reports indicate that stakeholders from low- and middle-income countries (LMICs) may be under-represented at such conferences. This study aims to describe the factors that impact LMIC representation at global health conferences.

Methods A systematic review of articles reporting factors determining global health conference attendance was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles presenting conference demographics and data on the barriers and/or facilitators to attendance were included. Articles were screened at title and abstract level by four independent reviewers. Eligible articles were read in full text, analysed and evaluated with a risk of bias assessment.

Results Among 8765 articles screened, 46 articles met inclusion criteria. Thematic analysis yielded two themes: ‘barriers to conference attendance’ and ‘facilitators to conference attendance’. In total, 112 conferences with 254 601 attendees were described, of which 4% of the conferences were hosted in low-income countries. Of the 98 302 conference attendees, for whom affiliation was disclosed, 38 167 (39%) were from LMICs.

Conclusion ‘Conference inequity’ is common in global health, with LMIC attendees under-represented at global health conferences. LMIC attendance is limited by systemic barriers including high travel costs, visa restrictions and lower acceptance rates for research presentations. This may be mitigated by relocating conferences to visa-friendly countries, providing travel scholarships and developing mentorship programmes to enable LMIC researchers to participate in global conferences.


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114. A baseline review of the ability of hospitals in Kenya to provide emergency and critical care services for COVID-19 patients

African Journal of Emergency Medicine


Authors: Benjamin W.Wachira, MargaritaMwai
Region / country: Eastern Africa – Kenya
Speciality: Critical care, Emergency surgery, Trauma and orthopaedic surgery, Trauma surgery

Introduction
As the Coronavirus Disease 2019 (COVID-19) cases in Kenya begin to rise, the number of severe and critical COVID-19 patients has the potential to quickly overload the local healthcare system beyond its capacity to treat people.

Objective
The purpose of this study was to gather information about the ability of hospitals in Kenya to provide emergency and critical care services and to identify priority actions for use by policymakers and other stakeholders as a roadmap toward strengthening the COVID-19 response in the country.

Methods
This was a comprehensive review of the published and grey literature on emergency and critical care services in Kenya published in the last three years through April 2020. Screening of articles was conducted independently by the authors and the final decision for inclusion was made collaboratively. A total of 15 papers and documents were included in the review.

Key recommendations.

There is an urgent need to strengthen prehospital emergency care in Kenya by establishing a single toll-free ambulance access number and an integrated public Emergency Medical Services (EMS) system to respond to severe and critical COVID-19 patients in the community and other emergency cases. Functional 24-h emergency departments (EDs) need to be established in all the level 4, 5 and 6 hospitals in the country to ensure these patients receive immediate lifesaving emergency care when they arrive at the hospitals. The EDs should be equipped with pulse oximeters and functioning oxygen systems and have the necessary resources and skills to perform endotracheal intubation to manage COVID-19-induced respiratory distress and hypoxia. Additional intensive care unit (ICU) beds and ventilators are also needed to ensure continuity of care for the critically ill patients seen in the ED. Appropriate practical interventions should be instituted to limit the spread of COVID-19 to healthcare personnel and other patients within the healthcare system. Further research with individual facility levels of assessment around infrastructure and service provision is necessary to more narrowly define areas with significant shortfalls in emergency and critical care services as the number of COVID-19 cases in the country increase.


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115. Tele-health and cancer care in the era of COVID-19: New opportunities in low and middle income countries (LMICs)

Cancer Treatment and Research Communications


Authors: Udhayvir Singh Grewal, Abhishek Shankar, Deepak Saini, Tulik Seth, Shubham Roy, Durre Aden, Dhiraj Bhandari, Pritanjali Singh
Region / country: Global
Speciality: Health policy, Surgical oncology

In the current era of COVID-19 pandemic where at least some degree of social distancing is the norm and hospitals have emerged as hotspots for acquiring the infection, it has become important for oncologists to devise methods of providing care to cancer patients while minimizing patients’ exposure to healthcare settings. In light of the on-going pandemic, it has been recommended that in-patient visits for cancer patients should be substituted by virtual visits and patients should be advised to proceed directly for infusion treatment. Telemedicine and tele-health based interventions have emerged as reasonably practical solutions to these impediments in the delivery of care to cancer patients. Technological advancements have resolved the issue of connectivity for telemedicine even to the remotest places. Teleconsultation is becoming an acceptable alternative for patients and health care providers in this era of information technology. Albeit the challenges that we are facing are diverse and therefore cannot have a singular full proof answer, telemedicine and tele-health based interventions seem to offer promise in effectively complementing our efforts in that direction. Telemedicine is beneficial for both patients and doctors in term to provide quality care without shifting to physical location.


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116. Protocol for a Systematic Review of Outcomes From Microsurgical Free Tissue Transfer Performed on Short-term Surgical Missions in Low-income and Middle-income Countries

Systematic Reviews


Authors: Henry Tobias de Berker, Urška Čebron, Daniel Bradley, Vinod Patel, Meklit Berhane, Fernando Almas, Gary Walton, Mekonen Eshete, Mark McGurk, Dominique Martin, Calum Honeyman
Region / country: Global
Speciality: Paediatric surgery, Plastic surgery

Background: In many units around the world, microsurgical free tissue transfer represents the gold standard for reconstruction of significant soft tissue defects following cancer, trauma or infection. However, many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources, infrastructure or training required to perform any microsurgical procedures. Long-term international collaborations have been formed with annual short-term reconstructive missions conducting microsurgery. In the first instance, these provide reconstructive surgery to those who need it. In the longer-term, they offer an opportunity for teaching and the development of sustainable local services.

Methods: A PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive, predetermined search strategy will be applied to the MEDLINE and Embase electronic databases from inception to December 2020. All clinical studies presenting sufficient data on free tissue transfer performed on short-term surgical missions (STSMs) in LMICs will be eligible for inclusion. The primary outcomes are rate of free flap failure, rate of emergency return to theatre for free flap salvage and successful salvage rate. The secondary outcomes include postoperative complications and any functional or patient reported outcome measures. Screening of studies, data extraction and assessments of study quality and bias will be conducted by two authors. Individual study quality will be assessed according to the Oxford Evidence-based Medicine Scales of Evidence 2, and risk of bias using either the ‘Revised Cochrane risk of bias tool for randomized trials’ (Rob2), or the ‘Risk of bias in non-randomized studies of interventions’ (ROBINS-I) tools. Overall strength of evidence will be assessed according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

Discussion: To-date the outcomes of microsurgical procedures performed on STSMs to LMICs are largely unknown. Improved education, funding and allocation of resources are needed to support surgeons in LMICs to perform free tissue transfer. STSMs provide a vehicle for sustainable collaboration and training. Disseminating microsurgical skills could improve the care received by patients living with reconstructive pathology in LMICs, but this is poorly established. This study sets out a robust protocol for a systematic review designed to critically analyse outcomes.


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117. Hydrostatic reduction of intussusception with intermittent radiography: an alternative to fluoroscopy or ultrasound-guided reduction in low-income and middle-income countries

World Journal of Pediatric Surgery


Authors: Tanvir Kabir Chowdhury, Md. Qumrul Ahsan, Mohammad Zonaid Chowdhury, Md. Tameem Shafayat Chowdhury, Md. Sharif Imam, Md. Afruzul Alam and Md. Abdullah Al Farooq
Region / country: Global
Speciality: Paediatric surgery

Background Although hydrostatic reduction of intussusception with ultrasound (US) or fluoroscopy guidance is well known, it is not yet well established in many low-income and middle-income countries. The aim of the study is to report our results of hydrostatic reduction with intermittent radiography, which has the potential to be practiced in resource-limited settings.

Methods We retrospectively analyzed our patients with intussusception from 2009 to 2019 (11 years). Hydrostatic reduction was performed using water-soluble contrast medium (iopamidol), and reduction was followed with intermittent X-rays taken after every 50 mL of diluted contrast injection. The procedure was not continuously monitored by US or fluoroscopy. Differences in outcome based on age and gender, and yearly trends of admission for intussusception, types of treatment and mortality were analyzed.

Results Among 672 patients, the ratio of boys to girls was 2.46:1.0, and their ages ranged from 1 month to 15 years (median 8 months). Hydrostatic reduction was performed successfully in 351 (52.23%) patients; 308 (45.83%) patients underwent surgery; and 13 (1.93%) patients died before any intervention. There were significant differences in age between patients with successful hydrostatic reduction (median 7 months) and patients needing surgery (median 9 months) (p<0.001). The number of successful hydrostatic reductions increased during the 11 years of the study (R2=0.88). One patient (0.15%) died after hydrostatic reduction, and 10 (1.49%) died after surgery.

Conclusion Hydrostatic reduction with intermittent radiography was performed successfully in more than half of the patients with acceptable complication rates.


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118. Epidemiological patterns of patients managed for cleft lip and palate during free outreach camps at a peripheral hospital in Kenya

Journal of Cleft Lip Palate and Craniofacial Anomalies


Authors: Gathariki Mukami, Muoki Angela, Nang’ole Ferdinand Wanjala
Region / country: Eastern Africa – Kenya
Speciality: Health policy, Maxillofacial and oral surgery, Plastic surgery

Context: Clefts involving lip and palate are the most common craniofacial anomalies. The prevalence varies widely according to various factors. There is a paucity of epidemiological data on cleft deformities in African populations. Aims: The aim was to determine the epidemiological patterns of patients managed for cleft lip and palate during free outreach camps in Kenya and subsequently compare it with other studies done nationally, regionally, and internationally. Design: Prospective Cohort Study. Subjects and Methods: This was a prospective cohort study. Data were collected during five cleft surgery outreach camps held at Kitale County Referral Hospital in Trans-Nzoia County, Kenya, between January 2016 and January 2018. Statistical Analysis Used: The study was statistically analyzed by the Statistical Package for the Social Sciences Windows version 21 software for descriptive characteristics. Results: A total of 84 patients were reviewed, of which 74 underwent surgical management. The study population included nine different Counties in Kenya (with one patient from Uganda) and were reported to have traveled between 3 and 450 km. The age range was from 5 weeks to 35 years with patients below 2 years of age making up the majority (58.3%). There was a male preponderance (61.9%). The most common cleft deformities were cleft lip (46.4%), cleft lip and palate (34.6%), and cleft palate (15.5%). Unilateral clefts were commonly left-sided (62%). Sex distribution varied with clinical diagnosis, and familial and syndromic association was rare. Conclusions: More initiative programs are recommended to address the unmet medical and surgical needs of the cleft deformities in various parts of the region.


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119. Long-term mortality after lower extremity amputation: A retrospective study at a second-level government hospital in Cape Town, South Africa

East and Central African Journal of Surgery


Authors: Salah Rodwan Husein, Megan Naidoo, Heather Bougard, MBChB, Kathryn M. Chu
Region / country: Southern Africa – South Africa
Speciality: Trauma and orthopaedic surgery, Vascular surgery

Background:
Long-term mortality after lower extremity amputation (LEA) is not well reported in low- and middle-income countries. The primary aim of this study was to report 30-day and one-year mortality after LEA in South Africa. The secondary objective was to report risk factors for one-year mortality.
Methods:
This was a retrospective study of patients undergoing LEA at New Somerset Hospital, a second-level government facility in Cape Town, South Africa from October 1, 2015 to October 31, 2016. A medical record review was undertaken to identify co-morbidities, operation details, and perioperative mortality rate. Outcome status was defined as alive, dead, or lost to follow-up. Outcomes at 30 days and one-year were reported.
Results:
There were 152 patients; 90 (59%) males and the median age was 60 years. Co-morbidities were available for 137 (90%). One hundred and eight (79%) had peripheral vascular disease and 91 (66%) had diabetes mellitus. Fifty-three (35%) had more than one LEA on the same or contralateral limb. There were 183 LEAs in 152 patients. The most common LEA was above knee amputation (n=104, 57%) followed by below-knee amputation (n=36, 20%). At 30 days, 102 (67%) of 152 were traced and 12 (12%) were dead. At one year, 86 (57%) were traced and 37 (43%) were dead.
Conclusions:
At this second-level South African hospital, 43% of patients undergoing LEA were dead after one year. In resource-constrained settings, mortality data are necessary when considering resource allocation for LEA and essential surgical care packages.


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120. Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

the lancet


Authors: GlobalSurg Collaborative and National Institute for Health Research Global Health Research Unit on Global Surgery
Region / country: Global
Speciality: Surgical oncology

Background
80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

Methods
This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

Findings
Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

Interpretation
Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.


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121. Cost of hospital care of women with postpartum haemorrhage in India, Kenya, Nigeria and Uganda: a financial case for improved prevention

Reproductive Health


Authors: Fiona Theunissen, Isotta Cleps, Shivaprasad Goudar, Zahida Qureshi, Olorunfemi Oludele Owa, Kidza Mugerwa, Gilda Piaggio, A. Metin Gülmezoglu, Miriam Nakalembe, Josaphat Byamugisha, Alfred Osoti, Sura Mandeep, Teko Poriot, George Gwako, Sunil Vernekar & Mariana Widmer
Region / country: Eastern Africa, Southern Asia, Western Africa – India, Kenya, Nigeria, Uganda
Speciality: Health policy, Obstetrics and Gynaecology

Objective
Access to quality, effective lifesaving uterotonics in low and middle-income countries (LMICs) remains a major barrier to reducing maternal deaths from postpartum haemorrhage (PPH). Our objective was to assess the costs of care for women who receive different preventative uterotonics, and with PPH and no-PPH so that the differences, if significant, can inform better resource allocation for maternal health care.

Methods
The costs of direct hospital care of women who received oxytocin or heat-stable carbetocin for prevention of PPH in selected tertiary care facilities in India, Kenya, Nigeria, and Uganda were assessed. We collected data from all women who had PPH, as well as a random sample of women without PPH. Cost data was collected for the cost of stay, PPH interventions, transfusions and medications for 2966 women. We analyzed the difference in cost of care at a facility level between women who experienced a PPH event and those who did not.

Key findings

The mean cost of care of a woman experiencing PPH in the study sites in India, Kenya, Nigeria, and Uganda exceeded the cost of care of a woman who did not experience PPH by between 21% and 309%. There was a large variation in cost across hospitals within a country and across countries.

Conclusion
Our results quantify the increased cost of PPH of up to 4.1 times that for a birth without PPH. PPH cost information can help countries to evaluate options across different conditions and in the formulation of appropriate guidelines for intrapartum care, including rational selection of quality-assured, effective medicines. This information can be applied to national assessment and adaptation of international recommendations such as the World Health Organization’s recommendations on uterotonics for the prevention of PPH or other interventions used to treat PPH.


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122. Epidemiology of injured patients in rural Uganda: A prospective trauma registry’s first 1000 days

plos one


Authors: Dennis J. Zheng,Patrick J. Sur,Mary Goretty Ariokot,Catherine Juillard,Mary Margaret Ajiko,Rochelle A. Dicker
Region / country: Eastern Africa – Uganda
Speciality: Health policy, Trauma and orthopaedic surgery, Trauma surgery

Trauma is a leading cause of morbidity and mortality worldwide. Data characterizing the burden of injury in rural Uganda is limited. Hospital-based trauma registries are a critical tool in illustrating injury patterns and clinical outcomes. This study aims to characterize the traumatic injuries presenting to Soroti Regional Referral Hospital (SRRH) in order to identify opportunities for quality improvement and policy development. From October 2016 to July 2019, we prospectively captured data on injured patients using a locally designed, context-relevant trauma registry instrument. Information regarding patient demographics, injury characteristics, clinical information, and treatment outcomes were recorded. Descriptive, bivariate, and multivariate statistical analyses were conducted. A total of 4109 injured patients were treated during the study period. Median age was 26 years and 63% were male. Students (33%) and peasant farmers (31%) were the most affected occupations. Falls (36%) and road traffic injuries (RTIs, 35%) were the leading causes of injury. Nearly two-thirds of RTIs were motorcycle-related and only 16% involved a pedestrian. Over half (53%) of all patients had a fracture or a sprain. Suffering a burn or a head injury were significant predictors of mortality. The number of trauma patients enrolled in the study declined by five-fold when comparing the final six months and initial six months of the study. Implementation of a context-appropriate trauma registry in a resource-constrained setting is feasible. In rural Uganda, there is a significant need for injury prevention efforts to protect vulnerable populations such as children and women from trauma on roads and in the home. Orthopedic and neurosurgical care are important targets for the strengthening of health systems. The comprehensive data provided by a trauma registry will continue to inform such efforts and provide a way to monitor their progress moving forward.


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123. Prostate Cancer Survival and Mortality according to a 13-year retrospective cohort study in Brazil: Competing-Risk Analysis

Rev Bras Epidemiol


Authors: Sonia Faria Mendes Braga , Rumenick Pereira da Silva , Augusto Afonso Guerra Junior , Mariangela Leal Cherchiglia
Region / country: South America – Brazil
Speciality: Surgical oncology, Urology surgery

Objective: To analyze cancer-specific mortality (CSM) and other-cause mortality (OCM) among patients with prostate cancer that initiated treatment in the Brazilian Unified Health System (SUS), between 2002 and 2010, in Brazil.

Methods: Retrospective observational study that used the National Oncological Database, which was developed by record-linkage techniques used to integrate data from SUS Information Systems, namely: Outpatient (SIA-SUS), Hospital (SIH-SUS), and Mortality (SIM-SUS). Cancer-specific and other-cause survival probabilities were estimated by the time elapsed between the date of the first treatment until the patients’ deaths or the end of the study, from 2002 until 2015. The Fine-Gray model for competing risk was used to estimate factors associated with patients’ risk of death.

Results: Of the 112,856 studied patients, the average age was 70.5 years, 21% died due to prostate cancer, and 25% due to other causes. Specific survival in 160 months was 75%, and other-cause survival was 67%. For CSM, the main factors associated with patients’ risk of death were: stage IV (AHR = 2.91; 95%CI 2.73 – 3.11), systemic treatment (AHR = 2.10; 95%CI 2.00 – 2.22), and combined surgery (AHR = 2.30, 95%CI 2.18 – 2.42). As for OCM, the main factors associated with patients’ risk of death were age and comorbidities.

Conclusion: The analyzed patients with prostate cancer were older and died mainly from other causes, probably due to the presence of comorbidities associated with the tumor.


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124. Survey of Social Media Use for Surgical Education During Covid-19

Journal of the society of laparoscopic & robotic surgeons


Authors: Diego Laurentino Lima , Raquel Nogueira Cordeiro Laurentino Lima , Dyego Benevenuto , Thiers Soares Raymundo , Phillip P Shadduck, Juliana Melo Bianchi , Flavio Malcher
Region / country: Global
Speciality: Surgical Education

Objective: To evaluate the use of social media platforms by medical students, surgical trainees, and practicing surgeons for surgical education during the Covid-19 pandemic.

Methods: An online, 15-question survey was developed and posted on Facebook and WhatsApp closed surgeon groups.

Results: The online survey was completed by 219 participants from South America (87%), North America (7%), Europe (5%), Central America, and Asia. Respondents included medical students (6.4%), surgical residents/fellows (24.2%), and practicing surgeons (69.4%). The most common age group was 35-44 years. When asked which social media platforms they preferred, the video sharing site YouTube (33.3%), the messaging app WhatsApp (21%), and “other” (including videoconferencing sites) (22.3%) were most popular. Respondents reported using social media for surgical education either daily (38.4%) or weekly (45.2%), for an average of 1-5 hours/week. Most (85%) opined that surgical conferences that were cancelled during the pandemic should be made available online, with live discussions.

Conclusion: Social media use for surgical education during Covid-19 appears to be increasing and evolving.


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125. Correlation of prostate volume with severity of lower urinary tract symptoms as measured by international prostate symptoms score and maximum urine flow rate among patients with benign prostatic hyperplasia

African Journal of Urology


Authors: Mudi Awaisu, Muhammed Ahmed, Ahmad Tijjani Lawal, Abdullahi Sudi, Musliu Adetola Tolani, Nasir Oyelowo, Muhammad Salihu Muhammad, Ahmad Bello & Hussaini Yusuf Maitama
Region / country: Western Africa – Nigeria
Speciality: Urology surgery

Background
The aim of the study is to find the correlation between the prostate volume and severity of lower urinary tract symptoms (LUTS) as measured by international prostate symptoms score and maximum urine flow rate among patients with benign prostatic hyperplasia (BPH).

Methods
The study was a prospective correlational study conducted between June 2016 and November 2017. A total of 290 patients who presented with LUTS suggestive of BPH and satisfied the inclusion criteria were consecutively recruited. Clinical evaluation including digital rectal examination of the prostate was done. Symptoms severity was assessed using the self-administered international prostate symptoms score (IPSS) questionnaire. Prostate volume was determined by transrectal ultrasound scan, and the urine flow rate was measured using uroflowmeter. Data were analyzed using SPSS version 20.0, and p value < 0.05 was taken to be statistically significant.

Results
The mean age of the patients was 64.22 ± 9.04 years with a range of 40 to 95 years. Most of the patients had moderate symptoms (55%) on IPSS with the mean IPSS value of 16.41 ± 7.43. The mean Qmax value was 16.55 ± 7.41 ml/s, and the median prostate volume (IQR) was 45.05 (35, 59). There was a positive significant correlation between prostate volume and IPSS (r = 0.179, p = 0.002) and a negative significant correlation between prostate volume and Qmax (r = − 0.176, p = 0.003).

Conclusion
This study showed a significant correlation between the prostate volume and IPSS, and also between prostate volume and maximum flow rate (Qmax).


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126. Functional recovery time after facial fractures: characteristics and associated factors in a sample of patients from southern Brazil

Rev Col Bras Cir


Authors: VinÍcius Azeredo Muller , Gustavo Krummenauer Bruksch , Giordano Santana SÓria , Karen DA Rosa Gallas , FlÁvio Renato Reis DE-Moura , Myrian Camara Brew , Caren Serra Bavaresco
Region / country: South America – Brazil
Speciality: Maxillofacial and oral surgery, Trauma surgery

Understanding the cause, severity, and elapsed time for the restoration of the functions of maxillofacial injuries can contribute to the establishment of clinical priorities aiming at effective treatment and further prevention of facial trauma. The objective of this study was to understand the factors associated with the restoration of mastication, ocular, and nasal functions in the face of trauma victims, estimating their recovery time after surgical treatment. We analyzed 114 medical records of patients treated at the Hospital Montenegro, who attended follow-up consultations for up to 180 days. For analysis of the recovery time, we performed survival analysis, followed by COX analysis. We observed that half of the patients recovered their functions within 20 days. The average time for recovery from trauma in the zygomatic-orbital-malar-nasal complex was 11 days, and in the maxillary-mandibular complex, 21 days (HR: 1.5 [0.99 2.3], p = 0.055). Although functional reestablishment has reached high rates after the surgical approach, it is necessary to analyze the failing cases, as well as the economic impacts and the prevention strategies associated with facial trauma, to improve the service to the population.


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127. Postoperative acute multiple organ failure after hepatectomy in a Nigerian male with sickle cell trait: a case report

Surgical Case Reports volume


Authors: Toshimitsu Iwasaki, Satoshi Nara, Yuuki Nishimura, Hiroki Ueda, Yoji Kishi, Minoru Esaki, Kazuaki Shimada & Nobuyoshi Hiraoka
Region / country: Western Africa – Nigeria
Speciality: General surgery, Surgical oncology

Background
Sickle cell disease (SCD) is a monogenic disease characterized by sickle hemoglobin (HbS). Patients homozygous for HbS experience symptoms resulting from sickled erythrocytes no later than adolescence. However, heterozygous HbS carriers, or those with the so-called sickle cell trait (SCT), may undergo surgery without their hemoglobinopathy being known.

Case presentation
A 53-year-old Nigerian male with hepatitis C infection underwent radiofrequency ablation therapy for multiple hepatocellular carcinomas (HCCs) 17 months prior. Follow-up computed tomography (CT) revealed a solitary tumor (3.2 cm) in the medial section of the cirrhotic liver. The Child–Pugh score was five, and the indocyanine green retention rate at 15 min was 17.4%. The nontumorous liver of the medial section accounted for 10% of the total liver volume according to CT volumetry. With the diagnosis of recurrent HCC, left medial sectionectomy was performed under intermittent blood flow occlusion by Pringle’s maneuver. Intraoperative ultrasonography confirmed that hepatic blood flow had been preserved after hepatectomy. However, laboratory tests on postoperative day (POD) 1 revealed severe liver damage: aspartate aminotransferase 9250 IU/L, alanine aminotransferase 6120 IU/L, total bilirubin 2.8 mg/dL, and prothrombin time% 20.9%. The patient’s renal and respiratory functions also deteriorated; therefore, continuous hemodiafiltration and plasma exchange were initiated under mechanical ventilation. Whole-body contrast-enhanced CT showed no apparent ischemia of the remnant liver, but diffuse cerebral infarction was detected. Despite intensive treatments, he died of multiple organ failure on POD 20. The pathological examination of the resected specimen revealed that the intrahepatic peripheral vessels were occluded by sickled erythrocytes. Additionally, chromatographic analysis of hemoglobin detected the presence of abnormal hemoglobin, although microscopic examination of the peripheral blood erythrocytes did not show morphological abnormalities. Based on these findings, we determined that he had SCT and developed vaso-occlusive crisis involving multiple organs just after hepatectomy.

Conclusion
SCD is a rare disease in eastern Asia, but its prevalence is increasing globally. Surgeons should pay increased attention to this disease, especially when performing hepatectomy under blood flow occlusion.


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128. Factors Associated with Congenital Heart Diseases Among Children in Uganda: A Case-Control Study at Mulago National Referral Hospital (Uganda Heart Institute)

Cardiology and Cardiovascular Research


Authors: Grace Kahambu Kapakasi , Ratib Mawa, Judith Namuyonga, Sulaiman Lubega
Region / country: Eastern Africa – Uganda
Speciality: Cardiothoracic surgery, Paediatric surgery

Congenital Heart Diseases (CHD) are among the leading causes of morbidity and mortality associated with congenital malformations among children. Not knowing the risk profile of CHD among children in Uganda impedes development of effective prevention interventions. In this hospital based unmatched case-control study we examined risk
factors for all types of CHD among 179 pair of case and control children aged 0-10 years old at Mulago National Referral Hospital. Odds ratios and their corresponding 95% confidence intervals were calculated using multivariate logistic regression. Low birth weight (adjusted OR: 3.15, 95% CI 1.48 – 6.69), high birth order ≥5th birth order (adjusted OR: 3.69 (1.10 – 12.54), maternal febrile illness during pregnancy, maternal and paternal alcohol consumption, and paternal socio-economic status were associated with CHD. Family history of CHD, maternal education level, maternal chronic illness, and paternal education level were not associated with CHD. The results suggest: low birth weight, high birth order, and maternal febrile illness during pregnancy, parental alcohol use and paternal socio-economic status as dominant risk factors for CHD among children. Rigorous implementation of public health policies and strategies targeting prevention of febrile illness during pregnancy, maternal malnutrition, parental alcohol consumption, delivery of high number of children per woman, might be important in reducing the burden of CHD among children in Uganda


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129. Use of simulators in video laparoscopic surgery in medical training: a prospective court study with medicine academic at a university in Southern Brazil

Revista do Colégio Brasileiro de Cirurgiões


Authors: JÚlia Tonietto Porto , Luciano Silveira Eifler , Lucas Pastori Steffen , Gabrielle Foppa Rabaioli , Joana Michelon Tomazzoni
Region / country: South America – Brazil
Speciality: General surgery, Surgical Education

Introduction: the onset of minimally invasive surgery, such as laparoscopic surgery, was accompanied by an increased frequency of complications, many of which were life-threatening. With the objective of minimizing morbidity and mortality and accelerating the learning curve, video laparoscopic surgery simulators were developed to improve the psychomotor skills required for these procedures.

Objective: to compare the performance of second year medical students of the Lutheran University of Brazil, in simulated videolaparoscopic surgeries performed at the Realistic Simulation Center of the Faculty of Health Sciences of Porto Alegre.

Method: prospective cohort study with 16 medical students with no prior experience in video-surgery simulation. The students performed simulated exercises and were evaluated regarding Coordination, Navigation by Instrument and Time in the accomplishment of the procedures.

Results: the sample consisted of 69% women and 31% men with a mean age of 23.2 years. The students obtained better results in the second simulation application. The skill in Navigation by Instrument task was the one that showed the best evolution in the studied group. The Total Time in the accomplishment of the procedures was the parameter with greater difference between the successive simulations.

Conclusion: medical students presented a significant improvement in their performance with the repetition of the simulation exercises, demonstrating that the Laparoscopic Surgery Simulators are a promising tool in medical training and development of surgical skills.


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130. Traumatic subarachnoid hemorrhage: a scoping review

medrxiv


Authors: Dylan P Griswold, ProfileLaura Fernandez, ProfileAndres M Rubiano
Region / country: Global
Speciality: Neurosurgery, Trauma surgery

Sixty-nine million people suffer from traumatic brain injury (TBI) each year, and TBI is the most common cause of subarachnoid hemorrhage (SAH). Traumatic SAH (tSAH) has been described as an adverse prognostic factor leading to progressive neurological deterioration and increased morbidity and mortality. However, a limited number of studies evaluate recent trends in the diagnostic and management of SAH in the context of trauma. The objective of this scoping review was to understand the extent and type of evidence concerning the diagnostic criteria and management of traumatic subarachnoid hemorrhage. This scoping review was conducted following the JBI methodology for scoping reviews. The review included adults who suffered SAH secondary to trauma. Data extracted from each study included study aim, country, methodology, population characteristics, outcome measures, a summary of findings, and future directives. Thirty studies met inclusion criteria. Studies were grouped into five categories by topic: tSAH associated with mild TBI (n=13), and severe TBI (n=3); clinical management and diagnosis (n=9); imaging (n=3); and 5) aneurysmal tSAH (n=1). Of the 30 studies, two came from a low-and middle-income country (LMIC); excluding China, nearly a high-income country. Patients with tSAH associated with mTBI have a very low risk of clinical deterioration and surgical intervention and should be managed conservatively when considering ICU admission. The Helsinki and Stockholm CT scoring systems, in addition to the AIS, Cr, age decision tree, may be valuable tools to use when predicting outcome and mortality.


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131. Fall in organ donations and transplants in Ceará in the COVID-19 pandemic: a descriptive study, April – June 2020

Epidemiologia e Serviços de Saúde


Authors: Anna Yáskara Cavalcante Carvalho de Araújo , Eliana Régia Barbosa de Almeida , Lúcio Kildare E Silva Lima , Tainá Veras de Sandes-Freitas , Antonio Germane Alves Pinto
Region / country: South America – Brazil
Speciality: Cardiothoracic surgery, General surgery, Ophthalmology, Other

Objective: To describe organ donations and transplants in Ceará state, Brazil, following the declaration of the COVID-19 pandemic.

Methods: This was a descriptive study using data from the Brazilian Organ Transplantation Association. The number of donors and transplants from April to June 2020 was compared to the same period in 2019 and to the first quarter of 2020.

Results: In the first half of 2020, the state registered 72 effective donors, just 17 (23.6%) of whom related to the second quarter. Of the 352 transplants in the first half of 2020, 37 (10.7%) were performed in the second quarter. Compared with the period from April to June 2019, there was a reduction of 67.9% and 89.3% in the number of donors and transplants, respectively, in the same period of 2020.

Conclusion: The number of donors and transplants in Ceará showed an important fall in the three months following the declaration of the COVID-19 pandemic, especially for kidney, heart and cornea transplants


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132. Treating Pediatric and Congenital Heart Disease Abroad? Imperatives for Local Health System Development

International Journal of Cardiology Congenital Heart Disease


Authors: Dominique Vervoort , Frank Edwin
Region / country: Global
Speciality: Cardiothoracic surgery, Health policy, Paediatric surgery

Over one million children are born with congenital heart defects each year, whereas four million children live with with rheumatic heart disease. Although a majority of these patients will eventually require surgical or interventional care, most live in areas without access to safe, timely, and affordable cardiac surgical care. Countries with limited or no local cardiac surgical care spend up to over 10% of their health budgets on sending patients abroad to receive cardiac care. Similarly, billions of dollars are spent each year on international medical tourism, notably including seeking cardiac surgical care abroad. Some low- and middle-income countries have successfully invested in domestic cardiac surgical services, saving tens of millions of dollars over time whilst strengthening local health systems. In this article, we describe international medical tourism for pediatric and congenital heart disease, and present an analysis on whether expenditure in seeking foreign care for cardiovascular patients is worth the cost in light of a neglect of investments in local cardiac services in countries with growing health systems.


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133. Distance-Learning Initiatives Targeting Non-physician Anesthesia Providers in Low-Resource Environments

Current Anesthesiology Reports


Authors: Shristi Shah, Oliver Ross, Stephen Pickering
Region / country: Global
Speciality: Anaesthesia, Health policy, Surgical Education

Abstract
Purpose of Review
“Distance-learning” encompasses a variety of didactics, from self-directed online learning to focused courses and programs. Despite increasing internet availability, focused distance-learning courses are rarely practiced in low- or middle-income countries, particularly among non-physician anesthetists. This review aims to discuss the availability, significance, and challenges of distance-learning programs for non-physician anesthesia providers in low-resource settings.

Recent Findings
Task shifting and sharing in anesthesia remains essential in low-resource settings to meet the demand of surgical need. Distance-learning may be the ideal option in these settings, as it can be used to train the individual at their workplace even in remote areas. Different models and techniques are described. Success depends on the course design, communication strategies, handling of technical issues, and support mechanisms.

Summary
Distance-learning should be an essential part of training and in-service support for non-physician anesthetists. Global advocates of safe, effective anesthesia services need to support the development and delivery of distance-learning courses.


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134. Building sustainable and consequential research capacity within a global alliance of paediatric surgical centres

Pediatric Surgery International


Authors: Suraj M. Gandhi, Krithi Ravi, Fatumata Jalloh-PA-R, Noel Peter, Kokila Lakhoo
Region / country: Global
Speciality: Paediatric surgery

The Global Health Research Group on Children’s Non-Communicable Diseases recently launched the PaedsCancer (COVID) study to measure the impact of the COVID-19 pandemic on paediatric cancer management worldwide. At the time of writing, collaborators hail from over 85 countries, of which over 64% are low- and middle-income countries (LMICs). Global Children’s NCDs recognises the risk of propagating HIC dependence in global collaborative paediatric surgery research; LMICs, where the surgical need is greatest, accounted for just 15% of surgical research reports from the 35 highest output countries from 2009 to 2013.


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135. Multisector Collaborations and Global Oncology: The Only Way Forward

American Society of Clinical Oncology


Authors: Charmaine Blanchard, Buhle Lubuzo, Frederick Chite Asirwa, Xolisile Dlamini, Susan C. Msadabwe-Chikuni, Michael Mwachiro, Cyprien Shyirambere, Deo Ruhangaza, Dan A. Milner, Jr, Katherine Van Loon, Rebecca DeBoer, Ute Dugan,Lawrence N. Shulman
Region / country: Global
Speciality: Surgical oncology

PURPOSE
At the 12th meeting of AORTIC (African Organization for Research and Training in Cancer) in Maputo, Mozambique, held between November 5 and November 8, 2019, a special workshop was organized to focus on the need for collaboration and coordination between governments and health systems in Africa with academic, industry, association, and other non-governmental organizations to effect sustainable positive change for the care of patients with cancer.
METHODS
Representatives from seven different projects in Africa presented implementation science and demonstration projects of their to date efforts in cancer system improvement including patient access, South-South partnerships, in-country specialized training, palliative care consortium, treatment outcomes, and focused pathology and diagnostic capacity building. Key partners of the various projects served as moderators and commentators during the session.
RESULTS
From across all the presentations, lessons learned and exemplary evidence of the value of partnerships were gathered and summarized.
CONCLUSION
The concluding synthesis of the presentations determined that with the broad needs across cancer requiring in-depth expertise at each point on a patient’s journey, no single organization can effect change alone. Multipartner collaborations not only should be the norm but should also be coordinated so that efforts are not duplicated and maximum patient access to cancer diagnosis and care is achieved.


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136. Impact of mhealth messages and environmental cues on hand hygiene practice among healthcare workers in the greater Kampala metropolitan area, Uganda: study protocol for a cluster randomized trial

BMC Health Services Research


Authors: Richard K. Mugambe, Jane Sembuche Mselle, Tonny Ssekamatte, Moses Ntanda, John Bosco Isunju, Solomon T. Wafula, Winnifred K. Kansiime, Prossy Isubikalu, David Ssemwanga, Habib Yakubu, Christine L. Moe
Region / country: Eastern Africa – Uganda
Speciality: Other

Abstract
Background
Hand hygiene (HH) among healthcare workers (HCWs) is critical for infection prevention and control (IPC) in healthcare facilities (HCFs). Nonetheless, it remains a challenge in HCFs, largely due to lack of high-impact and efficacious interventions. Environmental cues and mobile phone health messaging (mhealth) have the potential to improve HH compliance among HCWs, however, these remain under-studied. Our study will determine the impact of mhealth hygiene messages and environmental cues on HH practice among HCWs in the Greater Kampala Metropolitan Area (GKMA).
Methods
The study is a cluster-randomized trial, which will be guided by the behaviour centred design model and theory for behaviour change. During the formative phase, we shall conduct 30 key informants’ interviews and 30 semi-structured interviews to explore the barriers and facilitators to HCWs’ HH practice. Besides, observations of HH facilities in 100 HCFs will be conducted. Findings from the formative phase will guide the intervention design during a stakeholders’ insight workshop.
The intervention will be implemented for a period of 4 months in 30 HCFs, with a sample of 450 HCWs who work in maternity and children’s wards. HCFs in the control arm will receive innovatively designed HH facilities and supplies. HCWs in the intervention arm, in addition to the HH facilities and supplies, will receive environmental cues and mhealth messages. The main outcome will be the proportion of utilized HH opportunities out of the 9000 HH opportunities to be observed. The secondary outcome will be E. coli concentration levels in 100mls of hand rinsates from HCWs, an indicator of recent fecal contamination and HH failure. We shall run multivariable logistic regression under the generalized estimating equations (GEE) framework to account for the dependence of HH on the intervention.
Discussion
The study will provide critical findings on barriers and facilitators to HH practice among HCWs, and the impact of environmental cues and mhealth messages on HCWs’ HH practice.


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137. Admission Pattern and Extent of Resident Engagement in a Public Hospital Private-Wing surgical practice: Experience from St. Paul’s Hospital Millennium Medical College; Addis Ababa, Ethiopia

International Invention of Scientific Journal


Authors: Mahteme Bekele Muleta
Region / country: Eastern Africa – Ethiopia
Speciality: Health policy, Surgical Education

Objective: Establishment of private wing in public hospitals is one of the Ministry of health of Ethiopia’s health sector financial reform program which was launched in 2008. This study was initiated to illuminate the experiences on admission pattern and engagement of residents in procedures in private wing within a public hospital. Methodology:A hospital based retrospective study on surgical procedures was performed from September 2013 to August 2016. Data were collected by using structured questionnaire and analyzed with SPSS version 20.1. Quantitative and qualitative data were used in the analysis. Results: A total of 4995 patients were admitted and operated in the private wing; out of which 56.7% were females and 43.3% were males. Cholelithiasis is the leading cause of admission accounting to 44.9% of the general surgery admission followed by thyroid pathologies and hernias. BPH is the leading cause of admission followed by urolithiasis and urethral stricture in the urology unit. Residents have been involved in 62.7% private wing procedures. These procedures ranges from excision of soft tissue mass to abdominoperineal resection. Conclusion: Cholelithiasis, thyroid pathologies and hernias were common surgical pathologies threated in the private wing. Surgical residents were the primary assistant in most procedures. The private wing admission in a public hospital has opened a new window of opportunity in addressing the increased demand of surgical services and increased the engagement of surgical residents’ to a multitude of surgical procedures.


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138. Implementing an intrapartum package of interventions to improve quality of care to reduce the burden of preterm birth in Kenya and Uganda

Implementation Science Communications


Authors: Gertrude Namazzi, Kevin Abidha Achola, Alisa Jenny, Nicole Santos, Elizabeth Butrick, Phelgona Otieno, Peter Waiswa, Dilys Walker & Preterm Birth Initiative Kenya, Uganda Implementation Research Collaborative
Region / country: Eastern Africa – Kenya, Uganda
Speciality: Obstetrics and Gynaecology

Abstract
Background
Quality of care during the intrapartum and immediate postnatal period for maternal and newborn health remains a major challenge due to the multiple health system bottlenecks in low-income countries. Reports of complex interventions that have been effective in reducing maternal and newborn mortality in these settings are usually limited in description, which inhibits learning and replication. We present a detailed account of the Preterm Birth Initiative (PTBi) implementation process, experiences and lessons learnt to inform scale-up and replication.

Methods
Using the TiDieR framework, we detail how the PTBi implemented an integrated package of interventions through a pair-matched cluster randomized control trial in 20 health facilities in Migori County, Kenya, and the Busoga region in east central Uganda from 2016 to 2019. The package aimed to improve quality of care during the intrapartum and immediate postnatal period with a focus on preterm birth. The package included data strengthening (DS) and introduction of a modified WHO Safe Childbirth Checklist (mSCC), simulation-based training and mentoring (PRONTO), and a Quality Improvement (QI) Collaborative.

Results
In 2016, DS and mSCC were introduced to improve existing data processes and increase the quality of data for measures needed to evaluate study impact. PRONTO and QI interventions were then rolled out sequentially. While package components were implemented with fidelity, some implementation processes required contextual adaptation to allow alignment with national priorities and guidelines, and flexibility to optimize uptake.

Conclusion
Lessons learned included the importance of synergy between interventions, the need for local leadership engagement, and the value of strengthening local systems and resources. Adaptations of individual elements of the package to suit the local context were important for effective implementation, and the TIDieR framework provides the guidance needed in detailed description to replicate such a complex intervention in other settings. Detailed documentation of the implementation process of a complex intervention with mutually synergistic components can help contextualize trial results and potential for scale-up. The trial is registered at ClinicalTrials.govNCT03112018, registered December 2016, posted April 2017.


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139. Surgical residents’ opinions on international surgical residency in Flanders, Belgium

International Health


Authors: Gauthier Willemse, Joren Raymenants, Céline Clement, Paul Herijgers
Region / country: Western Europe – Belgium
Speciality: Anaesthesia, Obstetrics and Gynaecology, Surgical Education

Background
International electives benefit training of medical residents due to exposure to an increased scope of pathologies, improved physical examination skills, communication across cultural boundaries and more efficient resource utilization. Currently there is no mechanism for Belgian surgical residents to participate in international training opportunities and little research has addressed the international mobility of Belgian residents. The goal of this study was to examine the attitudes of Belgian residents towards international training among surgical residents.

Methods
An anonymous, structured electronic questionnaire was sent to a cohort of Belgian residents, including surgical residents, by e-mail and social media.

Results
In total, 342 respondents filled out the questionnaire out of a total of 5906 Belgian residents. The results showed that 334 of the residents came from Flanders (10.8%) and 8 came from French-speaking Brussels and Wallonia (0.28%). Surgical specialties represented 46% of respondents and included surgical, obstetric and anaesthesiology residents. The majority (98%) were interested in an international rotation, both in low- and middle-income countries (LMICs) and in high-income countries. A total of 84% were willing to conduct an international rotation during holidays and 91% would participate even when their international stay would not be recognised as part of their residency training. A minority (38%) had undertaken an international rotation in the past and, of those, 5% went to an LMIC.

Conclusion
The majority of surgical residents consider an international rotation as educationally beneficial, even though they are rarely undertaken. Our survey shows that in order to facilitate foreign rotations, Flemish universities and governmental institutions will have to alleviate the regulatory, logistical and financial constraints.


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140. Neonatal Septicaemia in Sub-Saharan Africa: A Protocol for Systematic Review and Meta-analysis

Research Square


Authors: Micheal Abel Alao, Oluwakemi O Tongo, Idowu Adejumoke Ayede, Michael Udochukwu Diala, Olayinka Rasheed Ibrahim, Daniel A Gbadero, Emmanuel Okechukwu Nna, Tina M Slusher
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Paediatric surgery

Background: The morbidity and mortality from neonatal septicaemia (NNS) in low-middle income country remain high at the background of strained health care delivery system.The burden, pooled risks and outcomes of NNS are largely unknown. We aimed to produce a protocol for synthesizing evidence from available data for neonatal septicaemia in sub-Saharan Africa.

Methods: We developed a search strategy using MeSH, text words and entry terms. Nine databases will be searched: PubMed, Embase, CINAHL, AJOL, Google Scholar, Web of Science, Cochrane Library, Research gate and Scopus. Only Observational studies retrievable in the English Language will be included. The primary measurable outcome is the proportion of neonatal with septicaemia while secondary outcomes include proportion of bacterial isolates and their antibiogram, risk factors for NNS, in hospital mortality, length of hospital stay, frequency of necrotizing enterocolitis and other sequel . All identified studies will be screened based on the inclusion criteria. Data will be deduplicated in Endnote version 9, before exporting to Rayyan QCRI for screening. Extractable data will include first author’s name and year of publication, the country and regions in sub-Saharan Africa, total neonatal admissions, number with sepsis, the sample size, bacterial isolates, antibiogram, in-hospital mortality, length of hospital stay and frequency of necrotizing enterocolitis.

All studies will be assessed for methodological, clinical and statistical heterogeneity. The NIH Quality assessment tool for observational studies and the Cochrane tool of risk of bias will be used to assess for the strength of evidence. Publication bias will be assessed using the funnel plot.

Discussion: Results will be presented as the prevalence, standard error and confidence interval of newborns with neonatal septicaemia in sub-Saharan Africa. Subgroup analysis using categorical data such as risk factors, bacterial isolates, antibiogram and outcomes of neonatal septicaemia will also be reported. A cumulative meta-analysis will be done to assess the time trend of the risk factors, pathogens and antibiogram.The CMA version 3 will be used for statistical analysis. Results will be presented in forest plots.


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141. Assessment of Knowledge and Compliance to Evidence-Based Guidelines for VAP Prevention among ICU Nurses in Tanzania

BMC Nursing


Authors: Vicent Bankanie, Anne Outwater, Li Wang, Li Yinglan
Region / country: Eastern Africa – Tanzania
Speciality: Critical care

Background: Implementation of evidence-based guidelines (EBGs) related to VAP is an effective measure for the prevention of ventilator-associated pneumonia (VAP). While low knowledge regarding the EBGs related to VAP prevention among ICU nurses is still a major concern among nurses in ICUs globally, the situation in Tanzania is scarcely known. This study aimed to assess the ICU nurses’ knowledge, compliance, and barriers toward evidence-based guidelines for the prevention of VAP in Tanzania.

Methods: A cross-sectional study, involving ICU nurses of major hospitals in Tanzania, was conducted. A structured questionnaire was administered among 116 ICU. Data analysis included descriptive statistics and independent t-test.

Results: The mean knowledge score was 38.6% which is lower than the lowest ever reported knowledge score for EBGs for VAP prevention. Nurses with a degree or higher level of nursing education performed significantly better than the nurses with a diploma or lower level of nursing education(p=0.004). The mean self-reported adherence score for EBGs for the prevention of VAP was 60.8%. The main barriers to the implementation of EBGs for VAP prevention were lack of skills (96.6%), lack of adequate staff (95.5%), and lack of knowledge (79.3%).

Conclusion: Considering the severity and impact of VAP, and the higher risks of HAIs in resource-limited countries like Tanzania, the lower level of knowledge and compliance implies the need for on-going educational interventions and evaluation of the implementation of the EBGs for VAP prevention by considering the local context.


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142. Global neurosurgery, Bangladesh and COVID-19 era

journal of Romanian Society of Neurosurgery


Authors: Robert Ahmed Khan, Moshiur Rahman, Amit Agrawal, Ezequiel Garcia-Ballestas, Luis Rafael Moscote-Salazar
Region / country: South-eastern Asia – Bangladesh
Speciality: Neurosurgery

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.


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143. Anastomotic leak following oesophagectomy: research priorities from an international Delphi consensus study

British Journal of Surgery


Authors: Oesophago-Gastric Anastomosis Study Group on behalf of the West Midlands Research Collaborative
Region / country: Global
Speciality: General surgery, Surgical oncology

Background
The Oesophago-Gastric Anastomosis Audit (OGAA) is an international collaborative group set up to study anastomotic leak outcomes after oesophagectomy for cancer. This Delphi study aimed to prioritize future research areas of unmet clinical need in RCTs to reduce anastomotic leaks.

Methods
A modified Delphi process was overseen by the OGAA committee, national leads, and engaged clinicians from high-income countries (HICs) and low/middle-income countries (LMICs). A three‐stage iterative process was used to prioritize research topics, including a scoping systematic review (stage 1), and two rounds of anonymous electronic voting (stages 2 and 3) addressing research priority and ability to recruit. Stratified analyses were performed by country income.

Results
In stage 1, the steering committee proposed research topics across six domains: preoperative optimization, surgical oncology, technical approach, anastomotic technique, enhanced recovery and nutrition, and management of leaks. In stages 2 and stage 3, 192 and 171 respondents respectively participated in online voting. Prioritized research topics include prehabilitation, anastomotic technique, and timing of surgery after neoadjuvant chemo(radio)therapy. Stratified analyses by country income demonstrated no significant differences in research priorities between HICs and LMICs. However, for ability to recruit, there were significant differences between LMICs and HICs for themes related to the technical approach (minimally invasive, width of gastric tube, ischaemic preconditioning) and location of the anastomosis.

Conclusion
Several areas of research priority are consistent across LMICs and HICs, but discrepancies in ability to recruit by country income will inform future study design.


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144. From short-term surgical missions towards sustainable partnerships. A survey among members of visiting teams

International Journal of Surgery Open


Authors: M. Botman, T.C.C. Hendriks, A.J. Keetelaar, F.T.C. Smit, C.B. Terwee, M. Hamer, E.Nuwass, M.E.H. Jaspers, H.A.H. Winters, S. Corlew
Region / country: Global
Speciality: Other, Surgical Education

Introduction
An estimated five billion people lack access to safe surgical care across the globe. Traditionally, providing short-term surgical missions has been the main strategy for health professionals from high-income countries to support surgical care in low- and middle-income countries. However, traditional missions have come under criticism because evidence of their sustainable value is lacking, along with any robust documentation and application of recommendations by participants of ongoing surgical missions. Using survey data collection and analysis, this study aims to provide a framework on how to improve the use of visiting surgical teams to strengthen surgical services in resource-poor settings.

Method
An online survey was conducted among members of foreign teams to collect data on five specific areas: basic characteristics of the mission, main activities. follow-up and reporting, the local registration process and collaboration with local actors. The survey included 58 respondents from 13 countries, and representing 20 organizations.

Results
During surgical missions, training activities were considered most impactful, and reporting on outcome/s, along with long-term follow-up were strongly recommended. According to almost all participants (94 percent), the focus should be on establishing collaborative practices with local actors, and encourage strategic, long-term changes under their leadership.

Conclusion
Building sustainable partnerships within local healthcare systems is the way forward for foreign surgical parties that aim to improve surgical care in low- and- middle income countries. When foreign help is offered, local stakeholders should be in the lead.


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145. The Impact of Inadequate Soft-tissue Coverage following Severe Open Tibia Fractures in Tanzania

Plastic and Reconstructive Surgery – Global Open


Authors: Jordan T. Holler, Madeline C. MacKechnie, Patrick D. Albright, Saam Morshed, David W. Shearer, Michael J. Terry
Region / country: Eastern Africa – Tanzania
Speciality: Trauma and orthopaedic surgery

Background:
Managing lower extremity fractures complicated by large soft-tissue defects is challenging for surgeons in low- and middle-income countries, and long-term quality of life (QOL) for these patients is unclear.

Methods:
We examined QOL, surgical complications, and longitudinal outcomes in 10 patients with Gustilo-Anderson Classification Type IIIB open tibia fractures seen at an orthopedic institute in Tanzania, from December 2015 to March 2017. Patients completed follow-up at 2-, 6-, 12-, 26-, and 52-week time points, and returned for qualitative interviews at 2.5 years. The primary outcome was QOL, as measured using EuroQoL-5D scores and qualitative semi-structured interview responses. The secondary outcome was rate of complication, as defined by reoperation for deep infection or nonunion.

Results:
Ten patients enrolled in the study and 7 completed 1-year follow-up. All fractures were caused by road traffic accidents and treated by external fixation. No patients received initial soft-tissue (flap) coverage of the wound. All patients developed an infected nonunion. No patients returned to work at 6 weeks, 3 months, or 6 months. EQ-5D index scores at 1 year were poor (0.71 ± 0.09). Interview themes included ongoing medical complications, loss of employment, reduced income, and difficulty with activities of daily living.

Conclusions:
Patients in low- and middle-income countries with IIIB open tibia fractures not treated with appropriate soft-tissue coverage experience poor QOL, high complication rates, and severe socioeconomic effects as a result of their injuries. These findings illustrate the need for resources and training to build capacity for extremity soft-tissue reconstruction in LMICs.


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146. Feasibility of HPV-based cervical cancer screening in rural areas of developing countries with the example of the North Tongu District, Ghana

Refubium – Freie Universitat Berlin Repository


Authors: Krings, Amrei
Region / country: Western Africa – Ghana
Speciality: Obstetrics and Gynaecology, Surgical oncology

Cervical cancer gains increasing recognition as a preventable threat to women’s health, as expressed by WHO Director General Dr. Ghebreyesus in his recent call for its elimination. Developing countries carry the global burden and despite existing recommendations for secondary prevention screening programs their implementation remains a barrier. This doctoral thesis aims to evaluate the feasibility of an HPV-based cervical cancer screening approach in the North Tongu District, Ghana.
Methods This work studied (i) the methodological validity of self-sampling specimens from cervical cancer patients for HPV oncoprotein testing before its use in a screening population, (ii) the HPV prevalence among 2002 women, 18-65 years of age, in the general population of the North Tongu Disctrict, Ghana, through a cross-sectional population-based study with self-sampling collection in rural communities, and (iii) the natural history of HPV infection by longitudinal comparison of HPV type-specific persistence and clearance for 104 women over a four years’ time period. Results Using self-sampling cervicovaginal lavage specimens for HPV oncoprotein detection was methodologically feasible with 95% sensitivity for HPV16/18 positive cervical cancer. However self-sampling cervicovaginal scraping specimens did not reveal reliable HPV oncoprotein test results during the cross-sectional assessment. The high-risk HPV prevalence found among women living in the North Tongu District, Ghana was 32.3% and 27.3% among women in the WHO-recommended screening age range of 30-49 years. Sample collection in the rural communities was successful. Infection associated risk factors were (i) increasing age, (ii) increasing number of sexual partners and (iii) marital status, in particular not being married. Over the four years’ time period 6.7% of the women observed had persistent high-risk HPV infection, while 93.3% cleared their initial infection and 21.2% acquired new infections.
Discussion The high-risk HPV prevalence found among the general population and women 30-49 years is high and therefore requires careful planning and good infrastructure to triage high-risk HPV positive women and reduce the number of women needing treatment. Using HPV oncoprotein triage from the same self-collected specimen is not reliable at this point, stratification by sociodemographic factors risks stigmatization and retesting for HPV persistence necessitates a well-functioning recall system and HPV genotyping.
Conclusion The high HPV prevalence found demands substantial governmental support and investment to build well-functioning screening infrastructure that offers necessary triage and treatment options for women high-risk HPV positive with increased risk for cervical cancer. Integrating local infrastructure and capacity is promising but requires regional assessment rather than one-size-fit-all approaches.


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147. Magnitude of Surgical Site Infection and Its Associated Factors Among Patients Who Underwent a Surgical Procedure at Debre Tabor General Hospital, Northwest Ethiopia

Research Square


Authors: Mequanint Bezie Walelign, Tadesse Wuletaw Demissie, Abaynew Honelign Desalegn
Region / country: Eastern Africa – Ethiopia
Speciality: Critical care, General surgery

Background: Surgical site infections are the commonest nosocomial infections and responsible for considerable morbidity and mortality as well as increased hospitalizations and treatment cost related to surgical operations. The aim of this study was to determine the magnitude and factors associated with surgical site infections at the surgical ward of Debre Tabor General Hospital, Northwest Ethiopia.

Method: Institution based cross-sectional study was conducted on patients who underwent a surgical procedure at Debre Tabor General Hospital in 2020. The sample size was determined using the single population proportion formula. Data were entered and analyzed using SPSS version 21 software. Bivariate and multivariate logistic regressions analysis were employed. The odds ratio and its 95% confidence interval were taken to test the association between the dependent and independent variables. A P-value of less than 0.05 will be considered statistically significant.

Result: In this study, a total of 191 patients have participated in the study yielding a response rate of 100%. The mean age of the respondents was 2.5 (SD ±0.68) years. The most age group 115(60.2%) resides at the age group greater than 40 years. More than one half(62.3) of the surgical clients were females. Most of the clients were farmers(32.5%) and unable to read and write(41.9) based on the occupation. The magnitude of surgical site infection in this study was found to be 11.5% (95% CI: 7.8%, 15.9%). The factors existence of comorbidity and antibiotic prophylaxis was given were found to be significantly associated with the magnitude of surgical site infection.

Conclusion: The magnitude of surgical site infection in this study was high. Proper management of patients with co-morbidity especially those with diabetes mellitus, proper administration of anesthesia, and delivering intravenous antimicrobial prophylaxis before surgery as ordered would significantly reduce the incidence of surgical site infection.


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148. Hospitals’ responsibility in response to the threat of infectious disease outbreak in the context of the coronavirus disease 2019 (COVID-19) pandemic: Implications for low- and middle-income countries

Global Health Journal


Authors: Ji Zhang, Xinpu Lu , Yinzi Jin, Zhi-Jie Zheng
Region / country: Global
Speciality: Health policy

The WHO declared the coronavirus disease 2019 (COVID-19) outbreak as a public health emergency of international concern on January 30, 2020, and then a pandemic on March 11, 2020. COVID-19 affected over 200 countries and territories worldwide, with 25,541,380 confirmed cases and 852,000 deaths associated with COVID-19 globally, as of September 1, 2020.

While facing such a public health emergency, hospitals were on the front line to deliver health care and psychological services. The early detection, diagnosis, reporting, isolation, and clinical management of patients during a public health emergency required the extensive involvement of hospitals in all aspects. The response capacity of hospitals directly determined the outcomes of the prevention and control of an outbreak.

The COVID-19 pandemic has affected almost all nations and territories regardless of their development level or geographic location, although suitable risk mitigation measures differ between developing and developed countries. In low- and middle-income countries (LMICs), the consequences of the pandemic could be more complicated because incidence and mortality might be associated more with a fragile health care system and shortage of related resources. As evidenced by the situation in Bangladesh, India, Kenya, South Africa, and other LMICs, socioeconomic status (SES) disparity was a major factor in the spread of disease, potentially leading to alarmingly insufficient preparedness and responses in dealing with the COVID-19 pandemic.4 Conversely, the pandemic might also bring more unpredictable socioeconomic and long-term impacts in LMICs, and those with lower SES fare worse in these situations.

This review aimed to summarize the responsibilities of and measures taken by hospitals in combatting the COVID-19 outbreak. Our findings are hoped to provide experiences, as well as lessons and potential implications for LMICs.


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149. Survival and Predictors of Mortality among Breast Cancer Patients Diagnosed at Hawassa Comprehensive Specialized and Teaching Hospital and Private Oncology Clinic in Southern Ethiopia: A Retrospective Cohort Study

Research Square


Authors: Abel Shita, Alemayehu Worku Yalew, Aragaw Tesfaw, Tsion Afework, Zenawi Hagos Gufie, Sefonias Getachew
Region / country: Eastern Africa – Ethiopia
Speciality: Surgical oncology

Background: Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death in over 100 countries. Despite the high burden of the problem, the survival status and the predictors for mortality are not yet determined well in Ethiopia. Therefore, we aimed to determine the survival and predictors of mortality among breast cancer patients diagnosed from 2013-2018 at Hawassa comprehensive specialized and teaching hospital and private oncology clinic in Southern Ethiopia.

Methods: Hospital-based retrospective cohort study of 302 patients was conducted. Data was collected on breast cancer patients diagnosed from January, 1st, 2013 to December, 30th, 2018 using a data extraction checklist and by telephone interview. The median survival was estimated by Kaplan- Meier. Log Rank test was used to compare survival among groups. Cox proportional hazards model was used to identify predictors. Results were repaired as hazard ratio (HR) along with the corresponding 95% CI. Sensitivity analysis was done with the assumption of loss to follow-ups (LTF) might die 3 months after the last hospital visit.

Results: Advanced stage diagnosis of breast cancer was found on 83.4 % of patients with breast cancer. The study participants were followed for a total of 4685.62 person-months. Their median survival was 50.61 months (IQR=18.38-50.80) which declined to 30.57 months in the worst-case analysis (WCA). The overall survival of patients at two years was 73.2% and it declines to 51.3 % in the worst-case analysis. Rural residence (AHR=2.71, 95% CI: 1.44, 5.09), travel time >7 hours (AHR=3.42, 95% CI: 1.05, 11.10), duration of symptom 7-23 months (AHR=2.63, 95% CI: 1.22, 5.64), > 23 months (AHR=2.37, 95% CI: 1.00, 5.59), advanced stage (AHR=3.01, 95% CI: 1.05, 8.59) and not taking chemotherapy (AHR=6.69, 95% CI: 2.20, 20.30) were independent predictors of death.

Conclusion: Above two-third of the patients have two years of overall survival in south Ethiopia. Rural residence, advanced stage, and poor adherence to chemotherapy were independent predictors of death. Thus, Improving early detection, diagnosis, and treatment capacity of breast cancer patients are an important way-outs to avert the problem with appropriate intervention means.


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150. Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low and middle-income countries: a systematic review protocol

BMJ open


Authors: Chukwudi Arnest Nnaji, Paul Kuodi, Fiona M Walter, and Jennifer Moodley
Region / country: Global
Speciality: Surgical oncology

Introduction
Breast and cervical cancers pose a major public health burden globally, with disproportionately high incidence, morbidity and mortality in low- and middle-income countries (LMICs). The majority of women diagnosed with cancer in LMICs present with late-stage disease, the treatment of which is often costlier and less effective. While interventions to improve the timely diagnosis of these cancers are increasingly being implemented in LMICs, there is uncertainty about their role and effectiveness. The aim of this review is to systematically synthesise available evidence on the nature and effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in LMICs.

Methods and analysis
A comprehensive search of published and relevant grey literature will be conducted. The following electronic databases will be searched: MEDLINE (via PubMed), Cochrane Library, Scopus, CINAHL, Web of Science and the International Clinical Trials Registry Platform (ICTRP). Evidence will be synthesised in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). Two reviewers will independently screen the search outputs, select studies using predefined inclusion criteria and assess each included study for risk of bias. If sufficient data are available and studies are comparable in terms of interventions and outcomes, a meta-analysis will be conducted. Where studies are not comparable and a meta-analysis is not appropriate, a narrative synthesis of findings will be reported.

Ethics and dissemination
As this will be a systematic review of publicly available data, with no primary data collection, it will not require ethical approval. Findings will be disseminated widely through a peer-reviewed publication and forums such as conferences, workshops and community engagement sessions. This review will provide a user-friendly evidence summary for informing further efforts at developing and implementing interventions for addressing delays in breast and cervical cancer diagnosis in LMICs.


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151. Challenges faced by cancer patients in Uganda: Implications for health systems strengthening in resource limited settings

Journal of Cancer Policy


Authors: Annet Nakaganda, Kristen Solt, Leocadia Kwagonza, Deborah Driscoll, Rebecca Kampia, Jackson Orema
Region / country: Eastern Africa – Uganda
Speciality: Health policy, Surgical oncology

Background
Uganda Cancer Institute (UCI), the only comprehensive cancer treatment center in Uganda, registers about 4000 new cancer patients a year. However, many cancer patients in Uganda never receive treatment due to a variety of challenges. We therefore conducted a study to identify and assess the challenges faced by cancer patients in Uganda.

Methods
A cross-sectional study conducted in April-May 2017 among adult cancer patients. 359 participants participated in an interviewer-administered survey. We used stratified random sampling to select the study participants. Data was analyzed in SPSS Statistics 24.

Results
35 % of the patients delayed initiating cancer treatment and 41 % missed medical appointments along their care journey. Delayed and missed appointments were mainly due to lack of money for cancer medicines, transportation and accommodation. Patients also expressed challenges with side effects of cancer treatment: 52 % sought help from health workers when they experienced side effects; 14 % used alternative medicine; and 21 % did not inform anyone. In addition, 55 % of the participants had limited knowledge about their disease and treatment. Other challenges when at UCI included: being hungry and thirsty throughout the day, long waiting hours, not having a resting place, not understanding what comes next, and having their records lost by hospital staff.

Conclusion
Challenges faced by cancer patients in Uganda result in enormous delays in initiation and continuation of cancer treatment. These challenges are often a result of the poor social-economic status of the patients; inadequate infrastructure for cancer care; and inefficiencies in the health care system.

Policy Summary
To improve the experience of patients, the National Cancer Control Plan should consider establishing regional cancer centers; creating a reliable supply of cancer medicines; and integrating navigation programmes into cancer care. Strengthening the whole health system, in relation to cancer service delivery, should remain a top priority for Uganda and other resource limited settings.


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152. Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study

The LANCET Global Health


Authors: Andrea Nove, Ingrid K Friberg, Luc de Bernis, Fran McConville, Allisyn C Moran, Maria Najjemba, Petra ten Hoope-Bender, Sally Tracy, Caroline S E Homer
Region / country: Global
Speciality: Critical care, Health policy, Obstetrics and Gynaecology, Paediatric surgery

Background
Strengthening the capacity of midwives to deliver high-quality maternal and newborn health services has been highlighted as a priority by global health organisations. To support low-income and middle-income countries (LMICs) in their decisions about investments in health, we aimed to estimate the potential impact of midwives on reducing maternal and neonatal deaths and stillbirths under several intervention coverage scenarios.

Methods
For this modelling study, we used the Lives Saved Tool to estimate the number of deaths that would be averted by 2035, if coverage of health interventions that can be delivered by professional midwives were scaled up in 88 countries that account for the vast majority of the world’s maternal and neonatal deaths and stillbirths. We used four scenarios to assess the effects of increasing the coverage of midwife-delivered interventions by a modest amount (10% every 5 years), a substantial amount (25% every 5 years), and the amount needed to reach universal coverage of these interventions (ie, to 95%); and the effects of coverage attrition (a 2% decrease every 5 years). We grouped countries in three equal-sized groups according to their Human Development Index. Group A included the 30 countries with the lowest HDI, group B included 29 low-to-medium HDI countries, and group C included 29 medium-to-high HDI countries.

Findings
We estimated that, relative to current coverage, a substantial increase in coverage of midwife-delivered interventions could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2·2 million deaths averted per year by 2035. Even a modest increase in coverage of midwife-delivered interventions could avert 22% of maternal deaths, 23% of neonatal deaths, and 14% of stillbirths, equating to 1·3 million deaths averted per year by 2035. Relative to current coverage, universal coverage of midwife-delivered interventions would avert 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths, allowing 4·3 million lives to be saved annually by 2035. These deaths averted would be particularly in the group B countries, which currently account for a large proportion of the world’s population and have high mortality rates compared with group C.

Interpretation
Midwives can help to substantially reduce maternal and neonatal mortality and stillbirths in LMICs. However, to realise this potential, midwives need to have skills and competencies in line with recommendations from the International Confederation of Midwives, to be part of a team of sufficient size and skill, and to work in an enabling environment. Our study highlights the potential of midwives but there are many challenges to the achievement of this potential. If increased coverage of midwife-delivered interventions can be achieved, health systems will be better able to provide effective coverage of essential sexual, reproductive, maternal, newborn, and adolescent health interventions.

Funding
New Venture Fund.


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

Journal of Neurosurgery


Authors: Wihasto Suryaningtyas, Joni Wahyuhadi, Agus Turchan, Eko Agus Subagio, Muhammad Arifin Parenrengi, Tedy Apriawan, Asra Al Fauzi, and Abdul Hafid Bajamal
Region / country: South-eastern Asia – Indonesia
Speciality: Neurosurgery

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.


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154. Surgical candidacy and treatment initiation among women with cervical cancer at public referral hospitals in Kampala, Uganda: a descriptive cohort study

BMJ Open


Authors: Megan Swanson, Miriam Nakalembe, Lee-may Chen, Stefanie Ueda, Jane Namugga, Carol Nakisige, Megan J Huchko
Region / country: Eastern Africa – Uganda
Speciality: Obstetrics and Gynaecology, Surgical oncology

Objectives This study aimed to report the proportion of women with a new diagnosis of cervical cancer recommended for curative hysterectomy as well as associated factors. We also report recommended treatments by stage and patterns of treatment initiation.

Design This was an observational cohort study. Inperson surveys were followed by a phone call.

Setting Participants were recruited at the two public tertiary care referral hospitals in Kampala, Uganda.

Participants Adult women with a new diagnosis of cervical cancer were eligible: 332 were invited to participate, 268 met the criteria and enrolled, and 255 completed both surveys.

Primary and secondary outcomes measures The primary outcome of interest was surgical candidacy; a secondary outcome was treatment initiation. Descriptive and multivariate statistical analyses examined the associations between predictors and outcomes. Sensitivity analyses were performed to examine outcomes in subgroups, including stage and availability of radiation.

Results Among 268 participants, 76% were diagnosed at an advanced stage (IIB–IVB). In total, 12% were recommended for hysterectomy. In adjusted analysis, living within 15 km of Kampala (OR 3.10, 95% CI 1.20 to 8.03) and prior screening (OR 2.89, 95% CI 1.22 to 6.83) were significantly associated with surgical candidacy. Radiotherapy availability was not significantly associated with treatment recommendations for early-stage disease (IA–IIA), but was associated with recommended treatment modality (chemoradiation vs primary chemotherapy) for locally advanced stage (IIB–IIIB). Most (67%) had started treatment. No demographic or health factor, treatment recommendation, or radiation availability was associated with treatment initiation. Among those recommended for hysterectomy, 55% underwent surgery. Among those who had initiated treatment, 82% started the modality that was recommended.

Conclusion Women presented to public referral centres in Kampala with mostly advanced-stage cervical cancer and few were recommended for surgery. Most were able to initiate treatment. Lack of access to radiation did not significantly increase the proportion of early-stage cancers recommended for hysterectomy.


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155. Methods for estimating economic benefits of surgical interventions in low-income and middle-income countries: a scoping review

BMJ Journal


Authors: Amy Hilla, Victoria Reese, Justice Nonvignon, Carrie B. Dolan
Region / country: Global
Speciality: Health policy

Objectives Studies indicate that many types of surgical care are cost-effective compared with other health interventions in low-income and middle-income countries (LMICs). However, global health investments to support these interventions remain limited. This study undertakes a scoping review of research on the economic impact of surgical interventions in LMICs to determine the methodologies used in measuring economic benefits.

Design The Arksey and O’Malley methodological framework for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist were used to review the data systematically. Online databases were used to identify papers published between 2005 and 2020, from which we selected 19 publications that quantitatively examined the economic benefits of surgical interventions in LMICs.

Results Majority of publications (79%) reported the use of disability-adjusted life-years (DALYs) to assess economic impact. In comparison, 21% used other measures, such as the value of statistical life or cost-effectiveness ratios, or no measure at all. 31% were systematic or retrospective reviews of the literature on surgical procedures in LMICs, while 69% either directly assessed economic impact in a specific area or evaluated the need for surgical procedures in LMICs. All studies reviewed related to the economic impact of surgical procedures in LMICs, with most about paediatric surgical procedures or a specific surgical specialty.

Conclusion To make informed policy decisions regarding global health investments, the economic impact must be accurately measured. Researchers employ a range of techniques to quantify the economic benefit of surgeries in LMICs, which limits understanding of overall economic value. We conclude that the literature would benefit from a careful selection of methods, incorporating age and disability weights based on the Global Burden of Disease weights, and converting DALYs to dollars using the value of statistical life approach and the human capital approach, reporting both estimates.


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156. Healthcare providers’ and managers’ knowledge, attitudes and perceptions regarding international medical volunteering in Uganda: a qualitative study

BMJ Journal


Authors: Fenella Hayes, Janet Clark, Mary McCauley
Region / country: Eastern Africa – Uganda
Speciality: Health policy, Other

Objectives The study sought to explore the knowledge, attitudes and perceptions of healthcare providers and health programme managers regarding the benefits, challenges and impact of international medical volunteers’ clinical placements. Views on how to better improve the work of international medical volunteers and the volunteer organisation Voluntary Service Overseas (VSO) for the benefit of local communities were also explored.

Settings Public healthcare facilities, VSO offices in Gulu and VSO offices in Kampala, Uganda.

Participants Ugandan healthcare providers (n=11) and health programme managers (n=6) who had worked with or managed international medical volunteers.

Interventions Data collection was conducted using key informant interviews. Transcribed interviews were coded by topic and grouped into categories. Thematic framework analysis using NVivo identified emerging themes.

Results Both healthcare providers and managers reported a beneficial impact of volunteers and working with the volunteer organisation (clinical service provision, multidisciplinary teamwork, patient-centred care, implementation of audits, improved quality of care, clinical teaching and mentoring for local healthcare providers); identified challenges of working with volunteers (language barriers and unrealistic expectations) and the organisation (lack of clear communication and feedback processes); and provided recommendations to improve volunteer placements and working partnership with the organisation (more local stakeholder input and longer placements). Most healthcare providers were positive and recommended that volunteers are enabled to continue to work in such settings if resources are available to do so.

Conclusions Healthcare providers based in a low-resource setting report positive experiences and impacts of working with international medical volunteers. Currently, there is lack of local feedback processes, and the establishment of such processes that consider local stakeholder reflections requires further strengthening. These would help gain a better understanding of what is needed to ensure optimal effectiveness and sustainable impact of international medical volunteer placements.


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157. Surgical site infection after gastrointestinal surgery in children: an international, multicentre, prospective cohort study

BMJ Journal


Authors: Ewen M Harrison
Region / country: Global
Speciality: General surgery, Paediatric surgery

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings.

Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI).

Results Of 1159 children across 181 hospitals in 51 countries, 523 (45·1%) children were from high HDI, 397 (34·2%) from middle HDI and 239 (20·6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12·8% (51/397) in middle HDI and 24·7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI.

Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda


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158. Rising Global Opportunities Among Orthopaedic Surgery Residency Programs

Journal of American Academy of Orthopaedic surgeons


Authors: Pfeifer, Jacob; Svec, Noah; Are, Chandrakanth; Nelson, Kari L.
Region / country: Northern America – United States of America
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Objective:
We surveyed Orthopaedic Surgery Residency (OSR) programs to determine international opportunities by the academic institutional region within the United States, location of the international experience, duration, residency program year (PGY), funding source, and resident participation to date.

Design:
We emailed a survey to all OSR programs in the United States to inquire about global opportunities in their residency programs. Further contact was made through an additional e-mail and up to three telephone calls. Data were analyzed using descriptive and chi-square statistics. This study was institutional review board exempt.

Setting:
This research study was conducted at the University of Nebraska Medical Center, a tertiary care facility in conjunction with the University of Nebraska Medical Center College of Medicine.

Participants:
The participants of this research study included program directors and coordinators of all OSR programs (185) across the United States.

Results:
A total of 102 OSR programs completed the survey (55% response rate). Notably, 50% of the responding programs offered a global health opportunity to their residents. Of the institutions that responded, those in the Midwest or South were more likely to offer the opportunity than institutions found in other US regions, although regional differences were not significant. Global experiences were most commonly: in Central or South America (41%); 1 to 2 weeks in duration (54%); and during PGY4 or PGY5 (71%). Furthermore, half of the programs provided full funding for the residents to participate in the global experience. In 33% of the programs, 10 or more residents had participated to date.

Conclusions:
Interest in global health among medical students is increasing. OSR programs have followed this trend, increasing their global health opportunities by 92% since 2015. Communicating the availability of and support for international opportunities to future residents may help interested students make informed decisions when applying to residency programs.


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159. Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala

Anesthesia and Analgesia


Authors: Zha, Yuanting; Truché, Paul; Izquierdo, Erick; Zimmerman, Kathrin; de Izquierdo, Sandra; Lipnick, Michael S; Law, Tyler J.; Gelb, Adrian W.; Evans, Faye M.
Region / country: Central America – Guatemala
Speciality: Anaesthesia, Health policy

BACKGROUND:
International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development.

METHODS:
In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented.

RESULTS:
Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking.

CONCLUSIONS:
This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.


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160. The challenges of implementing low-dose computed tomography for lung cancer screening in low- and middle-income countries

Nature Cancer


Authors: Eduardo Edelman Saul, Raquel B. Guerra, Michelle Edelman Saul, Laercio Lopes da Silva, Gabriel F. P. Aleixo, Raquel M. K. Matuda & Gilberto Lopes
Region / country: Global
Speciality: Cardiothoracic surgery, Surgical oncology

Lung cancer accounts for an alarming human and economic burden in low- and middle-income countries (LMICs). Recent landmark trials from high-income countries (HICs) by demonstrating that low-dose computed tomography (LDCT) screening effectively reduces lung cancer mortality have engendered enthusiasm for this approach. Here we examine the effectiveness and affordability of LDCT screening from the viewpoint of LMICs. We consider resource-restricted perspectives and discuss implementation challenges and strategies to enhance the feasibility and cost-effectiveness of LDCT screening in LMICs.


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161. The Impact of Delivering High-Quality Cataract Surgical Mentorship Through Distance Wet Laboratory Courses on Cataract Surgical Competency of Second and Final Year Residents.

Research Square


Authors: Amelia Geary, Qing Wen, Rosa Adrianzén, Nathan Congdon, R. Janani, Danny Haddad, Clare Szalay Timbo, Yousuf Khalifa
Region / country: South America – Peru
Speciality: Ophthalmology, Surgical Education

Background: This study aimed to assess the acceptability and effectiveness of training second and final-year residents, at the Regional Institute of Ophthalmology, a tertiary-level ophthalmic training center in Trujillo, Peru, in phacoemulsification cataract surgery through structured distance surgical mentorship wet lab courses.

Methods: Delivered three five-week distance surgical mentorship wet lab courses, administered through Cybersight, Orbis International’s telemedicine platform. Weekly lectures and demonstrations addressed specific steps in phacoemulsification surgery. Each lecture had two accompanying wet lab assignments, which residents completed and recorded in their institution’s wet lab and uploaded to Cybersight for grading. Competency was assessed through the anonymous grading of pre- and post-training surgical simulation videos, masked as to which videos were recorded before and after training, using a standardized competency rubric adapted from the International Council of Ophthalmology’s Ophthalmology Surgical Competency Assessment Rubric (ICO-OSCAR). Day one best-corrected post-operative visual acuity (BVCA) was assessed in the operative eye on the initial consecutive 4-6 surgeries conducted by the residents. An anonymous satisfaction survey was administered to trainees’ post-course.

Results: In total, 21 second and final-year residents participated in the courses, submitting a total of 210 surgical videos. Trainees’ average competency score (scale of 0-32) increased 6.95 (95%CI [4.28, 9.62], SD=5.01, p<0.0001, two sample t-test) from 19.3 (pre-training, 95%CI [17.2, 21.5], SD=4.04) to 26.3 (post-training, 95%CI [24.2, 28.3], SD=3.93). Among 100 post-training resident surgeries, visual acuity for 92 (92%) was ≥20/60, meeting the World Health Organization’s criterion for good cataract surgical quality.

Conclusions: Structured distance wet lab courses in phacoemulsification resulted in significantly improved cataract surgical skills. This model could be applicable to locations where there are obstacles to traditional in-person wet lab training and can also be effectively deployed to respond to a disruptive event in medical education, such as the current COVID-19 pandemic


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162. Psychological correlates of traumatic experiences and coping strategies of post amputation: A case study of Mulago Specialized National Hospital, Kampala, Uganada

Student’s Journal of health research Africa


Authors: SULAIMAN MAHMOOD KAKOOZA, ZAITUNE NANYUNJA, KIZITOMUWONGEb, FRANK PIO KIYINGI
Region / country: Eastern Africa – Uganda
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Background: The study assessed the effect of psychological correlates of traumatic experiences on coping strategies of post-amputation basing on evidence from Mulago specialized national hospital, Kampala-Uganda. It specifically analyzed the personality styles that enhance coping among amputees, assessed the psychological consequences among amputees, and examined the psychological interventions among amputees. Methodology: The study adopted a hospital-based prospective post-treatment design employing a quantitative research approach. The quantitative data were collected using questionnaires from 72 patients who were admitted for amputations and attending weekly amputee clinics and those using prostheses and orthosises. The data was processed at both the descriptive and inferential levels using SPSS version 20.0. Results: The study found extraversion as a statistically positive correlate with the confrontational form of coping style (r = 0.279, p = 0.031 < 0.05). It found a significantly positive correlate that enhanced planful problem solving (r =0.278, p =0.032< 0.05) and positive reappraisal (r = 0.301, p = 0.019 < 0.05) compared to conscientiousness as a negative correlate of coping styles particularly self-control (r =-0.326, p = 0.011< 0.05) and escape avoidance (r =-0.263, p =0.043 < 0.05). Results showed abnormal depression (46.7%), suffering abnormal anxiety (45.0%) alongside demonstrating symptoms of at least 2 Post-Traumatic Stress Disorders (46.7%) as the psychological consequences. The psychological interventions study found included specialized physician services (60.0%), primary care provision (45.0%) and financial assistance (46.7 among others Conclusion and discussion: Personality styles of extraversion, agreeableness, and conscientiousness are crucial in the coping styles among amputees and therefore need to be well established and aligned with supporting initiatives. The administrative staff of specialized units needs to put in place workable measures like avoiding unfair self-blame and inculcating a belief that they are still worth as to help amputees to improve their self-esteem thereby minimizing adverse psychological consequences.


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163. Prevalence of clinically-evident congenital anomalies in the Western highlands of Guatemala

Reproductive Health


Authors: Lester Figueroa, Ana Garces, K. Michael Hambidge, Elizabeth M. McClure, Janet Moore, Robert Goldenberg & Nancy F. Krebs
Region / country: Central America – Guatemala
Speciality: Paediatric surgery

Background
Congenital anomalies are a significant cause of death and disability for infants, especially in low and middle-income countries (LMIC), where 95% of all deaths due to anomalies occur. Limited data on the prevalence and survival of infants with congenital anomalies are available from Central America. Estimates have indicated that 53 of every 10,000 live births in Guatemala are associated with a congenital anomaly. We aim to report on the incidence and survival of infants with congenital anomalies from a population-based registry and classify the anomalies according to the International Classification of Disease, Tenth Revision (ICD-10).

Methods
We conducted a planned secondary analysis of data from the Maternal Newborn Health Registry (MNHR), a prospective, population-based study carried out by the Global Network for Women’s and Children’s Health Research in seven research sites. We included all deliveries between 2014 and 2018 in urban and rural settings in Chimaltenango, in the Western Highlands of Guatemala. These cases of clinically evident anomalies were reported by field staff and reviewed by medically trained staff, who classified them according to ICD – 10 categories. The incidence of congenital anomalies and associated stillbirth, neonatal mortality, and survival rates were determined for up to 42 days.

Results
Out of 60,142 births, 384 infants were found to have a clinically evident congenital anomaly (63.8 per 10,000 births). The most common were anomalies of the nervous system (28.8 per 10,000), malformations and deformations of the musculoskeletal system (10.8 per 10,000), and cleft lip and palate (10.0 per 10,000). Infants born with nervous system anomalies had the highest stillbirth and neonatal mortality rates (14.6 and 9.0 per 10,000, respectively).

Conclusions
This is the first population-based report on congenital anomalies in Guatemala. The rates we found of overall anomalies are higher than previously reported estimates. These data will be useful to increase the focus on congenital anomalies and hopefully increase the use of interventions of proven benefit.


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164. Radiologic-Pathologic Analysis of Increased Ethanol Localization and Ablative Extent Achieved by Ethyl Cellulose

Research Square


Authors: Erika Chelales, Robert Morhard, Corrine Nief, Brian Crouch, Alan Sag, Nirmala Ramanujam
Region / country: Global
Speciality: General surgery, Other

Purpose
Ethanol provides a rapid, low-cost ablative solution for liver tumors with a small technological footprint but suffers from uncontrolled diffusion in target tissue, limiting treatment precision and accuracy. The authors demonstrate that incorporating the gel-forming polymer ethyl cellulose to ethanol localizes the distribution. This therapy may have a low barrier of entry for cancer care in low- and middle- income countries.

Materials and Methods
The relationship of radiodensity to ethanol concentration was characterized with water-ethanol surrogates. Ex vivo EC-ethanol ablations were performed to optimize the formulation (n=6). In vivo ablations were performed to compare the optimal EC-ethanol formulation to pure ethanol (n=6). Ablations were monitored with CT and ethanol distribution volume was quantified. Livers were explanted, sectioned and stained with NADH-diaphorase to determine the ablative extent.

Results
CT imaging of ethanol-water surrogates demonstrated the ethanol concentration-radiodensity relationship is approximately linear. A concentration of 12% EC in ethanol created the largest distribution volume, more than 8-fold that of pure ethanol, ex vivo. In vivo, 12% EC-ethanol was superior to pure ethanol, yielding a distribution volume 3 times greater and an ablation zone 6 times greater than pure ethanol.

Conclusions
EC-ethanol, a novel gel formulation injectable ablative injectate, safely increases distribution and necrosis compared to pure ethanol.


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165. Virtual learning in global surgery: current strategies and adaptation for the COVID-19 pandemic

International Journal of Surgery Global Health


Authors: Joos Emilie, Zivkovic Irena, Shariff Farhana
Region / country: Global
Speciality: Health policy, Surgical Education

Modern surgical education has shifted to include technology as an integral component of training programs. The onset of the COVID-19 pandemic highlights the need to identify currently training modalities in global surgery and to delineate how these can be best used given the shift of global surgical training to the virtual setting. Here, we conducted a rapid review of the MEDLINE database examining the current status of training modalities in global surgical training programs and presented a case study of a virtual learning course on providing safe surgical care in the time of a pandemic. Our rapid review identified 285 publications, of which 101 were included in our analysis. Most articles describe training in high income country environments (87%, 88/101). The principal training modality described is apprenticeship (46%, 46/101), followed by simulation training (37%, 37/101), and virtual learning strategies (14%, 14/101). Our focused case study describes a virtual course entitled “Safe Surgical Care: Strategies During Pandemics,” created at the University of British Columbia by E.J., published 1-month postdeclaration of the pandemic. This multimodal course was rolled-out over a 5-week period and had significant engagement on an international level, with 1944 participants from 105 countries. With in-person training decreased as a result of the pandemic, virtual reality, virtual simulation, and telementoring may serve to bridge this gap. We propose that virtual learning strategies be integrated into global surgical training through the pursuit of increased accessibility, incorporation of telementoring, and inclusion in national health policy.


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166. High Prevalence of Antibiotic-Resistant Gram-Negative Bacteria Causing Surgical Site Infection in a Tertiary Care Hospital of Northeast India

Cureus Journal of Medical Science


Authors: Sangeeta Deka, Deepjyoti Kalita, Putul Mahanta, Dipankar Baruah
Region / country: Southern Asia – India
Speciality: General surgery, Obstetrics and Gynaecology, Trauma and orthopaedic surgery

Background and objective
Surgical site infections (SSI) are the most common healthcare-associated infections in low- and middle-income countries associated with substantial morbidity and mortality and impose heavy demands on healthcare resources. We aimed to study the microbiological profile of SSI pathogens and their antibiotic-resistant patterns in a tertiary care teaching hospital serving mostly rural population

Methods
A prospective, hospital-based cross-sectional study on pathogen profile and drug resistance was conducted from January 2015 to December 2016. Study subjects were the patients who developed signs of SSI after undergoing surgical procedures at three surgical wards (General Surgery, Orthopedics, and Obstetrics & Gynecology). The selection of the patients was based on CDC Module. Standard bacteriological methods were applied for isolation of pathogens and antibiotic-susceptibility testing based on CLSI (Clinical Laboratory Standard Institute) guidelines.

Results
Out of 518 enrolled subjects, 197 showed growth after aerobic culture yielding 228 pathogen isolates; 12.2% of samples showed polymicrobial growth. Escherichia coli (22.4%) and Klebsiella species (20.6%) were the predominant isolated bacteria followed by Staphylococcus species (18.4%), Pseudomonas species (12.3%), and Enterococcus species (6.6%). Gram-negative bacteria (GNB) were highly resistant to ampicillin (90.1%) and cefazolin (85.9%). High resistance was also observed to mainstay drugs like ceftriaxone (48.4%), cefepime (61%), amoxycillin-clavulanic acid (43.4%), and ciprofloxacin/levofloxacin (37.7%). Among the Gram-positive cocci, Staphylococcus aureus showed 85-96% resistance to penicillin and 65-74% to ampicillin. But GPCs were relatively less resistant to quinolones (16-18%) and macrolides (21.5%). S. aureus was 100% sensitive to vancomycin and clindamycin but vancomycin-resistant Enterococci was encountered in 3/15 (20%) isolates.

Conclusion
GNBs were responsible for more than two-thirds of aerobic-culture positive SSI and showed high resistance to the commonly used antibiotics thus leaving clinicians with few choices. This necessitates periodic surveillance of causative organisms and their antibiotic-susceptibility pattern to help in formulating hospital antibiotic policy. The antibiotic stewardship program is yet to be adopted in our hospital.


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167. The Withdrawal of the United States From the World Health Organization and Its Impact on Global Neurosurgery

Neurosurgery : The Registre of neurosurgical meme


Authors: Myron L Rolle, Ulrick S Kanmounye, Jacquelyn Corley, Kee B Park, Craig D McClain
Region / country: Northern America – United States of America
Speciality: Health policy, Neurosurgery

To the Editor:

Right now, in any low to middle income country (LMIC), a child has developed postinfectious life-threatening hydrocephalus or a mother has suffered a brain bleed after a motor vehicle collision. Their lives could be saved by neurosurgical procedures such as shunting, third ventriculostomies, or burr holes. In the poor countries of the world, these conditions are incredibly common and result in significant morbidity and mortality while taking a tremendous toll on national economies. The Lancet Commission on Global Surgery clearly demonstrated the utility in ensuring access to life-saving surgical interventions such as these.1 However, the efforts to help vulnerable people lead full and productive lives are now at profound risk due to the unfortunate decision by the United States to withdraw funding from the World Health Organization (WHO).

On July 7, 2020, the United States announced its withdrawal of large financial support to WHO due to concerns surrounding the agency’s coronavirus response. Global efforts in infectious disease control, nutrition, and education will certainly be impacted by this decision, but so will global neurosurgery. Defunding WHO could have a profound impact on the gains made in capacity-building efforts and improving access to neurosurgical care.

Global neurosurgery is the public health and clinical care of neurosurgical patients with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it.2 The Lancet Commission on Global Surgery incorporates all surgical disciplines, including global neurosurgery. The release of the Commission sounded the alarm on the investment of interdependent components of a surgical system such as anesthesia staff, nurses, operating rooms, critical care services, and biomedical engineers.3 With better capacity comes better neurosurgery and consequently improved treatment of the millions of patients every year with life-altering neurosurgical disease.

So where does WHO fit in? The United Nations (UN) has outlined its Sustainable Developmental Goals, which are to be reached by 2030. Global neurosurgery is related to targets #3 and #17—the promotion of healthy lives and global partnerships, respectively.4 WHO is the coordinating authority regarding health within the UN.

WHO is mandated to implement the health priorities set by its member states (MSs). In 2015, the members of WHO unanimously passed a resolution calling for “Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage.” The United States was a cosponsor of this historic resolution. Today, with the help of WHO and its key partners, more than 40 LMICs are currently in various stages of implementing the mandates of this resolution. Subspecialists such as neurosurgeons are transforming the profession by integrating the principle of health equity with WHO’s support. For example, WHO has partnered with the World Federation of Neurosurgical Societies (WFNS), the largest professional society within neurosurgery, to better understand the global neurosurgical disease burden and workforce deficits. This partnership also permits better access to local stakeholders to continue important advocacy efforts. Individual LMICs, under the WFNS-WHO partnership, can effectively push the agenda of improved neurosurgical care that is nationally or regionally specific.

At the World Health Assembly meeting in 2018, it was clear that WHO was increasing collaboration and communication between neurosurgical systems around the world.5 As Rosseau describes, neurosurgeons convened with health ministries and other key players to commit to “…sharing training, equipment, and other resources with the rest of the global surgery community.” Neurosurgeons seated at the table with WHO was a significant step in the right direction.

Finally, it is well known that WHO is one of the most significant champions of Universal Health Coverage (UHC). Neurosurgical care is part of UHC and thus needs to be protected at all costs. In a country like Uganda, where the average person makes $2280 USD/yr and may spend up to $1220 USD for a neurosurgical procedure, the economic burden on patients can be devastating.6 WHO encourages governments to strategically partner with the public and private sectors to ensure that all health needs, including neurosurgical ones, are economically met with the best quality of medicine available.

The global neurosurgery movement, as part of the broader global surgery movement, would not have been possible without WHO. The key stakeholders respect and depend on WHO to set global priorities and support the MS implementation of their mandates. Yes, WHO can improve. But the United States will be far more effective in driving the improvement as an MS. The consequences of withdrawal of funding from WHO are devastating and will adversely affect millions of people around the world and, in particular, neurosurgical patients.


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168. Surgical data strengthening in Ethiopia: results of a Kirkpatrick framework evaluation of a data quality intervention

Global Health Action


Authors: Sehrish Baria, Joseph Incorvia, Katherine R. Iverson, Abebe Bekelec, Kaya Garringera, Olivia Ahearna, Laura Drown , Amanu Aragaw Emiru, Daniel Burssae, Samson Workinehf, Ephrem Daniel Sheferaw, John G. Meara a,g and Andualem Beyene
Region / country: Eastern Africa – Ethiopia
Speciality: Health policy, Other

Background: One key challenge in improving surgical care in resource-limited settings is the lack of high-quality and informative data. In Ethiopia, the Safe Surgery 2020 (SS2020) project developed surgical key performance indicators (KPIs) to evaluate surgical care within the country. New data collection methods were developed and piloted in 10 SS2020 intervention hospitals in the Amhara and Tigray regions of Ethiopia.

Objective: To assess the feasibility of collecting and reporting new surgical indicators and measure the impact of a surgical Data Quality Intervention (DQI) in rural Ethiopian hospitals.

Methods: An 8-week DQI was implemented to roll-out new data collection tools in SS2020 hospitals. The Kirkpatrick Method, a widely used mixed-method evaluation framework for training programs, was used to assess the impact of the DQI. Feedback surveys and focus groups at various timepoints evaluated the impact of the intervention on surgical data quality, the feasibility of a new data collection system, and the potential for national scale-up.

Results: Results of the evaluation are largely positive and promising. DQI participants reported knowledge gain, behavior change, and improved surgical data quality, as well as greater teamwork, communication, leadership, and accountability among surgical staff. Barriers remained in collection of high-quality data, such as lack of adequate human resources and electronic data reporting infrastructure.

Conclusions: Study results are largely positive and make evident that surgical data capture is feasible in low-resource settings and warrants more investment in global surgery efforts. This type of training and mentorship model can be successful in changing individual behavior and institutional culture regarding surgical data collection and reporting. Use of the Kirkpatrick Framework for evaluation of a surgical DQI is an innovative contribution to literature and can be easily adapted and expanded for use within global surgery.


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169. Global prevalence of traumatic non-fatal limb amputation

SAGE Journals


Authors: Cody L McDonald, Sarah Westcott-McCoy, Marcia R Weaver, Juanita Haagsma and Deborah Kartin
Region / country: Global
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Background:
Reliable information on both global need for prosthetic services and the current prosthetist workforce is limited. Global burden of disease estimates can provide valuable insight into amputation prevalence due to traumatic causes and global prosthetists needed to treat traumatic amputations.

Objectives:
This study was conducted to quantify and interpret patterns in global distribution and prevalence of traumatic limb amputation by cause, region, and age within the context of prosthetic rehabilitation, prosthetist need, and prosthetist education.

Study design:
A secondary database descriptive study.

Methods:
Amputation prevalence and prevalence rate per 100,000 due to trauma were estimated using the 2017 global burden of disease results. Global burden of disease estimation utilizes a Bayesian metaregression and best available data to estimate the prevalence of diseases and injuries, such as amputation.

Results:
In 2017, 57.7 million people were living with limb amputation due to traumatic causes worldwide. Leading traumatic causes of limb amputation were falls (36.2%), road injuries (15.7%), other transportation injuries (11.2%), and mechanical forces (10.4%). The highest number of prevalent traumatic amputations was in East Asia and South Asia followed by Western Europe, North Africa, and the Middle East, high-income North America and Eastern Europe. Based on these prevalence estimates, approximately 75,850 prosthetists are needed globally to treat people with traumatic amputations.

Conclusion:
Amputation prevalence estimates and patterns can inform prosthetic service provision, education and planning.


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170. The scope of operative general paediatric surgical diseases in South Africa—the Chris Hani Baragwanath experience

Annals of Pediatric Surgery


Authors: Maame Tekyiwa Botchway, Deidre Kruger, Charles Adjei Manful & Andrew Grieve
Region / country: Southern Africa – South Africa
Speciality: General surgery, Paediatric surgery

Background
Infectious diseases have always been the lime light of global health with very little focus on childhood surgical conditions despite the fact that children constitute about half of the population in LMICs. A significant proportion of the burden of global disease can be reduced by surgical intervention. South Africa is one of the pioneers of the practice of paediatric surgery in Africa with a great burden of paediatric surgical conditions.

Few studies, if any, have investigated the burden of operative paediatric surgical procedures in South Africa. Therefore, this retrospective study aimed to look at the scope of operative paediatric surgical procedures at the Chris Hani Baragwanath Academic Hospital (CHBAH) based in Johannesburg, South Africa, and reports on the numbers of elective and emergency procedures over a 12-month study period.

Results
There were 1699 operative general paediatric surgical procedures of which 61.7% were electives and 38.3% were emergencies. The scope of general paediatric surgical conditions operated on fell under the categories of congenital anomalies, infections and tumours. Of these, surgeries for congenital anomalies were performed in almost all the subspecialties.

Conclusion
There is a high operative paediatric surgical burden at the CHBAH. The role of paediatric surgical care as an essential component of global health cannot be underrated.


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171. The ethical development and sustainability of trauma registries in low- and middle-income countries

ERA: Education and Research Archive


Authors: Grant, Chantalle L
Region / country: Global
Speciality: Health policy, Trauma surgery

Trauma registries are an anonymized, systematic, prospective data banks for trauma patients that may include details on demographics, injury details, hospital processes, and outcomes. They are an important component of trauma care systems and a tool for improving outcomes in trauma. Given the high rates of morbidity and mortality from trauma in low- and middle-income countries (LMICs), the implementation of trauma registries in LMICs is a growing area of interest; however, while many pilot trauma registries have been demonstrated to be feasible in LMICs, very few are sustainable in the long term. In this thesis, a trauma registry established in 2017 in Mbarara Regional Referral Hospital (MRRH), Uganda is examined. Since the establishment of this registry, data for over 3000 trauma patients has been collected, however, the registry faces questions of how to achieve long-term viability without the financial support of external partnerships. The aim of this thesis is therefore to evaluate several aspects of sustainability of trauma registries for low-income settings. First, the ethical importance of sustainability in global surgery was established through a scoping review on the literature on the ethics of global surgery. A grounded theory content analysis was completed to identify themes and gaps in the existing literature. Four major ethical domains in global surgery were identified: clinical care and delivery; education and exchange of trainees; research, monitoring, and evaluation; and engagement in collaborations and partnerships. While the literature on ethics in global surgery was sparse, mostly in the form of commentaries or editorials, and largely published by authors in high-income countries (HICs), the importance of including LMIC authors in the conversation on ethics in global surgery and the value of building sustainable collaborations and partnerships were key findings of this scoping review. Next, a literature review of considerations for the implementation of ethical and sustainable trauma registries in LMICs was completed. A number of practical challenges were identified for the development of trauma registries in LMICs and included funding sources, personnel requirements, technology access, and quality assurance mechanisms. Ethical considerations for trauma registry development were also identified, and included concerns of patient confidentiality, informed consent, and sustaining the registry. Strategies for these ethical and practical considerations for trauma registry development in LMICs are discussed, and opportunities for future research opportunities are explored. The widespread nature and accessibility of mobile phones in most low- and middle-income countries, including Uganda, makes the use of mobile phone technology in health a potential avenue for inexpensive health care innovation. A mobile application trauma registry was designed and implemented to minimize workload and contribute to sustainability of the registry. Healthcare workers involved in trauma then completed a validated questionnaire known as the Unified Theory of Acceptance and Use of Technology (UTAUT) for evaluating the usability of the mobile application trauma registry and predicting future use behaviours. Healthcare workers scored the mobile application highly, indicating a high potential for ongoing use. The UTAUT was also identified as a method for other trauma registries to predict future use and opportunities for sustainability. Finally, a potential means of financial self-sustainability for trauma registries in low-income countries was evaluated. In many public hospitals in low-income settings, government funding for patients seen is dependent on documentation of those patients. This study evaluated the improvements to patient documentation following the implementation of a trauma registry and concurrent patient registration system at MRRH. A significant improvement in patient documentation was found, with a 20-fold increase in trauma patients documented following the implementation of patient registration and a trauma registry. This more accurate documentation could then be used to apply for increased government funding for trauma patients and for sustaining the trauma registry in the long-term. The concurrent implementation of a patient registration system with a trauma registry therefore could be an avenue for financial viability for other trauma registries in low-income contexts. Taken together, these studies represent a compelling picture for the ethical imperative to develop sustainable trauma registries in LMICs and some of the strategies that may be undertaken to achieve this. By combining these techniques, we hope to achieve a sustainable, long-term trauma registry at MRRH that can serve as a model for other trauma registries in LMICs going forward.


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172. Double standards in healthcare innovations: the case of mosquito net mesh for hernia repair

BMJ Innovations


Authors: Mark Skopec, Alessandra Grillo, Alvena Kureshi, Yasser Bhatti, Matthew Harris
Region / country: Global
Speciality: General surgery, Health policy, Surgical Education

With over two decades of evidence available including from randomised clinical trials, we explore whether the use of low-cost mosquito net mesh for inguinal hernia repair, common practice only in low-income and middle-income countries, represents a double standard in surgical care. We explore the clinical evidence, biomechanical properties and sterilisation requirements for mosquito net mesh for hernia repair and discuss the rationale for its use routinely in all settings, including in high-income settings. Considering that mosquito net mesh is as effective and safe as commercial mesh, and also with features that more closely resemble normal abdominal wall tissue, there is a strong case for its use in all settings, not just low-income and middle-income countries. In the healthcare sector specifically, either innovations should be acceptable for all contexts, or none at all. If such a double standard exists and worse, persists, it raises serious questions about the ethics of promoting healthcare innovations in some but not all contexts in terms of risks to health outcomes, equitable access, and barriers to learning.


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173. Organ Donation and Transplantation in Sub-Saharan Africa: Opportunities and Challenges

Intech Open


Authors: Ifeoma Ulasi, Chinwuba Ijoma, Ngozi Ifebunandu, Ejikeme Arodiwe, Uchenna Ijoma, Julius Okoye, Ugochi Onu, Chimezie Okwuonu, Sani Alhassan, Obinna Onodugo
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Cardiothoracic surgery, Emergency surgery, General surgery, Health policy, Other, Paediatric surgery, Plastic surgery, Surgical oncology, Trauma and orthopaedic surgery, Urology surgery

Sub-Saharan Africa (SSA), occupying about 80% of the African continent is a heterogeneous region with estimated population of 1.1 billion people in 47 countries. Most belong to the low resource countries (LRCs). The high prevalence of end-organ diseases of kidney, liver, lung and heart makes provision of organ donation and transplantation necessary. Although kidney and heart transplantations were performed in South Africa in the 1960s, transplant activity in SSA lags behind the developed world. Peculiar challenges militating against successful development of transplant programmes include high cost of treatment, low GDP of most countries, inadequate infrastructural and institutional support, absence of subsidy, poor knowledge of the disease condition, poor accessibility to health-care facilities, religious and trado-cultural practices. Many people in the region patronize alternative healthcare as first choice. Opportunities that if harnessed may alter the unfavorable landscape are: implementation of the 2007 WHO Regional Consultation recommendations for establishment of national legal framework and self-sufficient organ donation/transplantation in each country and adoption of their 2020 proposed actions for organ/transplantation for member states, national registries with sharing of data with GODT, prevention of transplant commercialization and tourism. Additionally, adapting some aspects of proven successful models in LRCs will improve transplantation programmes in SSA.


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174. Skin substitutes for extensive burn coverage in Togo: A retrospective study

Science Direct


Authors: Kouevi-KokoTêt, Edem, Amouzou Komla Séna, Bakriga Batarabadja, Amegble Koffi Jude Dzidzo, Dellanh Yaovi Yanick, Dosseh Ekoué David Joseph
Region / country: Western Africa – Togo
Speciality: Emergency surgery, Plastic surgery, Trauma surgery

Four children, from 5 to 10 years aged, presented to the Sylvanus Olympio Hospital (SOTH) of Lomé (Togo) with severe (second-and third-degree) burns of 25–78% of total body surface area (TBSA) due to flame in domestic accidents and were treated using skin substitutes.
We conducted skin substitution by dermal templates (Integra®) for two children and by skin allografts for the other two. In the two cases of dermal templates, we performed a wound excision on day 30 in one case, and on day 28 in the other. In one case, we associated the coverage with the dermal template to a negative pressure wound therapy; we applied skin graft on day 18 and day 21. In the follow-up, we observed no complication in both cases.
In one of the two cases of skin allograft, we performed an eschar excision on day 8 and a donor skin allograft. we conducted another excision on day 15 while some parts were covered with skin autograft. The child died ten hours after the last procedure. The second patient had sequential excisions and coverage of some parts with skin allograft, and some others with skin autograft on day 42 In the fourth month, the child was discharged with a wound coverage of 74%, which was completed by another skin graft in the sixth month.
The availability of dermal templates compelled the choice between the two skin substitutes. The access to other grafting options, such as a deceased skin bank, could allow the SOTH surgical team to step forward to the burn care.


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175. Efficacy of Trans-abdominis Plane Block for Post Cesarean Delivery Analgesia in Low-income Countries: a Phase Three Feasibility Study.

research square


Authors: Evans Azina Sanga, Ansbert Sweetbert Ndebea, Shuweikha Salim, Mwemezi Kaino, Bernard Njau Kilimanjaro, Rogers Temu
Region / country: Eastern Africa – Tanzania
Speciality: Anaesthesia, Obstetrics and Gynaecology

Background: Optimal pain control in a parturient woman undergoing caesarean section is essential for preventing complications such as venous thrombo-embolism and improving maternal satisfaction, early
functional recovery, mother-baby bond and breastfeeding. Intentional pain assessment and adequate management to acceptable pain severity using multimodal methods can be achieved in low-middle
income countries (LMICs).

Aim: Is to assess the efficacy of transversus abdominis plane (TAP) block and satisfaction post-cesarean delivery analgesia at Kilimanjaro Christian Medical Centre in Low-Income countries.
Methods: The study population consisted of 72 participants who met criteria posted for elective and emergency caesarean section. They were blindly assigned into two groups: group A was the interventional group which received TAP block and standard pain management according to local protocols and consisted of 41 participants and group B was the control group which received standard pain management without TAP block and consisted of 31 participants. In Group A 30ml of 0.25% bupivacaine single shot was deposited in the TAP plane bilaterally for postoperative analgesia. Participants were randomized using a parallel method. Their demographics were recorded before surgery and visual analogue scale was used to assess postoperative pain at rest and on movement, and maternal satisfaction at 0hrs, 6hrs, 12hrs and 24hrs.
Results: Total of 72 patients were analyzed using NRS with pain score at 0hr, 6hr and 12hr was significantly low by about 50% in Intervened group as compared to control group with (p-value (2 tail) of <0.001 however at 24 hrs. was 0.272. Participant in group A had extra movements at 0hr, 6hrs and 12hrs with p-value <0.001 as compare to control cut had no significant difference when coughing. Maternal
satisfaction with pain management was 95.1% with no reported adverse event.

Conclusions: Trans Abdominis Plane block when used as part of multimodal pain management is more effective in managing post-cesarean pain resulting in less physical limitation and high maternal satisfaction.


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176. Analysing the Operative Experience of Paediatric Surgical Trainees in Sub-Saharan Africa Using a Web-Based Logbook

World Journal of Surgery


Authors: Ciaran Mooney, Sean Tierney, Eric O’Flynn, Miliard Derbew, Eric Borgstein
Region / country: Central Africa, Eastern Africa, Southern Africa
Speciality: Paediatric surgery, Surgical Education

Background
The expansion of local training programmes is crucial to address the shortages of specialist paediatric surgeons across Sub-Saharan Africa. This study assesses whether the current training programme for paediatric surgery at the College of Surgeons of East, Central and Southern Africa (COSECSA) is exposing trainees to adequate numbers and types of surgical procedures, as defined by local and international guidelines.
Methods
Using data from the COSECSA web-based logbook, we retrospectively analysed numbers and types of operations carried out by paediatric surgical trainees at each stage of training between 2015 and 2019, comparing results with indicative case numbers from regional (COSECSA) and international (Joint Commission on Surgical Training) guidelines.
Results
A total of 7,616 paediatric surgical operations were recorded by 15 trainees, at different stages of training, working across five countries in Sub-Saharan Africa. Each trainee recorded a median number of 456 operations (range 56–1111), with operative experience increasing between the first and final year of training. The most commonly recorded operation was inguinal hernia (n = 1051, 13.8%). Trainees performed the majority (n = 5607, 73.6%) of operations recorded in the eLogbook themselves, assisting in the remainder. Trainees exceeded both local and international recommended case numbers for general surgical procedures, with little exposure to sub-specialities.
Conclusions
Trainees obtain a wide experience in common and general paediatric surgical procedures, the number of which increases during training. Post-certification may be required for those who wish to sub-specialise. The data from the logbook are useful in identifying individuals who may require additional experience and centres which should be offering increased levels of supervised surgical exposure.


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177. Survey-based experiential learning as a means of raising professional awareness: a new educational approach for developing healthcare settings

Research Square


Authors: Ruhija Hodza-Beganovic, Peter Berggren , Karin Hugelius, Samuel Edelbring
Region / country: Eastern Europe, Northern Europe – Bosnia & Herzegovina, Montenegro, Sweden
Speciality: Surgical Education

Background This study outlines key aspects of professional development among health professionals in low- and middle-income countries (LMIC). LMICs need support in developing their continuing medical
education, and non-technical skills (NTS) that have been neglected in this respect. Given the nature of NTS, educational methods should be used experientially. This study aims to explore an interactive
an educational approach to increase NTS among health care professionals in an LMIC setting.

Methods. Key NTS concepts were identified and these directed the selection of research-based surveys. A series of workshops was designed in which a survey-based experiential approach was developed. The
educational process followed a pattern of individual reflection, small group discussion and relating the concepts to the local practice in a wider group.

Results. An approach to increase NTS in LMIC settings emerged in iterative development through conducting workshops with health care teams in the Balkans. The topics could be grouped into
individual, team, and organisational dimensions. The approach can be described as survey-based experiential learning involving steps in recurring interaction with participants. The steps include
identifying concepts in individual, team and organization dimensions and contextualising them using experiential learning on the individual and group levels.

Conclusion An overarching approach has been developed that addresses NTS in an LMIC setting. The survey-based experiential learning approach can be beneficial for raising professional awareness and the
development of sustainable healthcare settings in LMICs.


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178. A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes

Springer Link


Authors: Alexander F. Bedard, Lina V. Mata, Chelsea Dymond, Fabio Moreira, Julia Dixon, Steven G. Schauer, Adit A. Ginde, Vikhyat Bebarta, Ernest E. Moore, Nee-Kofi Mould-Millman
Region / country: Global
Speciality: Emergency surgery, Trauma and orthopaedic surgery, Trauma surgery

Background
Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation.

Main body
We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as “in-hospital mortality” as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure.

Conclusion
The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.


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179. Completeness of Medical Records of Trauma Patients Admitted to the Emergency Unit of a University Hospital, Upper Egypt

International Journal of Environmental Research and Public Health


Authors: Zeinab Mohammed, Ahmed Arafa, Shaimaa Senosy, El-Morsy Ahmed El-Morsy, Emad El-Bana, Yaseen Saleh, Jon Mark Hirshon
Region / country: Northern Africa – Egypt
Speciality: Emergency surgery, Trauma and orthopaedic surgery, Trauma surgery

Trauma records in Egyptian hospitals are widely suspected to be inadequate for developing a practical and useful trauma registry, which is critical for informing both primary and secondary prevention. We reviewed archived paper records of trauma patients admitted to the Beni-Suef University Hospital in Upper Egypt for completeness in four domains: demographic data including contact information, administrative data tracking patients from admission to discharge, clinical data including vital signs and Glasgow Coma Scale scores, and data describing the causal traumatic event (mechanism of injury, activity at the time of injury, and location/setting). The majority of the 539 medical records included in the study had significant deficiencies in the four reviewed domains. Overall, 74.3% of demographic fields, 66.5% of administrative fields, 55.0% of clinical fields, and just 19.9% of fields detailing the causal event were found to be completed. Critically, oxygen saturation, arrival time, and contact information were reported in only 7.6%, 25.8%, and 43.6% of the records, respectively. Less than a fourth of the records provided any details about the cause of trauma. Accordingly, the current, paper-based medical record system at Beni-Suef University Hospital is insufficient for the development of a practical trauma registry. More efforts are needed to develop efficient and comprehensive documentation of trauma data in order to inform and improve patient care.


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180. Patient Delay and Contributing Factors Among Breast Cancer Patients at Two Cancer Referral Centres in Ethiopia: A Cross-Sectional Study

Journal of Multidisciplinary Healthcare


Authors: Tesfaw A, Demis S, Munye T, Ashuro Z
Region / country: Eastern Africa – Ethiopia
Speciality: Surgical oncology

Background: Unlike developed countries, there is high mortality of breast cancer in low- and middle-income countries associated with prolonged patient delays and advanced stage presentations. However, evidence-based information about patient delay in presentation and contributing factors to diagnosis of breast cancer in Ethiopia is scarce.
Methods: Institution-based cross-sectional study was conducted at oncology units of the University of Gondar and Felege Hiwot specialized hospitals. A total of 371 female breast cancer patients who were newly diagnosed from September 2019 to April 30, 2020 were included. Data were entered using EPI info version 7.2 and analyzed in SPSS version 23. Descriptive statistics was used to summarize socio-demographic and clinical characteristic of the patients. Multivariable logistic regression at a P-value< 0.05 significance level was used to identify predictors of patient delay.
Results: A total of 281 (75.7%) patients had long patient delay of ≥ 90 days (3 months) with the average patient delay time of 8 months, and advanced stage diagnosis was found on 264 (71.2%) of patients. The median age of patients was 40 years. Rural residence (AOR=3.72; 95% CI=1.82– 7.61), illiterate (AOR=3.8; 95% CI=1.71– 8.64), having a painless wound (AOR=3.32; 95% CI=1.93, 5.72), travel distance ≥ 5 km (AOR=1.66; 95% CI=1.09– 3.00), having no lump/swelling in the armpit (AOR=6.16; 95% CI=2.80– 13.54), and no history of any breast problem before (AOR=2.46; 95% CI=(1.43– 4.22) were predictors for long patient delay.
Conclusion: Long patient delay and advanced stage diagnosis of breast cancer are higher in our study. Travel distance ≥ 5 km, rural residence, no history of any breast problem before, having no lump/swelling in the arm pit, a painless lump in the breast, and being illiterate were important predictors for patient delay. Therefore, public awareness programs about breast cancer should be designed to prevent patient delay in presentation and to promote early detection of cases before advancement.


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181. A country-level comparison of access to quality surgical and non-surgical healthcare from 1990-2016

PLOS One


Authors: Taylor Wurdeman ,Gopal Menon,John G. Meara,Blake C. Alkire
Region / country: Global
Speciality: Health policy

Background: The Healthcare Access and Quality (HAQ) index, developed by the Institute for Health Metrics and Evaluation, uses estimates of amenable mortality to quantify health system performance over time. While much is known about general health system performance globally, few studies have portrayed the performance of surgical systems. In order to quantify access to quality surgical care, evaluate changes over time, and link these changes to health care investments, surgical and non-surgical Health Access and Quality sub-indices were developed.

Design: We categorized 32 amenable mortality causes as either surgical or non-surgical conditions. Using principal components analysis and scaled amenable mortality rates, we constructed a surgical and non-surgical Health Access and Quality sub-index. Using these sub-indices, relative improvement over time was compared. An expenditure model with country fixed effects was built to explore drivers of differences in relative improvement of sub-indices.

Results: Compared to low-income countries, high-income countries have been 2.77 times more effective at improving surgical care (p < .05). Government expenditure on healthcare has a larger effect on improving surgical Health Access and Quality (p < 0.05) while development assistance for health has a larger effect on improving non-surgical Health Access and Quality (p < 0.05).

Conclusions and relevance: Global health investment must prioritize strengthening health systems as opposed to the historically favored vertical programming. In order to achieve health equity in low-income countries, more focus should be placed on domestic financing of surgical systems. Health Access and Quality sub-indices can be used by countries to identify targets, monitor progress, and evaluate interventions aimed at improving access to quality surgical healthcare.


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182. Maintaining paediatric cardiac services during the COVID-19 pandemic in a developing country in sub-Saharan Africa: guidelines for a “scale up” in the face of a global “scale down”

Cardiology in the Young


Authors: Ogochukwu J. Sokunbi [Opens in a new window] , Ogadinma Mgbajah , Augustine Olugbemi , Bassey O. Udom , Ariyo Idowu and Michael O. Sanusi
Region / country: Western Africa – Nigeria
Speciality: Cardiothoracic surgery, Paediatric surgery

The COVID-19 pandemic is currently ravaging the globe and the African continent is not left out. While the direct effects of the pandemic in regard to morbidity and mortality appear to be more significant in the developed world, the indirect harmful effects on already insufficient healthcare infrastructure on the African continent would in the long term be more detrimental to the populace. Women and children form a significant vulnerable population in underserved areas such as the sub-Saharan region, and expectedly will experience the disadvantages of limited healthcare coverage which is a major fall out of the pandemic. Paediatric cardiac services that are already sparse in various sub-Saharan countries are not left out of this downsizing. Restrictions on international travel for patients out of the continent to seek medical care and for international experts into the continent for regular mission programmes leave few options for children with cardiac defects to get the much-needed care.

There is a need for a region-adapted guideline to scale-up services to cater for more children with congenital heart disease (CHD) while providing a safe environment for healthcare workers, patients, and their caregivers. This article outlines measures adapted to maintain paediatric cardiac care in a sub-Saharan tertiary centre in Nigeria during the COVID-19 pandemic and will serve as a guide for other institutions in the region who will inadvertently need to provide these services as the demand increases.


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183. Publicly funded interfacility ambulance transfers for surgical and obstetrical conditions: A cross sectional analysis in an urban middle-income country setting

PLOS One


Authors: Paul Truche ,Rachel E. NeMoyer ,Sara Patiño-Franco ,Juan P. Herrera-Escobar ,Myerlandi Torres ,Luis F. Pino ,Gregory L. Peck
Region / country: South America – Colombia
Speciality: Emergency surgery, Health policy, Obstetrics and Gynaecology, Trauma and orthopaedic surgery, Trauma surgery

Introduction
Interfacility transfers may reflect a time delay of definitive surgical care, but few studies have examined the prevalence of interfacility transfers in the urban low- and middle-income (LMIC) setting. The aim of this study was to determine the number of interfacility transfers required for surgical and obstetric conditions in an urban MIC setting to better understand access to definitive surgical care among LMIC patients.

Methods
A retrospective analysis of public interfacility transfer records was conducted from April 2015 to April 2016 in Cali, Colombia. Data were obtained from the single municipal ambulance agency providing publicly funded ambulance transfers in the city. Interfacility transfers were defined as any patient transfer between two healthcare facilities. We identified the number of transfers for patients with surgical conditions and categorized transfers based on patient ICD-9-CM codes. We compared surgical transfers from public vs. private healthcare facilities by condition type (surgical, obstetric, nonsurgical), transferring physician specialty, and transfer acuity (code blue, emergent, urgent and nonurgent) using logistic regression.

Results
31,659 patient transports occurred over the 13-month study period. 22250 (70.2%) of all transfers were interfacility transfers and 7777 (35%) of transfers were for patients with surgical conditions with an additional 2,244 (10.3%) for obstetric conditions. 49% (8660/17675) of interfacility transfers from public hospitals were for surgical and obstetric conditions vs 32% (1466/4580) for private facilities (P<0.001). The most common surgical conditions requiring interfacility transfer were fractures (1,227, 5.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), trauma (652, 2.9%), and acute abdomen (271, 1.2%).

Conclusion
Surgical and obstetric conditions account for nearly half of all urban interfacility ambulance transfers. The most common reasons for transfer are basic surgical conditions with public healthcare facilities transferring a greater proportion of patient with surgical conditions than private facilities. Timely access to an initial healthcare facility may not be a reliable surrogate of definitive surgical care given the substantial need for interfacility transfers.


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184. Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study

BMC Musculoskeletal Disorders


Authors: Ulla Plenge, Romy Parker, Shamiela Davids, Gareth L. Davies, Zahnne Fullerton, Lindsay Gray, Penelope Groenewald, Refqah Isaacs, Ntambue Kauta, Frederik M. Louw, Andile Mazibuko, David M. North, Marc Nortje, Glen M. Nunes, Neo Pebane, Chantal Rajah, John Roos, Paul Ryan, Winlecia V. September, Heidi Shanahan, Ruth E. Siebritz, Rian W. Smit, Simon Sombili, Alexandra Torborg, Johan F. van der Merwe, Nico van der Westhuizen & Bruce Biccard
Region / country: Southern Africa – South Africa
Speciality: Trauma and orthopaedic surgery

Background
Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice.

Methods
From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was ‘days alive and at home up to 30 days after surgery’ (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice.

Results
Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3–5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25–27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%).

Conclusion
Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if ‘buy-in’ from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative.


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185. Association between volume resuscitation & mortality among injured patients at a tertiary care hospital in Kigali, Rwanda

African Journal of Emergency Medicine


Authors: Catalina González Marqués, Katelyn Moretti, Siraj Amanullah, Chantal Uwamahoro, Vincent Ndebwanimana, Stephanie Garbern, Sonya Naganathan, Kyle Martin Joseph Niyomiza, Annie Gjesvik, Menelas Nkeshimana, Adam C.Levine, Adam R.Aluisio
Region / country: Eastern Africa – Rwanda
Speciality: Critical care, Emergency surgery, Trauma and orthopaedic surgery, Trauma surgery

Background
Injuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K).

Methods
Data were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Results
From the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids.

Conclusions
Injured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.


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186. Assessment of diagnostics capacity in hospitals providing surgical care in two Latin American states

EClinical Medicine


Authors: Lina Roa, Ellie Moeller, Zachary Fowler, Rodrigo Vaz Ferreira, Sebastian Mohar, Tarsicio Uribe-Leitz, Aline Gil Alves Guilloux, Alejandro Mohar, Robert Riviello, John G Meara, Jose Emerson dos Santos Souza,Valeria Macias
Region / country: South America – Brazil, Mexico
Speciality: Anaesthesia, General surgery, Obstetrics and Gynaecology

Background
Diagnostic services are an essential component of high-quality surgical, anesthesia and obstetric (SAO) care. Efforts to scale up SAO care in Latin America have often overlooked diagnostics capacity. This study aims to analyze the capacity of diagnostic services, including radiology, pathology, and laboratory medicine, in hospitals providing SAO care in the states of Chiapas, Mexico and Amazonas, Brazil.

Methods
A stratified cross-sectional evaluation of diagnostic capacity in hospitals performing surgery in Chiapas and Amazonas was performed using the Surgical Assessment Tool (SAT). National data sources were queried for indicators of diagnostics capacity in terms of workforce, infrastructure and diagnosis utilization. Fisher’s exact tests and chi-square tests were used to compare categorical variables between the private and public sector in Chiapas while descriptive statistics are used to compare Amazonas and Chiapas.

Findings
In Chiapas, 53% (n = 17) of public and 34% (n = 20) of private hospitals providing SAO care were assessed. More private hospitals than public hospitals could always provide x-rays (35% vs 23.5%) and ultrasound (85% vs 47.1%). However neither sector could consistently perform basic laboratory testing such as complete blood counts (70.6% public, 65% private). In Amazonas, 30% (n = 18) of rural hospitals were surveyed. Most had functioning x-ray machine (77.8%) and ultrasound (55.6%). The majority of hospitals could provide complete blood count (66.7%) but only one hospital (5.6%) could always perform an infectious panel. Both Chiapas and Amazonas had dramatically fewer diagnostic practitioners per capita in each state compared to the national average capacity.

Interpretation
Facilities providing SAO care in low-resource states in Mexico and Brazil often lack functioning diagnostics services and workforce. Scale-up of diagnostic services is essential to improve SAO care and should occur with emphasis on equitable and adequate resource allocation.


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187. Health care during electricity failure: The hidden costs

PLOS One


Authors: Abigail Mechtenberg, Brady McLaughlin, Michael DiGaetano, Abigail Awodele, Leslie Omeeboh, Emmanuel Etwalu, Lydia Nanjula, Moses Musaazi, Mark Shrime
Region / country: Global
Speciality: Health policy, Other

Background
Surgery risks increase when electricity is accessible but unreliable. During unreliable electricity events and without data on increased risk to patients, medical professionals base their decisions on anecdotal experience. Decisions should be made based on a cost-benefit analysis, but no methodology exists to quantify these risks, the associated hidden costs, nor risk charts to compare alternatives.

Methods
Two methodologies were created to quantify these hidden costs. In the first methodology through research literature and/or measurements, the authors obtained and analyzed a year’s worth of hour-by-hour energy failures for four energy healthcare system (EHS) types in four regions (SolarPV in Iraq, Hydroelectric in Ghana, SolarPV+Wind in Bangladesh, and Grid+Diesel in Uganda). In the second methodology, additional patient risks were calculated according to time and duration of electricity failure and medical procedure impact type. Combining these methodologies, the cost from the Value of Statistical Lives lost divided by Energy shortage ($/kWh) is calculated for EHS type and region specifically. The authors define hidden costs due to electricity failure as VSL/E ($/kWh) and compare this to traditional electricity costs (always defined in $/kWh units), including Levelized Cost of Electricity (LCOE also in $/kWh). This is quantified into a fundamentally new energy healthcare system risk chart (EHS-Risk Chart) based on severity of event (probability of deaths) and likelihood of event (probability of electricity failure).

Results
VSL/E costs were found to be 10 to 10,000 times traditional electricity costs (electric utility or LCOE based). The single power source EHS types have higher risks than hybridized EHS types (especially as power loads increase over time), but all EHS types have additional risks to patients due to electricity failure (between 3 to 105 deaths per 1,000 patients).

Conclusions
These electricity failure risks and hidden healthcare costs can now be calculated and charted to make medical decisions based on a risk chart instead of anecdotal experience. This risk chart connects public health and electricity failure using this adaptable, scalable, and verifiable model.


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

International Journal of Surgery: Global Health


Authors: Ellen Wilkinson, Noel Aruparayil, Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, William Bolton, Julia Brown, David Jayne
Region / country: South-eastern Asia – India
Speciality: General surgery, Other

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.


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189. Cross-sectional analysis tracking workforce density in surgery, anesthesia, and obstetrics as an indicator of progress toward improved global surgical access

International Journal of Surgery: Global Health


Authors: Megan E. Bouchard, Jeanine Justiniano, Dominique Vervoort, Julian Gore-Booth, Adupa Emmanuel, Monica Langer
Region / country: Global
Speciality: Anaesthesia, General surgery, Health policy, Obstetrics and Gynaecology

Introduction: Safe surgical care, including anesthesia, obstetrics, and trauma, is an essential component of a functional health system, yet is lacking in much of the world. One indicator of surgical access is the number of specialist surgeons, anesthesiologists, and obstetricians (SAO) per 100,000 population, but global progress reaching threshold SAO density (SAOD) is unknown. This study measured SAOD change/trajectory and highlighted components of workforce expansion.
Methods: SAOD in 2019 was captured utilizing publicly available medical licensing data for a convenience sample of 21 countries. Projected 2030 SAOD were estimated by extrapolating annual changes since 2015. Ugandan medical students were surveyed regarding postgraduate plans and SAO training availability. Workforce contribution by nonphysician surgical and anesthetic providers was measured in Sierra Leone.
Results: Three low-income countries (LICs), 4 lower middle-income countries (L-MICs), 7 upper middle-income countries (UMICs), and 7 high-income countries (HICs) were included. Overall SAOD increased since 2015. The average 2019 SAOD was 1.16±0.81 (LICs), 3.19±1.92 (L-MICs), 20.98±12.55 (UMICs), and 44.04±12.41 (HICs). The projected 2030 SAOD in LICs and L-MICs remains below 20. In Uganda, 144 specialist SAO training positions and practice preferences predict an inadequate future workforce. In Sierra Leone, nonphysician providers contributed a 6-fold increase in the surgical workforce, though remains inadequate.
Conclusions: Despite incremental positive changes since 2015, the current SAOD trajectory is inadequate to realize 2030 access goals. Increased training and retention of specialists and nonphysician providers are necessary to address this critical deficit.


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190. Addressing the Burden of Antimicrobial Resistance in Vietnamese Hospitals

The Open University


Authors: Vu Quoc, Dat
Region / country: South-eastern Asia – Vietnam
Speciality: Other

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.


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191. Clubfoot patients’ demographic profile and outcomes of using the ponseti method at three selected hospitals in Zimbabwe

Wits Institutional Repository environment on DSpace


Authors: Mudariki, Debra
Region / country: Southern Africa – Zimbabwe
Speciality: Trauma and orthopaedic surgery

Background: Clubfoot is the most common musculoskeletal congenital abnormality and the Ponseti method is regarded as the gold standard of treatment. It has proven to be affordable, simple, and effective in correcting this deformity, particularly in low resource settings similar to Zimbabwe. Aim: The aim of this study was to establish the demographic profile and outcomes of patients with clubfoot treated using the Ponseti method at 3 hospitals in Zimbabwe, as well as determine whether results obtained were similar to those from regional and international research. Methodology: A descriptive retrospective records review of patients with clubfoot treated between January 2013 and December 2015 at Parirenyatwa, Harare Central and Mutare Provincial Hospitals was conducted. The main outcome was the final Pirani score at the end of the corrective phase. Data was analysed using STATISTICA Version 13.5. Results: There were 310 participants, mostly male (64.2%), with the majority (79.7%) in the maintenance phase of treatment. A total of 88.3% of the were participants between zero and two years of age at initial presentation, and the median (IQR) age was 3months (0.15-11months). Clubfoot was mostly of idiopathic (90.5%) and bilateral (55.2%) presentation, with positive family history of the deformity reported in 14.5% of participants. Mean (SD)Pirani scores at initial assessment for the right and left feet were 3.92 (1.33) and 3.99 (1.25) respectively. The Mean (SD) number of casts applied before tenotomy was 7.14 (4.48) ranging from 0-26 casts, and 72.5% of the participants had a tenotomy done. The proportion of left and right feet that attained a Pirani score of one or less at the end of the corrective phase was 79.2% and 82.5% respectively. Relapse was reported for 42.6% of participants in braces. At time of data collection, as many as 73.6% of the participants had stopped attending the clinics. Conclusion: Clubfoot treated using the Ponseti method had a good outcome at the end of the corrective phase. The demographic profile of patients managed at the three clinics and their treatment outcomes were in line with literature findings. There is, however, evidence of poor compliance and a high loss to follow up during the bracing phase and these need to be addressed to improve long term results.


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192. Simulator-based ultrasound training for identification of endotracheal tube placement in a neonatal intensive care unit using point of care ultrasound

BMC Medical Education


Authors: Khushboo Qaim Ali, Sajid Bashir Soofi, Ali Shabbir Hussain, Uzair Ansari, Shaun Morris, Mark Oliver Tessaro, Shabina Ariff & Hasan Merali
Region / country: Southern Asia – Pakistan
Speciality: Anaesthesia, Paediatric surgery, Surgical Education

Background
Simulators are an extensively utilized teaching tool in clinical settings. Simulation enables learners to practice and improve their skills in a safe and controlled environment before using these skills on patients. We evaluated the effect of a training session utilizing a novel intubation ultrasound simulator on the accuracy of provider detection of tracheal versus esophageal neonatal endotracheal tube (ETT) placement using point-of-care ultrasound (POCUS). We also investigated whether the time to POCUS image interpretation decreased with repeated simulator attempts.

Methods
Sixty neonatal health care providers participated in a three-hour simulator-based training session in the neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH), Karachi, Pakistan. Participants included neonatologists, neonatal fellows, pediatric residents and senior nursing staff. The training utilized a novel low-cost simulator made with gelatin, water and psyllium fiber. Training consisted of a didactic session, practice with the simulator, and practice with intubated NICU patients. At the end of training, participants underwent an objective structured assessment of technical skills (OSATS) and ten rounds of simulator-based testing of their ability to use POCUS to differentiate between simulated tracheal and esophageal intubations.

Results
The majority of the participants in the training had an average of 7.0 years (SD 4.9) of clinical experience. After controlling for gender, profession, years of practice and POCUS knowledge, linear mixed model and mixed effects logistic regression demonstrated marginal improvement in POCUS interpretation over repeated simulator testing. The mean time-to-interpretation decreased from 24.7 (SD 20.3) seconds for test 1 to 10.1 (SD 4.5) seconds for Test 10, p < 0.001. There was an average reduction of 1.3 s (β = − 1.3; 95% CI: − 1.66 to − 1.0) in time-to-interpretation with repeated simulator testing after adjusting for the covariates listed above.

Conclusion
We found a three-hour simulator-based training session had a significant impact on technical skills and performance of neonatal health care providers in identification of ETT position using POCUS. Further research is needed to examine whether these skills are transferable to intubated newborns in various health settings.


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193. Incidence, Mortality, and Survival Trends of Primary CNS Tumors in Cali, Colombia, From 1962 to 2019

JCO Global Oncology


Authors: Ivy Riano , Pablo Bravo , Luis Eduardo Bravo , Luz Stella Garcia, Paola Collazos, and Edwin Carrascal
Region / country: South America – Colombia
Speciality: Neurosurgery, Surgical oncology

PURPOSE
Global studies have shown varying trends of CNS tumors within geographic regions. In Colombia, the epidemiologic characteristics of CNS neoplasms are not well elucidated. We aimed to provide a summary of the descriptive epidemiology of primary CNS tumors among the urban population of Cali, Colombia.

METHODS
We conducted a time-trend study from 1962 to 2019 using the Population-Based Cali Cancer Registry. The age-standardized rates per 100,000 person-years were obtained by direct method using the world standard population. Results were stratified by sex, age group at diagnosis, and histologic subtype. We used Joinpoint regression analysis to detect trends and obtain annual percentage change (APC) with 95% CIs. We estimated 5-year net survival using the Pohar-Perme method.

RESULTS
During 1962 to 2016, 4,732 new cases of CNS tumors were reported. From 1985 to 2019, a total of 2,475 deaths from malignant CNS tumors were registered. A statistically significant increase in the trends of incidence (APC, 2.8; 95% CI, 2.1 to 3.5) and mortality (APC, 1.5; 95% CI, 1.1 to 2.0) rates was observed during the study. The most common malignant CNS tumor was glioblastoma (17.8% of all tumors), and the most frequent benign tumor was meningioma (17.2%). Malignancy was more common in males than in females. Unspecified malignant neoplasms represented 32% of all cases. The highest 5-year net survival was 31.4% during 2012 to 2016.

CONCLUSION
Our findings demonstrate an increasing burden of primary CNS tumors for the last 60 years, with a steady rate from the early 2010s. There was an improvement of 5-year net survival for the last decade. Males had higher mortality than did females. Additional efforts are needed to fully explore the geographic, environmental, and genetic contributors of CNS malignancies within the region.


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194. First Intraoperative Radiation Therapy Center in Africa: First 2 Years in Operation, Including COVID-19 Experiences

JCO Global oncology


Authors: Yastira Ramdas , Carol-Ann Benn, Michelle van Heerden
Region / country: Southern Africa – South Africa
Speciality: General surgery, Surgical oncology

PURPOSE
There is a shortage of radiation therapy service centers in low- to middle-income countries. TARGIT–intraoperative radiation therapy (IORT) may offer a viable alternative to improve radiation treatment efficiency and alleviate hospital patient loads. The Breast Care Unit in Johannesburg became the first facility in Africa to offer TARGIT-IORT, and the purpose of this study was to present a retrospective review of patients receiving IORT at this center between November 2017 and May 2020.

PATIENTS AND METHODS
Patient selection criteria were based mainly on the latest American Society of Radiation Oncology guidelines. Selection criteria included early-stage breast carcinoma (luminal A) and luminal B with negative upfront sentinel lymph node biopsy that negated external-beam radiation therapy (EBRT). Patient characteristics, reasons for choosing IORT, histology, and use of oncoplastic surgery that resulted in complications were recorded.

RESULTS
One hundred seven patients successfully received IORT/TARGIT-IORT. Mean age was 60.8 years (standard deviation, 9.3 years). A total of 73.8% of patients presented with luminal A, 15.0% with luminal B, and 5.6% with triple-negative cancer. One patient who presented with locally advanced breast cancer (T4N2) opted for IORT as a boost in addition to planned EBRT. Eighty-seven patients underwent wide local excision (WLE) with mastopexy, and 12 underwent WLE with parenchymal. Primary reasons for selecting IORT/TARGIT-IORT were distance from the hospital (43.9%), choice (40.2%), and age (10.3%).

CONCLUSION
This retrospective study of IORT/TARGIT-IORT performed in Africa confirms its viability, with low complication rates and no detrimental effects with breast conservation, resulting in positive acceptance and the potential to reduce Oncology Center patient loads. Limitations of the study include the fact that only short-term data on local recurrence were available. Health and socioeconomic value models must still be addressed in the African setting.


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195. Effects of helping mothers survive bleeding after birth in-service training of maternity staff : a cluster-randomized trial and mixed-method evaluation

GLOBAL PUBLIC HEALTH Karolinska Institutet


Authors: Alwy Al-beity, Fadhlun M
Region / country: Eastern Africa – Tanzania
Speciality: Obstetrics and Gynaecology

Background: Postpartum Haemorrhage (PPH) causes a significant amount of morbidity and mortality among mothers giving birth in sub-Saharan Africa, Tanzania included. One root cause is the insufficient health worker skills to address postpartum haemorrhage. To combat this in-service training using competency-based simulation is proposed.

Aim: To assess the effectiveness of the Helping Mothers Survive Bleeding After Birth (HMS BAB) in-service training of maternity staff on PPH related health outcomes, and health workers’ skills. The thesis also assessed health workers’ perceptions of the training and facility preparedness to support care of women with PPH in Tanzania.

Methods: Study I was conceptualised as a cluster-randomized trial. Interrupted time-series analysis was used to compare the following PPH related health outcomes i) PPH near miss and ii) PPH case fatality between 10 intervention and 10 comparison clusters. Study II was a before-after study of health workers (n=636), and assessed skills change immediately and ten months after the training, as well as the association between health workers’ characteristics and skill change. Study III was a qualitative study using seven Focus Group Discussions (FGD) of health workers to explore their perceptions of the training implementation. A deductive theory-driven analysis informed by integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework was used. Study IV explored health workers (FGDs, n=7) and health managers (In-depth interviews, n=12) perceptions of health facility preparedness to support care given to women with PPH. The data was analysed using thematic analysis.

Results: There was a significant decline of severe PPH cases in intervention clusters compared to the comparison clusters observed immediately after the intervention. This was sustained in the post-intervention period (Study I). A small reduction in PPH case fatality was observed in intervention clusters during the post-intervention period. Health workers’ skills were significantly improved immediately after the training with a small decline at ten-months follow up (Study II). In Study III health workers reported positive perceptions of the training: the content, the training technique, use of simulated scenarios and peer practice facilitators enhanced learning. Challenges to successful training were related to organization of the training and allocating time for weekly skill practices. In Study IV health workers reported poor facility preparedness with inconsistencies and insufficiencies of resources, including few and overwhelmed maternity staff. This constrained their ability to use the new skills and to provide quality PPH-care. Additional challenges on human interactions such as communication, collaborations and leadership were highlighted.

Conclusion: The HMS BAB one-day training followed by eight weekly drills was effective in reducing PPH morbidities and mortality and improved health workers skills. Implementational challenges included i) organizational aspects of in-facility training, and ii) protected time for health workers to engage in weekly drills. Health providers voiced their struggle to put their new knowledge into practice highlighting insufficiencies in health facility readiness, such as lack of drugs and blood products.


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196. Impact of High-Dose-Rate Brachytherapy Training via Telehealth in Low- and Middle-Income Countries

JCO Global Oncology


Authors: Jeremy B. Hatcher, Oluwadamilola Oladeru , Betty Chang, Sameeksha Malhotra, Megan Mcleod , Adam Shulman, Claire Dempsey, Layth Mula-Hussain , Michael Tassoto, Peter Sandwall , Sonja Dieterich, Lina Sulieman, Dante Roa , and Benjamin Li
Region / country: Global
Speciality: Surgical Education, Surgical oncology

PURPOSE
Our objective was to demonstrate the efficacy of a telehealth training course on high-dose-rate (HDR) brachytherapy for gynecologic cancer treatment for clinicians in low- and middle-income countries (LMICs)

METHODS
A 12-week course consisting of 16 live video sessions was offered to 10 cancer centers in the Middle East, Africa, and Nepal. A total of 46 participants joined the course, and 22 participants, on average, attended each session. Radiation oncologists and medical physicists from 11 US and international institutions prepared and provided lectures for each topic covered in the course. Confidence surveys of 15 practical competencies were administered to participants before and after the course. Competencies focused on HDR commissioning, shielding, treatment planning, radiobiology, and applicators. Pre- and post-program surveys of provider confidence, measured by 5-point Likert scale, were administered and compared.

RESULTS
Forty-six participants, including seven chief medical physicists, 16 senior medical physicists, five radiation oncologists, and three dosimetrists, representing nine countries attended education sessions. Reported confidence scores, both aggregate and paired, demonstrated increases in confidence in all 15 competencies. Post-curriculum score improvement was statistically significant (P < .05) for paired respondents in 11 of 15 domains. Absolute improvements were largest for confidence in applicator commissioning (2.3 to 3.8, P = .009), treatment planning system commissioning (2.2 to 3.9, P = .0055), and commissioning an HDR machine (2.2 to 4.0, P = .0031). Overall confidence in providing HDR brachytherapy services safely and teaching other providers increased from 3.1 to 3.8 and 3.0 to 3.5, respectively.

CONCLUSION
A 12-week, low-cost telehealth training program on HDR brachytherapy improved confidence in treatment delivery and teaching for clinicians in 10 participating LMICs.


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

Annals of Medicine and Surgery


Authors: Pervaiz Mahmood Hashmi, Marij Zahid, Arif Ali, Hammad Naqi, Anum Sadruddin Pidani, Alizah Pervaiz Hashmi, Shahryar Noordin
Region / country: Southern Asia – Pakistan
Speciality: Trauma and orthopaedic surgery

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.


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198. Antibiotic prophylaxis in a global surgical context

Southern African Journal of Anaesthesia and Analgesia


Authors: J Glasbey
Region / country: Global
Speciality: Critical care, General surgery

Surgical site infection (SSI) is a global problem, and has been highlighted as the foremost research priority for perioperative researchers across high-, middle- and low-income settings. Depending on the degree of intraoperative contamination, baseline patient risk and other infection control measures, as many as 50% of patients can suffer surgical wound infections within the 30-days after an operation. As a result, SSI has been the focus of several recent global initiatives including randomised controlled trials of health technologies, quality improvement bundle studies, and prospective cohort studies.


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199. Placing equity at the core of vascular surgery research

Journal of Vascular Surgery


Authors: Xiya Ma, Elizabeth Miranda, Dominique Vervoort
Region / country: Global
Speciality: Vascular surgery

Debus et al have performed a comprehensive longitudinal analysis of vascular surgery publications in 15 major international journals during a 10-year period. Their results confirm previous findings suggesting a dominance of high-income country authors and institutions, especially articles in English, a trend that maintains academic power imbalances, whereby barriers for non-English-speaking and low- and middle-income countries (LMICs) authors are upheld.


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200. Diagnostic assistance to improve acute burn referral and triage : assessment of routine clinical tools at specialised burn centres and potential for digital health development at point of care

Karolinska Institutet


Authors: Constance Boissin
Region / country: Southern Africa – South Africa
Speciality: Critical care, Trauma surgery

Background: Inappropriate referral of patients for specialised care leads to overburdened health systems and improper treatment of patients who are denied transfer due to a scarcity of resources. Burn injuries are a global health problem where specialised care is particularly important for severe cases while minor burns can be treated at point of care. Whether several solutions, existing or in development, could be used to improve the diagnosis, referral and triage of acute burns at admission to specialised burn centres remains to be evaluated.

Aim: The overarching aim of this thesis is to determine the potential of diagnostic support tools for referral and triage of acute burns injuries. More specifically, sub-aims include the assessment of routine and digital health tools utilised in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis.

Methods: Studies I and II were two retrospective studies of patients admitted to the paediatric (I) and the adult (II) specialised burn centres of the Western Cape province in South Africa. Study I examined adherence to referral criteria at admission of 1165 patients. Logistic regression was performed to assess the associations between adherence to the referral criteria and patient management at the centre. Study II assessed mortality prediction at admission of 372 patients. Logistic regression was performed to evaluate associations between patient, injury and admission-related characteristics with mortality. The performance of an existing mortality prediction model (the ABSI score) was measured. Study III and IV were related to two image-based digital-health tools for remote diagnosis. In Study III, 26 burns experts provided a diagnosis in terms of burn size and depth for 51 images of acute burn cases using their smartphone or tablet. Diagnostic accuracy was measured with intraclass correlation coefficient. In Study IV, two deep-learning algorithms were developed using 1105 annotated acute burn images of cases collected in South Africa and Sweden. The first algorithm identifies a burn area from healthy skin, and the second classifies burn depth. Differences in performances by patient Fitzpatrick skin types were also measured.

Results: Study I revealed a 93.4% adherence to the referral criteria at admission. Children older than two years (not fulfilling the age criterion) as well as those fulfilling the severity criterion were more likely to undergo surgery or stay longer than seven days at the centre. At the adult burn centre (Study II), mortality affected one in five patients and was associated with gender, burn size, and referral status after adjustments for all other variables. The ABSI score was a good estimate of mortality prediction. In Study III experts were able to accurately diagnose burn size, and to a lesser extent depth, using handheld devices. A wound identifier and a depth classifier algorithm could be developed with assessments of relatively high accuracy (Study IV). Differences were observed in performances by skin types of the patients.

Conclusions: Altogether the findings inform on the use in clinical practice of four different tools that could improve the accuracy of the diagnosis, referral and triage of patients with acute burns. This would reduce inequities in access to care by improving access for both paediatric and adult patient populations in settings that are resource scarce, geographically distant or under high clinical pressure.


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201. Recommendations from the ASCO Academic Global Oncology Task Force

JCO Global Oncology


Authors: Julie R. Gralow, Fredrick Chite Asirwa, Ami Siddharth Bhatt, Maria T. Bourlon, Quyen Chu, Alexandru E. Eniu, Patrick J. Loehrer, Gilberto Lopes, Lawrence N. Shulman , Julia Close, Jamie Von Roenn, Michal Tibbits, and Doug Pyle
Region / country: Global
Speciality: Surgical oncology

In recognition of the rising incidence and mortality of cancer in low- and middle-resource settings, as well as the increasingly international profile of its membership, ASCO has prioritized efforts to enhance its engagement at a global level. Among the recommendations included in the 2016 Global Oncology Leadership Task Force report to the ASCO Board of Directors was that ASCO should promote the recognition of global oncology as an academic field. The report suggested that ASCO could serve a role in transitioning global oncology from an informal field of largely voluntary activities to a more formal discipline with strong research and well-defined training components. As a result of this recommendation, in 2017, ASCO formed the Academic Global Oncology Task Force (AGOTF) to guide ASCO’s contributions toward formalizing the field of global oncology. The AGOTF was asked to collect and analyze key issues and barriers toward the recognition of global oncology as an academic discipline, with an emphasis on training, research, and career pathways, and produce a set of recommendations for ASCO action. The outcome of the AGOTF was the development of recommendations designed to advance the status of global oncology as an academic discipline.


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202. Healthcare markets in post-conflict settings: Experiences of formal private-for-profit healthcare organisations in Gulu District, Northern Uganda

Queen Margaret University, Edinburgh


Authors: Namakula, Justine
Region / country: Eastern Africa – Uganda
Speciality: Other

There is a paradox between the post-conflict setting and the healthcare market in Northern Uganda. While there is a strong missionary sector and apparent ongoing rehabilitation of the government facilities, the popularity of the formal private for-profit sector has steadily increased in Gulu municipality, northern Uganda, which has a high poverty-afflicted population. Therefore, there is need to understand why and how we can leverage the potential of the formal private for-profit providers (FPFPs) to accelerate Universal Health Coverage (UHC) goals. The study explored the experiences of the FPFPs based in Gulu municipality regarding the market in which they operated during and after the conflict. In particular, the study sought to understand the characteristics of and changes in FPFPs over time, as well as the challenges, coping strategies, opportunities, and linkages with others in the market. This was a case study using mixed methods with a quant-qual sequential approach. The methods included organisational survey, life-history interviews, key informant interviews and observation. This study utilised the New Institutional Economics (NIE) theory as an analytical lens. Data analysis was conducted using SPSS, ATLAS.ti ver. 7.0 and UCINET ver. 11.0 software. The findings suggest that FPFPs increased in number and experienced internal changes within individual businesses across the conflict periods. Conflict provides the context in which the FPFP businesses started and operate (d) and explains their survival patterns and the emergent regulatory context. The FPFPs were faced with diverse challenges embedded in the active conflict that further complicated operational costs and regulatory mechanisms. Notably, some of the coping strategies compromise the quality of the services provided. There is a dense relational network for FPFPs in Gulu municipality, and these numerous relational links have positive implications for the broader coverage of the goal for UHC, the reduction of transaction costs as well as their continued relevance in the market. FPFPs were continuously faced with a dilemma of balancing optimization of their incomes with their altruism objectives. In the period following conflict, FPFPs attempted to implement various mechanisms to ensure that the poor could access health care. The mechanisms were enabled by the managers’ ad hoc judgements as well as partnerships with the local government and NGOs in the area. These ranged from price exemptions and reductions to price discrimination and breaking down doses. The study concludes by noting that FPFPs play a critical role in service provision in post-conflict northern Uganda. However, they cannot be ‘exclusively’ pro-poor, given that they are formed with a profit maximization objective. Some coping strategies and some mechanisms to enable the poor to access services may compromise quality. Hence, the government needs to enforce regulations to control the number of FPFPs opening business as well as quality. There is evidence of partnerships between the government and FPFPs. This needs to be continuous and expanded to include more FPFPs if UHC goals are to be achieved.


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203. Improving Pediatric Neuro-Oncology Survival Disparities in the United States–Mexico Border Region: A Cross-Border Initiative Between San Diego, California, and Tijuana, Mexico

JCO Global Oncology


Authors: Paula Aristizabal, Luke P. Burns, Nikhil V. Kumar, Bianca P. Perdomo, Rebeca Rivera-Gomez, Mario A. Ornelas, David Gonda, Denise Malicki, Courtney D. Thornburg, William Roberts, Michael L. Levy, and John R. Crawford
Region / country: Northern America – Mexico, United States of America
Speciality: Neurosurgery

PURPOSE
Treatment of children with CNS tumors (CNSTs) demands a complex, interdisciplinary approach that is rarely available in low- and middle-income countries. We established the Cross-Border Neuro-Oncology Program (CBNP) between Rady Children’s Hospital, San Diego (RCHSD), and Hospital General, Tijuana (HGT), Mexico, to provide access to neuro-oncology care, including neurosurgic services, for children with CNSTs diagnosed at HGT. Our purpose was to assess the feasibility of the CBNP across the United States-Mexico border and improve survival for children with CNSTs at HGT by implementing the CBNP.

PATIENTS AND METHODS
We prospectively assessed clinicopathologic profiles, the extent of resection, progression-free survival, and overall survival (OS) in children with CNSTs at HGT from 2010 to 2017.

RESULTS
Sixty patients with CNSTs participated in the CBNP during the study period. The most common diagnoses were low-grade glioma (24.5%) and medulloblastoma (22.4%). Of patients who were eligible for surgery, 49 underwent resection at RCHSD and returned to HGT for collaborative management. Gross total resection was achieved in 78% of cases at RCHSD compared with 0% at HGT (P < .001) and was a predictor of 5-year OS (hazard ratio, 0.250; 95% CI, 0.067 to 0.934; P = .024). Five-year OS improved from 0% before 2010 to 52% in 2017.

CONCLUSION
The CBNP facilitated access to complex neuro-oncology care for underserved children in Mexico through binational exchanges of resources and expertise. Survival for patients in the CBNP dramatically improved. Gross total resection at RCHSD was associated with higher OS, highlighting the critical role of experienced neurosurgeons in the treatment of CNSTs. The CBNP model offers an attractive alternative for children with CNSTs in low- and middle-income countries who require complex neuro-oncology care, particularly those in close proximity to institutions in high-income countries with extensive neuro-oncology expertise.


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204. Frugal innovations that helped mission hospitals manage during the pandemic and further suggestions

Gnanaraj Jesudian a, Kevin Gnanaraj b, Biju Islaryc, Botoho Sumid, George Mathew


Authors: Gnanaraj Jesudian, Kevin Gnanaraj, Biju Islaryc, Botoho Sumid, George Mathew
Region / country: Southern Asia – India
Speciality: Other, Surgical Education, Urology surgery

The COVID-19 pandemic with the suddenly announced lockdown in India caused great stress to already resource-constrained rural mission hospitals. Frugal innovations helped some of the mission hospitals cope with the lockdown and resume regular work. Personal Protective Equipment was made locally and staff were trained to take care of the infected patients. Cell phones and the zoom app helped them with communications. The Gas Insufflation Less Laparoscopic surgical technique helped them perform safe surgeries and allow quicker turnover of patients. The innovative Laptop Cystoscope helped in follow up treatment of patients treated earlier by specialists and for emergency treatment. Empowering local mission hospital doctors and modern communication methods helped these hospitals maintain services during the pandemic.


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205. The embodiment of low-field MRI for the diagnosis of infant hydrocephalus in Uganda

2020 IEEE Global Humanitarian Technology Conference (GHTC)


Authors: Jan Carel Diehl, Frank van Doesum, Martien Bakker, Martin van Gijzen, Thomas O’Reilly, Ivan Muhumuza, Johnes Obungoloch, Edith Mbabazi Kabachelor
Region / country: Eastern Asia – Uganda
Speciality: Neurosurgery, Other

Compared to other parts of the world, theincidence of hydrocephalus in children is very high in subSaharan Africa. Magnetic resonance imaging (MRI) would be the
preferred diagnostic method for infant hydrocephaleus. However, in practice, MRI is seldom used in sub-Saharan Africa due to its high prize, low mobility, and high power consumption.
A low-cost MRI technology is under development by reducing the strength of the magnetic field and the use of alternative technologies to create the magnetic field. This paper describes the embodiment design process to match this new MRI technology under development with the specific characteristics of the healthcare system in Uganda.

A context exploration was performed to identify factors that may affect the design and implementation of the low-field MRI in Ugandan hospitals and Ugandan healthcare environment. The key-insights from the technology- and context-exploration were translated into requirements which were the starting point for the design process. The concept development did have a focus on Cost-effective design, Design for durability & reliability, and Design for repairability. The final design was validated by stakeholders from the Ugandan Healthcare context.


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206. Global prevalence of congenital heart disease in school-age children: a meta-analysis and systematic review

BMC Cardiovascular Disorders


Authors: Yingjuan Liu, Sen Chen, Liesl Zühlke, Sonya V. Babu-Narayan, Graeme C. Black, Mun-kit Choy, Ningxiu Li & Bernard D. Keavney
Region / country: Global
Speciality: Cardiothoracic surgery

Background
Congenital heart disease (CHD) is the commonest birth defect. Studies estimating the prevalence of CHD in school-age children could therefore contribute to quantifying unmet health needs for diagnosis and treatment, particularly in lower-income countries. Data at school age are considerably sparser, and individual studies have generally been of small size. We conducted a literature-based meta-analysis to investigate global trends over a 40-year period.

Methods and results
Studies reporting on CHD prevalence in school-age children (4–18 years old) from 1970 to 2017 were identified from PubMed, EMBASE, Web of Science and Google Scholar. According to the inclusion criteria, 42 studies including 2,638,475 children, reporting the prevalence of unrepaired CHDs (both pre-school diagnoses and first-time school-age diagnoses), and nine studies including 395,571 children, specifically reporting the prevalence of CHD first diagnosed at school ages, were included. Data were combined using random-effects models. The prevalence of unrepaired CHD in school children during the entire period of study was 3.809 (95% confidence intervals 3.075–4.621)/1000. A lower proportion of male than female school children had unrepaired CHD (OR = 0.84 [95% CI 0.74–0.95]; p = 0.001). Between 1970–1974 and 1995–1999, there was no significant change in the prevalence of unrepaired CHD at school age; subsequently there was an approximately 2.5-fold increase from 1.985 (95% CI 1.074–3.173)/1000 in 1995–1999 to 4.832 (95% CI 3.425–6.480)/1000 in 2010–2014, (p = 0.009). Among all CHD conditions, atrial septal defects and ventricular septal defects chiefly accounted for this increasing trend. The summarised prevalence (1970–2017) of CHD diagnoses first made in childhood was 1.384 (0.955, 1.891)/1000; during this time there was a fall from 2.050 [1.362, 2.877]/1000 pre-1995 to 0.848 [0.626, 1.104]/1000 in 1995–2014 (p = 0.04).

Conclusions
Globally, these data show an increased prevalence of CHD (mainly mild CHD conditions) recognised at birth/infancy or early childhood, but remaining unrepaired at school-age. In parallel there has been a decrease of first-time CHD diagnoses in school-age children. These together imply a favourable shift of CHD recognition time to earlier in the life course. Despite this, substantial inequalities between higher and lower income countries remain. Increased healthcare resources for people born with CHD, particularly in poorer countries, are required.


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207. A review of fetal cardiac monitoring, with a focus on low-and middle-income countries

Physiological Measurement


Authors: Camilo Ernesto Valderrama Cuadros, Nasim Katebi, Faezeh Marzbanrad, Peter Rohloff, Gari D Clifford
Region / country: Global
Speciality: Obstetrics and Gynaecology

There is limited evidence regarding the utility of fetal monitoring during pregnancy, particularly during labor and delivery. Developed countries rely on consensus `best practices’ of obstetrics and gynecology professional societies to guide their protocols and policies. Protocols are often driven by the desire to be as safe as possible and avoid litigation, regardless of the cost of downstream treatment. In high-resource settings, there may be a justification for this approach. In low-resource settings, in particular, interventions can be costly and lead to adverse outcomes in subsequent pregnancies. Therefore, it is essential to consider the evidence and cost of different fetal monitoring approaches, particularly in the context of treatment and care in low-to-middle income countries. This article reviews the standard methods used for fetal monitoring, with particular emphasis on fetal cardiac assessment which is a reliable indicator of fetal well-being. An overview of fetal monitoring practices in low-to-middle income counties, including perinatal care access challenges, is also presented. Finally, an overview of how mobile technology may help reduce barriers to perinatal care access in low-resource settings is provided.


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208. The Global Burden of Rheumatic Heart Disease: Population-Related Differences (It is Not All the Same!)

Brazilian Journal of Cardiovascular Surgery


Authors: Manuel J. Antunes
Region / country: Global
Speciality: Cardiothoracic surgery

Rheumatic heart disease (RHD) remains the most common cardiovascular disease in young adults and adolescents in need of heart surgery in low- and middle-income countries (LMICs).
The mean age of patients is 20-25 years, often much younger. By contrast, the few patients with chronic RHD in developed countries present a mean age of around 55 years. It is absolutely fundamental to differentiate these two types of population. Pathology, lesions and surgical methods are different, and the results should not be compared. It is not all the same!
A certain enthusiasm for mitral repair has recently surged, with several reports showing excellent results in children and young adults, resulting from the renewed interest of cardiac surgeons, also based on new and modified techniques developed in the meantime. While surgery is easily accessible to patients in developed countries, the situation in LMICs is often dramatic, with countries where there is a complete absence of or few surgical facilities absolutely unable to meet gigantic demands. Many foreign surgical teams conduct humanitarian missions in several of these countries. They are just a “drop of water in the ocean” of needs.

In some cases, however, these missions led to the establishment of local teams that now work independently and, in some cases, outperform the foreign teams still visiting.


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209. Designing for Health Accessibility: Case Studies of Human-Centered Design to Improve Access to Cervical Cancer Screening

escholarship – Berkeley, University of California


Authors: Kramer, Julia
Region / country: Central America, Southern Asia – India, Nicaragua
Speciality: Health policy, Obstetrics and Gynaecology, Surgical oncology

Our world faces immense challenges in global health and equity. There continue to be huge disparities in access to health care across geographies, despite the massive strides that have been made to address health issues. In this dissertation, I explore the role of human-centered design to improve global health access and reduce disparities. Human-centered design, a cross-disciplinary creative problem-solving approach, has been applied and studied in both academic research and practice, but its role in improving global health access remains poorly understood.

In this dissertation, I present research on designing for health accessibility in the context of one particular disease: cervical cancer. Every year, 300,000 women around the world die of cervical cancer and ninety percent of these deaths occur in low- and middle-income countries. Cervical cancer is an illustrative example of the global disparities in access to health care, given that cervical cancer is preventable and the majority of global cervical cancer mortality is in low- and middle-income countries.

My research examines the work of two organizations that created unique solutions to improve access to cervical cancer screening in India and Nicaragua. I develop case studies of each organization grounded in ethnographic fieldwork, including over 250 hours of observation and 15 interviews over two years. Through these case studies, I show how early efforts to understand the barriers inhibiting cervical cancer screening access allow design practitioners to create novel and feasible ways to address these barriers. This demonstrates the importance of design practitioners considering multiple dimensions of accessibility, including availability, physical accessibility, accommodation, affordability, and acceptability, while conducting design research in order to improve the potential impact of their ideas and prototypes. Overall, this dissertation establishes the foundation of a new paradigm to “design for accessibility” that can inspire further application and research across sectors to address the many social equity and accessibility challenges facing our world.


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210. Access to Radiotherapy for Cancer treatment (ARC) Project’: Guidance for low and middle-income countries establishing safe and sustainable radiotherapy services

Open Publication of UTS scholars


Authors: Andrew Donkor
Region / country: Global
Speciality: Health policy, Surgical oncology

Efforts to improve access to cancer care, including radiotherapy services in low and middle-income countries (LMICs) is challenging. Many radiotherapy initiatives in LMICs have failed to fully deliver on their promise because of multi-faceted barriers at the systems, organisational and patient levels, leading to significant wastage of scarce resources. Greater guidance on how to assess and build LMICs’ readiness for establishing sustainable radiotherapy services is needed to improve cancer care outcomes in LMICs. 𝗔𝗶𝗺: The ‘𝗔ccess to 𝗥adiotherapy for 𝗖ancer treatment (ARC) Project’ aimed to provide practical guidance to LMICs on establishing safe and sustainable radiotherapy services. 𝗠𝗲𝘁𝗵𝗼𝗱𝘀: The mixed qualitative methods ARC Project involved a: systematic review; and two-part qualitative study. The systematic review synthesised strategies adopted by LMICs to improve access to cancer treatment and palliative care. Semi-structured interviews undertaken with global radiotherapy experts explored perceived facilitators and barriers to establishing sustainable radiotherapy services in LMICs. The mid-point meta-inference of the systematic review and semi-structured interview data generated a draft list of requirements, which was circulated to global experts during the second part-of the qualitative study. The final meta-inference was undertaken following the completion of the three studies. 𝗙𝗶𝗻𝗱𝗶𝗻𝗴𝘀: The systematic review identified that comparatively few studies have focused specifically on improving radiotherapy in LMICs, with no research evaluating effectiveness. The semi-structured interviews identified three key facilitators to establishing sustainable radiotherapy services in LMICs, namely: committing to a vision of improving cancer care; making it happen and sustaining a safe service; and leveraging off radiotherapy to strengthen integrated cancer care. The mid-point meta-inference generated 42 potential requirements, which were organised into four readiness domains: commitment (n=13); cooperation (n=7); capacity (n=17); and catalyst (n=5). The participant validation confirmed 37 of the generated requirements as relevant for inclusion in a radiotherapy service development readiness self-assessment guide for use by LMICs. The end-point meta-inference of the ARC Project’s integrated data presented the ‘𝗥𝗘adiness 𝗦𝗘lf-𝗔ssessment (RESEA) Guide’, with 120 questions that may help LMICs at macro and meso level to determine and create action plans to improve their readiness to establish radiotherapy services. 𝗖𝗼𝗻𝗰𝗹𝘂𝘀𝗶𝗼𝗻𝘀: The ARC Project has identified a complex combination of facilitators and barriers that influence the establishment of sustainable radiotherapy services in LMICs. It has developed a RESEA Guide to provide support for LMICs seeking to establish sustainable radiotherapy services. Further work is needed to evaluate the acceptability and feasibility of the RESEA Guide and inform further refinements.


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211. Neural Tube Defects and Associated Factors among Neonates Admitted to the Neonatal Intensive Care Units in Hiwot Fana Specialized University Hospital, Harar, Ethiopia

Global Pediatric Health


Authors: Yunus Edris, Hanan Abdurahman, Assefa Desalew, Fitsum Weldegebreal
Region / country: Eastern Africa – Ethiopia
Speciality: Neurosurgery, Paediatric surgery

Background:
Neural tube defects are a major public health problem and substantially contribute to morbidity and mortality, particularly in low-income countries, including Ethiopia. There are a paucity of data on the magnitude and associated factors of neural tube defects in Ethiopia, particularly in the study setting.

Objective:
This study aimed to assess the magnitude of neural tube defects and associated factors among neonates admitted to the neonatal intensive care unit in Hiwot Fana Specialized University Hospital, Harar, Ethiopia.

Methods:
A hospital-based cross-sectional study was employed from October 2019 to January 2020. A total of 420 newborn-mother pairs were included consecutively. Data were collected using a face-to-face interviewer-administered questionnaire and clinical examination. Data were entered into Epi Data version 3.1 and analyzed using the statistical package for Social Sciences version 20.0 software. An adjusted odds ratio (AOR) with 95% confidence interval (CI) was used to identify the associated factors. A p-value <.05 was considered statistically significant.

Results:
The magnitude of neural tube defects was 5.71% (95% CI: 3.5-7.9). Approximately 83.5% of infants had spinal bifida and 16.5% anencephaly. In multivariable logistic regression analyses, preterm birth (32-34 weeks) (AOR= 3.84; 95% CI: 2.1,10.7), low birth weight (1000-1500 g) (AOR = 4.74; 95% CI: 1.8, 9.1), 1500-2500 g (AOR = 3.01; 95% CI: 2. 1, 13.2), maternal coffee consumption (AOR = 11.2; 95% CI: 3.1, 23.7), a history of abortion or stillbirth (AOR = 9.6; 95% CI:7.6,19.4), radiation exposure (AOR = 5.0; 95% CI:1.6,14.3), and intake of anticonvulsant drugs during pregnancy (AOR = 4.75; 95% CI: 1.5,16.2) were factors associated with neural tube defects.

Conclusion:
In this study, the burden of neural tube defects was 5.71% among neonates admitted to the neonatal intensive care unit, which was a public health concern. Increased attention to the monitoring of neural tube defects in eastern Ethiopia is crucial to improve birth outcomes in the study setting.


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212. Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children

African Journal of Emergency Medicine


Authors: African Journal of Emergency Medicine
Region / country: Western Africa – Ghana
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Introduction
Ghana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana.

Methods
We performed a retrospective cohort study of injured children aged 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08–0.55).

Conclusions
NHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children.


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213. Steerable and Reusable Bipolar Vessel Sealer: Design, Development and Validation

TU Delft Library


Authors: Philip de Haes
Region / country: Global
Speciality: General surgery

A new radical design approach arose from the need to develop a bipolar electrosurgical instrument that is modular and cleanable, thus reusable and therefore suitable for low- and middle-income countries (LMICs). Advanced Bipolar Vessel Sealer (BVS) instruments that are currently on the market cannot be cleaned or maintained well and are therefore most often sold as disposables. Especially in LMICs it is a significant financial burden for hospitals. This possibly leads to the re-use of single-use intended instruments which in turn jeopardizes patient safety. Simultaneously, designing a reusable instrument fits well in the transition to a more circular and sustainable society. To perform advanced laparoscopic surgery with cleanable and affordable electrosurgical instruments, a new design approach is needed. A first phase was initiated by the creation of a cable less steering principle called Shaft Actuated Tip Articulation (SATA) mechanism [6]. Unfortunately, by adding electrically conductive wires to a SATA instrument it loses its modularity and thus cleanability, precisely for which the SATA technology offered a solution in the first place. In addition, there are no non-robotically controlled and reusable BVS instruments with two DOFs available on the market. By being steerable, the user of the instrument is able to deliver a higher quality seal as well as to seal more difficult-to-reach blood vessels and tissue. In this thesis project the goal is to redesign a SATA instrument which sustains bipolar vessel sealing and thus designing a BVS that is easy to clean, easily disinfected and sterilized and which is reusable for a vast amount of surgical procedures. Ideas have been gained by analysing the SATA mechanism and studying commonly used BVS devices. A systematic selection procedure based on the design requirements has resulted in a winning concept for the conduction of electricity through the SATA instrument. For the design of the tip, determining factors were elaborated on, including the construction of the open and close mechanism and the force transmission ratio between the required seal force on the blood vessel or tissue and the necessary tensile force in the core of the instrument. The most critical components of the final model have been identified and evaluated by means of FEM simulations and an experiment. The FEM simulations of the tip components show that the design is satisfactory and that a safety factor of ~1.5 has been achieved. This means that these components do not fail due to normal use and they have a long lifespan as well. In the experiment a flexible nitinol guidewire with Teflon coating was tested for wear by pulling the guidewire through an angled SATA hinge. After some necessary adjustments and additions to the design of the BVS, the results were improved but not optimal. The outcome of this project is a good basis for the BVS design where the steerability has been maintained as well as the modularity and cleanability. The reusability depending on the flexible coating around the core needs to be further investigated and improved.


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214. Otitis media with effusion in Africa‐prevalence and associated factors: A systematic review and meta‐analysis

Laryngoscope Investigative Otolaryngology


Authors: Emmanuel Choffor‐Nchinda, Antoine Bola Siafa, Jobert Richie Nansseu
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: ENT surgery

Objectives
To estimate the overall and subgroup prevalence of otitis media with effusion (OME) in Africa, and identify setting‐specific predictors in children and adults.

Methods
PubMed, African Journals Online, African Index Medicus, Afrolib, SciELO, Embase, Scopus, Web of Science, The Cochrane Library, GreyLit and OpenGray were searched to identify relevant articles on OME in Africa, from inception to December 31st 2019. A random‐effects model was used to pool outcome estimates.

Results
Overall, 38 studies were included, with 27 in meta‐analysis (40 331 participants). The overall prevalence of OME in Africa was 6% (95% CI: 5%‐7%; I2 = 97.5%, P < .001). The prevalence was 8% (95% CI: 7%‐9%) in children and 2% (95% CI: 0.1%‐3%) in adolescents/adults. North Africa had the highest prevalence (10%; 95% CI: 9%‐13%), followed by West and Southern Africa (9%; 95% CI: 7%‐10% and 9%; 95% CI: 6%‐12% respectively), Central Africa (7%; 95% CI: 5%‐10%) and East Africa (2%; 95% CI: 1%‐3%). There was no major variability in prevalence over the last four decades. Cleft palate was the strongest predictor (OR: 5.2; 95% CI: 1.4‐18.6, P = .02). Other significant associated factors were age, adenoid hypertrophy, allergic rhinitis in children, and type 2 diabetes mellitus, low CD4 count in adults.

Conclusion
OME prevalence was similar to that reported in other settings, notably high‐income temperate countries. Health care providers should consider age, presence of cleft palate, adenoid hypertrophy and allergic rhinitis when assessing OME in children and deciding on a management plan. More research is required to confirm risk factors and evaluate treatment options.


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215. Delays Experienced by Patients With Pediatric Cancer During the Health Facility Referral Process: A Study in Northern Tanzania

JCO Global Oncology


Authors: Luke Maillie , Nestory Masalu , Judy Mafwimbo, Mastidia Maxmilian and Kristin Schroeder
Region / country: Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Paediatric surgery, Surgical oncology

PURPOSE
It is estimated that 50%-80% of patients with pediatric cancer in sub-Saharan Africa present at an advanced stage. Delays can occur at any time during the care-seeking process from symptom onset to treatment initiation. Referral delay, the time from first presentation at a health facility to oncologist evaluation, is a key component of total delay that has not been evaluated in sub-Saharan Africa.

METHODS
Over a 3-month period, caregivers of children diagnosed with cancer at a regional cancer center (Bugando Medical Centre [BMC]) in Tanzania were consecutively surveyed to determine the number and type of health facilities visited before presentation, interventions received, and transportation used to reach each facility.

RESULTS
Forty-nine caregivers were consented and included in the review. A total of 124 facilities were visited before BMC, with 31% of visits (n = 38) resulting in a referral. The median referral delay was 89 days (mean, 122 days), with a median of two facilities (mean, 2.5 facilities) visited before presentation to BMC. Visiting a traditional healer first significantly increased the time taken to reach BMC compared with starting at a health center/dispensary (103 v 236 days; P = .02). Facility visits in which a patient received a referral to a higher-level facility led to significantly decreased time to reach BMC (P < .0001). Only 36% of visits to district hospitals and 20.6% of visits to health centers/dispensaries yielded a referral, however.

CONCLUSION
The majority of patients were delayed during the referral process, but receipt of a referral to a higher-level facility significantly shortened delay time. Referral delay for pediatric patients with cancer could be decreased by raising awareness of cancer and strengthening the referral process from lower-level to higher-level facilities.


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

Journal of Critical Care


Authors: Kapil Dev Soni, Monty Khajanchi, Nakul Raykar, Bhakti Sarang, Gerard M.O’Reilly, Satish Dharap, Peter Cameron, Naveen Sharma, Teresa Howard, Nathan Farrow, Nobhojit Roy
Region / country: South-eastern Asia – India
Speciality: Critical care, Emergency surgery, Trauma and orthopaedic surgery, Trauma surgery

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”.


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217. Mechanical Ventilation Supply and Options for the COVID-19 Pandemic: Leveraging All Available Resources for a Limited Resource in a Crisis

Annals of the American Thoracic Society


Authors: Mohammad Dar, Lakshmana Swamy , Daniel Gavin , and Arthur Theodore
Region / country: Global
Speciality: Critical care

The novel Coronavirus disease (COVID-19) has exposed critical supply shortages both in the United States and worldwide including those in ICU and hospital bed supply, hospital staff, and mechanical ventilators. Many of those critically ill have required days to weeks of supportive mechanical invasive ventilation (MV) as part of their treatment. Previous estimates set the US availability of mechanical ventilators at approximately 62,000 full-featured ventilators, with 98,000 non-full featured devices (including non-invasive devices). Given the limited availability of this resource both in US and in low- and middle-income countries, we provide a framework to approach the shortage of MV resources. Here we discuss evidence and possibilities to reduce overall MV needs, strategies to maximize the availability of MV devices designed for invasive ventilation, the literature underlying methods to create and fashion new sources of potential ventilation that are available to hospitals and front-line providers, and discuss the staffing needs necessary to support MV efforts. The pandemic has already pushed cities like New York and Boston well beyond previous ICU capacity in its first wave. As hotspots continue to develop around the country and the globe, it is evident that issues may arise ahead regarding the efficient and equitable use of resources. This unique challenge may continue to stretch resources and require care beyond previously set capacities and boundaries. The approaches presented here provide a review of the known evidence and strategies for those at the front-line facing this challenge.


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218. Does health insurance contribute to improved utilization of health care services for the elderly in rural Tanzania? A cross-sectional study

Global Health Action


Authors: Malale Tungu , Paul Joseph Amani , Anna-Karin Hurtig , Angwara Dennis Kiwara , Mughwira Mwangu , Lars Lindholm & Miguel San Sebastiån
Region / country: Eastern Africa – Tanzania
Speciality: Health policy

Background: Health care systems in developing countries such as Tanzania depend heavily on out-of-pocket payments. This mechanism contributes to inefficiency, inequity and cost, and is a barrier to patients seeking access to care. There are efforts to expand health insurance coverage to vulnerable groups, including older adults, in Sub-Saharan African countries.

Objective: To analyse the association between health insurance and health service use in rural residents aged 60 and above in Tanzania.

Methods: Data were obtained from a household survey conducted in the Nzega and Igunga districts. A standardised survey instrument from the World Health Organization Study on global AGEing and adult health was used. This comprised of questions regarding demographic and socio-economic characteristics, health and insurance status, health seeking behaviours, sickness history (three months and one year prior to the survey), and the receipt of health care. A multistage sampling method was used to select wards, villages and respondents in each district. Local ward and hamlet officers guided the researchers in identifying households with older people. Crude and adjusted logistic regression methods were used to explore associations between health insurance and outpatient and inpatient health care use.

Results: The study sample comprised 1,899 people aged 60 and above of whom 44% reported having health insurance. A positive statistically significant association between health insurance and the utilisation of outpatient and inpatient care was observed in all models. The odds of using outpatient (adjusted OR = 2.20; 95% CI: 1.54, 3.14) and inpatient services (adjusted OR = 3.20; 95% CI: 2.46, 4.15) were higher among the insured.

Conclusion: Health insurance is a predictor of outpatient and inpatient health services in people aged 60 and above in rural Tanzania. Further research is needed to understand the perceptions of both the insured and uninsured regarding the quality of care received.


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219. An Exploratory Qualitative Study of the Prevention of Road Trac Collisions and Neurotrauma in India: Perspectives From Key Informants in an Indian Industrial City (Visakhapatnam)

Research Square


Authors: Santhani M Selveindran, Gurusinghe Samarutilake, K Madhu Narayana Rao, Jogi Patisappu, Christine Hill, Angelos Kolias, Rajesh Pathi, Peter Hutchinson, N Vijayasekhar
Region / country: Southern Asia – India
Speciality: Neurosurgery, Trauma surgery

Background: Despite current preventative strategies, road traffic collisions (RTCs) and resultant neurotrauma remain a major problem in India. This study seeks to explore local perspectives in the context within which RTCs take place and identify potential suggestions for improving the current status.

Methods: Ten semi-structured interviews were carried out with purposively selected key informants from the city of Visakhapatnam, Andhra Pradesh. Participants were from one of the following categories: commissioning stakeholders; service providers; community or local patient group/advocacy group representatives. Transcripts from these interviews were analysed qualitatively using the Framework Method.

Results: Participants felt RTCs are a serious problem in India and a leading cause of neurotrauma. Major risk factors identified related to user behaviour such as speeding and not using personal safety equipment, and the user state, namely drink driving and underage driving. Other reported risk factors included poor infrastructure, moving obstacles on the road, overloaded vehicles and substandard safety equipment. Participants discussed how RTCs affect not only the health of the victim, but are also a burden to the healthcare system, families, and the national economy. Although there are ongoing preventative strategies being carried out by both the government and the community, challenges to successful prevention emerged from the interviews which included resource deficiencies, inconsistent implementation, lack of appropriate action, poor governance, lack of knowledge and the mindset of the community and entities involved in prevention. Recommendations were given on how prevention of RTCs and neurotrauma might be improved, addressing the areas of education and awareness, research, the pre-hospital and trauma systems, enforcement and legislation, and road engineering, in addition to building collaborations and changing mindsets.

Conclusions: RTCs remain a major problem in India and a significant cause of neurotrauma. Addressing the identified gaps and shortfalls in current approaches and reinforcing collective responsibility towards road safety would be the way forward in improving prevention and reducing the burden.


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220. Barriers to inguinal hernia repair in Ghana: prospective, multi-centre cohort study

Journal of Medical and Biomedical Sciences


Authors: Abass Alhassan, Francis Atidana Abantanga, Omar Omar, Dmitri Nepogodiev, Aneel Bhang, Saeed F. Majeed, Kwame Opare-Asamoah, Michael Ohene Yeboah, Stephen Tabiri
Region / country: Western Africa – Ghana
Speciality: General surgery

Inguinal hernia (IH) is the most common general surgical pathology in Ghana with hernia repair rate very low. The objective was to assess patient-perceived barriers to IH repair in Ghana and identify predictors of experiencing delays until surgery. A multicenter prospective study was conducted during the Ghana Hernia Society outreach. Data regarding diagnosis using Kingsnorth’s classification of IH, age of patients, duration of hernia, reason for delay in repair, insurance status, American Society of Anesthesiologists (ASA) class, travel distance, region, hospital, and waiting times were obtained from patients and folders. Multivariable linear regression models were constructed to analyze delay until surgery and Kingsnorth’s classification while controlling for the covariates of age, insurance status, ASA class among others. The most common reasons were queues for surgery (23%), poverty (10%), and seeking traditional medicine (9%). On multivariate linear regression, increasing age and ASA class III were predictors of longer delays. Patients experienced significant increase of 1.1 years delay to surgery for every 10 year increase in of age. ASA Class III patients were significantly more likely to be delayed by 11.5 years compared to ASA Class I patients. Efforts should be made to address and overcome the barriers to IH repair identified.


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221. The Practice of Paediatric Radiation Oncology in Low- and Middle-income Countries: Outcomes of an International Atomic Energy Agency Study

Clinical Oncology


Authors: Y. Anacak, E. Zubizarreta, M. Zaghloul, S. Laskar, J. Alert, S. Gondhowiardjo, A. Giselvania, R. Correa-Villar, F. Pedrosa, B. Dorj, S. Kame, rS.C. Howard, Y. Quintana, R.C. Ribeiro, E. Rosenblatt,K. Hopkins
Region / country: Global
Speciality: Paediatric surgery, Surgical oncology

Aims
Childhood cancer survival is suboptimal in most low- and middle-income countries (LMICs). Radiotherapy plays a significant role in the standard care of many patients. To assess the current status of paediatric radiotherapy, the International Atomic Energy Agency (IAEA) undertook a global survey and a review of practice in eight leading treatment centres in middle-income countries (MICs) under Coordinated Research Project E3.30.31; ‘Paediatric radiation oncology practice in low and middle income countries: a patterns-of-care study by the International Atomic Energy Agency.’

Materials and methods
A survey of paediatric radiotherapy practices was distributed to 189 centres worldwide. Eight leading radiotherapy centres in MICs treating a significant number of children were selected and developed a database of individual patients treated in their centres comprising 46 variables related to radiotherapy technique.

Results
Data were received from 134 radiotherapy centres in 42 countries. The percentage of children treated with curative intent fell sequentially from high-income countries (HICs; 82%) to low-income countries (53%). Increasing deficiencies were identified in diagnostic imaging, radiation staff numbers, radiotherapy technology and supportive care. More than 92.3% of centres in HICs practice multidisciplinary tumour board decision making, whereas only 65.5% of centres in LMICs use this process. Clinical guidelines were used in most centres. Practice in the eight specialist centres in MICs approximated more closely to that in HICs, but only 52% of patients were treated according to national/international protocols whereas institution-based protocols were used in 41%.

Conclusions
Quality levels in paediatric radiotherapy differ among countries but also between centres within countries. In many LMICs, resources are scarce, coordination with paediatric oncology is poor or non-existent and access to supportive care is limited. Multidisciplinary treatment planning enhances care and development may represent an area where external partners can help. Commitment to the use of protocols is evident, but current international guidelines may lack relevance; the development of resources that reflect the capacity and needs of LMICs is required. In some LMICs, there are already leading centres experienced in paediatric radiotherapy where patient care approximates to that in HICs. These centres have the potential to drive improvements in service, training, mentorship and research in their regions and ultimately to improve the care and outcomes for paediatric cancer patients.


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222. Barriers to the uptake of cervical cancer services and attitudes towards adopting new interventions in Peru

Preventive Medicine Reports


Authors: Lavanya Vasudevana, Sandra Stinnett, Cecelia Mizelle, Katherine Melgar, Christina Makarushka, Michelle Pieters, Luis Enrique Roman Sanchez, Jose Jeronimo, Megan J.Huchkobh, Rae Jean Proeschold-Bell
Region / country: South America – Peru
Speciality: Obstetrics and Gynaecology, Surgical oncology

Cervical cancer mortality is high among Peruvian women of reproductive age. Understanding barriers and facilitators of cervical cancer screening and treatment could facilitate development of contextually-relevant interventions to reduce cervical cancer incidence and mortality. From April – October 2019, we conducted a cross-sectional survey with 22 medical personnel and administrative staff from Liga Contra el Cancer, in Lima, Peru. The survey included structured and open-ended questions about participants’ roles in cervical cancer prevention and treatment, perceptions of women’s barriers and facilitators for getting screened and/or treated for cervical cancer, as well as attitudes towards adopting new cervical cancer interventions. For structured questions, the frequency of responses for each question was calculated. For responses to open-ended questions, content analysis was used to summarize common themes. Our data suggest that the relative importance and nature of barriers that Peruvian women face are different for cervical cancer screening compared to treatment. In particular, participants mentioned financial concerns as the primary barrier to treatment and a lack of knowledge or awareness of human papillomavirus and/or cervical cancer as the primary barrier to screening uptake among women. Participants reported high willingness to adopt new interventions or strategies related to cervical cancer. Building greater awareness about benefits of cervical cancer screening among women, and reducing financial and geographic barriers to treatment may help improve screening rates, decrease late-stage diagnosis and reduce mortality in women who have a pre-cancer diagnosis, respectively. Further studies are needed to generalize study findings to settings other than Lima, Peru.


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223. Evaluation of a digital triage platform in Uganda: A quality improvement initiative to reduce the time to antibiotic administration

Plos One


Authors: Victor Lee, Dustin Dunsmuir, Stephen Businge, Robert Tumusiime, James Karugaba, Matthew O. Wiens, Matthias Görges, Niranjan Kissoon, Sam Orach, Ronald Kasyaba, J. Mark Ansermino
Region / country: Central Africa, Eastern Africa – Uganda
Speciality: Emergency surgery, Health policy, Other

Background
Sepsis is the leading cause of death in children under five in low- and middle-income countries. The rapid identification of the sickest children and timely antibiotic administration may improve outcomes. We developed and implemented a digital triage platform to rapidly identify critically ill children to facilitate timely intravenous antibiotic administration.

Objective
This quality improvement initiative sought to reduce the time to antibiotic administration at a dedicated children’s hospital outpatient department in Mbarara, Uganda.

Intervention and study design
The digital platform consisted of a mobile application that collects clinical signs, symptoms, and vital signs to prioritize children through a combination of emergency triggers and predictive risk algorithms. A computer-based dashboard enabled the prioritization of children by displaying an overview of all children and their triage categories. We evaluated the impact of the digital triage platform over an 11-week pre-implementation phase and an 11-week post-implementation phase. The time from the end of triage to antibiotic administration was compared to evaluate the quality improvement initiative.

Results
There was a difference of -11 minutes (95% CI, -16.0 to -6.0; p < 0.001; Mann-Whitney U test) in time to antibiotics, from 51 minutes (IQR, 27.0–94.0) pre-implementation to 44 minutes (IQR, 19.0–74.0) post-implementation. Children prioritized as emergency received the greatest time benefit (-34 minutes; 95% CI, -9.0 to -58.0; p < 0.001; Mann-Whitney U test). The proportion of children who waited more than an hour until antibiotics decreased by 21.4% (p = 0.007).

Conclusion
A data-driven patient prioritization and continuous feedback for healthcare workers enabled by a digital triage platform led to expedited antibiotic therapy for critically ill children with sepsis. This platform may have a more significant impact in facilities without existing triage processes and prioritization of treatments, as is commonly encountered in low resource settings.


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224. Top 10 Resources in Global Surgery

Global Health: Science and Practice


Authors: Alliance Niyikuri, Emily R. Smith, Dominique Vervoort, Mark G. Shrime, Stav Brown, Alexander W. Peters, Gavin Yamey and Emmanuel Makasa
Region / country: Global
Speciality: Health policy, Other

The need is great. Surgical disease is among the top 15 causes of disability, and surgical conditions account for up to 30% of total disability-adjusted life years (DALYs) lost worldwide—with the greatest need in low- and middle-income countries (LMICs). Surgery has been shown to be highly cost-effective when compared with standard global health interventions.
The transition from the Millennium Development Goals to the Sustainable Development Goals has ushered in a new era for the global surgery community. Sustainable Development Goal 3, to “ensure healthy lives and promote well-being at all ages,” emphasizes health system strengthening and universal health coverage.6 The provision of available, accessible, safe, timely, and affordable surgical and anesthesia care is identified as an integral component of a functional health system in countries at all levels of economic development and as essential to achieving universal health coverage. In addition, the importance of increasing education, safety, and capacity for the provision of surgical, anesthetic, and obstetric care is highlighted by several global health and development agencies and policy makers, including the World Bank and the World Health Organization (WHO).

As a result, the emerging field of global surgery has increased in priority among health practitioners, including nonphysician surgeons and anesthetists, researchers, and students. Evidence of this prioritization includes a shift toward incorporating surgical care as an integral part of global health systems strengthening in LMICs that has occurred and will likely continue to grow in importance within global health agendas. Lastly, interest in the field from an academic research standpoint is evidenced by the increase in peer-reviewed publications. Between 2005 and 2015, research publications in the field of global surgery increased from approximately 570 articles in 2005 to more than 4,000 articles published in 2015, according to PubMed.

Because of the growing interest in global surgery, momentum in this emerging field, and the importance of global surgery in the training of health professionals, we aimed to summarize the top resources in global surgery to orient readers to the field. We undertook a 2-stage process to identify and select the top 10 resources in global surgery.


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225. Choices for operative management of fractures in a developing country.

Ethiopian medical journal


Authors: Baidoo Richard Ogirma, Odei-Ansong Francis, Baidoo Ebikela Ivie
Region / country: Western Africa – Ghana
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Aims: Operative management of fractures has changed significantly in the 21st century with the introduction of simple but effective devices and procedures to improve fracture care and healing outcomes. This study describes the commonest fractures treated surgically, type of fractures and operative fixation methods used for patients seeking orthopaedic services in two hospitals in Ghana.

Methods: Review of all patients who have had operative fracture fixation at the Cape Coast Teaching Hospital and St. Joseph Orthopaedic Hospital between January 2016 to December 2018. Operation records of 1,168 were reviewed for their age, gender, fractured bone, type of fracture, operative fixation method and devices used for fixation.

Results: A total of 1,168 fractured patients were treated operatively irrespective of age in the 3 year period reviewed. Males (817)compared to females (351) in a ratio of 2.3:1. The 21 – 40 year age group had the highest number of fractures (50% of femur fractures, 52% of tibial and 56% of forearm fractures) managed operatively. Plate osteosynthesis was found to be the most preferred method of fixation for the major long bones; femur 360(66 %), Humerus 69(78% ), radius and ulna 81(78%).

Conclusion: Fractures of the femur and tibial shafts represent an overwhelming majority of operatively managed long bone fractures. Plating as opposed to the gold standard of intramedullary nailing was the most commonly employed fixation method for femur and tibial fractures, so scarce resources should be channelled towards acquiring the requisite instrumentation and skill set for the fixation of these fractures.


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226. A Retrospective Analysis of Breast Cancer at BPKMCH, Nepal

Nepalese Journal of cancer


Authors: Chin Bahadur Pun, Sadina Shrestha, Ranjan Raj Bhatta, Greta Pandey, Suraj Uprety, Shankar Bastakoti, Ishan Dhungana, Nandita Jha
Region / country: Southern Asia – Nepal
Speciality: Surgical oncology

ntroduction: Breast cancer is the most common cancer and also the leading cause of cancer related mortality in women worldwide which impact 2.1 million women each year. Breast cancer rates are increasing in nearly every region globally. Methods: This was retrospective study at Department of Pathology in B P Koirala Memorial Cancer Hospital effective from 15 April 2018 to 14 April 2019. All the data were retrieved and analyzed.Results: Total 205 breast cancer cases were analyzed, among them 198 cases were females accounting 96.5 % and 7 cases were males accounting 3.5 %.Among 205 cases, 181 ( 88.6% ) cases were invasive ductal Carcinoma No Special Type. Majority of cases 111 (54%) were diagnosed with Nottingham grading system grade II of breast cancer.According to our study breast cancer was most common in the age group 41-50 years ( 32.2% ).Conclusion: Breast cancer is more common in females than in males. Most common affected age group was 41-50 years. Most common histological type was invasive ductal carcinoma NST. Similarly, left sided breast cancer was more common than right.


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227. Management of liver trauma in urban university hospitals in India: an observational multicentre cohort study

World Journal of Emergency Surgery


Authors: Yash Sinha, Monty U Khajanchi, Ramlal P Prajapati, Satish Dharap, Kapil Dev Soni, Vineet Kumar, Santosh Mahindrakar, Nobhojit Roy
Region / country: South-eastern Asia – India
Speciality: Emergency surgery, General surgery, Trauma and orthopaedic surgery, Trauma surgery

Background
Low- and middle-income countries (LMICs) contribute to 90% of injuries occurring in the world. The liver is one of the commonest organs injured in abdominal trauma. This study aims to highlight the demographic and management profile of liver injury patients, presenting to four urban Indian university hospitals in India.

Methods
This is a retrospective registry-based study. Data of patients with liver injury either isolated or concomitant with other injuries was used using the ICD-10 code S36.1 for liver injury. The severity of injury was graded based on the World Society of Emergency Surgery (WSES) grading for liver injuries.

Results
A total of 368 liver injury patients were analysed. Eighty-nine percent were males, with road traffic injuries being the commonest mechanism. As per WSES liver injury grade, there were 127 (34.5%) grade I, 96 (26.1%) grade II, 70 (19.0%) grade III and 66 (17.9%) grade IV injuries. The overall mortality was 16.6%. Two hundred sixty-two patients (71.2%) were managed non-operatively (NOM), and 106 (38.8%) were operated. 90.1% of those managed non-operatively survived.

Conclusion
In this multicentre cohort of liver injury patients from urban university hospitals in India, the commonest profile of patient was a young male, with a blunt injury to the abdomen due to a road traffic accident. Success rate of non-operative management of liver injury is comparable to other countries.


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228. Adult congenital cardiac life-long needs evaluation in a low-middle income country, Pakistan

Journal of the Pakistan Medical Association


Authors: Laila Akbar Ladak, Disty Pearson, Kathy Jenkins, Muneer Amanullah, Waris Ahmad, Kaitlin Doherty Schmeck, Amy Verstappen, & Babar Sultan Hasan.
Region / country: Southern Asia – Pakistan
Speciality: Cardiothoracic surgery

Objective: Adult congenital heart diseases (ACHD) have distinct health care needs that require life-long care. Limited data is available from low-middle income countries (LMIC). This descriptive study conducted in Pakistan aimed to assess patients and health care professionals understanding of the needs for ACHD care and the perceived barriers to care.

Methods: A telephone survey was conducted of ACHD patients. An e-mail survey was sent to the pediatric and adult cardiologists of five institutions (3 public and 2 private) that provide ACHD services in Pakistan. Descriptive statistics (frequencies, mean ± SD, median) were used for data analysis.

Results: A total of 128 ACHD patients were surveyed, 65 (51%) were females with a mean age of 29.4±10.4 years. Atrial septal defect repair was the most common surgical procedure. Mean age at surgery was 25.6±10.49 years, and a surgical follow-up period of 3.8±2.3 years.

Majority (n=3, 60%) of the health care professionals (HCPs) responded that 75-100% of the ACHD surgical patients would need lifelong care, yet 10-25% return to their cardiology clinics.

Most of the surveyed ACHD patients (89%, n=114) demonstrated a lack of understanding of life-long care after surgery due to not being communicated by their HCPs. Cost and travelling issues were the barriers highlighted by HCPs. Both ACHD patients (96%, n=122) and HCP (100%, n=5) underscored their interest in life-long care.


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229. An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country

PLOS One


Authors: Armand Zimmerman, Samara Fox, Randi Griffin, Taylor Nelp, Erika Bárbara Abreu Fonseca Thomaz, Mark Mvungi, Blandina T Mmbaga, Francis Sakita , Charles J Gerardo, Joao Ricardo Nickenig Vissoci, Catherine A Staton
Region / country: Eastern Africa – Tanzania
Speciality: Emergency surgery, Neurosurgery, Trauma and orthopaedic surgery

Background
Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting.

Methods
We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes.

Results
Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery.

Conclusions
Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.


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230. Recording patient data in burn unit logbooks in Rwanda – who and what are we missing?

Journal of Burn Care & Research


Authors: Elizabeth Miranda, MD MPH, Lotta Velin, Faustin Ntirenganya, MD PhD, Robert Riviello, MD MPH, Francoise Mukagaju, MD, Ian Shyaka, MD, Yves Nezerwa, MD, Laura Pompermaier, MD PhD
Region / country: Eastern Africa – Rwanda
Speciality: Emergency surgery, Trauma and orthopaedic surgery

Systematic data collection in high-income countries has demonstrated a decreasing burn morbidity and mortality, whereas lack of data from low- and middle-income countries hinder a global overview of burn epidemiology. In low- and middle-income countries, dedicated burn registries are few. Instead, burn data are often recorded in logbooks or as one variable in trauma registries, where incomplete or inconsistently recorded information is a known challenge. The University Teaching Hospital of Kigali hosts the only dedicated burn unit in Rwanda and has collected data on patients admitted for acute burn care in logbooks since 2005. This study aimed to assess the data registered between January 2005 and December 2019, to evaluate the extent of missing data, and to identify possible factors associated with “missingness”. All data were analyzed using descriptive statistics, Fisher’s exact test, and Wilcoxon Rank Sum test. In this study, 1,093 acute burn patients were included and 64.2% of them had incomplete data. Data completeness improved significantly over time. The most commonly missing variables were whether the patient was referred from another facility and information regarding whether any surgical intervention was performed. Missing data on burn mechanism, burn degree, and surgical treatment were associated with in-hospital mortality. In conclusion, missing data is frequent for acute burn patients in Rwanda, although improvements have been seen over time. As Rwanda and other low- and middle-income countries strive to improve burn care, ensuring data completeness will be essential for the ability to accurately assess the quality of care, and hence improve it.


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231. An antibiotic stewardship program in a surgical ICU of a resource-limited country: financial impact with improved clinical outcomes

Journal of Pharmaceutical Policy and Practice


Authors: Kashif Hussain, Muhammad Faisal Khan, Gul Ambreen, Syed Shamim Raza, Seema Irfan, Kiren Habib, and Hasnain Zafar
Region / country: Southern Asia – Pakistan
Speciality: Emergency surgery, General surgery

Background
Antibiotic resistance (ABX-R) is alarming in lower/middle-income countries (LMICs). Nonadherence to antibiotic guidelines and inappropriate prescribing are significant contributing factors to ABX-R. This study determined the clinical and economic impacts of antibiotic stewardship program (ASP) in surgical intensive care units (SICU) of LMIC.

Method
We conducted this pre and post-test analysis in adult SICU of Aga Khan University Hospital, Pakistan, and compared pre-ASP (September–December 2017) and post-ASP data (April–July 2018). January–March 2018 as an implementation/training phase, for designing standard operating procedures and training the team. We enrolled all the patients admitted to adult SICU and prescribed any antibiotic. ASP-team daily reviewed antibiotics prescription for its appropriateness. Through prospective-audit and feedback-mechanism changes were made and recorded. Outcome measures included antibiotic defined daily dose (DDDs)/1000 patient-days, prescription appropriateness, antibiotic duration, readmission, mortality, and cost-effectiveness.

Result
123 and 125 patients were enrolled in pre-ASP and post-ASP periods. DDDs/1000 patient-days of all the antibiotics reduced in the post-ASP period, ceftriaxone, cefazolin, metronidazole, piperacillin/tazobactam, and vancomycin showed statistically significant (p < 0.01) reduction. The duration of all antibiotics use reduced significantly (p < 0.01). Length of SICU stays, mortality, and readmission reduced in the post-ASP period. ID-pharmacist interventions and source-control-documentation were observed in 62% and 50% cases respectively. Guidelines adherence improved significantly (p < 0.01). Net cost saving is 6360US$ yearly, mainly through reduced antibiotics consumption, around US$ 18,000 (PKR 2.8 million) yearly.

Conclusion
ASP implementation with supplemental efforts can improve the appropriateness of antibiotic prescriptions and the optimum duration of use. The approach is cost-effective mainly due to the reduced cost of antibiotics with rational use. Better source-control-documentation may further minimize the ABX-R in SICU.


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232. Exploring the factors motivating continued Lay First Responder participation in Uganda: a mixed-methods, 3-year follow-up

Emergency Medicine Journal


Authors: Peter G Delaney, Zachary J Eisner, T Scott Blackwell, Ibrahim Ssekalo, Rauben Kazungu, Yang Jae Lee, John W Scott, Krishnan Raghavendran
Region / country: Eastern Africa – Uganda
Speciality: Emergency surgery, Trauma and orthopaedic surgery, Trauma surgery

Background The WHO recommends training lay first responders (LFRs) as the first step towards establishing emergency medical services (EMS) in low-income and middle-income countries. Understanding social and financial benefits associated with responder involvement is essential for LFR programme continuity and may inform sustainable development.

Methods A mixed-methods follow-up study was conducted in July 2019 with 239 motorcycle taxi drivers, including 115 (75%) of 154 initial participants in a Ugandan LFR course from July 2016, to evaluate LFR training on participants. Semi-structured interviews and surveys were administered to samples of initial participants to assess social and economic implications of training, and non-trained motorcycle taxi drivers to gauge interest in LFR training. Themes were determined on a per-question basis and coded by extracting keywords from each response until thematic saturation was achieved.

Results Three years post-course, initial participants reported new knowledge and skills, the ability to help others, and confidence gain as the main benefits motivating continued programme involvement. Participant outlook was unanimously positive and 96.5% (111/115) of initial participants surveyed used skills since training. Many reported sensing an identity change, now identifying as first responders in addition to motorcycle taxi drivers. Drivers reported they believe this led to greater respect from the Ugandan public and a prevailing belief that they are responsible transportation providers, increasing subsequent customer acquisition. Motorcycle taxi drivers who participated in the course reported a median weekly income value that is 24.39% higher than non-trained motorcycle taxi counterparts (p<0.0001).

Conclusions A simultaneous delivery of sustained social and perceived financial benefits to LFRs are likely to motivate continued voluntary participation. These benefits appear to be a potential mechanism that may be leveraged to contribute to the sustainability of future LFR programmes to deliver basic prehospital emergency care in resource-limited settings.


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

Indian Journal of Surgery


Authors: Vikesh Agrawal, Dhananjaya Sharma & Sanjay Kumar Yadav
Region / country: South-eastern Asia – India
Speciality: Health policy

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.


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234. Epidemiological characteristics of child injury in a tertiary paediatric surgical centre in Bangladesh

Asian Journal of Medical and Biological Research


Authors: Tanvir Kabir Chowdhury, Ayesha Sadia, Rumana Khan, Abida Farjana, Efat Sharmin, Kafil Hasan, Fatima Farhana Rini, Md Abdullah Al Farooq
Region / country: South-eastern Asia – Bangladesh
Speciality: Paediatric surgery, Trauma and orthopaedic surgery, Trauma surgery

While high income countries (HICs) have reduced the mortality from child injury, it is increasing in the low- and middle-income countries (LMICs). However, injury registry and reporting are inconsistent and not well developed in the LMICs. This study aims at describing the epidemiology of child injury in a tertiary paediatric surgical centre in Bangladesh. We retrospectively analysed all patients of injury between 0 and 12 years of age admitted in the Department of Paediatric Surgery, Chattogram Medical College Hospital during January 2017 to June 2020. Analysis was done for the hospital prevalence, age and sex distribution, seasonal variations, mechanism of injury, site of involvement, and mortality from injury. There were a total of 538 patients and male to female ratio was 2.01:1. Hospital prevalence was 6.71%. Mean age was 6.60 ± 3.32 years. School age children were affected more (51.7%); and “6-10 years” age group had the highest number injuries (251 patients, 46.65%). The most common mechanisms of injuries were road-traffic accident (RTA, 35.32%), followed by fall (26.39%) and „stab or cut injury‟ (20.63%). Males experienced more abdominal injuries and females had more perineal injuries (P=0.00). RTA was the commonest mechanism in males (37.05%) and falls were the commonest mechanism in females (32.96%). „Stab or cut injury‟ was the commonest mechanism in infants and toddlers, and RTA was commonest among pre-school and school age children. There were no significant seasonal variations (P=0.09). There were 5.76% intentional injuries. Mortality was 2.60% and major causes of mortality were RTA and animal assaults. Injuries were more prevalent during the mid-childhood with an overall increasing trend with age. Mechanism of injury and site of involvement were different among different age groups and between sexes.


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235. Global Surgery: The Perspective of Public Health Students

Global Journal of Health Science


Authors: Brittany A, Hout Eric P, Matthews Jan-Michael Van Gent
Region / country: Northern America – United States of America
Speciality: Other

Current research has emphasized the importance of increased involvement of medical professionals and global health specialists for the success of global surgery efforts. This quantitative descriptive study aimed to examine public health students’ perceptions of global surgery. A 21- question mixed method online survey was distributed over eight weeks via student email to all students enrolled in the Masters of Public Health Program at A.T. Still University (ATSU) College of Graduate Health Studies. Of 212 students, 35 (16.5%) respondents completed the survey with 30 students reporting interest in global health in their future public health careers. Two-thirds of students erroneously identified infectious diseases as the leading cause of death worldwide, not traumatic injury. Participants identified infectious disease and OB/GYN as the two medical fields to contribute significantly to global health. Surgical care was felt to be the least economically cost-effective medical field for low and middle-income countries (LMICs). As the first project to report perspectives of public health students regarding global surgery, this study highlighted several significant misconceptions concerning global surgery. Like the results from similar studies in medical students, it is alarming that there is such a paucity of community health knowledge surrounding surgery and its effects on global surgical needs. Further research should focus on the effect on student perceptions after curriculum modification include education regarding the burden of surgical disease and role of global surgery.


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236. Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process

JCO Global Oncology


Authors: Lydia E. Pace, Lauren E. Schleimer , Cyprien Shyirambere, André Ilbawi, Jean Marie Vianney Dusengimana, Jean Bosco Bigirimana, Francois Regis Uwizeye, Mary Chamberlin , Yeonsoo Sara Lee, Lawrence N. Shulman, Susan Troyan, Benjamin O. Anderson, Catherine Duggan, Daniel S. O’Neil, Allison Dvaladze, Jane Brock , Cam Nguyen, Deogratias Ruhangaza, Olivier Habimana, Nicaise Nsabimana, John Butonzi, Eugene Nkusi, Tharcisse Mpunga
Region / country: Central Asia, Eastern Africa – Rwanda
Speciality: General surgery, Surgical oncology

PURPOSE
The burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings.

METHODS
To identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda.

RESULTS
Our systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda.

CONCLUSION
A modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.


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237. Road Traffic Accident Research in India: A Scientometric Study from 1977 to 2020

DigitalCommons@University of Nebraska


Authors: Jayaprakash G. Hugar, Mirza Muhammad Naseer, Abu Waris, Muhammad Ajmal Khan
Region / country: Southern Asia – India
Speciality: Emergency surgery, Trauma and orthopaedic surgery, Trauma surgery

This study carried out the scientometric analysis of road traffic accident research in India from 1977 to 2020. It aimed to examine type of publications with their citations and usage, the year wise publication and citation growth, most preferred journals, authors’ preference of keywords used, collaboration of Indian authors, authorship pattern and most prolific authors, and top contributing organizations. During 44 years of study, 1,132 research items were published and indexed in Web of Science (WoS) bibliographic database. Analysis discovered that number of publications increased from one (0.08%) in 1977 to 182 (16.07%) in 2018 and observed good progress in scholarly literature.

Majority of scholarly publications were published in the form of article (740, 65.37%). From 2006 to 2018, number of publications increased rapidly from 11 (0.97%) to 182 (16.07%) publications, which was the most productive year for the researchers. On an average 25.73 documents were published per year and received 392.95 citations per year. Journal of Evaluation of Medical and Dental Sciences published majority of the publications (108, 30.50%). The word “Trauma” was the most frequently used keyword. Majority of publications (83.38%) on road traffic accidents (RTA) were written by the Indian authors individually or with local collaboration. Majority of the publications (1,081, 95.49%) were written by multiple authors while 51 publications (4.51%) were from single author. Most prolific authors were Tiwari, G. and Mohan, D. with 18 publications each. The Indian Institute of Technology was highly contributing organization, which published 120 documents (10.60%).


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238. Decompressive Craniectomy in Traumatic Brain Injury: An Institutional Experience of 131 Cases in Two Years

Neurotrauma Reports


Authors: Ana Cristina Veiga Silva, Matheus Araújo de Oliveira Farias, Luiz Severo Bem Jr., Marcelo Moraes Valença, and Hildo Rocha Cirne de Azevedo Filho
Region / country: South America – Brazil
Speciality: Emergency surgery, Neurosurgery, Trauma surgery

Decompressive craniectomy (DC) effectively reduces intracranial pressure (ICP), but is not considered to be a first-line procedure. We retrospectively analyzed sociodemographic, clinical, and surgical characteristics associated with the prognosis of patients who underwent DC to treat traumatic intracranial hypertension (ICH) at the Restauração Hospital (HR) in Recife, Brazil between 2015 and 2016, and compared the clinical features with surgical timing and functional outcome at discharge. The data were collected from 131 medical records in the hospital database. A significant majority of the patients were young adults (age 18-39 years old; 75/131; 57.3%) and male (118/131; 90.1%). Road traffic accidents, particularly those involving motorcycles (57/131; 44.5%), were the main cause of the traumatic event. At initial evaluation, 63 patients (48.8%) were classified with severe traumatic brain injury (TBI). Pupil examination showed no abnormalities for 91 patients (71.1%), and acute subdural hematoma was the most frequently observed lesion (83/212; 40%). Glasgow Outcome Scale (GOS) score was used to categorize surgical results and 51 patients (38.9%) had an unfavorable outcome. Only the Glasgow Coma Scale (GCS) score on admission (score of 3-8) was more likely to be associated with unfavorable outcome (p-value = 0.009), indicating that this variable may be a determinant of mortality and prognostic of poor outcome. Patients who underwent an operation sooner after injury, despite having a worse condition on admission, presented with clinical results that were similar to those of patients who underwent surgery 12 h after hospital admission. These results emphasize the importance of early DC for management of severe TBI. This study shows that DC is a common procedure used to manage TBI patients at HR.


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239. Real-world Treatment Patterns of Lung Cancerexperience of Resource Restricted Country

Research Square


Authors: Ivane Kiladze, Elene Mariamidze, Branislav Jeremic
Region / country: Eastern Europe, Western Asia – Georgia
Speciality: Cardiothoracic surgery, Surgical oncology

Background:

Lung cancer (LC) continues to be a significant worldwide public health issue. In recent years there have been several publications addressing specifics of LC worldwide, but none concerning Georgia- country with high number of smoking population and LC cases. We conducted the first study in Georgian population, that aims current LC practice.

Methods:

The aim of the study was to provide an overview of treatment of LC, with discussion situation in this field and indicating the future strategies for improved cancer care in the country. Medical, radiation and surgical oncologists providing treatment of LC in main hospitals (n=13) over the country, filled questionnaire that addressed specific information regarding the treatment aspects of LC reflecting current surgical aspects, systemic treatment and radiotherapy (RT).

Results

There is no national screening program, while radiologic imaging is readily available. The vast majority of patients in the country present with advanced stages at diagnosis and they are treated with systemic therapy and/or RT.

The surgical treatment is largely underutilized with the differences being observed among surgeons on the optimal timing and the extent of surgery, as well as role of surgery in specific clinical situations.

Improved health care system, well equipped hospitals, availability of many anticancer drugs and existence of modern RT technology, are coupled with slow appearance of country-adapted guidelines and protocols as well as enforcing MDT meetings.

There is limited access to expensive novel agents, psychological support and high quality palliative care.

Conclusions

There is still much work to be done, with all above steps considered mandatory to improve effectiveness and quality of care of LC patients.


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240. Case series of hyena bite injuries and their surgical management in a resource-limited setup: 1-year experience

Journal of Surgical Case Reports


Authors: Metasebia W Abebe, Tezazu Tefera, Mengistu G Mengesha, Mulualem W Mengesha, Sisay Teshome
Region / country: Eastern Africa – Ethiopia
Speciality: Emergency surgery, Trauma and orthopaedic surgery, Trauma surgery

Animal bites are a significant cause of morbidity and mortality and pose a major public health problem worldwide. Children are reportedly the most common victims of animal bites. Bites may be limited to superficial tissues or lead to extensive disfiguring injuries, fractures, infections and rarely result in death. Recently, human injuries caused by non-domesticated animals are increasingly common as ecosystems change and humans encroach on previously wild land. Wild animals like hyenas have been reported to prey on humans and cattle in parts of Africa. Discussed here are four children out of 11 patients that presented with hyena bites-the children had severe bites to the face and head with extensive soft tissue loss, fractures and concomitant severe infections that led to high mortality, indicating the necessity for advanced intensive care and multidisciplinary treatment needed in such situations.


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241. Anal high-grade and late-stage cancer management in low-income setting: a case report

Journal of Surgical Case Reports


Authors: Anna Claudia Colangelo, Damiano Pizzol, Mario Antunes
Region / country: Northern Africa – Sudan
Speciality: Surgical oncology

The burden of cancer is increasing in sub-Saharan Africa due to ageing, common risk factors and population growth. Anal cancer is a human papillomavirus-related rare disease with an incidence rate of 1.8 per 100 000 persons overall with an increasing incidence of by 2% per year in the last three decades. Despite that gold standard management is well described, in low-income countries, there is no possibility for a proper management. We presented a late-stage anal cancer case that reflects the urgent necessity to create the adequate condition for the development of effective oncologic approach including prevention, diagnosis and management.


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242. Benefits and Barriers to Increasing Regional Anesthesia in Resource-Limited Settings

Local and Regional Anesthesia


Authors: Lena Ebba Dohlman, Andrew Kwikiriza, Odinakachukwu Ehie
Region / country: Global
Speciality: Anaesthesia, Health policy, Surgical Education

Safe and accessible surgical and anesthetic care is critically limited for over half of the world’s population, particularly in Sub-Saharan African and Southeast Asian countries. Increasing the use of regional anesthesia in these areas has potential benefits regarding access, safety, and cost-effectiveness. Perioperative anesthesia-related mortality is significantly higher in resource-limited countries and every effort should be made to encourage the use of anesthetic techniques in these countries that are safest under the present conditions. Studies from Sub-Saharan Africa, although limited in number, have shown a lower risk of death with regional compared to general anesthesia. Regional anesthesia has the further benefit of decreasing the risk of COVID-19 spread to healthcare providers by avoiding the aerosol-generating procedures that occur during general anesthesia. Neuraxial regional anesthesia is relatively easy to teach and perform and is considered the anesthetic of choice for surgeries below the umbilicus in resource-limited settings due to its safety, efficacy, and low cost. Although regional anesthesia has multiple potential advantages, education and training of anesthetic providers in low-and-middle-income countries (LMIC) are a significant barrier to growth. Anesthesia professionals, especially in Sub-Saharan Africa, are often poorly supported and undervalued, and recruitment and retention of adequate numbers of trained practitioners are a continuing problem. Greater use of regional anesthesia could be one way to safely increase anesthesia access and simultaneously create value and enthusiasm for the field. Deficits in anesthesia infrastructure, equipment, and drugs also limit anesthesia capacity in low-and middle-income countries. Ultrasound-guided regional anesthesia may be helpful in improving access to safe and reliable anesthesia in low-resource countries as it continues to become more user-friendly, durable, and affordable.


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243. Quality indicators for the diagnosis and surgical management of breast cancer in South Africa

Breast


Authors: Sarah Nietz, Paul Ruff, Wenlong Carl Chen, Daniel S O’Neil, Shane A Norris
Region / country: Southern Africa – South Africa
Speciality: Surgical oncology

Introduction: Quality indicators (QIs) for breast cancer care have been developed and applied in high-income countries and contributed to improved quality of care and patient outcomes over time.

Materials and methods: A modified Delphi process was used to derive expert consensus. Potential QIs were rated by a panel of 17 breast cancer experts from various subspecialties and across South African provinces. Each QI was rated according to importance to measure, scientific acceptability and feasibility. Scoring ranged from 1 (no agreement) to 5 (strong agreement). Inclusion thresholds were set a priori at mean ratings ≥4 with a coefficient variation of ≥25%. Levels of evidence were determined for each indicator.

Results: The literature review identified 790 potential QIs. After categorisation and removal of duplicates, 52 remained for panel review. There was strong consensus for 47 which were merged to 30 QIs by exclusion of similar indicators and indicator grouping. The final set included eight QIs with level I or II evidence and two QIs with level III evidence which were deemed “mandatory” due to clinical priority and impact on care. The remaining QIs with lower-level evidence were grouped as eight “recommended” QIs (regarded as standard of care) and twelve “optional” QIs (not regarded as standard of care).

Conclusion: A regional set of QIs was developed to facilitate standardised treatment and auditing of surgical care for breast cancer patients in South Africa. Routine monitoring of the ten mandatory QIs, which were selected to have the most substantial impact on patient outcome, is proposed.


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244. Delayed presentation of subaxial cervical spine dislocations: A retrospective review of 14 cases managed at a specialist spinal surgery unit in Durban, South Africa

East and Central African Journal of Surgery


Authors: Anand Balasubramanian, Govender Shanmugam
Region / country: Southern Africa – South Africa
Speciality: Emergency surgery, Neurosurgery, Trauma and orthopaedic surgery, Trauma surgery

Background: The subaxial cervical spine is the most commonly injured region of the spinal column and these injuries are frequently missed. The objective of this case series (n=14) was to highlight the issues encountered with delayed presentation (> 2 weeks) of sub axial cervical spine dislocations/fracture dislocations and the outcomes following surgical management of these injuries.

Methods: We analyzed 14 adults with 9 unifacet and 5 bifacet dislocations who presented after a mean delay of 27.3 days. Demographic profile, mechanism of injury, reasons for delayed presentation, pre-operative imaging studies, clinical presentation, surgical management, complications and outcomes were analyzed. A literature review was also undertaken to assess the incidence, etiology and outcomes associated with these injuries and highlight methods available for appropriate screening of the cervical spine in an attempt to mitigate delays.

Results: Pre-operative reduction with skull traction was unsuccessful in 3 out of 5 bifacet dislocations while all but one unifacet dislocations were reduced successfully. All injuries were managed operatively with anterior cervical discectomy and fusion (ACDF) with instrumentation.

Posterior release prior to anterior discectomy and fusion were performed in 3 patients where dislocations were irreducible pre-operatively. Neurological improvement was seen in 9 patients.

Conclusions: A favorable outcome can be expected following surgery for delayed presentation of sub axial cervical spine injuries, especially in the resource limited, low- and middle-income countries (LMICs).


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245. Functional Neurosurgery in Africa: A Scoping Review

AfricaArXiv Preprints


Authors: Nathalie Christelle Ghomsi, Aminata Yandeh Sallah, Kantenga Dieu MerciKabulo, Ulrick Sidney Kanmounye, Crescencia Mashauri, Stephane Nguembu,Abdullahi Jimoh
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Neurosurgery

Functional neurosurgery covers a set of neurosurgical techniques that aims at restoring functional neurologic disorders. In Africa, less data is available to map out this activity, though the increased prevalence of diseases such as epilepsy or Parkinson’s disease, which results in a high morbidity and mortality rate. However, functional neurosurgery remains very scarce and costly in these countries, hence difficult to implement. A scoping review will be performed to map functional neurosurgery activities in Africa. The Arksey and O’Malley’s scoping review methodology will be used to collect data, and a PRISMA chart used to follow-up data.


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246. Gasless Laparoscopic Surgery for Minimally Invasive Surgery in Low-Resource Settings: Methods for Evaluating Surgical Field of View and Abdominal Wall Lift Force

Surgical Innovation


Authors: William S Bolton, Noel K. Aruparayil, Manish Chauhan, William R. Kitchen, Kevin J. N. Gnanaraj, Alice M. Benton, Sophie E. Hutchinson, Joshua R. Burke, Jesudian Gnanaraj, David G. Jayne, and Peter R. Culmer
Region / country: Global
Speciality: General surgery

Laparoscopic surgery has advantages over open surgery for several abdominal conditions due to improved short-term outcomes. Performing laparoscopic surgery in many low and middle-income country (LMIC) settings is restricted by the lack of general anaesthesia (GA) and carbon dioxide (CO2) insufflation. Gasless laparoscopic surgery employs the use of a mechanical anterior abdominal wall lift device to create internal space within the abdomen. This negates the need for GA and CO2 which may help increase adoption of laparoscopic surgery in LMIC settings.

The safety and efficacy of gasless techniques appear to be non-inferior when compared to conventional laparoscopic surgery for many gastrointestinal and gynaecological conditions.3 However, concerns from surgeons before adopting this technique are operative field of view and safety concerns including damage to the abdominal wall during the lift.3 Many lift devices produce a tenting effect, creating an angular cavity that can restrict view. Monitoring to ensure a ‘safe’ force is applied is also essential, as lifting the abdominal wall carries the potential for trauma if too much force is applied. Our aim was to develop methods that may be used in future clinical studies aimed at mitigating these concerns by assessing field of view and force exerted on tissues during gasless lift procedures.


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247. Changing the face of global health: short-term surgical trips

ENT and Audiology News


Authors: Samuel N Okerosi, Joyce Aswani, Charles M Gathiru, James Netterville
Region / country: Eastern Africa – Kenya
Speciality: ENT surgery

With the growth of global health awareness, global surgery has emerged as a key focus area. This article examines short-term surgical trips (STSTs) as one of the ways used to address some of the gaps in global surgery. It demonstrates the Kenyan experience in organising and participating in a short-term surgical trip with a 10-year history. Their experience has been that STSTs should be co-organised between the regional hosting surgeons and the visiting surgical team, with an emphasis on education rather that the ‘number of surgeries’ performed during each camp.


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248. Occurrence, associated risk factors, and treatment of surgical site infections in Pakistan

European Journal of Inflammation


Authors: Faiz Ullah Khan,Yu Fang, Zakir Khan, Farman Ullah Khan, Zafar Iqbal Malik, Naveed Ahmed, Amir Hayat Khan, Asim.ur.Rehman
Region / country: Southern Asia – Pakistan
Speciality: General surgery, Urology surgery

Globally, surgical site infections are one of the common infections which lead to a large amount of mortality and morbidity in postsurgical care. The risk for surgical site infection is multidimensional which includes mainly; patient, surgery, and hospital-related factors. This study is aimed to determine the burden of SSIs along with contributed risk factors. A prospective observational cross-sectional study was conducted in one of the largest public-sector hospitals in Pakistan. A total of 412 patients were recruited in the study with full consent and monitored for 30 days after surgery with direct and indirect surveillance. Overall, in seven different surgical procedures the incidence (29.8%) rate of SSI was observed; in appendectomy (n = 17, 4.1%), exploratory laparotomy (n = 51, 12.6%), laparoscopic cholecystectomy (n = 12, 2.90%), mesh repair (n = 17, 4.01%), thyroidectomy (5, 1.2%), transurethral resection of the prostate (n = 11, 2.6%), and transurethral resection of the bladder (10, 2.4%). The average SSI rate in every single procedure was about 18 (4.27%) per surgical procedure out of 123 (29.85%) SSI cases. Types of SSI identified were superficial, deep incisional and organ/space (n = 76, 18.4%, n = 23, 5.5%, and n = 24, 5.7%). Incidence of SSIs during admission, at readmission, and post-surveillance cases were (n = 50, 12.1%, n = 25, 6.0% and n = 48, 11.6%). Associated risk factors found contributed to the incidence of SSI (p < 0.05). Pre-operative (n = 348, 84.5%) and 6 (1.5%) surgical patients did not received the post-operative antibiotics. The P. aeruginosa (n = 15, 12.1%) and S. aureus (13, 10.5%). Cefoperazone and sulbactam were the most prescribed antibiotics. Associated risk factors and treatment outcomes of surgical patients have a direct association with the incidence of SSI. Hospital-based antimicrobial stewardship, implementation of surgical guidelines, patient care, and education are needed to develop at wards level in hospitals.


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249. Safe Laparoscopy in Low and Middle Income Countries by reducing Surgical Site Infections through Laparoscopic Instrument Cleaning

TUDelft


Authors: Girish Malage
Region / country: Southern Asia – India
Speciality: General surgery

Access to safe and affordable surgery is nothing short of a basic human right and people from all walks of life are entitled to it. But, five people from resource-constrained low and middle-income countries are vulnerable and left to fend for themselves when the need for surgery is a life governing event. Inhabitants of these regions are scourged by high mortality and morbidity due to surgical infection caused by the use of unclean and unsterile surgical instruments. Reduction in infections can be achieved by using clean and sterile surgical instruments. Laparoscopy, is a promising technique of surgery developed to efficiently perform complex abdominal surgeries with the use of small and minimum incisions on the patient. Laparoscopy’s minimally invasive nature allows complex surgeries to take place without the need of an absolutely sterile operating room, although the sterility of the surgical instruments cannot be compromised. The added benefit of faster recovery from smaller wounds makes it even more desirable for this context. The Minimally Invasive Surgery and Interventional Techniques Lab of the TU Delft has initiated projects addressing the health and well-being of resource-constrained, underdeveloped communities like rural India through frugal innovation. Rural Indian hospitals are grossly underfunded, under-maintained, and understaffed. Sterile processing practices in rural India are rudimentary compared to high-income hospitals like the ones in the Netherlands. In high-income hospitals, all used surgical instruments are cleaned and sterilized in dedicated central sterile processing departments (CSSD) by highly trained and well protected sterile processing technicians. However, rural India usually employs small teams of local undertrained and semi-literate nurses to carry out every primary and ancillary duty in the hospital. The lack of dedicated CSSDs exacerbates the nurse’s workload and exposure to harmful pathogenic surgical instruments. Laparoscopic instruments developed in high-income nations are seldom designed keeping low resource contexts in mind. The geometrical complexity of instruments keeps increasing but cleaning methods in rural India have stagnated. Resource constraints are a major reason as to why proper international and national guidelines for reprocessing cannot be followed. Hence hospitals cannot guarantee 100% safe and sterile instruments as compared so standardized outcomes in high-income hospitals. In this graduation project, the distinct reprocessing journey of surgical instruments for the two diverse economic contexts were studied. A comparative analysis of both reprocessing journeys uncovered severe unsafe and unfavorable practices in rural India. Significant data and insights from the research have hence paved the way for focusing on the “Cleaning” stage of the laparoscopic instrument reprocessing journey in rural India. This MSc graduation project aims at designing a frugal solution for cleaning and repurposing laparoscopic instruments, dedicated to hospitals in rural India where the demand for laparoscopy is high but surgeries are less due to resource constraints like lack of laparoscopic instruments and repurposing devices. The involvement of an Indian nurse and laparoscopic surgeon provided first-hand information about the problems and requirements in the rural Indian context. Prototyping and testing of various cleaning setups were conducted to extract the most viable design solution. Insights from the research and testing were combined into the concept design of a frugal mechanical washer and subsequently an “Envisioned Reprocessing Journey” for rural Indian hospitals to suggest a standard protocol for keeping most of their existing infrastructure in mind. Evaluations with the Indian nurse revealed that this device could indeed be a game-changer to the existing practices of reprocessing laparoscopic instruments in rural India.


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250. Surgical Site Infections and Prophylaxis Antibiotic Use in the Surgical Ward of Public Hospital in Western Ethiopia: A Hospital-Based Retrospective Cross-Sectional Study

Infection and Drug Resistance


Authors: Belayneh Kefale, Gobezie T Tegegne, Amsalu Degu, Mulugeta Molla, and Yitayih Kefale
Region / country: Eastern Africa – Ethiopia
Speciality: General surgery

Objective
Surgical site infection (SSI) is one of the leading causes of hospital-acquired infection among hospitalized patients. It causes significant health problems and results in an extended length of hospital stay, increased cost, and increased patient morbidity and mortality. To prevent the development of SSI, surgical antibiotic prophylaxis (SAP) administration before surgery is an evidence-based practice. Therefore, this study aimed to assess the prevalence of SSIs and surgical antibiotic prophylaxis practice, and identifying the gap in practicing prophylactic surgical antibiotic use.

Methods
A retrospective cross-sectional study design was conducted on randomly selected 281 participants who fulfilled the inclusion criteria. Appropriateness of surgical antibiotic prophylaxis was assessed by clinical pharmacists based on the standard treatment guideline. Descriptive and multivariate logistic regression analyses were performed in SPSS version 25. Statistical significance was set at p <0.05.

Results
The overall prevalence of SSI was 19.6% (95% CI: 19–20.2). Majority of surgical patients (88.6%) got surgical antibiotic prophylaxis. Ceftriaxone and metronidazole (45.4%), and ceftriaxone (33.3%) were the most frequently used prophylactic antibiotics. Presence of comorbidity (AOR=9.18, 95% CI: 5.17–17.9, p<0.001), contaminated (AOR=6.01, 95% CI: 1.77–16.8, p=0.019) and dirty (AOR=7.20, 95% CI: 1.23–12.1, p=0.029) wound classes, devoid of prophylactic antibiotics (AOR=6.63, 95% CI: 0.89–19.3, p=0.006), the timing of prophylactic antibiotic administration between 1 hour and 2 hours before incision (AOR=8.2, 95% CI: 4.34–18.1, p=0.001), and 48 hours duration of surgical antimicrobial prophylaxis (AOR=7.20, 95% CI: 1.23–28.17, p=0.027) were significantly associated with the development of SSIs.

Conclusion
The prevalence of SSI was relatively high despite most surgical patients were given prophylactic antibiotics. The presence of comorbidity, contaminated and dirty wound classes, devoid of prophylactic antibiotics, administering prophylactic antibiotics between 1 hour and 2 hours before incision, and 48 hours duration of surgical antibiotic prophylaxis were significantly associated with SSIs.


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251. Self-reported confidence and perceived training needs of surgical interns at a regional hospital in Ghana: a questionnaire survey

BMC Medical Education


Authors: Mee Joo Kang 1 2, Reuben Kwesi Sakyi Ngissah
Region / country: Western Africa – Ghana
Speciality: Surgical Education

Background
Due to disparities in their regional distribution of the surgical specialists, those who have finished “housemanship,” which is the equivalent of an internship, are serving as main surgical care providers in rural areas in Ghana. However, the quantitative volume of postgraduate surgical training experience and the level of self-reported confidence after formal training have not been investigated in detail in sub-Saharan Africa.

Methods
The quality-assessment data of the Department of surgery at a regional hospital in Ghana was obtained from the convenience samples of house officers (HOs) who had their surgical rotation before July 2019. A self-reported questionnaire with 5-point Likert-type scale and open-ended responses regarding the 35 topics listed as learning objectives by the Medical and Dental Council of Ghana were retrospectively reviewed to investigate the volume of surgical experience, self-reported confidence, and perceived training needs.

Results
Among 52 respondents, the median self-reported number of patients experienced for each condition was less than 11 cases. More than 40% of HOs reported that they had never experienced cases of liver tumor (n = 21, 40.4%), portal hypertension (n = 23, 44.2%), or cancer chemotherapy/cancer therapy (n = 26, 50.0%). The median self-confidence score was 3.69 (interquartile range, 3.04 ~ 4.08). More than 50% of HOs scored ≤2 points on the self-confidence scale of gastric cancer (n = 28, 53.8%), colorectal cancer (n = 31, 59.6%), liver tumors (n = 32, 61.5%), and cancer chemotherapy/cancer therapy (n = 38, 73.1%). The top 3 reasons for not feeling confident were the limited number of patients (n = 42, 80.8%), resources and infrastructure (n = 21, 40.4%), and amount of supervision (n = 18, 34.6%). Eighteen HOs (34.6%) rated their confidence in their surgical skills as ≤2 points. Of all respondents, 76.9% (n = 40) were satisfied with their surgical rotation and 84.6% (n = 44) perceived the surgical rotation as relevant to their future work. Improved basic surgical skills training (n = 27, 51.9%) and improved supervision (n = 18, 34.6%) were suggested as a means to improve surgical rotation.

Conclusions
Surgical rotation during housemanship (internship) should be improved in terms of cancer treatment, surgical skills, and supervision to improve the quality of training, which is closely related to the quality of surgical care in rural areas.


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252. Radiological staging of rectal cancer in a resource limited setting

BMC Research Notes


Authors: Naradha Lokuhetty, Suranjith L. Seneviratne, Fathima Asma Rahman, Thanushka Marapana, Roshan Niloofa, and Ishan De Zoysa
Region / country: Southern Asia – Sri Lanka
Speciality: General surgery, Surgical oncology

Objective
Current guidelines on rectal cancer (RC) management recommend pre-operative MRI for loco-regional staging and CT for staging of metastases. This allows appropriate selection of patients for chemo-radiotherapy (CRT). However, MRI is not freely available in many low-income countries. We assessed the status of pre-operative imaging for RC in Sri Lanka and evaluated the performance of CT in RC staging.

Results
A pre-tested interview-administered questionnaire was used to assess the pre-operative use of MRI and CT in RC. CT findings from 37 RC patients were then compared with histopathology findings. Of the 64 surgeons interviewed, 57 (89.1%) did not request an MRI for their RC patients. Reasons cited included limited availability and long waiting times due to competing health needs. A CT was requested by all. In RC, the overall accuracy of CT for T staging was 43.2% and 29.7% of T1–T2 tumours were over-staged as T3. The overall accuracy of CT for regional lymph node staging was 70.3%. In summary, CT alone is not suitable for RC staging in any setting. It leads to over-staging and patients may thus receive unnecessary CRT. Steps must be taken to improve access to pre-operative MRI among Sri Lankan RC patients.


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253. The role of medical equipment in the spread of nosocomial infections: a cross-sectional study in four tertiary public health facilities in Uganda

BMC Public Health


Authors: Robert T. Ssekitoleko, Solomon Oshabaheebwa, Ian G. Munabi, Martha S. Tusabe, C. Namayega, Beryl A. Ngabirano, Brian Matovu, Julius Mugaga, William M. Reichert & Moses L. Joloba
Region / country: Eastern Africa – Uganda
Speciality: Anaesthesia, Health policy

Background
With many medical equipment in hospitals coming in direct contact with healthcare workers, patients, technicians, cleaners and sometimes care givers, it is important to pay close attention to their capacity in harboring potentially harmful pathogens. The goal of this study was to assess the role that medical equipment may potentially play in hospital acquired infections in four public health facilities in Uganda.

Methods
A cross-sectional study was conducted from December 2017 to January 2018 in four public health facilities in Uganda. Each piece of equipment from the neonatal department, imaging department or operating theatre were swabbed at three distinct points: a location in contact with the patient, a location in contact with the user, and a remote location unlikely to be contacted by either the patient or the user. The swabs were analyzed for bacterial growth using standard microbiological methods. Seventeen bacterial isolates were randomly selected and tested for susceptibility/resistance to common antibiotics. The data collected analyzed in STATA version 14.

Results
A total of 192 locations on 65 equipment were swabbed, with 60.4% of these locations testing positive (116/192). Nearly nine of ten equipment (57/65) tested positive for contamination in at least one location, and two out of three equipment (67.7%) tested positive in two or more locations. Of the 116 contaminated locations 52.6% were positive for Bacillus Species, 14.7% were positive for coagulase negative staphylococcus, 12.9% (15/116) were positive for E. coli, while all other bacterial species had a pooled prevalence of 19.8%. Interestingly, 55% of the remote locations were contaminated compared to 66% of the user contacted locations and 60% of the patient contacted locations. Further, 5/17 samples were resistant to at least three of the classes of antibiotics tested including penicillin, glycylcycline, tetracycline, trimethoprim sulfamethoxazole and urinary anti-infectives.

Conclusion
These results provides strong support for strengthening overall disinfection/sterilization practices around medical equipment use in public health facilities in Uganda. There’s also need for further research to make a direct link to the bacterial isolates identified and cases of infections recorded among patients in similar settings.


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254. Patient and Economic Burden of Presbyopia: A Systematic Literature Review

Clinical Ophthalmology


Authors: John Berdahl , Chandra Bala , Mukesh Dhariwal , Jessie Lemp-Hull , Divyesh Thakker , Shantanu Jawla
Region / country: Global
Speciality: Ophthalmology

Purpose: The objective of this systematic literature review (SLR) was to collate, report, and critique published evidence related to epidemiology and patient and economic burden of presbyopia.

Patients and methods: A systematic literature search was conducted in MEDLINE®, Embase®, and Cochrane Library databases from the time of inception through October 2018 using Cochrane methodology. Studies published in English language reporting on epidemiology and patient and economic burden of presbyopia were included.

Results: Initial systematic literature search yielded 2,228 citations, of which 55 met the inclusion criteria (epidemiology, 44; patient burden, 14; economic burden, 1) and were included in this review. Globally, 1.09 billion people are estimated to be affected by presbyopia. The reported presbyopia prevalence varied across regions and by age groups, with the highest prevalence of 90% reported in the Latin America region in adults ≥35 years. Presbyopic patients report up to 22% decrease in quality-of-life (QoL) score, and up to 80% patients with uncorrected presbyopia report difficulty in performing near-vision related tasks. About 12% of presbyopes required help in performing routine activities, and these visual limitations reportedly induce distress and low self-esteem in presbyopia patients. Uncorrected presbyopia led to a 2-fold increased difficulty in near-vision-related tasks and a >8-fold increased difficulty in very demanding near-vision-related tasks. Further, uncorrected presbyopia leads to a decrement in patients’ QoL, evident by the low utility values reported in the literature. Annual global productivity losses due to uncorrected and under-corrected presbyopia in working-age population (<50 years) were estimated at US$ 11 billion (0.016% of the global domestic product (GDP) in 2011, which increased to US$ 25.4 billion if all people aged <65 years were assumed to be productive.

Conclusion: Uncorrected presbyopia affects patients' vision-related quality of life due to difficulty in performing near-vision-related tasks. In addition, un-/under-corrected presbyopia could lead to productivity losses in working-age adults.


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255. Laparoscopic vs open colorectal surgery: Economic and clinical outcomes in the Brazilian healthcare

medicine


Authors: Ulysses Ribeiro Jr, Daiane Oliveira Tayar , Rodrigo Antonini Ribeiro , Priscila Andrade , Silvio Mauro Junqueira Jr
Region / country: South America – Brazil
Speciality: General surgery

Laparoscopic surgery has become the preferred surgical approach of several colorectal conditions. However, the economic results of this are quite controversial. The degree of adoption of laparoscopic technology, as well as the aptitude of the surgeons, can have an influence not only in the clinical outcomes but also in the total procedure cost. The aim of this study was to evaluate the clinical and economic outcomes of laparoscopic colorectal surgeries, compared to open procedures in Brazil.All patients who underwent elective colorectal surgeries between January 2012 and December 2013 were eligible to the retrospective cohort. The considered follow-up period was within 30 days from the index procedure. The outcomes evaluated were the length of stay, blood transfusion, intensive care unit admission, in-hospital mortality, use of antibiotics, the development of anastomotic leakage, readmission, and the total hospital costs including re-admissions.Two hundred eighty patients, who met the eligibility criteria, were included in the analysis. Patients in the laparoscopic group had a shorter length of stay in comparison with the open group (6.02 ± 3.86 vs 9.86 ± 16.27, P < .001). There were no significant differences in other clinical outcomes between the 2 groups. The total costs were similar between the 2 groups, in the multivariate analysis (generalized linear model ratio of means 1.20, P = .074). The cost predictors were the cancer diagnosis and age.Laparoscopic colorectal surgery presents a 17% decrease in the duration of the hospital stay without increasing the total hospitalization costs. The factors associated with increased hospital costs were age and the diagnosis of cancer.


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256. Supply the demand: Assessment of the feasibility of local non-urologists in relieving the burden of chronic indwelling catheters in a low-income country

Canadian Urological Association Journal


Authors: Adam Bobrowski, Madhur Nayan, Olivier Heimrath, Duncan Goche, Enok Ludzu, Rajiv K. Singal
Region / country: Eastern Africa – Malawi
Speciality: General surgery, Surgical Education, Urology surgery

Introduction: Despite the high prevalence rates of urinary retention in sub-Saharan Africa, regional deficiencies in urological care have culminated in inadequate medical management, and a backlog of urology cases. Our study examined the efficacy and safety of a surgical camp enlisting local non-urologists performing simple open prostatectomy on the rate of chronic catheter usage secondary to urinary retention.

Methods: We reported on a prospective case series of patients with chronic indwelling catheters who underwent open simple prostatectomy during a one-week urology camp in the Machinga District of Malawi. All operations were performed by a locally trained general surgeon and a clinical officer.

Results: Twenty-three (47.9%) of 48 male patients with urinary retention assessed for eligibility for open simple prostatectomy were deemed eligible and underwent the procedure. Of the patients who underwent an open simple prostatectomy, histopathological findings demonstrated benign prostatic hyperplasia in 19 patients (82.6%), while six patients (26.1%) had coincidental malignancy. At postoperative followup, the entire cohort was catheter-free and reported regular sexual activity and the ability to return to work, while 87.0% noted improvements in social integration and 34.8% cited higher self-esteem. Two patients required treatment for infection and one patient experienced fascial dehiscence. Two months following prostatectomy, all patients were catheter-free and able to void independently.

Conclusions: Local surgical practitioners without formal urology training can successfully perform open simple prostatectomy to relieve patients of chronic indwelling catheters and assist in addressing the disease burden in a low-resource setting.


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257. An Analysis of 30-Day in-Hospital Trauma Mortality in Four Urban University Hospitals Using the Australia India Trauma Registry

World Journal of Surgery


Authors: Prashant Bhandarkar, Priti Patil, Kapil Dev Soni, Gerard M. O’Reilly, Satish Dharap, Joseph Mathew, Naveen Sharma, Bhakti Sarang, Anita Gadgil, Nobhojit Roy
Region / country: South-eastern Asia – India
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Background
India has one-sixth (16%) of the world’s population but more than one-fifth (21%) of the world’s injury mortality. A trauma registry established by the Australia India Trauma Systems Collaboration (AITSC) Project was utilized to study 30-day in-hospital trauma mortality at high-volume Indian hospitals.

Methods
The AITSC Project collected data prospectively between April 2016 and March 2018 at four Indian university hospitals in New Delhi, Mumbai, and Ahmedabad. Patients admitted with an injury mechanism of road or rail-related injury, fall, assault, or burns were included. The associations between demographic, physiological on-admission vitals, and process-of-care parameters with early (0–24 h), delayed (1–7 days), and late (8–30 days) in-hospital trauma mortality were analyzed.

Results
Of 9354 patients in the AITSC registry, 8606 were subjected to analysis. The 30-day mortality was 12.4% among all trauma victims. Early (24-h) mortality was 1.9%, delayed (1–7 days) mortality was 7.3%, and late (8–30 days) mortality was 3.2%. Abnormal physiological parameters such as a low SBP, SpO2, and GCS and high HR and RR were observed among non-survivors. Early initiation of trauma assessment and monitoring on arrival was an important process of care indicator for predicting 30-day survival.

Conclusions
One in ten admitted trauma patients (12.4%) died in urban trauma centers in India. More than half of the trauma deaths were delayed, beyond 24 h but within one week following injury. On-admission physiological vital signs remain a valid predictor of early 24-h trauma mortality.


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258. Factors Associated with Waiting Time for Patients Scheduled for Elective Surgical Procedures at the University Teaching Hospital (UTH) in Zambia

The Annals of Medical and Health Sciences Research


Authors: Mubanga Musonda, Jacobs Choolwe, Rizk Jean, Gajewski Jakub, Pittalis Chiara and Mweene Cheelo
Region / country: Eastern Africa – Zambia
Speciality: General surgery, Other

Background: Measuring waiting times for elective surgical procedures is vital because it is considered as a proxy for evaluating the quality of surgical care. The aim was to examine waiting time for elective surgery at the University Teaching Hospital (UTH) in Zambia, looking at both patient and facility factors. Methods: This was a crosssectional study utilizing data from medical records of patients who were scheduled for elective surgical procedures at the UTH, between 1st December 2018 and 31st January 2019. The Weibull regression model was used to examine waiting times from admission to surgery using patient profiles and to assess the factors associated with waiting time. Results: During the study period, 182 patients underwent elective surgical procedures. The overall median waiting time was 9 days (interquartile range 4 to – 18 days). Significant differences in waiting time were observed by the surgical unit (log-rank test, p=0.01). Lack of blood products from the blood bank and lack of operating theatre time were significant determinants of longer times (p=0.02, event time ratio [ETR] 2.23), and (p=0.01, ETR 1.96) respectively. Patients from the neuro-surgical unit experienced a waiting time that was 2.72 (p=0.04) times more than patients from other surgical units. Conclusion: We were able to determine waiting times for elective surgical procedures and this can be used to plan for surgery given patient profiles. Additionally, we found that the unavailability of blood products for transfusion and lack of operating theatre time increase waiting time for elective surgery. Ensuring the availability of blood products may reduce waiting time for surgery.


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259. Assessment of Retinoblastoma Capacity in the Middle East, North Africa, and West Asia Region

JCO Global Oncology


Authors: Michala Burges, Ibrahim Qaddoumi, Rachel C. Brennan, Lisa Krull, Natasha Sahr, Carlos Rodriguez-Galindo, Sima Jeha and Matthew W. Wilson
Region / country: Middle East, Northern Africa, Western Asia
Speciality: Ophthalmology

PURPOSE
We aimed to evaluate the capacity to treat retinoblastoma in the Middle East, North Africa, and West Asia region.

METHODS
A Web-based assessment that investigated retinoblastoma-related pediatric oncology and ophthalmology infrastructure and associated capacity at member institutions of the Pediatric Oncology East and Mediterranean group was distributed. Data were analyzed in terms of availability, location, and confidence of use for each resource needed for the management of retinoblastoma. Resources were categorized by diagnostics, focal therapy, chemotherapy, advanced treatment, and supportive care. Responding institutions were further divided into an asset-based tiered system.

RESULTS
In total, responses from 23 institutions were obtained. Fifteen institutions reported the availability of an ophthalmologist, 12 of which held primary off-site appointments. All institutions reported the availability of a pediatric oncologist and systemic chemotherapy A significant portion of available resources was located off site. Green laser was available on site at seven institutions, diode laser at six institutions, cryotherapy at 12 institutions, and brachytherapy at nine institutions. There existed marked disparity between the availability of some specific ophthalmic resources and oncologic resources.

CONCLUSION
The assessment revealed common themes related to the treatment of retinoblastoma in low- and- middle-income countries, including decentralization of care, limited resources, and lack of multidisciplinary care. Resource disparities warrant targeted intervention in the Middle East, North Africa, and West Asia region to advance the management of retinoblastoma in the region.


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260. Establishment of a high-dependency unit in Malawi

BMJ Global Health


Authors: Ben Morton, Ndaziona Peter Banda, Edna Nsomba, Clara Ngoliwa, Sandra Antoine, Joel Gondwe, Felix Limbani, Marc Yves Romain Henrion, James Chirombo, Tim Baker, Patrick Kamalo, Chimota Phiri, Leo Masamba, Tamara Phiri, Jane Mallewa, Henry Charles Mwandumba, Kwazizira Samson Mndolo, Stephen Gordon, Jamie Rylance
Region / country: Southern Africa – Malawi
Speciality: Anaesthesia

Adults admitted to hospital with critical illness are vulnerable and at high risk of morbidity and mortality, especially in sub-Saharan African settings where resources are severely limited. As life expectancy increases, patient demographics and healthcare needs are increasingly complex and require integrated approaches. Patient outcomes could be improved by increased critical care provision that standardises healthcare delivery, provides specialist staff and enhanced patient monitoring and facilitates some treatment modalities for organ support. In Malawi, we established a new high-dependency unit within Queen Elizabeth Central Hospital, a tertiary referral centre serving the country’s Southern region. This unit was designed in partnership with managers, clinicians, nurses and patients to address their needs. In this practice piece, we describe a participatory approach to design and implement a sustainable high-dependency unit for a low-income sub-Saharan African setting. This included: prospective agreement on remit, alignment with existing services, refurbishment of a dedicated physical space, recruitment and training of specialist nurses, development of context-sensitive clinical standard operating procedures, purchase of appropriate and durable equipment and creation of digital clinical information systems. As the global COVID-19 pandemic unfolded, we accelerated unit opening in anticipation of increased clinical requirement and describe how the high-dependency unit responded to this demand.


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261. The role of non-governmental organizations in advancing the global surgery and anesthesia goals

Journal of Public Health and Emergency


Authors: Desmond T. Jumbam, Libby Durnwald, Ruben Ayala, Ulrick Sidney Kanmounye
Region / country: Global
Speciality: Anaesthesia, Health policy

Non-governmental organizations (NGOs) are indispensable to social and economic development, particularly in states with limited resources or poor governance. With about five billion people globally lacking access to safe, timely and affordable surgical and anesthesia care, mostly in low-income and middle-income countries (LMICs), NGOs can play a critical role in meeting this significant surgical need and advancing the global surgery and anesthesia goals set by the Lancet Commission on Global Surgery in alignment with the Sustainable Development Goals (SDGs). Surgical-NGOs (s-NGOs) have historically and continue to play a vital role in reducing the surgical burden globally, providing at least 3 million surgical procedures annually in LMICs. They have done this primarily through service delivery by employing temporary platforms such as short-term surgical trips and self-contained surgical platforms or through the setting up of specialized hospitals. With the advent of the SDGs, s-NGOs are increasingly investing in strengthening local health systems by supporting various dimensions of the health systems building blocks. Health systems strengthening interventions by s-NGOs have primarily focused on the training of skilled local surgical workforce (pre-service and in-service) and investing in health infrastructure through equipment and supplies donations to capacitate local health facilities to provide high-quality sustainable surgical and anesthesia care. Despite these laudable efforts, s-NGOs have not been without challenges and criticism especially around the cost-effectiveness, sustainability, equity and quality of care provided. In this article, we review the current landscape of s-NGOs and the challenges they face. We also examine the roles of s-NGOs in advancing the global surgery and anesthesia goals and SDGs in light of the ongoing COVID-19 pandemic.


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262. Estimation of the National Surgical Needs in India by Enumerating the Surgical Procedures in an Urban Community Under Universal Health Coverage

World Journal of Surgery


Authors: Prashant Bhandarkar, Anita Gadgil, Priti Patil, Monali Mohan & Nobhojit Roy
Region / country: Southern Asia – India
Speciality: General surgery, Obstetrics and Gynaecology, Trauma and orthopaedic surgery, Trauma surgery

Background
11% of the global burden of disease requires surgical care or anaesthesia management or both. Some studies have estimated this burden to be as high as 30%. The Lancet Commission for Global Surgery (LCoGS) estimated that 5000 surgeries are required to meet the surgical burden of disease for 100,000 people in LMICs. Studies from LMICs, estimating surgical burden based on enumeration of surgeries, are sparse.

Method
We performed this study in an urban population availing employees’ heath scheme in Mumbai, India. Surgical procedures performed in 2017 and 2018, under this free and equitable health scheme, were enumerated. We estimated the surgical needs for national population, based on age and sex distribution of surgeries and age standardization from our cohort.

Result
A total of 4642 surgeries were performed per year for a population of 88,273. Cataract (22.8%), Caesareans (3.8%), surgeries for fractures (3.27%) and hernia (2.86%) were the commonest surgeries. 44.2% of surgeries belonged to the essential surgeries. We estimated 3646 surgeries would be required per 100,000 Indian population per year. One-third of these surgeries would be needed for the age group 30–49 years, in the Indian population.

Conclusion
A total of 3646 surgeries were estimated annually to meet the surgical needs of Indian population as compared to the global estimate of 5000 surgeries per 100,000 people. Caesarean section, cataract, surgeries for fractures and hernia are the major contributors to the surgical needs. More enumeration-based studies are needed for better estimates from rural as well as other urban areas.


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263. Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process

JCO Blogbal Oncology


Authors: Lydia E. Pace, Lauren E. Schleimer, Cyprien Shyirambere, André Ilbawi, Jean Marie Vianney Dusengimana, Jean Bosco Bigirimana, Francois Regis Uwizeye, Mary Chamberlin, Yeonsoo Sara Lee, Lawrence N. Shulman, Susan Troyan, Benjamin O. Anderson, Catherine Duggan, Daniel S. O’Neil, Allison Dvaladze, Jane Brock, Cam Nguyen, Deogratias Ruhangaza, Olivier Habimana, Nicaise Nsabimana, John Butonzi, Eugene Nkusi, Tharcisse Mpunga, Nancy L. Keating
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: General surgery, Surgical oncology

PURPOSE
The burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings.

METHODS
To identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda.

RESULTS
Our systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda.

CONCLUSION
A modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.


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264. Beyond technology: review of systemic innovation stories in global surgery

Journal of Public Health and Epidemiology


Authors: Xiya Ma, Hannah S. Thomas, Ulrick Sidney Kanmounye
Region / country: Global
Speciality: Other

Since the launch of the Lancet Commission on Global Surgery (LCOGS) in 2015, significant attention and interest have been invested in breaking down the barriers that prevent universal access to essential surgical, obstetric and anesthesia (SOA) services. Improving access to surgical care in low-resource areas, whether in low- and middle-income countries (LMICs) or within vulnerable populations in high-income countries (HICs), requires stakeholders to think outside of the box. Innovation, or the process of creatively resolving a problem, is a crucial strategy for addressing complex challenges in global health and global surgery. While technology has traditionally taken the spotlight, novel ideas that support surgical systems strengthening and advance the agenda of achieving access for all should also be highlighted. This narrative review will focus on the principal ideas and trends in global surgery innovation, stretching beyond habitual technological advancements. By centering the narrative around non-technological achievements, we will explore emerging ideas that are transforming infrastructures in health systems strengthening, financial capacity, advocacy, and research and partnerships. From the development of National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) to the creation of collaborative authorship, systemic innovations have and will continue to improve the delivery and quality of essential surgical services in areas of need around the world.


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265. Global surgery: importance, controversy and opportunity

The bulletin


Authors: N Aruparayil, M Doe, CE Grimes
Region / country: Global
Speciality: Other

Serving those in limited resource settings does not only enhance surgical training, it advances universal access to holistic and affordable care.

An eight-year-old girl succumbs to 60% burns with inadequate dressings and analgesia (MD). A new father loses his wife to post-partum haemorrhage and must then bag-mask his dying baby (NA).

These experiences have lived long in the memory of the authors and have propelled us to play our part in global surgery. But what is ‘global surgery’?

Global surgery is an ‘area for study, research, practice, and advocacy that places priority on improving health outcomes and achieving health equity for all people worldwide who are affected by surgical conditions’.1 In 2015, The Lancet Commission on Global Surgery found that nine in ten people living in low- and middle-income countries (LMICs) are unable to access basic surgical care.2 Its report highlighted significant health and economic disparities for untreated surgical conditions, and recommended core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care when needed.

Those indicators include access to timely essential surgical care, specialist surgical workforce density, surgical volume, perioperative mortality and protection against impoverishing or catastrophic expenditure. The statistics regarding the workforce density are especially concerning, illustrating a considerable shortage of healthcare providers. It is estimated that LMICs, which make up 48% of the global population, only have 20% of the specialist surgeons, anaesthetists and obstetricians in the world, with the poorest nations having only 0.7 specialist providers per 100,000 population.3 Although these figures shed light on the scale of the problem, and reinforce the issues around inequality and access to surgical care, statistics mean little to the individual. We enter our profession not with a yearning to improve a number but to provide holistic care for our patients, locally or globally.


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266. Cost-effectiveness analysis of tranexamic acid for the treatment of traumatic brain injury, based on the results of the CRASH-3 randomised trial: a decision modelling approach

BMJ Global Health


Authors: Jack Williams, Ian Roberts, Haleema Shakur-Still, Fiona E Lecky, Rizwana Chaudhri, Alec Miners
Region / country: Northern Europe, Southern Asia – Pakistan, United Kingdom
Speciality: Neurosurgery, Trauma and orthopaedic surgery

Introduction An estimated 69 million traumatic brain injuries (TBI) occur each year worldwide, with most in low-income and middle-income countries. The CRASH-3 randomised trial found that intravenous administration of tranexamic acid within 3 hours of injury reduces head injury deaths in patients sustaining a mild or moderate TBI. We examined the cost-effectiveness of tranexamic acid treatment for TBI.

Methods A Markov decision model was developed to assess the cost-effectiveness of treatment with and without tranexamic acid, in addition to current practice. We modelled the decision in the UK and Pakistan from a health service perspective, over a lifetime time horizon. We used data from the CRASH-3 trial for the risk of death during the trial period (28 days) and patient quality of life, and data from the literature to estimate costs and long-term outcomes post-TBI. We present outcomes as quality-adjusted life years (QALYs) and 2018 costs in pounds for the UK, and US dollars for Pakistan. Incremental cost-effectiveness ratios (ICER) per QALY gained were estimated, and compared with country specific cost-effective thresholds. Deterministic and probabilistic sensitivity analyses were also performed.

Results Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI, at £4288 per QALY in the UK, and US$24 per QALY in Pakistan. Tranexamic acid was 99% and 98% cost-effective at the cost-effectiveness thresholds for the UK and Pakistan, respectively, and remained cost-effective across all deterministic sensitivity analyses. Tranexamic acid was even more cost-effective with earlier treatment administration. The cost-effectiveness for those with severe TBI was uncertain.

Conclusion Early administration of tranexamic acid is highly cost-effective for patients with mild or moderate TBI in the UK and Pakistan, relative to the cost-effectiveness thresholds used. The estimated ICERs suggest treatment is likely to be cost-effective across all income settings globally.


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267. Day case laparoscopic cholecystectomy at Kilimanjaro Christian Medical Centre, Tanzania

Surgical Endoscopy


Authors: Imogen Cullen, Fadlo Shaban, Oroog Ali, Matthew Breckons, Kondo Chilonga, Daudi Wapalila, Jamil Suleilman, Mercy Elinisa, Bronwyn Woodburn, Richard Walker & Liam Horgan
Region / country: Eastern Africa – Tanzania
Speciality: General surgery

Introduction: The Lancet Commission on Global Surgery has promoted the case for safe, affordable surgical care in low- and middle-income countries (LMICs). In 2017, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania introduced a day case laparoscopic cholecystectomy (DCLC) service, the first of its kind in Sub-Saharan Africa (SSA). We aimed to evaluate this novel service in terms of safety, feasibility and acceptability by patients and staff.

Methods: This study used mixed methods and was split into two stages. In stage 1, we reviewed records of all laparoscopic cholecystectomies (LCs) comparing day cases and admissions. These patients were followed up with a telephone questionnaire to investigate complication rates and receive service feedback. Stage 2 consisted of semi-structured interviews with staff exploring the challenges KCMC faced in implementing DCLC.

Results: 147 laparoscopic cholecystectomies were completed: 109 were planned for DCLC, 82 (75.2%) of which were successful, whilst 27 (24.8%) patients were admitted. No variables significantly predicted unplanned admission, the commonest causes for which were pain and nausea. In the DCLC group there was 1 readmission. 62 patients answered the follow up questionnaire, 60 (97%) of which were satisfied with the service. Stage 2 interviews suggested staff to be motivated for DCLC but revealed poor organisation of the day case pathway.

Conclusion: High rates of DCLC combined with low rates of complications and readmission suggests DCLC is feasible at KCMC. However, staff interviews alluded to administrative problems preventing KCMC from reaching its full DCLC potential. A dedicated day case surgery unit would address most of these problems.


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268. Evaluation of Portable Tablet-Based Audiometry in a South Indian Population

Indian Journal of Otolaryngology and Head & Neck Surgery


Authors: Sreeya Yalamanchali, Rita Ruby Albert, Hinrich Staecker, Rohit Nallani, P Naina & Kevin J Sykes
Region / country: South-eastern Asia – India
Speciality: ENT surgery

While a comprehensive booth audiogram is the gold standard for diagnosis of hearing loss, access to this may not be available in remote and low resource settings. The aims of this study were to validate a tablet-based audiometer in a tertiary medical center in India and explore its capacity in improving access to hearing healthcare. Subjects presenting to Ear–Nose–Throat clinics for conventional booth audiometry testing were recruited for subsequent tablet-based audiometric testing. Testing with the tablet was conducted in a non-sound-treated hospital clinic room. Bilateral air and bone conduction hearing threshold data from 250 through 4000 Hz were validated against conventional booth audiometry. In addition, a small feasibility study was conducted in rural clinics. 70 participants (37 adults and 33 children between the ages 5–18) were assessed. 69% were male, with a mean age of 29.7 years. Sensitivity and specificity for the tablet were 89% (95% CI 80–94%) and 70% (95% CI 56–82%), respectively. While median differences in air conduction thresholds between conventional and tablet audiograms showed statistical significance at 250, 500, and 1000 Hz (p < 0.001), the threshold results of the tablet audiometer were within 5 dB of the conventional audiogram and not clinically significant. Ten patients were successfully screened in rural clinics with tablet audiometry. Tablet portable audiometry is a valid tool for air and bone conduction threshold assessment outside of conventional sound booths. It can accurately identify hearing impairment and offers a screening tool for hearing loss in low resource settings.


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269. Patterns of neurosurgical conditions at a major government hospital in Cambodia

Asian Journal of Neurosurgery


Authors: Miri Kim, Chung Bin Yoo, Owen Lee-Park, Sam Nang, Din Vuthy, Kee B Park, Iv Vycheth
Region / country: South-eastern Asia – Cambodia
Speciality: Neurosurgery

Background: Low- and middle-income countries (LMICs) have a growing and largely unaddressed neurosurgical burden. Cambodia has been an understudied country regarding the neurosurgical pathologies and case volume. Rapid infrastructure development with noncompliance of safety regulations has led to increased numbers of traumatic injuries. This study examines the neurosurgical caseload and pathologies of a single government institution implementing the first residency program in an effort to understand the neurosurgical needs of this population. Methods: This is a longitudinal descriptive study of all neurosurgical admissions at the Department of Neurosurgery at Preah Kossamak Hospital (PKH), a major government hospital, in Phnom Penh, Cambodia, between September 2013 and June 2018. Results: 5490 patients were admitted to PKH requiring neurosurgical evaluation and care. Most of these admissions were cranial injuries related to road traffic accidents primarily involving young men compared to women by approximately 4:1 ratio. Spinal pathologies were more evenly distributed in age and gender, with younger demographics more commonly presenting with traumatic injuries, while the older with degenerative conditions. Conclusions: Despite increased attention and efforts over the past decade, Cambodia’s neurosurgical burden mirrors that of other LMICs, with trauma affecting most patients either on the road or at the workplace. Currently, Cambodia has 34 neurosurgeons to address the growing burden of a country of 15 million with an increasing life expectancy of 69 years of age, stressing the importance of better public health policies and urgency for building capacity for safe and affordable neurosurgical care.


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270. Effect of Coronavirus Disease 2019 and Pandemics on Global Surgical Outreach

JAMA Otolaryngol Head Neck Surg


Authors: Kylie Azizzadeh; Usama S. Hamdan; Parsa P. Salehi
Region / country: Global
Speciality: Health policy

The ongoing coronavirus disease 2019 (COVID-19) pandemic has led to a health care crisis, changing billions of lives worldwide. The ramifications of the contagion will likely be felt for the foreseeable future and will undoubtedly have a momentous effect on health care. While recent publications have focused on optimizing health care delivery, patient care, and physician safety in the setting of COVID-19, not much has been discussed regarding the effect on surgical global health programs (SGHPs).

Prior to the novel coronavirus outbreak from Wuhan, China, SGHPs played an important role in delivering care to low- and middle-income countries (LMICs). Such mission trips have long been a staple for facial plastic surgeons, plastic surgeons, and otolaryngologists–head and neck surgeons.1 Humanitarian organizations perform more than 250 000 procedures globally per year. Despite the volume of care provided, LMICs continue to demonstrate significant unmet surgical needs. While one-third of the global population inhabits LMICs, only 3% to 6% of operations occur there. From a global health perspective, access to surgical services have been cited as integral to minimizing patient morbidity and mortality.Economically, it is estimated that lack of access to surgical services in LMICs may contribute to cumulative losses of $20.7 trillion to the global economy from 2015 to 2030. During this uncertain time, SGHPs ought to consider how they may aid in the ongoing crisis and to consider the short- and long-term effects on global surgical outreach.


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271. Colorectal Surgery in the time of Covid 19

Colorectal Disease


Authors: Neil Smart
Region / country: Global
Speciality: General surgery, Health policy

At the time of writing (early August 2020) the world is still in the middle of the Covid 19 pandemic with over 18 million recorded cases and nearly 700 000 deaths. Those countries (e.g. parts of the UK and Spain) that had seen peaks in March, April & May had started to see the onset of second waves. The Australian State of Victoria had declared a state of disaster with lockdown imposed in Melbourne and the virus was widespread across the USA. Low & Middle Income Countries (LMICs) had seen rising numbers of cases and the head of the World Health Organisation, Tedros Adhanom Ghebreyesus, had declared that there is ‘no silver bullet at the moment – and there might never be’. Advances in Covid 19 research over the preceding months had focused on various drug combinations and vaccine development with each development hailed as a major victory. Despite the positive news stories with no paucity of hyperbole in the lay press, the reality remains a grossly disrupted health sector that has been crippled by the greatest public health crisis in a generation. The political fallout of the (mis)management of the pandemic continues to ripple across the world and the resultant economic recession in many nations has seen the prospect of rising health expenditure slip away as unemployment levels surge and government borrowing rockets to prop up stuttering economies.


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272. Surgical management of cervical cancer in a resource‐limited setting: One year of data from the National Cancer Institute, Sri Lanka

International Journal of Obstetrics and Gynaecology


Authors: Malitha Patabendige, Rajitha D. Wijesinghe, M.W.A.B. Wijesuriya, Chinthana Hapuachchige
Region / country: Southern Asia – Sri Lanka
Speciality: Obstetrics and Gynaecology

Objective
To evaluate the surgical management of cervical cancer without the use of preoperative pelvic imaging in a resource‐limited setting.

Methods
A retrospective study was carried out using clinical records and the ongoing electronic database at the Gynaecological Oncology Unit, National Cancer Institute (Apeksha Hospital), Maharagama, Sri Lanka. Details regarding the radical hysterectomies carried out from January 1, 2019, to December 31, 2019, were retrospectively studied.

Results
Out of nearly 700 patients with cervical cancer admitted during the year 2019, 57 surgically managed radical hysterectomies were included. Of these, seven cases were ineligible and excluded and 50 cases of radical hysterectomies were included for analysis. Mean age was 53.6 ± 9.5 years and median parity was 3 (range 2–4). Of the cases, 94% were found to have no parametrial involvement showing the success of clinical examination in assessing local tumor spread. Overall, 11 (22.0%) were upstaged due to lymph node metastasis that was statistically significant.

Conclusion
Preoperative clinical staging is a practical method in selecting surgically treatable cervical cancer in low‐ and middle‐income countries (LMICs). Combining clinical assessment with comparatively more readily available computed tomography scans could be helpful in triaging patients for treatment of cervical cancer in LMICs.


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273. Is the Whole Greater Than the Sum of Its Parts? The Implementation and Outcomes of a Whole Blood Program in Ecuador

BMC Emergency Medicine


Authors: Amber Nicole Himmler, Monica Eulalia Galarza Armijos, Jeovanni Reinoso Naranjo, Sandra Gioconda Peña Patiño, Doris Sarmiento Altamirano, Nube Flores Lazo, Raúl Pino Andrade, Hernán Sacoto Aguilar, Lenin Fernández de Córdova, Cecibel Cevallos Agurto, Nakul Raykar, Juan Carlos Puyana, Juan Carlos Salamea Molina
Region / country: South America – Ecuador
Speciality: Emergency surgery

Background: Hemorrhagic shock is a major cause of mortality in low-and-middle-income countries (LMICs). Many institutions in LMICs lack the resources to adequately prescribe balanced resuscitation. This study aims to describe the implementation of a whole blood program in Latin America and discuss the outcomes of the patients that received whole blood (WB).

Methods: We conducted a retrospective review of patients resuscitated with WB from 2013-2019. Five units of O+ WB were made available on a consistent basis for patients presenting in hemorrhagic shock. Variables collected included: sex, age, service treating the patient, units of WB administered, units of components administered, admission vital signs, admission hemoglobin, Shock Index, intraoperative crystalloid and colloid administration, symptoms of transfusion reaction, length-of-stay and in-hospital mortality.

Results: The sample includes a total of 101 patients, 57 of whom were trauma and acute care surgery (TACS) patients and 44 of whom were obstetrics and gynecology patients. No patients developed symptoms consistent with a transfusion reaction. Average shock index was 1.16 (±0.55). On average, patients received 1.66 (±0.80) units of whole blood. Overall mortality was 14/101 (13.86%) in the first 24 hours and 6/101 (5.94%) after 24 hours.

Conclusion: Implementing a WB protocol is achievable in LMICs. Whole blood allows for more efficient delivery of hemostatic resuscitation and is ideal for resource-restrained settings. To our knowledge, this is the first description of a whole blood program implemented in a civilian hospital in Latin America.


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274. Perspectives on perioperative management of children’s surgical conditions during the COVID-19 pandemic in low-income and middle-income countries: a global survey

World Journal of Pediatric Surgery


Authors: Paul Truche, Alexis Bowder, Amber Trujillo Lalla, Robert Crum, Fabio Botelho, Henry Elliot Rice, Bellisa Caldas Lopes, Sarah Greenberg, Faye Evans, John Gerard Meara, Emmanuel Adoyi Ameh, and David Patrick Mooney
Region / country: Global
Speciality: Paediatric surgery

Background
Many organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019 (COVID-19) pandemic. We surveyed providers of children’s surgical care working in low-income and middle-income countries (LMICs) to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices.

Methods
A survey of children’s surgery providers in LMICs was performed. Respondents reported how their perioperative practice had changed in response to COVID-19. They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform. Changes in surgical practice reported by respondents were analyzed thematically.

Results
A total of 132 responses were obtained from 120 unique institutions across 30 LMICs. 117/120 institutions (97.5%) had issued formal guidance on delaying or limiting elective children’s surgical procedures. Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities (82% in LICs vs 99% in lower middle-income countries and 100% in upper middle-income countries, p=0.036). Although 122 (97%) providers believed cases should be limited during a global pandemic, there was no procedure where more than 61% of providers agreed cases should be delayed or canceled.

Conclusions
There is little consensus on which procedures should be limited or delayed among LMIC providers. Expansion of testing capacity and local, context-specific guidelines may be a better strategy than international consensus, given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.


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275. Pragmatic multicentre factorial randomized controlled trial testing measures to reduce surgical site infection in low‐ and middle‐income countries: study protocol of the FALCON trial

Colorectal Disease


Authors: D. Nepogodiev, A. Bhangu, FALCON Collaborative
Region / country: Global
Speciality: General surgery, Other

Aim
Surgical site infection (SSI) is the commonest postoperative complication worldwide, representing a major burden for patients and health systems. Rates of SSI are significantly higher in low‐ and middle‐income countries (LMICs) but there is little high‐quality evidence on interventions to prevent SSI in LMICs.

Method
FALCON is a pragmatic, multicentre, 2 x 2 factorial, stratified randomized controlled trial, with an internal feasibility study, which will address the need for evidence on measures to reduce rates of SSI in patients in LMICs undergoing abdominal surgery. To assess whether either (1) 2% alcoholic chlorhexidine versus 10% povidone‐iodine for skin preparation, or (2) triclosan‐coated suture versus non‐coated suture for fascial closure, can reduce surgical site infection at 30‐days post‐surgery for each of (1) clean‐contaminated and (2) contaminated/dirty surgery. Patients with predicted clean‐contaminated or contaminated/dirty wounds with abdominal skin incision ≥ 5 cm will be randomized 1:1:1:1 between (1) 2% alcoholic chlorhexidine and noncoated suture, (2) 2% alcoholic chlorhexidine and triclosan‐coated suture, (3) 10% aqueous povidone–iodine and noncoated suture and (4) 10% aqueous povidone–iodine and triclosan‐coated suture. The two strata (clean‐contaminated versus contaminated/dirty wounds) are separately powered. Overall, FALCON aims to recruit 5480 patients. The primary outcome is SSI at 30 days, based on the Centers for Disease Control definition of SSI.

Conclusion
FALCON will deliver high‐quality evidence that is generalizable across a range of LMIC settings. It will influence revisions to international clinical guidelines, ensuring the global dissemination of its findings.


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276. Essential Vascular Surgical Care in Low and Middle Income Countries: Towards the Tipping Point

European Journal of Vascular and Endovascular surgery


Authors: Xiya Ma Dominique Vervoort
Region / country: Global
Speciality: Vascular surgery

We read with great interest Prendes et al.’ s commentary on lower limb revascularisation in low and middle income countries (LMICs). It has become increasingly apparent that the burden of vascular diseases disproportionally affects vulnerable and LMIC populations as a result of the epidemiological transition away from infectious diseases and towards non-communicable diseases, as a result of the rise in smoking, air pollution, obesity, diabetes, and trauma. Access to emergency and essential vascular surgical care, however, is grossly lacking in LMICs.


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277. Evaluation of a Ten-Year Team-Based Collaborative Capacity-Building Program for Pediatric Cardiac Surgery in Uzbekistan: Lessons and Implications

Annals of Global Health


Authors: Seungheon Han, Sugy Choi, Jongho Heo, Jayoung Park, and Woong-Han Kim
Region / country: Central Asia – Uzbekistan
Speciality: Cardiothoracic surgery, Paediatric surgery

Background:
Most children who have congenital heart disease in low- and middle-income countries (LMICs), including Uzbekistan, do not receive adequate and timely pediatric cardiac surgical care. To strengthen the surgical capacity of a local pediatric cardiac surgery team in Tashkent, Uzbekistan, the JW LEE Center for Global Medicine at Seoul National University College of Medicine has developed a team-based training program and has been collaboratively conducting surgeries and care in order to transfer on-site knowledge and skills from 2009 to 2019.

Objectives:
To evaluate the long-term effects of the collaborative program on the cardiac surgical capacity of medical staff (teamwork, surgical complexity, and patients’ pre-surgical weights) as well as changes in the lives of the patients and their families. To derive lessons and challenges for other pediatric cardiac surgical programs in LMICs.

Methods:
To assess the effects of this ten-year long program, a mixed-methods design was developed to examine the trend of surgical complexity measured by Risk Adjustment for Congenital Heart Surgery 1 score (RACHS-1) and patients’ pre-surgical weights via medical record review (surgical cases: n = 107) during the decade. Qualitative data was analyzed from in-depth interviews (n = 31) with Uzbek and Korean medical staff (n = 10; n = 4) and caregivers (n = 17).

Findings:
During the decade, the average RACHS-1 of the cases increased from 1.9 in 2010 to 2.78 in 2019. The average weight of patients decreased by 2.8 kg from 13 kg to 10.2 kg during the decade. Qualitative findings show that the surgical capacity, as well as attitudes toward patients and colleagues of the Uzbek medical staff, improved through the effective collaboration between the Uzbek and Korean teams. Changes in the lives of patients and their families were also found following successful surgery.

Conclusions:
Team-based training of the workforce in Uzbekistan was effective in improving the surgical skills, teamwork, and attitudes of medical staff, in addition, a positive impact on the life of patients and their families was demonstrated. It can be an effective solution to facilitate improvements in pediatric cardiovascular disease in LMICs if training is sustained over a long period.


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278. An Analysis of Factors Associated with Burn Injury Outcomes in Low- and Middle-Income Countries

Journal of Surgical Research


Authors: Caitlin Jacobs BS, Jonathan Vacek MD MS, Benjamin Many MD MS, Megan Bouchard MD, Fizan Abdullah MD PhD
Region / country: Global
Speciality: Emergency surgery

Background
Burn injuries are a major cause of morbidity and mortality within low- and middle-income countries (LMICs). The World Health Organization developed the Global Burn Registry to centralize data collection for the guidance of burn prevention programs. This study analyzed the epidemiologic and hospital-specific factors associated with burn injury outcomes in LMICs and high-income countries (HICs).

Methods
A retrospective review was performed using the Global Burn Registry over 3 y. Patients were stratified by income region. Bivariate analyses and stepwise regressions were performed to evaluate patient and hospital demographics and variables associated with injury patterns and outcomes. Outcomes of interest included mortality and length of stay.

Results
Over the study period, data were collected on 1995 patients from 10 LMICs (20 hospitals) and four HICs (four hospitals). Significantly higher mortality was seen in LMICs compared with HICs (17% versus 9%; P < 0.001). There was no significant difference between income regions for injury patterns (P = 0.062) or total body surface area of the burn injury (P = 0.077). Of the LMIC hospitals in this data set, 11% did not have reliable access to an operating theater.

Conclusions
HICs had a lower overall mortality even with higher rates of concurrent injuries, as well as longer length of stay. LMIC hospitals had fewer resources available, which could explain increased mortality, given similar total body surface area. This study highlights how investing in health care infrastructure could lead to improved outcomes for patients in low-resource settings.


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279. Public health approaches to addressing trachoma

AMSA Journal of Global Health


Authors: Sally Boardman
Region / country: Global
Speciality: Health policy, Ophthalmology

Introduction: Trachoma is a neglected tropical disease (NTD) caused by infection with Chlamydia trachomatis (C. trachomatis) and is the leading cause of preventable blindness globally. It is a disease rooted in poverty and remains endemic in several low- and middle-income countries, predominantly in the tropics, where determinants of health—including poor hygiene, sanitation, and living conditions—favour disease transmission. This paper aims to critically appraise the public health approaches addressing trachoma, namely implementation of the WHO ‘SAFE’ strategy, with reference to trachoma control in Tanzania.

Methods: Online databases were searched for literature containing relevant keywords. Literature sources included published data, peer-reviewed publications, and relevant grey literature.

Results: The SAFE strategy has been highly effective in reducing the global prevalence of trachoma. However, it has failed to reach its target of global elimination by 2020. Strengths of this approach include the dual focus on preventative and curative aspects of trachoma management and the GET2020 Alliance to aid state implementation. Challenges in trachoma management include the political landscape influencing global health governance and funding, as well as a pressing need for an intersectoral ‘Health in All Policies’ approach to address the social determinants of health perpetuating trachoma transmission.

Conclusions: An integrated, multisectoral approach to trachoma management with NTDs is required to attain increased and sustainable progress across the spectrum of NTDs, reduce the risk of resurgence, and achieve the United Nations Sustainable Development Goals (SDGs). This progress can be achieved only by continuing to address the underlying determinants of health and utilising integrated management programs.


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280. Temporal trends in childhood cancer survival in Egypt, 2007 to 2017: A large retrospective study of 14 808 children with cancer from the Children’s Cancer Hospital Egypt

International Journal Of Cancer


Authors: Ranin M. Soliman, Alaa Elhaddad, Jason Oke, Wael Eweida, Iman Sidhom, Sonia Ahmed, Hany Abdelrahman, Emad Moussa, Mohamed Fawzy, Manal Zamzam, Wael Zekri, Hanafy Hafez, Mohamed Sedky, Amr Abdalla, Mahmoud Hammad, Hossam Elzomor, Sahar Ahmed, Madeha Awad, Sayed Abdelhameed, Enas Mohsen, Lobna Shalaby, Heba Fouad, Nourhan Tarek, Sherif Abouelnaga, Carl Heneghan
Region / country: Northern Africa – Egypt
Speciality: Surgical oncology

Childhood cancer is a priority in Egypt due to large numbers of children with cancer, suboptimal care and insufficient resources. It is difficult to evaluate progress in survival because of paucity of data in National Cancer Registry. In this study, we studied survival rates and trends in survival of the largest available cohort of children with cancer (n = 15 779, aged 0‐18 years) from Egypt between 2007 and 2017, treated at Children’s Cancer Hospital Egypt‐(CCHE), representing 40% to 50% of all childhood cancers across Egypt. We estimated 5‐year overall survival (OS) for 14 808 eligible patients using Kaplan‐Meier method, and determined survival trends using Cox regression by single year of diagnosis and by diagnosis periods. We compared age‐standardized rates to international benchmarks in England and the United States, identified cancers with inferior survival and provided recommendations for improvement. Five‐year OS was 72.1% (95% CI 71.3‐72.9) for all cancers combined, and survival trends increased significantly by single year of diagnosis (P < .001) and by calendar periods from 69.6% to 74.2% (P < .0001) between 2007‐2012 and 2013‐2017. Survival trends improved significantly for leukemias, lymphomas, CNS tumors, neuroblastoma, hepatoblastoma and Ewing Sarcoma. Survival was significantly lower by 9% and 11.2% (P < .001) than England and the United States, respectively. Significantly inferior survival was observed for the majority of cancers. Although survival trends are improving for childhood cancers in Egypt/CCHE, survival is still inferior in high‐income countries. We provide evidence‐based recommendations to improve survival in Egypt by reflecting on current obstacles in care, with further implications on practice and policy.


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281. In-Hospital Postoperative Mortality Rates for Selected Procedures in Tanzania’s Lake Zone

World Journal of Surgery


Authors: Taylor Wurdeman, Christopher Strader, Shehnaz Alidina, David Barash, Isabelle Citron, Ntuli Kapologwe, Erastus Maina, Fabian Massaga, Adelina Mazhiqi, John G. Meara, Gopal Menon, Cheri Reynolds, Meaghan Sydlowski, John Varallo, Sarah Maongezi, Mpoki Ulisubisya
Region / country: Eastern Africa – Tanzania
Speciality: Emergency surgery, General surgery, Obstetrics and Gynaecology

Background
Postoperative mortality rate is one of six surgical indicators identified by the Lancet Commission on Global Surgery for monitoring access to high-quality surgical care. The primary aim of this study was to measure the postoperative mortality rate in Tanzania’s Lake Zone to provide a baseline for surgical strengthening efforts. The secondary aim was to measure the effect of Safe Surgery 2020, a multi-component intervention to improve surgical quality, on postoperative mortality after 10 months.

Methods
We prospectively collected data on postoperative mortality from 20 health centers, district hospitals, and regional hospitals in Tanzania’s Lake Zone over two time periods: pre-intervention (February to April 2018) and post-intervention (March to May 2019). We analyzed postoperative mortality rates by procedure type. We used logistic regression to determine the impact of Safe Surgery 2020 on postoperative mortality.

Results
The overall average in-hospital non-obstetric postoperative mortality rate for all surgery procedures was 2.62%. The postoperative mortality rates for laparotomy were 3.92% and for cesarean delivery was 0.24%. Logistic regression demonstrated no difference in the postoperative mortality rate after the Safe Surgery 2020 intervention.

Conclusions
Our results inform national surgical planning in Tanzania by providing a sub-national baseline estimate of postoperative mortality rates for multiple surgical procedures and serve as a basis from which to measure the impact of future surgical quality interventions. Our study showed no improvement in postoperative mortality after implementation of Safe Surgery 2020, possibly due to low power to detect change.


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282. Feasibility and Safety of Prosthetic Implants forInguinal Hernia Repair in a Nigerian Tertiary Hospital

Medical Journal of Zambia


Authors: Aloysius Ogbuanya, Fabian Olisa, Amobi Oguonu, Nonyelum Ugwu
Region / country: Western Africa – Nigeria
Speciality: General surgery

Background: Worldwide, inguinal hernia repair is the commonest surgical procedure in general surgery, but the optimal repair technique for inguinal hernia has not been defined and accepted in most parts of Africa and other developing nations. The aim of this study was to determine the epidemiology of inguinal hernias and feasibility of mesh implants in our centre.

Methodology: This was a descriptive cross-sectional study of consecutive adult patients with uncomplicated inguinal hernias who received polypropylene mesh for repair of their inguinal hernias. Selection criteria included inguinoscrotal/inguinolabial hernia, recurrent or bilateral hernia or bubunoceles with wide defects. Descriptive statistics and tests of significance were done.

Results: Inguinal hernia represented 77.3% of all abdominal wall hernias encountered during the study. However, only 27.8% (100 patients) of the 360 patients that satisfied the inclusion criteria received mesh implants. Of the 100 patients studied, 31% had recurrent hernias, 48% harbored complete inguinoscrotal/inguinolabial hernia while 13% had incomplete inguinoscrotal hernia. Majority (86%) had unilateral hernia.The annual repair rates using mesh implants increased progressively from 4% in 2013 to 40% in 2017. A quarter (25%) had comorbidities. Majority (60%) of repairs were under general anesthesia. The overall postoperative complication rate was 14%. Wound infection rate was 3.5%. There was statistically significant difference in the rates of wound-related events between recurrent and primary inguinal hernias (p=0.000). There was no mortality or recurrence recorded in this study.

Conclusion: The uptake of mesh implants for inguinal hernia repair in our environment is low, though the trend is changing with higher proportions of patients accepting mesh implants in recent time. Elective inguinal hernia surgery with polypropylene mesh is feasible, safe, effective and reproducible in our setting.


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283. Palliative surgery in gastrointestinal malignancy: experience from a regional cancer centre

International Surgery Journal


Authors: Prafulla Kumar Das, Kalyan Pandey, Padmalaya Deavi, Swodeep Mohanty, Kunal Goutam, Subrat Samantara, Bharat Bhushan Satpathy, Nilesh B. Patil, Subhranshu Lekha
Region / country: South-eastern Asia – India
Speciality: General surgery, Surgical oncology

Background: With so much burden of advanced incurable disease, the role of palliative surgery is paramount for gastrointestinal malignancies improving quality of life. Aim of the study was to study the indications, risks and outcome of palliative surgeries in gastrointestinal malignancies, the burden of disease requiring palliative surgery, and to describe strategies to improve end of life care.

Methods: All the patients diagnosed with gastrointestinal malignancy and who underwent palliative surgery between January 2017 and December 2017 were analysed.

Results: A total of 186 cases underwent palliative surgery. The most common age group affected was between 50-60 years and the mean age was 54.55 years. Stomach was the most common primary consisting of 58.60% followed by colorectal (23.66%), small intestine (9.68%), hepato-pacreatico-billiary (4.30%), and oesophageal (3.76%) primary. Major complications were seen in 4.84% of cases. Average symptomatic relief was observed for 5.5 months in cases of stomach and 7 months in case of colorectal malignancies. 35.48% cases were alive at the end of one year.

Conclusions: Present study concludes that palliative surgery improves quality of life of the patient, provides them with time to accept death and live rest of the life in a dignified manner.


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284. Pediatric Solid Tumor Care and Multidisciplinary Tumor Boards in Low- and Middle-Income Countries in Southeast Asia

JCO Global Oncology


Authors: Mohd Yusran Othman, MBBS, MPaedSurg, Sally Blair, MD, MPH, Shireen A. Nah, MBBS, MS, Hany Ariffin, MBBS, MPaed, PhD, Chatchawin Assanasen, MD, Shui Yen Soh, MBBS, MRCPCH, Anette S. Jacobsen, MBBCh, FAMS, Catherine Lam, MD, MPH and Amos H. P. Loh, MBBS, FAMS
Region / country: South-eastern Asia
Speciality: Other, Paediatric surgery, Surgical oncology

PURPOSE
Pediatric solid tumors require coordinated multidisciplinary specialist care. However, expertise and resources to conduct multidisciplinary tumor boards (MDTBs) are lacking in low- and middle-income countries (LMICs). We aimed to profile the landscape of pediatric solid tumor care and practices and perceptions on MDTBs among pediatric solid tumor units (PSTUs) in Southeast Asian LMICs.

METHODS
Using online surveys, availability of specialty manpower and MDTBs among PSTUs was first determined. From the subset of PSTUs with MDTBs, one pediatric surgeon and one pediatric oncologist from each center were queried using 5-point Likert scale questions adapted from published questionnaires.

RESULTS
In 37 (80.4%) of 46 identified PSTUs, availability of pediatric-trained specialists was as follows: oncologists, 94.6%; surgeons, 91.9%; radiologists, 54.1%; pathologists, 40.5%; radiation oncologists, 29.7%; nuclear medicine physicians, 13.5%; and nurses, 81.1%. Availability of pediatric-trained surgeons, radiologists, and pathologists was significantly associated with the existence of MDTBs (P = .037, .005, and .022, respectively). Among 43 (89.6%) of 48 respondents from 24 PSTUs with MDTBs, 90.5% of oncologists reported > 50% oncology-dedicated workload versus 22.7% of surgeons. Views on benefits and barriers did not significantly differ between oncologists and surgeons. The majority agreed that MDTBs helped to improve accuracy of treatment recommendations and team competence. Complex cases, insufficient radiology and pathology preparation, and need for supplementary investigations were the top barriers.

CONCLUSION
This first known profile of pediatric solid tumor care in Southeast Asia found that availability of pediatric-trained subspecialists was a significant prerequisite for pediatric MDTBs in this region. Most PSTUs lacked pediatric-trained pathologists and radiologists. Correspondingly, gaps in radiographic and pathologic diagnoses were the most common limitations for MDTBs. Greater emphasis on holistic multidisciplinary subspecialty development is needed to advance pediatric solid tumor care in Southeast Asia.


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285. Primary Health-Care Service Delivery and Accessibility in the Digital Age

Intech Open


Authors: Thierry Edoh
Region / country: Global
Speciality: Health policy

The primary care is within a health-care system, the first contact and main point for people requiring health and medical care. Patients requiring specialized health and medical care are directed to the appropriate specialists by a general physician (GP) who coordinates the needed specialist care. GPs base their decisions partially on patient-centered information and partially on the results of medical examinations. Many health-IT systems for primary health care are available today. Their first aims are to assist GPs in their daily duties and the patient in collecting his medical data and to self-manage his conditions. IT systems enabling the patient to collect accurate information on his condition to self-manage his condition provide accurate patient-centric data, which shows the potential to outperform patient-centered information, which in turn is based on the patient’s personal feeling and perception. Patient-centered information are biased. Beyond providing patient-centric information, health-IT systems can facilitate access to health-care services, increase the quality, efficiency, and effectiveness of health-care services, and can contribute to reducing medical expenses. This chapter aims to paint down the global trend of health-IT systems and the supporting technology. The chapter will further present some existing health-IT systems and discuss their role in the health-care accessibility, particularly in rural regions.


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286. Challenges and opportunities for managing pediatric central nervous system tumors in China

Pediatric Investigations


Authors: Anthony Pak‐Yin Liu Daniel C. Moreira Chenchen Sun, Lisa Krull, Yijin Gao Bo Yang Chenran Zhang Kejun He Xiaojun Yuan Godfrey Chi‐Fung Chan Xiaofei Sun Xiaoli Ma Ibrahim A. Qaddoumi
Region / country: Eastern Asia – China
Speciality: Paediatric surgery, Surgical oncology

Central nervous system (CNS) tumors represent the most deadly cancer in pediatric age group. In China, thousands of children are diagnosed with CNS tumors every year. Despite the improving socioeconomic status and availability of medical expertise within the country, unique challenges remain for the delivery of pediatric neuro‐oncology service. In this review, we discuss the existing hurdles for improving the outcome of children with CNS tumors in China. Need for precise disease burden estimation, lack of intra‐ and inter‐hospital collaborative networks, high probability of treatment abandonment, along with financial toxicities from treatment represent the key challenges that Chinese healthcare providers encounter. The tremendous opportunities for advancing the status of pediatric neuro‐oncology care in and beyond the country are explored.


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287. Letter to the Editor: COVID-19 & Neurosurgical Training in Low- and Middle-Income Countries

World Neurosurgery


Authors: Ulrick Sidney Kanmounye, Adam Ammar, Ignatius Esene, Abdessamad El Ouahabi, and Kee Park
Region / country: Global
Speciality: Neurosurgery, Surgical Education

On June 11, 2020, the World Federation of Neurosurgical Societies (WFNS)’ Global Neurosurgery Committee (GNC) and Young Neurosurgeons Forum (YNF) discussed the effects of coronavirus disease 2019 (COVID-19) on training in low- and middle-income countries (LMICs). During this event, the leadership of the WFNS and stakeholders of global neurosurgery identified challenges and proposed solutions to the issues faced by trainees during the pandemic. We recount the problems and action items that were identified during the meeting.

Each year, 23 million patients develop neurosurgical conditions, and 78% of them live in LMICs.1 LMICs have <56% of the specialist neurosurgical workforce and require an additional 23,300 neurosurgeons to meet local neurosurgical demands.1 , 2 Few LMICs have sufficient capacity to make up for the local workforce deficit; thus, neurosurgeons from all over the world are working to find sustainable solutions.3 This movement has given birth to the field of global neurosurgery—”an area for study, research, practice, and advocacy that places a priority on improving health outcomes and achieving health equity for all people worldwide who are affected by neurosurgical conditions or need neurosurgical care.”4 To coordinate the efforts of global neurosurgeons, the WFNS has created an ad-hoc committee: the WFNS GNC.5

In addition to the difficulties already faced in providing neurosurgical care in LMICs, the current COVID-19 pandemic has further strained healthcare resources, especially for those in low-resource settings.6 To understand the effects of the pandemic on training and propose solutions to the issues identified, the WFNS GNC and the WFNS YNF co-hosted a webinar. The webinar was held on June 11, 2020, and titled “COVID-19 & Neurosurgical Training in Low- and Middle-Income Countries: The Global Neurosurgery Perspective.”


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288. Implementation and evaluation of nonclinical interventions for appropriate use of cesarean section in low- and middle-income countries: protocol for a multisite hybrid effectiveness-implementation type III trial

Implementation Science


Authors: Alexandre Dumont, Ana Pilar Betrán, Charles Kaboré, Myriam de Loenzien, Pisake Lumbiganon, Meghan A Bohren, Quoc Nhu Hung Mac, Newton Opiyo, Guillermo Carroli, Kristi Sidney Annerstedt, Valéry Ridde, Ramón Escuriet, Michael Robson, Claudia Hanson, QUALI-DEC research group
Region / country: Global – Argentina, Burkina Faso, Thailand, Vietnam
Speciality: Health policy, Obstetrics and Gynaecology

Background: While cesarean sections (CSs) are a life-saving intervention, an increasing number are performed without medical reasons in low- and middle-income countries (LMICs). Unnecessary CS diverts scarce resources and thereby reduces access to healthcare for women in need. Argentina, Burkina Faso, Thailand, and Vietnam are committed to reducing unnecessary CS, but many individual and organizational factors in healthcare facilities obstruct this aim. Nonclinical interventions can overcome these barriers by helping providers improve their practices and supporting women’s decision-making regarding childbirth. Existing evidence has shown only a modest effect of single interventions on reducing CS rates, arguably because of the failure to design multifaceted interventions effectively tailored to the context. The aim of this study is to design, adapt, and test a multifaceted intervention for the appropriate use of CS in Argentina, Burkina Faso, Thailand, and Vietnam.

Methods: We designed an intervention (QUALIty DECision-making-QUALI-DEC) with four components: (1) opinion leaders at heathcare facilities to improve adherence to best practices among clinicians, (2) CS audits and feedback to help providers identify potentially avoidable CS, (3) a decision analysis tool to help women make an informed decision on the mode of birth, and (4) companionship to support women during labor. QUALI-DEC will be implemented and evaluated in 32 hospitals (8 sites per country) using a pragmatic hybrid effectiveness-implementation design to test our implementation strategy, and information regarding its impact on relevant maternal and perinatal outcomes will be gathered. The implementation strategy will involve the participation of women, healthcare professionals, and organizations and account for the local environment, needs, resources, and social factors in each country.

Discussion: There is urgent need for interventions and implementation strategies to optimize the use of CS while improving health outcomes and satisfaction in LMICs. This can only be achieved by engaging all stakeholders involved in the decision-making process surrounding birth and addressing their needs and concerns. The study will generate robust evidence about the effectiveness and the impact of this multifaceted intervention. It will also assess the acceptability and scalability of the intervention and the capacity for empowerment among women and providers alike.


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289. Cost of breast cancer care in low and middle-income countries: a scoping review protocol

OSF Registries


Authors: Parsa Erfani; Kayleigh Bhangdia; Jean Claude Mugunga; Lydia E. Pace; Temidayo Fadelu
Region / country: Global
Speciality: General surgery, Surgical oncology

bjective: This review will describe the scope of the literature on the cost of breast cancer care in low and middle income countries (LMICs), summarize estimated costsof breast cancer diagnosis andtreatment, and assess the methodologies used to calculate cost. Introduction: In the past decade, there has been global momentum to improve capacity for breast cancer care in LMICs, which have higher rates of breast cancer mortality compared to high income countries. Understanding the cost of delivering breast cancer care in LMICs is critical to guide effective cancer care delivery strategies and policy.Inclusion criteria:Studies that estimate the cost of breast cancer diagnosis andtreatment in LMICs will be included. Studies not available in English will be excluded.Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses -Scoping Review guidelines will be utilized. The search strategy has been developed in consultation with a medical librarian and will be performed in five electronic databases from their inception (MEDLINE, Embase, Web of Science, Global Health, WHO Global Index Medicus) as well as ingray literature. Two independent reviewers will review all abstracts and titles in the primary screen and full-text articles in the secondary screen. A third reviewer will adjudicate conflicts. One reviewer will perform data extraction. Study characteristics and cost estimates will be summarized in narrative and tabular formats. The methodological quality of studies will be evaluated using a validated economic evaluation tool as well as a ranking system that denotes the comprehensiveness of cost analysis inputs


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290. A Case Study of a Point-of-Care Electronic Medical Record [SABER] in Totonicapán, Guatemala: Benefits, Challenges, and Future Directions

Annals of Global Health


Authors: Nicholas H. Aldredge , Dorian Rodriguez, Jessica González, David R. Burt
Region / country: Central America – Guatemala
Speciality: Health policy

Background: The adoption of electronic medical records (EMRs) in lower-income nations has progressed slowly due to the lack of adequate infrastructure, funding, and training. However, EMRs have been successfully implemented previously in resource-limited health systems in South Africa, Haiti, Cameroon, Kenya, and Peru. Detailed, organized, and easily accessible medical records are particularly important in emergency departments due to the volume and acuity of the patient population.

Methods: In order to further study the plausibility of an EMR in a resource-limited emergency department, a web-based, Spanish-language EMR known as SABER was developed for use in Hospital Nacional José Felipe Flores in Totonicapán, Guatemala. The software collects patient data including demographics, triage, initial evaluation, review of systems, physical exam, and evaluation and plan. It then generates a .pdf file consistent with information requirements of the Guatemalan Ministry of Health. Local physicians, medical students, and nurses were trained in the use of the software, which debuted in July 2016. To assess the effectiveness of SABER as an EMR, focus groups and Likert scale surveys were conducted with six physicians and 31 medical students working in the Hospital Nacional emergency department.

Results: Thirty of 32 medical students and six of six doctors would recommend SABER to another provider. Positive aspects identified by staff include ease of use, quick data entry, and the potential for large data set research.

Discussion: Remaining challenges include incorporating electronic nursing orders and lab results, troubleshooting technology problems including printer difficulties, a lack of electronic signature capability, and lack of integration with the rest of the hospital. Our study is consistent with other studies that show use of an EMR may help to reduce health disparities through improved patient records, medical data collection, and organization.


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291. Developing a National Integrated Road Traffic Injury Registry System: A Conceptual Model for a Multidisciplinary Setting

Journal of Multidisciplinary Healthcare


Authors: Homayoun Sadeghi-Bazargani,Alireza Sadeghpour, Michael Lowery Wilson, Alireza Ala, Farzad Rahmani
Region / country: Middle East – Iran
Speciality: Emergency surgery, Health policy

Introduction: Despite a high burden of traffic injuries, effective integrated or linked injury surveillance systems are rarely available in many low- and middle-income countries (LMICs). The aim of the current study was to define a conceptual model for developing a national integrated traffic injury registry in Iran.
Methods: A mult-method study financially and technically supported by the World Health Organization, Iranian Ministry of Health, Iranian Traffic Police, and the Iranian Legal Medicine Organization was conducted. A theoretical framework, forming the core conceptual components, was developed based on expert reviews. The preliminary conceptual model was developed by a panel of experts and tailored through a national workshop of 50 scientists, authorities and experts from nearly all sectors related to road safety promotion and injury management. It was then sent out to external reviewers in order to assess and improve the content validity of the model.
Results: The conceptual model was developed to have six components. These included 1) aims and core definitions; 2) content and core measurements; 3) data flow; 4) data collection routines; 5) organizational matrix; 6) implementation organization. The Haddon’s matrix was adapted to be used as the theoretical framework in defining the content and data flow components of IRTIR. Five subcomponents were defined in the content and core measurements component with each having several subcategories. Each subcomponent/subcategory was finally divided into several item groups to guide defining the final data measurement variables. The data flow component was defined with six data sequence stations. Through the organizational matrix component, five major organizations relevant to road traffic safety were defined as core data production contributors. Some organizations also owned several sub-organizations which contributed in this regard.
Conclusion: It is concluded that the IRTIR conceptual model includes the required six components for developing a national integrated registry for Iran. Its main component called, content and core measurements, leads the researchers in developing final data collection tools in developing the national registry of road traffic injuries in Iran.


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292. Cancer Care in the Era of COVID-19: Changing Rules of Engagement of Social Media Applications to Support Cancer Patients in LMICs

Indian Journal of Surgical Oncology


Authors: Sanjay Kumar Yadav, Ronald Kintu Luwaga, Vahagn Hambardzumyan, Nishtha Yadav & Sanjeet Kumar Jaiswal
Region / country: Eastern Africa – Uganda
Speciality: Health policy, Surgical oncology

A patient texts a picture of his neck (Fig. 1a and b) showing no tumor from 240 miles away. Even though he could not come to hospital due to lockdown, he is able to continue his tyrosine kinase inhibitor therapy with the support of a social media (SoMe) application. Another patient in Uganda sends a photograph, which aids in home-based evaluation of her post-mastectomy wound (Fig. 1c).

COVID-19 pandemic has been a crucial wake-up call for many high-income countries (HICs), as it has brought to the fore the fragility of their healthcare systems [1]. Yet, the situation in low- and middle-income countries (LMICs) can only be left to imagination as healthcare system was already fragile here. Amidst the pandemic, care of cancer patients has suffered a substantial setback. It is now apparent that cancer and COVID-19 form a deadly duo as patients having both are at very high risk of severe event [2]. Patients with cancer are at higher risk with severe events occurring in 7 (39%) of 18 patients with cancer vs 124 (8%) of 1572 patients without cancer.


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293. Emergency general surgery in a public hospital in Malaysia

The Medical journal of Malaysia


Authors: Kandasami Palayan, Yita Tang, Chi Xuan Sam, Chern Wayne Kee, Muhammad Naim Rusman, Afifah Aflah Mohd Derus, Mahadevan Deva Tata
Region / country: Southern Asia – Malaysia
Speciality: Emergency surgery, General surgery

Introduction: Patients undergoing emergency general surgery (EGS) are at risk for death and complications. Information on the burden of EGS is critical for developing strategies to improve the outcomes.

Methods: In this retrospective cohort study, medical records of all general surgical operations in a public hospital were reviewed for the period 1st January 2017 to 31st December 2017. Data on patient demographics, operative workload, case mix, time of surgery and outcomes were analysed.

Results: Of the 2960 general surgical operations that were performed in 2017, 1720 (58.1%) of the procedures were performed as emergencies. The mean age for the patients undergoing emergency general surgical procedures was 37.9 years (Standard Deviation, ±21.0), with male preponderance (57.5%). Appendicitis was the most frequent diagnosis for the emergency procedures (43%) followed by infections of the skin and soft tissues (31.6%). Disorders of the colon and rectum ranked as the third most common condition, accounting for 6.7% of the emergency procedures. Majority of emergency surgery (59.3%) took place after office hours and on weekends. Post-operative deaths and admissions to critical care facilities increased during EGS when compared to elective surgery, p<0.01.

Conclusions: EGS constitutes a major part of the workload of general surgeons and it is associated significant risk for death and post-operative complications. The burden of EGS must be recognised and patient care systems must evolve to make surgery safe and efficient.


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294. Towards a framework approach to integrating pathways for infection prevention and antibiotic stewardship in surgery: a qualitative study from India and South Africa

Research square


Authors: Singh S, Mendelson M, Surendran S, Bonaconsa C, Mbamalu O, Nampoothiri V, Boutall A, Hampton M, Dhar P, Pennel T, Tarrant C, Leather A, Holmes A, Charani E
Region / country: Southern Africa, Southern Asia – India, South Africa
Speciality: Health policy

Background The surgical pathway remains a hard to reach, critical target for antimicrobial stewardship (AMS) and infection prevention and control (IPC). We investigated the drivers for surgical AMS and IPC, across cardiovascular and thoracic surgery (CVTS) and gastrointestinal surgery teams in two academic hospitals in South Africa (SA) and India. Materials and methods An ethnographic observational study of IPC and AMS was conducted (July 2018–August 2019), with data gathered from 190 hours of non-participant observations (138 India, 60 SA); face-to-face interviews with patients (6 India, 7 South Africa), and healthcare professionals (HCPs) (44 India, 61 SA); and, in-depth patient case studies (4 India, 2 SA). A grounded theory approach aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of moving between the coded data and the higher-level themes, ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of findings. Results Across surgical pathways, multiple barriers exist impeding effective IPC and AMS practices. The existing, implicit roles of HCPs (including nurses, and senior surgeons) are overlooked as interventions target junior doctors, bypassing the opportunity for integrating care across the surgical team members. Critically, the ownership of decisions remains with the operating surgeons and entrenched hierarchies restrict the integration of other HCPs in IPC and AMS. Conclusions IPC and AMS are not integrated in surgery. Identifying the implicit existing HCPs roles in IPC and AMS is critical and will facilitate the development of effective and transparent processes across the surgical team for IPC and AMS. Developing a framework approach that includes nurse leadership, empowering pharmacists and engaging surgical leads is essential for integrated care.


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295. Evaluation of Morbidity and Mortality in Eclampsia: A Study in a Tertiary Care Hospital, Rajshahi, Bangladesh

Scholars Journal of Applied Medical Sciences


Authors: Dr. Nahid Sultana, Dr. Md. Zulfiqur Ali, Dr. Shakina Khatun
Region / country: Southern Asia – Bangladesh
Speciality: Obstetrics and Gynaecology

Introduction: Eclampsia is a hypothetically life-threatening rare tricky situation of the hypertensive disorders of pregnancy, which is responsible for huge records in morbidity and deaths among women of reproductive age and their offspring. It is an occurrence of convulsion linked with pregnancy complicated by preeclampsia. The estimate of incidence and the burden of eclampsia is still a challenging pursuit worldwide; currently only seven countries have national data on the topic. Aim of the study: To assess the morbidity and mortality in eclampsia. Methods: This was a cross sectional observational study carried out in the Department of Obstetrics and Gynaecology in 250 Bedded General Hospital, Pabna, Bangladesh during the period from June 2016 and July 2016. Proper written consent form all the participants were obtained and the ethical committee of the hospital had approved the study before starting the
intervention. In total 178 pregnant women with eclampsia were finalized as the study population. Result: In our study we found in total 148 live births from total 178 mothers which were 83.15% against total study population. Among all the babies 139 were survived which was 93.91% among total live births. Death after birth was 9 in number which was 6.08% among total live births. Early neonatal death was 13 in number which was 7.3% against total mothers. Stillbirths were 16 in number which was 9% against total mothers. In perinatal complication analysis we found 42 babies with jaundice which was 28.38% among live births. Babies with septicemia were 28 (18.92%), with respiratory distress 25 (16.89%), with neonatal convulsion were 7(4.73%) and with no complication were 46 (31.08%). Conclusion: It was observed in our study that; lower income families have a worse performance in all obstetric health
care indicators among women with eclampsia. So, Proper health care and mental health facilities in order to get better obstetric and perinatal outcomes might be the faster route to reduce severe maternal outcome due to eclampsia.


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296. Assessing Patient Safety Culture: Application of the Safety Attitudes Questionnaire in a Kenyan Setting

The Open nursing Journal


Authors: Nickcy Mbuthia, Mary Moleki
Region / country: Eastern Africa – Kenya
Speciality: Health policy

Background:
Patient safety has recently been declared a global health priority. Achievement and sustenance of a culture of patient safety require a regular and timely assessment of the organization. The Safety Attitudes Questionnaire is a patient safety culture assessment tool whose usefulness has been established in countries, but a few studies have been published from Africa, more so, in Kenyan settings.

Objective:
To evaluate the reliability of the Safety Attitudes Questionnaire in assessing the patient safety culture in a Kenyan setting and to assess healthcare workers’ perceptions of patient safety culture.

Methods:
A descriptive quantitative approach was utilized whereby the Safety Attitudes Questionnaire was administered to 241 healthcare workers in two public hospitals. The Cronbach’s α was calculated to determine the internal consistency of the SAQ. Descriptive and inferential statistics were used to analyze and describe the data on patient safety culture.

Results:
The total scale Cronbach’s alpha of the SAQ was 0.86, while that of the six dimensions was 0.65 to 0.90. The overall mean score of the total SAQ was 65.8 (9.9). Participants had the highest positive perception for Job Satisfaction with a mean score of 78.3 (16.1) while the lowest was evaluated for Stress Recognition with a mean score of 53.8 (28.6).

Conclusion:
The SAQ demonstrated satisfactory internal consistency and is suitable for use in the Kenyan context. The perception of patient safety culture in the Kenyan hospital is below international recommendations. There is a need for implementation of strategies for the improvement of the organization culture in Kenyan hospitals.


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297. Pediatric Patients in a Local Nepali Emergency Department: Presenting Complaints, Triage and Post-Discharge Mortality

Global Pediatric Health


Authors: Samita Giri, Tine Halvas-Svendsen, Tormod Rogne, Sanu Krishna Shrestha, Henrik Døllner,, Erik Solligård,, Kari Risnes
Region / country: Southern Asia – Nepal
Speciality: Emergency surgery

Background. In low-income countries, pediatric emergency care is largely underdeveloped although child mortality in emergency care is more than twice that of adults, and mortality after discharge is high. Aim. We aimed at describing characteristics, triage categories, and post-discharge mortality in a pediatric emergency population in Nepal. Methods. We prospectively assessed characteristics and triage categories of pediatric patients who entered the emergency department (ED) in a local hospital. Patient households were followed-up by telephone interviews at 90 days. Results. The majority of pediatric emergency patients presented with injuries and infections (~40% each). Girls attended ED less frequent than boys. High triage priority categories (orange and red) were strong indicators for intensive care need and for mortality after discharge. Conclusion. The study supports the use and development of a pediatric triage systems in a low-resource general ED setting. We identify a need for interventions that can reduce mortality after pediatric emergency care. Interventions to reduce pediatric emergency disease burden in this setting should emphasize prevention and effective treatment of infections and injuries.


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298. Continuing Education for Prehospital Healthcare Providers in India – A Novel Course and Concept

Open Access Emerg Med


Authors: Benjamin D Lindquist, Kathryn W Koval, Peter C Acker, Corey B Bills, Ayesha Khan, Sybil Zachariah, Jennifer A Newberry, G V Ramana Rao, Swaminatha V Mahadevan, and Matthew C Strehlow
Region / country: Southern Asia – India
Speciality: Emergency surgery, Obstetrics and Gynaecology, Trauma surgery

Background
Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public–private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India.

Methods
From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide).

Lessons Learned
During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials.

Conclusion
These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries.


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299. The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

The Lancet


Authors: Gene Bukhman, Ana O Mocumbi, Rifat Atun, Anne E Becker, Zulfiqar Bhutta, Agnes Binagwaho, Chelsea Clinton, Matthew M Coates, Katie Dain, Majid Ezzati, Gary Gottlieb, Indrani Gupta, Neil Gupta, Adnan A Hyder, Yogesh Jain, Margaret E Kruk, Julie Makani, Andrew Marx, J Jaime Miranda, Ole F Norheim, Rachel Nugent, Nobhojit Roy, Cristina Stefan, Lee Wallis, Bongani Mayosi†, for the Lancet NCDI Poverty Commission Study Group
Region / country: Global
Speciality: Health policy

We live in an era of unprecedented global wealth. Nevertheless, about one billion people in low-income and lower-middle-income countries (LLMICs) still experience levels of poverty that have long been described as “beneath any reasonable definition of human decency”, in the words of former World Bank president, Robert McNamara. This Commission was formed at the end of 2015 in the conviction that non-communicable diseases and injuries (NCDIs) are an important, yet an under-recognised and poorly-understood contributor to the death and suffering of this vulnerable population. The aims of the Commission were to rethink global policies, mend a great disparity in health, and broaden the global health agenda in the interest of equity.

There are ways, with demonstrated effectiveness in real-world conditions, to address the constellation of afflictions known as NCDIs. We have found, however, that the world’s poorest billion are being systematically deprived of those life-saving and life-changing interventions. This unfair exclusion stems both from a lack of global solidarity with the poorest of the poor, and from inadequate descriptions and comprehension of the problem. NCDIs are commonly represented as complications of ageing and development. In fact, they also constitute a large and diverse burden of illness among children and young adults, who make up the largest proportion of people living in extreme poverty around the world. Public health discourse and global solutions have generally focused on preventing NCDIs through changes in human behaviours, and not on addressing the inadequate resources available for the poor to be properly nourished, live safely, and to access health care. Meanwhile, treatments for NCDIs account for the largest gap in health financing for LLMICs, making a mockery of international commitments to universal health coverage (UHC).


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300. Factors Associated with Loss to Follow-up among Cervical Cancer Patients in Rwanda

Annals of Global Health


Authors: Placide Habinshuti, Marc Hagenimana, Cam Nguyen, Paul H. Park, Tharcisse Mpunga, Lawrence N. Shulman, Alexandra Fehr,Gilbert Rukundo, Jean Bosco Bigirimana, Stephanie Teeple, Catherine Kigonya, Gilles Francois Ndayisaba, Francois Uwinkindi, Thomas Randall, and Ann C. Miller
Region / country: Central Africa, Eastern Africa – Rwanda
Speciality: Obstetrics and Gynaecology, Surgical oncology

Background:
Cervical cancer is among the most common cancers affecting women globally. Where treatment is available in low- and middle-income countries, many women become lost to follow-up (LTFU) at various points of care.

Objective:
This study assessed predictors of LTFU among cervical cancer patients in rural Rwanda.

Methods:
We conducted a retrospective study of cervical cancer patients enrolled at Butaro Cancer Center of Excellence (BCCOE) between 2012 and 2017 who were either alive and in care or LTFU at 12 months after enrollment. Patients are considered early LTFU if they did not return to clinic after the first visit and late LTFU if they did not return to clinic after the second visit. We conducted two multivariable logistic regressions to determine predictors of early and late LTFU.

Findings:
Of 652 patients in the program, 312 women met inclusion criteria, of whom 47 (15.1%) were early LTFU, 78 (25.0%) were late LTFU and 187 (59.9%) were alive and in care. In adjusted analyses, patients with no documented disease stage at presentation were more likely to be early LTFU vs. patients with stage 1 and 2 when controlling for other factors (aOR: 14.93, 95% CI 6.12–36.43). Patients who travel long distances (aOR: 2.25, 95% CI 1.11, 4.53), with palliative care as type of treatment received (aOR: 6.65, CI 2.28, 19.40) and patients with missing treatment (aOR: 7.99, CI 3.56, 17.97) were more likely to be late LTFU when controlling for other factors. Patients with ECOG status of 2 and higher were less likely to be late LTFU (aOR: 0.26, 95% CI 0.08, 0.85).

Conclusion:
Different factors were associated with early and later LTFU. Enhanced patient education, mechanisms to facilitate diagnosis at early stages of disease, and strategies that improve patient tracking and follow-up may reduce LTFU and improve patient retention.


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301. Building global surgical workforce capacity through academic partnerships

Journal of Public Health and Emergency


Authors: Zineb Bentounsi, Anisa Nazir
Region / country: Global
Speciality: Health policy, Surgical Education

Nearly 5 billion of the world’s growing population lacks access to safe, accessible and equitable surgical care. It results in millions of disabilities and death due to common diseases treated surgically. The severe shortage of the surgical workforce, as well as the unequal distribution of providers in urban, compared with rural areas, is a challenge faced by many communities. Global surgery academic partnerships between institutions in high-income countries (HICs) and low-middle income countries have played an essential role in developing surgical workforce capacity. There is also an increased interest from students and trainees in HICs to partake in international training opportunities. However, not all partnerships are equal and sometimes raise critical ethical concerns. Various recommendations have been made to define and create equitable, sustainable and ethical collaborations that focus on the priorities of the low-middle-income country (LMIC) institutions and trainees. In this article, we review some of the academic partnerships that exist and other training models that provide sustainable and accessible education and resources for mutual learning between surgical trainees from both high-income and low-middle income countries. There is an overwhelming need for high-income and low-income institutions to work together to create equitable and ethical partnerships and build a workforce to provide safe and accessible surgery for all.


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302. Surgery and universal health coverage: Designing an essential package for surgical care expansion and scale-up

Journal of Global Health


Authors: Ché L Reddy, Dominique Vervoort, John G Meara, and Rifat Atun
Region / country: Global
Speciality: Health policy

Five billion people worldwide lack access to safe, timely, and affordable surgical and anaesthesia care, resulting in over 18 million deaths each year and one-third of the global burden of disease. In 2015, the World Health Organization and the Member States recognised surgical and anaesthesia care as a component of universal health coverage (UHC). National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs) are long-term, strategic plans being developed by several low- and middle-income countries to strengthen emergency and essential surgical services by embedding within the government’s broader plans to implement UHC. Crucial, however, is the need for countries to define which surgical services should be included in essential health service packages. An approach that prioritises populations with the greatest need is vital for achieving financial risk protection and equity in global health. NSOAPs uniquely cross-cut health systems, allowing for the convergence of emergency and essential surgical care with other essential health services to meet broader UHC objectives.

How should surgical care (including obstetrics and gynaecology, anaesthesia, and the whole surgical ecosystem) be integrated within universal health coverage (UHC)? What surgical procedures should be included in essential health care packages? Who will receive such services? Who will pay? These are some of the questions that confront governments seeking to improve surgical care through UHC. These questions are not only daunting from a health systems perspective but also because of the scale of governmental challenges in increasingly uncertain political, economic, and socio-cultural contexts. The third Sustainable Development Goal (SDG Target 3.8) identifies UHC as a target for countries to attain by 2030 [1]. Surgical care is an integral component of UHC [2]: one-third of the global burden of disease, it is estimated, requires surgical intervention; 18 million people die from surgically treatable conditions annually [3]; and an additional 4.2 million die within 30 days of a surgical procedure each year [4,5]. There is an imperative to provide access to safe, timely, and affordable surgical services as part of UHC to achieve equity in global health systems.


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303. A Novel and Simple Technique of Reconstructing the Central Arch Mandibular Defects-a Solution During the Resource-Constrained Setting of COVID Crisis

Indian Journal of Surgical Oncology


Authors: Shiv Rajan, Naseem Akhtar, Vijay Kumar, Sameer Gupta, Sanjeev Misra, Arun Chaturvedi, Puneet Prakash, and Tashbihul Azhar
Region / country: South-eastern Asia – India
Speciality: ENT surgery, Maxillofacial and oral surgery, Plastic surgery, Surgical Education

The current COVID 19 pandemic has a major impact on healthcare delivery globally. Oral cancer involving anterior arch of mandible is difficult to reconstruct and ideally, requires free fibular osteomyocutaneous flap. During this time of resource constraint situation, these free flaps are not a great choice, as it increases exposure of both patient and surgical team to the deadly virus. We are describing a novel method of reconstruction after resection of oral cancer involving anterior arch of mandible. In this new technique, we have reconstructed central arch defect by hanging bipaddle pectoralis major myocutaneous flap with orbicularis oris muscle using ethylene terephthalate suture. Operative time, early postoperative complications and early cosmetic and functional outcome were assessed. We have used this novel technique in eight patients of T4a oral cancer involving anterior arch of mandible and skin over chin. Mean operative time was 180 min. One patient had minor flap loss with surgical site infection (Clavien-Dindo grade I). In all patients, we were able to discharge all patients on eighth postoperative day. Cosmetic outcome and functional outcomes were mostly satisfactory. All patients were able to oppose their lips without any oral incompetence and drooling. Tongue mobility was good. There was no incidence of ‘Andy Gump deformity’. This is a feasible option for reconstructing anterior arch defect in resource- and time-limited setting of COVID 19 pandemic. This technique can also be used in comorbid conditions where it is not advisable to do very long surgery.


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304. Which Surgical Operations Should be Performed in District Hospitals in East, Central and Southern Africa? Results of a Survey of Regional Clinicians

World Journal of Surgery


Authors: Zineb Bentounsi, Chris Lavy, Chiara Pittalis, Morgane Clarke, Jean Rizk, Grace Le, Ruairi Brugha, Eric Borgstein & Jakub Gajewski
Region / country: Central Africa, Eastern Asia, Southern Africa
Speciality: Health policy

Background
In East, Central and Southern Africa (ECSA), district hospitals (DH) are the main source of surgical care for 80% of the population. DHs in Africa must provide basic life-saving procedures, but the extent to which they can offer other general and emergency surgery is debated. Our paper contributes to this debate through analysis and discussion of regional surgical care providers’ perspectives.

Methods
We conducted a survey at the College of Surgeons of East, Central and Southern Africa Conference in Kigali in December 2018. The survey presented the participants with 59 surgical and anaesthesia procedures and asked them if they thought the procedure should be done in a district level hospital in their region. We then measured the level of positive agreement (LPA) for each procedure and conducted sub-analysis by cadre and level of experience.

Results
We had 100 respondents of which 94 were from ECSA. Eighteen procedures had an LPA of 80% or above, among which appendicectomy (98%), caesarean section (97%) and spinal anaesthesia (97%). Twenty-one procedures had an LPA between 31 and 79%. The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. Twenty procedures had an LPA below 30% among which paediatric anaesthesia and surgery.

Conclusion
Our study offers the perspectives of almost 100 surgical care providers from ECSA on which surgical and anaesthesia procedures should be provided in district hospitals. This might help in planning surgical care training and delivery in these hospitals.


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305. The landscape of academic global surgery: a rapid review

Research Gate


Authors: Jayoung Park, Mee-Lang Cheoun, Sugy Choi, Jongho Heo, Woong-Han Kim
Region / country: Global
Speciality: Other, Surgical Education

Interest in academic global surgery, which comprises clinical, educational, and research collaborations to improve surgical care between academic surgeons in high-income countries and low- and middle-income countries (LMICs) and their corresponding academic institutions, has grown over the years. However, there is no collective knowledge of academic global surgery. Thus, this review aims to understand the current landscape of academic global surgery and discuss future directions. A rapid review, a streamlined approach, was conducted to identify and summarize emerging studies systematically. The keywords applied in the search strategy were “global surgery” and “academic programs”. The total number of retrieved articles in PubMed was 390, and after the investigation, 20 articles were extensively reviewed for the result section. According to the results, this study provided findings regarding: (I) perceptions of residents, faculty, and surgical program directors toward academic global surgery programs, (II) key program characteristics of implemented academic global surgery programs, and (III) evaluation results of available academic global surgery programs. We also drew lessons and challenges for a useful guide for future academic global surgery research and the development of optimal educational programs. This review identified a small but rich set of information on academic global surgery. Further research and discussion are needed on how to successfully incorporate the academic global surgery program into medical institutions


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306. Surgical referrals in Northern Tanzania: a prospective assessment of rates, preventability, reasons and patterns

BMC Health Services Research


Authors: Desmond T. Jumbam, Gopal Menon, Tenzing N. Lama, William Lodge II, Sarah Maongezi, Ntuli A. Kapologwe, Isabelle Citron, David Barash, John Varallo, Erin Barringer, Monica Cainer, Mpoki Ulisubisya, Shehnaz Alidina & Boniface Nguhuni
Region / country: Eastern Africa – Tanzania
Speciality: Health policy

Background
An effective referral system is essential for a high-quality health system that provides safe surgical care while optimizing patient outcomes and ensuring efficiency. The role of referral systems in countries with under-resourced health systems is poorly understood. The aim of this study was to examine the rates, preventability, reasons and patterns of outward referrals of surgical patients across three levels of the healthcare system in Northern Tanzania.

Methods
Referrals from surgical and obstetric wards were assessed at 20 health facilities in five rural regions prospectively over 3 months. Trained physician data collectors used data collection forms to capture referral details daily from hospital referral letters and through discussions with clinicians and nurses. Referrals were deemed preventable if the presenting condition was one that should be managed at the referring facility level per the national surgical, obstetric and anaesthesia plan but was referred.

Results
Seven hundred forty-three total outward referrals were recorded during the study period. The referral rate was highest at regional hospitals (2.9%), followed by district hospitals (1.9%) and health centers (1.5%). About 35% of all referrals were preventable, with the highest rate from regional hospitals (70%). The most common reasons for referrals were staff-related (76%), followed by equipment (55%) and drugs or supplies (21%). Patient preference accounted for 1% of referrals. Three quarters of referrals (77%) were to the zonal hospital, followed by the regional hospitals (17%) and district hospitals (12%). The most common reason for referral to zonal (84%) and regional level (66%) hospitals was need for specialist care while the most common reason for referral to district level hospitals was non-functional imaging diagnostic equipment (28%).

Conclusions
Improving the referral system in Tanzania, in order to improve quality and efficiency of patient care, will require significant investments in human resources and equipment to meet the recommended standards at each level of care. Specifically, improving access to specialists at regional referral and district hospitals is likely to reduce the number of preventable referrals to higher level hospitals, thereby reducing overcrowding at higher-level hospitals and improving the efficiency of the health system.


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307. Antibiotic Use in Low and Middle-Income Countries and the Challenges of Antimicrobial Resistance in Surgery

Antibiotics


Authors: Massimo Sartelli, Timothy C Hardcastle, Fausto Catena, Alain Chichom-Mefire, Federico Coccolini, Sameer Dhingra, Mainul Haque, Adrien Hodonou, Katia Iskandar, Francesco M Labricciosa, Cristina Marmorale, Ibrahima Sall, Leonardo Pagani
Region / country: Global
Speciality: General surgery, Health policy

Antimicrobial resistance (AMR) is a phenomenon resulting from the natural evolution of microbes. Nonetheless, human activities accelerate the pace at which microorganisms develop and spread resistance. AMR is a complex and multidimensional problem, threatening not only human and animal health, but also regional, national, and global security, and the economy. Inappropriate use of antibiotics, and poor infection prevention and control strategies are contributing to the emergence and dissemination of AMR. All healthcare providers play an important role in preventing the occurrence and spread of AMR. The organization of healthcare systems, availability of diagnostic testing and appropriate antibiotics, infection prevention and control practices, along with prescribing practices (such as over-the-counter availability of antibiotics) differs markedly between high-income countries and low and middle-income countries (LMICs). These differences may affect the implementation of antibiotic prescribing practices in these settings. The strategy to reduce the global burden of AMR includes, among other aspects, an in-depth modification of the use of existing and future antibiotics in all aspects of medical practice. The Global Alliance for Infections in Surgery has instituted an interdisciplinary working group including healthcare professionals from different countries with different backgrounds to assess the need for implementing education and increasing awareness about correct antibiotic prescribing practices across the surgical pathways. This article discusses aspects specific to LMICs, where pre-existing factors make surgeons’ compliance with best practices even more important.


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308. Clinical course and short-term outcome of postsplenectomy reactive thrombocytosis in children without myeloproliferative disorders: A single institutional experience from a developing country

plos one


Authors: Zlatan Zvizdic, Aladin Kovacevic, Emir Milisic, Asmir Jonuzi, Semir Vranic
Region / country: Southern Europe – Bosnia & Herzegovina
Speciality: General surgery

Objectives: To evaluate the clinical outcome and complications in the pediatric population who had splenectomy at our institution, emphasizing the incidence of postplenectomy reactive thrombocytosis (RT) and its clinical significance in children without underlying hematological malignancies.

Materials and methods: The medical records of pediatric patients undergoing splenectomy were retrospectively reviewed for the period 1999-2018. The following variables were analyzed: Demographic parameters (age, sex), indications for surgery, operative procedures, preoperative and postoperative platelet count (postplenectomy RT), the use of anticoagulant therapy, and postoperative complications. The patients were divided into two groups according to indications for splenectomy: The non-neoplastic hematology group and the non-hematology group (splenectomy for trauma or other spleen non-hematological pathology).

Results: Fifty-two pediatric (37 male and 15 female) patients who underwent splenectomy at our institution were reviewed. Thirty-four patients (65%) were in the non-hematological group (splenic rupture, cysts, and abscess) and 18 patients (35%) in the non-neoplastic hematological group (hereditary spherocytosis and immune thrombocytopenia). The two groups did not differ significantly in regards to the patients’ age, sex, and preoperative platelet count (P>0.05 for all variables). Forty-nine patients (94.2%) developed postplenectomy RT. The percentages of mild, moderate and extreme thrombocytosis were 48.9%, 30.7%, and 20.4%, respectively. The comparisons of RT patients between the non-neoplastic hematology and the non-hematology group revealed no significant differences in regards to the patients’ age, sex, preoperative and postoperative platelet counts, preoperative and postoperative leukocyte counts, and the average length of hospital stay (P>0.05 for all variables). None of the patients from the cohort was affected by any thrombotic or hemorrhagic complications.

Conclusions: We confirm that RT is a very common event following splenectomy, but in this study it was not associated with clinically evident thrombotic or hemorrhagic complications in children undergoing splenectomy for trauma, structural lesions or non-neoplastic hematological disorders.


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309. Initial Experience Using 3-Dimensional Printed Models for Head and Neck Reconstruction in Haiti

Ear, Nose & Throat Journal


Authors: Swar Vimawala, Terry Gao, Jared Goldfarb, Dominick Gadaleta, Bon Ku, Patrick Jean-Gilles, Adam Luginbuhl, Robert Pugliese, Donald Weed, Joseph M Curry
Region / country: Caribbean – Haiti
Speciality: ENT surgery, Surgical Education

This report describes the first use of a novel workflow for in-house computer-aided design (CAD) for application in a resource-limited surgical outreach setting. Preoperative computed tomography imaging obtained locally in Haiti was used to produce rapid-prototyped 3-dimensional (3D) mandibular models for 2 patients with large ameloblastomas. Models were used for patient consent, surgical education, and surgical planning. Computer-aided design and 3D models have the potential to significantly aid the process of complex surgery in the outreach setting by aiding in surgical consent and education, in addition to expected surgical applications of improved anatomic reconstruction.


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310. Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade

international journal of health policy and management


Authors: Jaymie A Henry, Angela S Volk, Sicily K Kariuki, Kiraitu Murungi, Trina Firmalo, Ruth Laibon Masha, Orion Henry, Peter Arimi, Patrick Mwai, Estella Waiguru, Evans Mwiti, Dan Okoro, Angella Langat, Cosmas Mugambi, Erin Anastasi, Gillian Slinger, Chris Lavy, Rosalind Owen, Erin Stieber, Marc Lester Suntay, Danny Haddad, Robert Lane, Joel Buenaventura, Neil Parsan, Fizan Abdullah, Michael Nebeker, Lismore Nebeker, Charles Mock, Larry Hollier, Pankaj Jani
Region / country: Global
Speciality: General surgery

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society’s role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.


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311. An Endovascular Surgery Experience in Far-Forward Military Healthcare-A Case Series

Military medicine


Authors: Daniel J Coughlin, Jason H Boulter, Charles A Miller, Brian P Curry, Jacob Glaser, Nathanial Fernandez, Randy S Bell, Albert J Schuette
Region / country: Central Asia – Afghanistan
Speciality: Vascular surgery

Introduction: The advancement of interventional neuroradiology has drastically altered the treatment of stroke and trauma patients. These advancements in first-world hospitals, however, have rarely reached far forward military hospitals due to limitations in expertise and equipment. In an established role III military hospital though, these life-saving procedures can become an important tool in trauma care.

Materials and methods: We report a retrospective series of far-forward endovascular cases performed by 2 deployed dual-trained neurosurgeons at the role III hospital in Kandahar, Afghanistan during 2013 and 2017 as part of Operations Resolute Support and Enduring Freedom.

Results: A total of 15 patients were identified with ages ranging from 5 to 42 years old. Cases included 13 diagnostic cerebral angiograms, 2 extremity angiograms and interventions, 1 aortogram and pelvic angiogram, 1 bilateral embolization of internal iliac arteries, 1 lingual artery embolization, 1 administration of intra-arterial thrombolytic, and 2 mechanical thrombectomies for acute ischemic stroke. There were no complications from the procedures. Both embolizations resulted in hemorrhage control, and 1 of 2 stroke interventions resulted in the improvement of the NIH stroke scale.

Conclusions: Interventional neuroradiology can fill an important role in military far forward care as these providers can treat both traumatic and atraumatic cerebral and extracranial vascular injuries. In addition, knowledge and skill with vascular access and general interventional radiology principles can be used to aid in other lifesaving interventions. As interventional equipment becomes more available and portable, this relatively young specialty can alter the treatment for servicemen and women who are injured downrange.


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312. Trauma system developments reduce mortality in hospitalized trauma patients in Al-Ain City, United Arab Emirates, despite increased severity of injury

World J Emerg Surg


Authors: David O Alao, Arif Alper Cevik, Hani O Eid, Zia Jummani, Fikri M Abu-Zidan
Region / country: Middle East – United Arab Emirates
Speciality: Trauma surgery

Background: Trauma is a leading cause of death in the United Arab Emirates (UAE). There have been major developments in the trauma system in Al-Ain City during the last two decades. We aimed to study the effects of these developments on the trauma pattern, severity, and clinical outcome of hospitalized trauma patients in Al-Ain City, United Arab Emirates.

Methods: This is a retrospective analysis of two separate sets of prospectively collected trauma registry data of Al-Ain Hospital. Data were collected over two periods: from March 2003 to March 2006 and from January 2014 to December 2017. Demography, injury mechanism, injury location, and clinical outcomes of 2573 trauma patients in the first period were compared with 3519 patients in the second period.

Results: Trauma incidence decreased by 38.2% in Al-Ain City over the last 10 years. Trauma to females, UAE nationals, and the geriatric population significantly increased over time (p < 0.0001, Fisher's exact test for each). Falls on the same level significantly increased over time, while road traffic collisions and falls from height significantly decreased over time (p < 0.0001, Fisher's exact test for each). Mortality significantly decreased over time (2.3% compared with 1%, p < 0.0001, Fisher's exact test).

Conclusions: Developments in the trauma system of our city have reduced mortality in hospitalized trauma patients by 56% despite an increased severity of injury. Furthermore, the injury incidence in our city decreased by 38.2% over the last decade. This was mainly in road traffic collisions and work-related injuries. Nevertheless, falls on the same level in the geriatric population continue to be a significant problem that needs to be addressed.


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313. COVID-19’s Impact on Neurosurgical Training in Southeast Asia

World Neurosurg


Authors: Nunthasiri Wittayanakorn, Vincent Diong Weng Nga, Mirna Sobana, Nor Faizal Ahmad Bahuri, Ronnie E Baticulon
Region / country: South-eastern Asia – Indonesia, Malaysia, Philippines, Singapore, Thailand
Speciality: Neurosurgery, Surgical Education

Objective: Neurosurgery departments worldwide have been forced to restructure their training programs due to the coronavirus disease 2019 (COVID-19) pandemic. In this study, we describe the impact of COVID-19 on neurosurgical training in Southeast Asia.

Methods: We conducted an online survey among neurosurgery residents in Indonesia, Malaysia, Philippines, Singapore, and Thailand from 22 to 31 May 2020 using Google Forms. The 33-item questionnaire collected data on elective and emergency neurosurgical operations, ongoing learning activities, and health worker safety.

Results: A total of 298 out of 470 neurosurgery residents completed the survey, equivalent to a 63% response rate. The decrease in elective neurosurgical operations in Indonesia and in the Philippines (median=100% for both) was significantly greater compared with other countries (p <.001). For emergency operations, trainees in Indonesia and Malaysia had a significantly greater reduction in their caseload (median=80% and 70%, respectively) compared with trainees in Singapore and Thailand (median=20% and 50%, respectively, p <.001). Neurosurgery residents were most concerned about the decrease in their hands-on surgical experience, uncertainty in their career advancement, and occupational safety in the workplace. Most of the residents (221, 74%) believed that the COVID-19 crisis will have a negative impact on their neurosurgical training overall.

Conclusions: An effective national strategy to control COVID-19 is crucial to sustain neurosurgical training and to provide essential neurosurgical services. Training programs in Southeast Asia should consider developing online learning modules and setting up simulation laboratories, to allow trainees to systematically acquire knowledge and develop practical skills during these challenging times.


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314. Sword of Damocles: application of the ethical principles of resource allocation to essential cancer surgery patients requiring beds in limited supply during the COVID-19 pandemic

Eur Surg


Authors: Sammy Al-Benna
Region / country: Global
Speciality: Health policy, Surgical oncology

As a surge of COVID-19 (coronavirus disease 2019) patients strains the health care systems, shortages of health care professionals and life-saving equipment such as ventilators are forcing hospitals to make difficult decisions [1, 2]. It is critical that these health care systems consider whether non-essential surgical procedures can be delayed to ration medical equipment and interventions. Theatre list shortages occur for many reasons, including lack of beds, lack of ventilators, lack of anaesthetic staff, lack of surgical staff, lack of nursing staff and material shortages (e.g. personal protective equipment). Contributing to resource scarcity is the prolonged intubation many COVID-19 patients require as they recover from pneumonia, often two to three weeks, with several hours spent in the prone position and then, typically, a very slow weaning. During shortages, health care systems must determine how to fairly distribute these scarce resources to patients. Unfortunately, no single distribution framework applies to all shortages. However, general allocation principles for scarce health care resources, grounded in distributive justice and utility, can be applied, although particular rules will differ depending on the circumstances.


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315. Postoperative Pulmonary Complications in Complex Pediatric and Adult Spine Deformity: A Retrospective Review of Consecutive Patients Treated at a Single Site in West Africa

Global Spine Journal


Authors: Irene Wulff 1, Henry Ofori Duah 1, Henry Osei Tutu 1, Gerhard Ofori-Amankwah 1, Kwadwo Poku Yankey, Mabel Adobea Owiredu, Halima Bidemi Yahaya, Harry Akoto, Audrey Oteng-Yeboah, Oheneba Boachie-Adjei, FOCOS Spine Research Group
Region / country: Western Africa – Ghana
Speciality: Neurosurgery, Trauma and orthopaedic surgery

Study Design:
Retrospective review of consecutive series.

Objectives:
This study sought to assess the incidence, risk factors, and outcomes of pulmonary complication following complex spine deformity surgery in a low-resourced setting in West Africa.

Methods:
Data of 276 complex spine deformity patients aged 3 to 25 years who were treated consecutively was retrospectively reviewed. Patients were categorized into 2 groups during data analysis based on pulmonary complication status: group 1: yes versus group 2: no. Comparative descriptive and inferential analysis were performed to compare the 2 groups.

Results:
The incidence of pulmonary complication was 17/276 (6.1%) in group 1. A total of 259 patients had no events (group 2). There were 8 males and 9 females in group 1 versus 100 males and 159 females in group 2. Body mass index was similar in both groups (17.2 vs 18.4 kg/m2, P = .15). Average values (group 1 vs group 2, respectively) were as follows: preoperative sagittal Cobb angle (90.6° vs 88.7°, P = .87.), coronal Cobb angle (95° vs 88.5°, P = .43), preoperative forced vital capacity (45.3% vs 62.0%, P = .02), preoperative FEV1 (forced expiratory volume in 1 second) (41.9% vs 63.1%, P < .001). Estimated blood loss, operating room time, and surgery levels were similar in both groups. Thoracoplasty and spinal osteotomies were performed at similar rates in both groups, except for Smith-Peterson osteotomy. Multivariate logistic regression showed that every unit increase in preoperative FEV1 (%) decreases the odds of pulmonary complication by 9% (OR = 0.91, 95% CI 0.84-0.98, P = .013).

Conclusion:
The observed 6.1% incidence of pulmonary complications is comparable to reported series. Preoperative FEV1 was an independent predictor of pulmonary complications. The observed case fatality rate following pulmonary complications (17%) highlights the complexity of cases in underserved regions and the need for thorough preoperative evaluation to identify high-risk patients.


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316. Increases in cholecystectomy for gallstone related disease in South Africa

Scientific Reports


Authors: Zafar Ahmed Khan, Muhammed Uzayr Khan, Martin Brand
Region / country: Southern Africa – South Africa, Zimbabwe
Speciality: General surgery

tudies suggest that the rate gallstone disease in Africa is low. Previous studies suggested an increase in gallstone rates and cholecystectomies related to urbanization and the adoption of Western lifestyle habits. This study examined cholecystectomy rates for gallstone disease in South Africa (SA). An audit of cholecystectomies in SA was done by reviewing gallbladder specimens processed by the SA National Health Laboratory Service (NHLS) from 2004 and 2014. Urbanization rates were obtained from Statistics South Africa and BMI data from previously published studies. Fisher’s exact test, t test’s and Pearson’s R were used for comparisons; cholecystectomy rates were calculated per 100,000 population. 33,467 cholecystectomy specimens were analysed. There was a 92% absolute increase in cholecystectomies during the study period (Pearson r 0.94; p < 0.01) with the overall cholecystectomy rate increasing by 65% from 8.36 to 13.81 per 100,000 population. The data was divided into two equal periods and compared. During the second period there was a 28.8% increase in the number cholecystectomies and patients were significantly younger (46.9 vs 48.2 years; p ≤ 0.0001). The Northern Cape was the only province to show a decline in the cholecystectomy rate in this period and was also the only province to record a decline in urbanization. Population based studies in SA demonstrate increases in BMI and an association with increased urbanization. This nationwide African study demonstrates a sustained increase in cholecystectomies for gallstone disease. Increases in BMI and urbanization may be responsible for this trend.


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317. Interventions to improve the quality of cataract services: protocol for a global scoping review

BMJ Open


Authors: Miho Yoshizaki Jacqueline Ramke, João M Furtado, Helen Burn, Stephen Gichuhi, Iris Gordon, Ada Aghaji, Ana P Marques, William H Dean, Nathan Congdon, John Buchan, Matthew J Burton
Region / country: Global
Speciality: Ophthalmology

Introduction
Cataract is the leading cause of blindness globally and a major cause of vision impairment. Cataract surgery is an efficacious intervention that usually restores vision. Although it is one of the most commonly conducted surgical interventions worldwide, good quality services (from being detected with operable cataract to undergoing surgery and receiving postoperative care) are not universally accessible. Poor quality understandably reduces the willingness of people with operable cataract to undergo surgery. Therefore, it is critical to improve the quality of care to subsequently reduce vision loss from cataract. This scoping review aims to summarise the nature and extent of the published literature on interventions to improve the quality of services for primary age-related cataract globally.

Methods and analysis
We will search MEDLINE, Embase and Global Health for peer-reviewed manuscripts published since 1990, with no language, geographic or study design restrictions. To define quality, we have used the elements adopted by the WHO—effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency—to which we have added the element of planetary health. We will exclude studies focused on the technical aspects of the surgical procedure and studies that only involve children (<18 years). Two reviewers will screen all titles/abstracts independently, followed by a full-text review of potentially relevant articles. For included articles, data regarding publication characteristics, study details and quality-related outcomes will be extracted by two reviewers independently. Results will be synthesised narratively and presented visually using a spider chart.

Ethics and dissemination
Ethical approval was not sought, as our review will only include published and publicly accessible information. We will publish our findings in an open-access peer-reviewed journal and develop an accessible summary of the results for website posting. A summary of the results will be included in the ongoing Lancet Global Health Commission on Global Eye Health.


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318. A geospatial analysis of two-hour surgical access to district hospitals in South Africa

BMC Health Serv Res


Authors: Kathryn M Chu, Angela J Dell, Harry Moultrie, Candy Day, Megan Naidoo, Stephanie van Straten, Sarah Rayne
Region / country: Southern Africa – South Africa
Speciality: Emergency surgery, Health policy, Obstetrics and Gynaecology

Background
In a robust health care system, at least 80% of a country’s population should be able to access a district hospital that provides surgical care within 2 hours. The objective was to identify the proportion of the population living within 2 hours of a district hospital with surgical capacity in South Africa.

Methods
All government hospitals in the country were identified. Surgical district hospitals were defined as district hospitals with a surgical provider, a functional operating theatre, and the provision of at least one caesarean section annually. The proportion of the population within two-hour access was estimated using service area methods.

Results
Ninety-eight percent of the population had two-hour access to any government hospital in South Africa. One hundred and thirty-eight of 240 (58%) district hospitals had surgical capacity and 86% of the population had two-hour access to these facilities.

Conclusion
Improving equitable surgical access is urgently needed in sub-Saharan Africa. This study demonstrated that in South Africa, just over half of district hospitals had surgical capacity but more than 80% of the population had two-hour access to these facilities. Strengthening district hospital surgical capacity is an international mandate and needed to improve access.


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319. Mobile technologies to support healthcare provider to healthcare provider communication and management of care

Cochrane Database Syst Rev


Authors: Daniela C Gonçalves-Bradley, Ana Rita J Maria, Ignacio Ricci-Cabello, Gemma Villanueva, Marita S Fønhus, Claire Glenton, Simon Lewin , Nicholas Henschke, Brian S Buckley, Garrett L Mehl, Tigest Tamrat, Sasha Shepperd
Region / country: Global
Speciality: Health policy, Surgical Education

Background: The widespread use of mobile technologies can potentially expand the use of telemedicine approaches to facilitate communication between healthcare providers, this might increase access to specialist advice and improve patient health outcomes.

Objectives: To assess the effects of mobile technologies versus usual care for supporting communication and consultations between healthcare providers on healthcare providers’ performance, acceptability and satisfaction, healthcare use, patient health outcomes, acceptability and satisfaction, costs, and technical difficulties.

Search methods: We searched CENTRAL, MEDLINE, Embase and three other databases from 1 January 2000 to 22 July 2019. We searched clinical trials registries, checked references of relevant systematic reviews and included studies, and contacted topic experts.

Selection criteria: Randomised trials comparing mobile technologies to support healthcare provider to healthcare provider communication and consultations compared with usual care.

Data collection and analysis: We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence.

Main results: We included 19 trials (5766 participants when reported), most were conducted in high-income countries. The most frequently used mobile technology was a mobile phone, often accompanied by training if it was used to transfer digital images. Trials recruited participants with different conditions, and interventions varied in delivery, components, and frequency of contact. We judged most trials to have high risk of performance bias, and approximately half had a high risk of detection, attrition, and reporting biases. Two studies reported data on technical problems, reporting few difficulties. Mobile technologies used by primary care providers to consult with hospital specialists We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: – probably make little or no difference to primary care providers following guidelines for people with chronic kidney disease (CKD; 1 trial, 47 general practices, 3004 participants); – probably reduce the time between presentation and management of individuals with skin conditions, people with symptoms requiring an ultrasound, or being referred for an appointment with a specialist after attending primary care (4 trials, 656 participants); – may reduce referrals and clinic visits among people with some skin conditions, and increase the likelihood of receiving retinopathy screening among people with diabetes, or an ultrasound in those referred with symptoms (9 trials, 4810 participants when reported); – probably make little or no difference to patient-reported quality of life and health-related quality of life (2 trials, 622 participants) or to clinician-assessed clinical recovery (2 trials, 769 participants) among individuals with skin conditions; – may make little or no difference to healthcare provider (2 trials, 378 participants) or participant acceptability and satisfaction (4 trials, 972 participants) when primary care providers consult with dermatologists; – may make little or no difference for total or expected costs per participant for adults with some skin conditions or CKD (6 trials, 5423 participants). Mobile technologies used by emergency physicians to consult with hospital specialists about people attending the emergency department We assessed the certainty of evidence for this group of trials as moderate. Mobile technologies: – probably slightly reduce the consultation time between emergency physicians and hospital specialists (median difference -12 minutes, 95% CI -19 to -7; 1 trial, 345 participants); – probably reduce participants’ length of stay in the emergency department by a few minutes (median difference -30 minutes, 95% CI -37 to -25; 1 trial, 345 participants). We did not identify trials that reported on providers’ adherence, participants’ health status and well-being, healthcare provider and participant acceptability and satisfaction, or costs. Mobile technologies used by community health workers or home-care workers to consult with clinic staff We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: – probably make little or no difference in the number of outpatient clinic and community nurse consultations for participants with diabetes or older individuals treated with home enteral nutrition (2 trials, 370 participants) or hospitalisation of older individuals treated with home enteral nutrition (1 trial, 188 participants); – may lead to little or no difference in mortality among people living with HIV (RR 0.82, 95% CI 0.55 to 1.22) or diabetes (RR 0.94, 95% CI 0.28 to 3.12) (2 trials, 1152 participants); – may make little or no difference to participants’ disease activity or health-related quality of life in participants with rheumatoid arthritis (1 trial, 85 participants); – probably make little or no difference for participant acceptability and satisfaction for participants with diabetes and participants with rheumatoid arthritis (2 trials, 178 participants). We did not identify any trials that reported on providers’ adherence, time between presentation and management, healthcare provider acceptability and satisfaction, or costs.

Authors’ conclusions: Our confidence in the effect estimates is limited. Interventions including a mobile technology component to support healthcare provider to healthcare provider communication and management of care may reduce the time between presentation and management of the health condition when primary care providers or emergency physicians use them to consult with specialists, and may increase the likelihood of receiving a clinical examination among participants with diabetes and those who required an ultrasound. They may decrease the number of people attending primary care who are referred to secondary or tertiary care in some conditions, such as some skin conditions and CKD. There was little evidence of effects on participants’ health status and well-being, satisfaction, or costs.


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320. Implementing oncology clinical trials in Nigeria: a model for capacity building

BMC Health Serv Res


Authors: Atara Ntekim, Abiola Ibraheem, Adenike Adeniyi-Sofoluwe, Toyosi Adepoju, Mojisola Oluwasanu, Toyin Aniagwu, Olutosin Awolude, Williams Balogun, Olayinka Kotila, Prisca Adejumo, Chinedum Peace Babalola, Ganiyu Arinola, Oladosu Ojengbede, Christopher O Olopade, Olufunmilayo I Olopade
Region / country: Western Africa – Nigeria
Speciality: Surgical oncology

Background: There is both higher mortality and morbidity from cancer in low and medium income countries (LMICs) compared with high income countries (HICs). Clinical trial activities and development of more effective and less toxic therapies have led to significant improvements in morbidity and mortality from cancer in HICs. Unfortunately, clinical trials remain low in LMICs due to poor infrastructure and paucity of experienced personnel to execute clinical trials. There is an urgent need to build local capacity for evidence-based treatment for cancer patients in LMICs.

Methods: We conducted a survey at facilities in four Teaching Hospitals in South West Nigeria using a checklist of information on various aspects of clinical trial activities. The gaps identified were addressed using resources sourced in partnership with investigators at HIC institutions.

Results: Deficits in infrastructure were in areas of patient care such as availability of oncology pharmacists, standard laboratories and diagnostic facilities, clinical equipment maintenance and regular calibrations, trained personnel for clinical trial activities, investigational products handling and disposals and lack of standard operating procedures for clinical activities. There were two GCP trained personnel, two study coordinators and one research pharmacist across the four sites. Interventions were instituted to address the observed deficits in all four sites which are now well positioned to undertake clinical trials in oncology. Training on all aspects of clinical trial was also provided.

Conclusions: Partnerships with institutions in HICs can successfully identify, address, and improve deficits in infrastructure for clinical trial in LMICs. The HICs should lead in providing funds, mentorship, and training for LMIC institutions to improve and expand clinical trials in LMIC countries.


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321. We Asked the Experts: Global Surgery—Seeing Beyond the Silo

World Journal of Surgery


Authors: Grace Umutesi, Justine Davies, Bethany L. Hedt-Gauthier
Region / country: Global
Speciality: Anaesthesia, Obstetrics and Gynaecology

The COVID-19 pandemic requires comprehensive health systems response, with 14% of infected people developing severe sickness leading to hospitalization and 5% admitted to an intensive care unit [1]. The need for oxygen and intensive care means that perhaps for the first time, surgery and anesthesia find themselves playing a central role in a global health emergency; but is global surgery integrated enough to the wider global health community to have an impact?


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322. Cost-Effectiveness of Operating on Traumatic Spinal Injuries in Low-Middle Income Countries: A Preliminary Report From a Major East African Referral Center

Global Spine Journal


Authors: Cost-Effectiveness of Operating on Traumatic Spinal Injuries in Low-Middle Income CounNoah L. Lessing, BS, Scott L. Zuckerman, MD, MPH, Albert Lazaro, MD, Ashley A. Leech, PhD, MS, Andreas Leidinger, MD, Nicephorus Rutabasibwa, MD, Hamisi K. Shabani, MD, PhD, Halinder S. Mangat, MD, Roger Härtl, MD
Region / country: Eastern Africa – Tanzania
Speciality: Neurosurgery, Trauma surgery

Study Design:
Retrospective cost-effectiveness analysis.

Objectives:
While the incidence of traumatic spine injury (TSI) is high in low-middle income countries (LMICs), surgery is rarely possible due to cost-prohibitive implants. The objective of this study was to conduct a preliminary cost-effectiveness analysis of operative treatment of TSI patients in a LMIC setting.

Methods:
At a tertiary hospital in Tanzania from September 2016 to May 2019, a retrospective analysis was conducted to estimate the cost-effectiveness of operative versus nonoperative treatment of TSI. Operative treatment included decompression/stabilization. Nonoperative treatment meant 3 months of bed rest. Direct costs included imaging, operating fees, surgical implants, and length of stay. Four patient scenarios were chosen to represent the heterogeneity of spine trauma: Quadriplegic, paraplegic, neurologic improvement, and neurologically intact. Disability-adjusted-life-years (DALYs) and incremental-cost-effectiveness ratios were calculated to determine the cost per unit benefit of operative versus nonoperative treatment. Cost/DALY averted was the primary outcome (i.e., the amount of money required to avoid losing 1 year of healthy life).

Results:
A total of 270 TSI patients were included (125 operative; 145 nonoperative). Operative treatment averaged $731/patient. Nonoperative care averaged $212/patient. Comparing operative versus nonoperative treatment, the incremental cost/DALY averted for each patient outcome was: quadriplegic ($112-$158/DALY averted), paraplegic ($47-$67/DALY averted), neurologic improvement ($50-$71/DALY averted), neurologically intact ($41-$58/DALY averted). Sensitivity analysis confirmed these findings without major differences.

Conclusions:
This preliminary cost-effectiveness analysis suggests that the upfront costs of spine trauma surgery may be offset by a reduction in disability. LMIC governments should consider conducting more spine trauma cost-effectiveness analyses and including spine trauma surgery in universal health care.


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323. Why Do They Leave? Challenges to Retention of Surgical Clinical Officers in District Hospitals in Malawi

international journal of health policy and management


Authors: Jakub Gajewski ,Marisa Wallace, Chiara Pittalis, Gerald Mwapasa, Eric Borgstein, Leon Bijlmakers, Ruairi Brugha
Region / country: Southern Africa – Malawi
Speciality: General surgery, Health policy

Background
Low- and middle-income countries (LMICs) are the worst affected by a lack of safe and affordable access to safe surgery. The significant unmet surgical need can be in part attributed to surgical workforce shortages that disproportionately affect rural areas of these countries. To combat this, Malawi has introduced a cadre of non-physician clinicians (NPCs) called clinical officers (COs), trained to the level of a Bachelor of Science (BSc) in Surgery. This study explored the barriers and enablers to their retention in rural district hospitals (DHs), as perceived by the first cohort of COs trained to BS