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1. 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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2. 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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3. 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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4. 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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5. 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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6. 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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7. 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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8. 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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9. 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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10. 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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11. 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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12. 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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13. 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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14. 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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15. 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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16. 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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17. 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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18. 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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19. 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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20. 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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21. 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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22. 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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23. 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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24. 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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25. 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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26. 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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27. 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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28. 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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29. 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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30. 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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31. 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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32. 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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33. 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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34. 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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35. 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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36. 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 BSc in Surgery level in Malawi.

Methods
A longitudinal qualitative research approach was used based on interviews with 16 COs, practicing at DHs, during their BSc training (2015); and again with 15 of them after their graduation (2019). Data from both time points were analysed and compared using a top-down thematic analysis approach.

Results
Of the 16 COs interviewed in 2015, 11 intended to take up a post at a DH following graduation; however, only 6 subsequently did so. The major barriers to remaining in a DH post as perceived by these COs were lack of promotion, a more attractive salary elsewhere; and unclear, stagnant career progression within surgery. For those who remained working in DH posts, the main enablers are a willingness to accept a low salary, to generate greater opportunities to engage in additional earning opportunities; the hope of promotional opportunities within the government system; and greater responsibility and recognition of their surgical knowledge and skills as a BSc-holder at the district level.

Conclusion
The sustainability of surgically trained NPCs in Malawi is not assured and further work is required to develop and implement successful retention strategies, which will require a multi-sector approach. This paper provides insights into barriers and enablers to retention of this newly-introduced cadre and has important lessons for policy-makers in Malawi and other countries employing NPCs to deliver essential surgery.


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37. Outcomes of trauma education workshop in Vietnam: improving diagnostic and surgical skills

BMC Medical Education


Authors: Sugy Choi, Jieun Kim, Jongho Heo, Dung Thi Ngoc Nguyen, Son Hong Nguyen, Woong-Han Kim
Region / country: South-eastern Asia – Vietnam
Speciality: Surgical Education, Trauma surgery

Background
Unintentional injuries have emerged as a significant public health issue in low- and middle-income countries (LMIC), especially in Vietnam, where there is a poor quality of care for trauma. A scarcity of formal and informal training opportunities contributes to a lack of structure for treating trauma in Vietnam. A collaborative trauma education project by the JW LEE Center for Global Medicine in South Korea and the Military Hospital 175 in Vietnam was implemented to enhance trauma care capacity among medical staff across Ho Chi Minh City in 2018. We aimed to evaluate a part of the trauma education project, a one-day workshop that targeted improving diagnostic and surgical skills among the medical staff (physicians and nurses).

Methods
A one-day workshop was offered to medical staff across Ho Chi Minh City, Vietnam in 2018. The workshop was implemented to enhance the trauma care knowledge of providers and to provide practical and applicable diagnostic and surgical skills. To evaluate the workshop outcomes, we utilized a mixed-methods survey data. All participants (n = 27) voluntarily completed the post-workshop questionnaire. Quality of contents, satisfaction with teaching skills, and perceived benefit were used as outcomes of the workshop, measured by 5-point Likert scales (score: 1–5). Descriptive statistics were performed, and open-ended questions were analyzed by recurring themes.

Results
The results from the post-workshop questionnaire demonstrated that the participants were highly satisfied with the quality of the workshop contents (mean = 4.32 standard deviation (SD) = 0.62). The mean score of the satisfaction regarding the teaching skills was 4.19 (SD = 0.61). The mean score of the perceived benefit from the workshop was 4.17 (SD = 0.63). The open-ended questions revealed that the program improved their knowledge in complex orthopedic surgeries neglected prior to training.

Conclusions
Positive learning experiences highlighted the need for the continuation of the international collaboration of skill development and capacity building for trauma care in Vietnam and other LMIC.


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38. Evaluation of Gasless Laparoscopy as a Tool for Minimal Access Surgery in Low- to Middle-Income Countries: A Phase II Non-Inferiority Randomized Controlled Study

J Am Coll Surg


Authors: Anurag Mishra, Lovenish Bains, Gnanaraj Jesudin, Noel Aruparayil, Rajdeep Singh, Shashi
Region / country: Southern Asia – India
Speciality: General surgery

Background: Minimal access surgery [MAS] is not available to most people in the rural areas of Low Middle-Income Countries [LMIC]. This leads to an increase in the morbidity and the economic loss to the poor and the marginalized. The Gasless laparoscopic surgeries [GAL] are possible in rural areas as they could be carried out under spinal-anaesthesia. In most cases, it does not require the logistics of providing gases for pneumoperitoneum and general anaesthesia. The current study compares GAL with conventional Laparoscopic surgeries [COL] for general surgical procedures METHODS: A single-centre, non-blinded randomized control trial [RCT] was conducted to evaluate non – inferiority of GAL versus COL at a teaching hospital in New Delhi. Patients were allocated into two groups and underwent MAS (Cholecystectomies and appendectomies). The procedure was carried out by two surgeons by randomly choosing between GAL and COL. The data was collected by postgraduates and analyzed by a biostatistician.

Results: 100 patients who met the inclusion criteria were allocated into two groups. No significant difference was observed in the mean operating time between GAL group (52.9 min) vs COL group (55 minutes) [p=0.3]. The intraoperative vital signs were better in the GAL group [p < 0.05]. The postoperative pain score was slightly higher in the GAL group [p = 0.01]; however, it did not require additional analgesics.

Conclusions: No significant differences were found between the two groups. GAL can be classed as non-inferior compared to COL and has the potential to be adopted in low resource settings.


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39. The physical impact of long bone fractures on adults in KwaZulu-Natal

South African Journal of Physiotherapy


Authors: Sevani Singaram, Mergan Naidoo
Region / country: Southern Africa – South Africa
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Background: Limb fractures are increasingly common in low-income and middle-income countries due to an increase in motor vehicle and other accidents. Fractures may often lead to physical impairment that affects an individual’s ability to carry out tasks.

Objectives: To assess the physical impact of long bone fractures on adults in KwaZulu-Natal.

Method: A standardised questionnaire pertaining to activities at home and leisure was used to establish patient-reported outcomes at nine public hospitals. English-speaking and isiZulu-speaking participants who had sustained a single long bone fracture in the preceding 4 to 12 weeks at the time of data collection were included. The following activities were evaluated: walking, running, exercising, driving, performing household chores, writing, answering telephones, texting on a cell phone, bathing, using crockery and preparing meals.

Results: A total of 821 participants completed the questionnaire. Ninety-three per cent had closed long bone fractures and 69 per cent were lower limb fractures. Fifty-seven per cent of the fractures were caused by a fall. Female participants (p = 0.19) with lower limb fractures were more likely to have greater difficulty in performing tasks and participants 60 years of age and older (p = 0.001) were significantly more likely to have difficulty performing tasks.

Conclusion: These findings illustrate the daily limitations in patients’ everyday activities at home, leisure and in activities such as driving.

Clinical implications: This study highlights the difficulty that some individuals, particularly women and individuals 60 years of age and older, face in performing daily tasks after experiencing a long bone fracture.


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40. Using modified Delphi method to propose and validate components of child injury surveillance system for Iran

Chinese Journal of Traumatology


Authors: Tania Azadi, Farahnaz Sadoughi, Davoud Khorasani-Zavareh
Region / country: Middle East – Iran
Speciality: Paediatric surgery, Trauma surgery

Purpose
Child injuries are a public health concern globally. Injury Surveillance Systems (ISSs) have a beneficial impact on child injury prevention. There is a need for evidence-based consensus on frameworks to establish child ISSs. This research aims to investigate the key components of a child ISS for Iran and to propose a framework for implementation.

Methods
Data were gathered through interview with experts using unstructured questions from January 2017 to December 2018 to identify child ISS functional components. Qualitative data were analyzed using content analysis method. Then, modified Delphi method was used to validate the functional components. Based on the outcomes of the content analysis, a questionnaire with closed questions was developed to be presented to a group of experts. Consensus was achieved in two rounds.

Results
In round one, 117 items reached consensus. In round two, 5 items reached consensus and were incorporated into final framework. Consensus was reached for 122 items comprising the final framework and representing 7 key components: goals of the system, data sources, data set, coalition of stakeholders, data collection, data analysis and data distribution. Each component consisted of several sub-components and respective elements.

Conclusion
This agreed framework will assist in standardizing data collection, analysis and distribution to detect child injury problems and provide evidence for preventive measures.


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41. Considerations for service delivery for emergency care in low resource settings

African Journal of Emergency Medicine


Authors: Harveen Bal Bergquist, Taylor W.Burkholder, Osama A.Muhammad Ali, Yasein Omer, Lee A. Wallis
Region / country: Global
Speciality: Emergency surgery, Health policy

In a shift from the more traditional disease focused model of global health interventions, increasing attention is now being placed on the importance of strengthening healthcare systems as a key component for achieving improved health outcomes. As emergency care systems continue to develop and strengthen around the world, the concept of service delivery provides one way to assess how well these systems are functioning. By focusing on service delivery, a system can be evaluated based on its ability to provide patients with access to the high-quality emergency care that they deserve. While the concept of service delivery is commonly used to evaluate the effectiveness of care in high-resource settings, its use in low resource settings has previously been limited due to challenges in operationalizing the concept in a context appropriate way. This article will begin by discussing the concept of service delivery as it specifically applies to emergency care systems and then discuss some of the challenges in defining and assessing this concept in low resource settings. The article will then discuss several new tools that have been developed to specifically address ways to evaluate emergency care service delivery in low-resource settings that can be used to inform future systems strengthening activities.


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42. The EQ-5D-3L administered by text message compared to the paper version for hard-to-reach populations in a rural South African trauma setting: a measurement equivalence study

Archives of Orthopaedic and Trauma Surgery


Authors: Henry G. Burnand, Samuel E. McMahon, Adrian Sayers, Tembisa Tshengu, Norrie Gibson, Ashley W. Blom, Michael R. Whitehouse, Vikki Wylde
Region / country: Southern Africa – South Africa
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Introduction
Administering patient-reported outcome measures (PROMs) by text message may improve response rate in hard-to-reach populations. This study explored cultural acceptability of PROMs and compared measurement equivalence of the EQ-5D-3L administered on paper and by text message in a rural South African setting.

Materials and methods
Participants with upper or lower limb orthopaedic pathology were recruited. The EQ-5D was administered first on paper and then by text message after 24 h and 7 days. Differences in mean scores for paper and text message versions of the EQ-5D were evaluated. Test–retest reliability between text message versions was evaluated using Intraclass Correlation Coefficients (ICCs).

Results
147 participants completed a paper EQ-5D. Response rates were 67% at 24 h and 58% at 7 days. There were no differences in means between paper and text message responses for the EQ-5D Index (p = 0.95) or EQ-5D VAS (p = 0.26). There was acceptable agreement between the paper and 24-h text message EQ-5D Index (0.84; 95% Confidence Interval (CI) 0.78–0.89) and EQ-5D VAS (0.73; 95% CI 0.64–0.82) and acceptable agreement between the 24-h and 7-day text message EQ-Index (0.72; CI 0.62–0.82) and EQ-VAS (0.72; CI 0.62–0.82). Non-responder traits were increasing age, Xhosa as first language and lower educational levels.

Conclusions
Text messaging is equivalent to paper-based measurement of EQ-5D in this setting and is thus a viable tool for responders. Non-responders had similar socioeconomic characteristics and attrition rates to traditional modes of administration. The EQ-5D by text message offers potential clinical and research uses in hard-to-reach populations.


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43. Country Income Is Only One of the Tiles: The Global Journey of Antimicrobial Resistance among Humans, Animals, and Environment

Antibiotics


Authors: Angela Pieri, Richard Aschbacher, Giada Fasani, Jole Mariella, Lorenzo Brusetti, Elisabetta Pagani, Massimo Sartell, Leonardo Pagani
Region / country: Global
Speciality: Health policy

Antimicrobial resistance (AMR) is one of the most complex global health challenges today: decades of overuse and misuse in human medicine, animal health, agriculture, and dispersion into the environment have produced the dire consequence of infections to become progressively untreatable. Infection control and prevention (IPC) procedures, the reduction of overuse, and the misuse of antimicrobials in human and veterinary medicine are the cornerstones required to prevent the spreading of resistant bacteria. Purified drinking water and strongly improved sanitation even in remote areas would prevent the pollution from inadequate treatment of industrial, residential, and farm waste, as all these situations are expanding the resistome in the environment. The One Health concept addresses the interconnected relationships between human, animal, and environmental health as a whole: several countries and international agencies have now included a One Health Approach within their action plans to address AMR. Improved antimicrobial usage, coupled with regulation and policy, as well as integrated surveillance, infection control and prevention, along with antimicrobial stewardship, sanitation, and animal husbandry should all be integrated parts of any new action plan targeted to tackle AMR on the Earth. Since AMR is found in bacteria from humans, animals, and in the environment, we briefly summarize herein the current concepts of One Health as a global challenge to enable the continued use of antibiotics.


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44. Factors associated with patient payments exceeding National Health Insurance fees and out-of-pocket payments in Lao PDR

Global Health Action


Authors: Kongmany Chaleunvong, Bounfeng Phoummalaysith, Bouaphat Phonvixay, Manithong Vonglokham, Vanphanom Sychareun, Jo Durham, Dirk Essink
Region / country: South-eastern Asia – Laos
Speciality: Health policy

Background
Attaining universal health coverage is a target in the Sustainable Development Goals. In Lao PDR, to achieve universal health coverage, the government is implementing a national insurance scheme, initially targeting the informal sector.

Objective
The purpose was to assess: i) the percentage of NHI patients who paid above the scheduled amount, based on individual billing payment; and ii) the factors related to overpayment.

Methods
Descriptive cross-sectional study based on a structured questionnaire administered at health facilities in face-to-face interviews with 1,850 patients in six provinces.

Results
All 1,850 participants worked in the informal sector. Of these, 78.8% of respondents (77.9% of in-patients; 79.5% of out-patients) made co-payments or were exempted from. Factors associated with in-patients paying above the scheduled fee were living in the province and district (OR = 2.8; 95%CI 1.2 to 6.3); not having documents with them (OR = 21.2; 95%CI 5.6 to 80.3); or not having documents (OR: 7.8; 95% CI 2.1 to 28.6). Significant factors associated with additional costs for out-patients were level of facility used at the provincial hospital (OR:1.4; 95% CI 1.1 to 1.9); older age (OR = 2.2; 95%CI 1.5 to 3.1); living in the province and district (OR = 2.3; 95%CI 1.5 to 3.7); living more than 5 km from the facility (OR = 1.4; 95%CI 1.1 to 1.9); buying medicine or supplies outside of the health facility (OR: 5.6; 95% CI 3.1 to 10.2); not bringing documents (OR:9.1; 95% CI 6.1 to 13.5), not having the right documents (OR: 8.9; 95% CI 5.4 to 14.8).

Conclusions
A number of patients paid above scheduled fee rates, which may deter people from utilising services when needing them. There is a need for increased understanding of the benefits of the national insurance scheme among patients and healthcare staff.


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45. Antibiotic Prescribing to Patients with Infectious and Non-Infectious Indications Admitted to Obstetrics and Gynaecology Departments in Two Tertiary Care Hospitals in Central India

Antibiotics


Authors: Anna Machowska, Kristoffer Landstedt ,Cecilia Stålsby Lundborg, Megha Sharma
Region / country: Southern Asia – India
Speciality: Obstetrics and Gynaecology

Background: Patients admitted to obstetrics and gynaecology (OBGY) departments are at high risk of infections and subsequent antibiotic prescribing, which may contribute to antibiotic resistance (ABR). Although antibiotic surveillance is one of the cornerstones to combat ABR, it is rarely performed in low- and middle-income countries. Aim: To describe and compare antibiotic prescription patterns among the inpatients in OBGY departments of two tertiary care hospitals, one teaching (TH) and one nonteaching (NTH), in Central India. Methods: Data on patients’ demographics, diagnoses and prescribed antibiotics were collected prospectively for three years. Patients were divided into two categories- infectious and non-infectious diagnosis and were further divided into three groups: surgical, nonsurgical and possible-surgical indications. The data was coded based on the Anatomical Therapeutic Chemical classification system, and the International Classification of Disease system version-10 and Defined Daily Doses (DDDs) were calculated per 1000 patients. Results: In total, 5558 patients were included in the study, of those, 81% in the TH and 85% in the NTH received antibiotics (p < 0.001). Antibiotics were prescribed frequently to the inpatients in the nonsurgical group without any documented bacterial infection (TH-71%; NTH-75%). Prescribing of broad-spectrum, fixed-dose combinations (FDCs) of antibiotics was more common in both categories in the NTH than in the TH. Overall, higher DDD/1000 patients were prescribed in the TH in both categories. Conclusions: Antibiotics were frequently prescribed to the patients with no documented infectious indications. Misprescribing of the broad-spectrum FDCs of antibiotics and unindicated prescribing of antibiotics point towards threat of ABR and needs urgent action. Antibiotics prescribed to the inpatients having nonbacterial infection indications is another point of concern that requires action. Investigation of underlying reasons for prescribing antibiotics for unindicated diagnoses and the development and implementation of antibiotic stewardship programs are recommended measures to improve antibiotic prescribing practice.


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46. Intestinal Perforations Associated With a High Mortality and Frequent Complications During an Epidemic of Multidrug-resistant Typhoid Fever in Blantyre, Malawi

Clinical Infectious Diseases


Authors: Franziska Olgemoeller, Jonathan J Waluza, Dalitso Zeka, Jillian S Gauld, Peter J Diggle, Jonathan M Read, Thomas Edwards, Chisomo L Msefula, Angeziwa Chirambo, Melita A Gordon, Emma Thomson, Robert S Heyderman, Eric Borgstein, Nicholas A Feasey
Region / country: Southern Africa – Malawi
Speciality: General surgery

Background
Typhoid fever remains a major source of morbidity and mortality in low-income settings. Its most feared complication is intestinal perforation. However, due to the paucity of diagnostic facilities in typhoid-endemic settings, including microbiology, histopathology, and radiology, the etiology of intestinal perforation is frequently assumed but rarely confirmed. This poses a challenge for accurately estimating burden of disease.

Methods
We recruited a prospective cohort of patients with confirmed intestinal perforation in 2016 and performed enhanced microbiological investigations (blood and tissue culture, plus tissue polymerase chain reaction [PCR] for Salmonella Typhi). In addition, we used a Poisson generalized linear model to estimate excess perforations attributed to the typhoid epidemic, using temporal trends in S. Typhi bloodstream infection and perforated abdominal viscus at Queen Elizabeth Central Hospital from 2008–2017.

Results
We recruited 23 patients with intraoperative findings consistent with intestinal perforation. 50% (11/22) of patients recruited were culture or PCR positive for S. Typhi. Case fatality rate from typhoid-associated intestinal perforation was substantial at 18% (2/11). Our statistical model estimates that culture-confirmed cases of typhoid fever lead to an excess of 0.046 perforations per clinical typhoid fever case (95% CI, .03–.06). We therefore estimate that typhoid fever accounts for 43% of all bowel perforation during the period of enhanced surveillance.

Conclusions
The morbidity and mortality associated with typhoid abdominal perforations are high. By placing clinical outcome data from a cohort in the context of longitudinal surgical registers and bacteremia data, we describe a valuable approach to adjusting estimates of the burden of typhoid fever.


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47. Results from the first audit of an intensive care unit in Botswana

Southern African Journal of Critical Care


Authors: A O MilanI, M CoxII, K MolebatsiIII
Region / country: Southern Africa – South Africa
Speciality: Anaesthesia

BACKGROUND: Botswana is an economically stable middle-income country with a developing health system and a large HIV and infectious disease burden. Princess Marina Hospital (PMH) is the largest referral and teaching hospital with a mixed eight-bed intensive care unit (ICU
OBJECTIVES: To conduct an audit of PMH ICU in order to investigate major admission categories and quantify morbidity and mortality figures using a validated scoring system for quality improvement, education and planning purposes
METHODS: PMH medical records and laboratory data were accessed to record demographics, referral patterns, diagnoses, HIV status, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores and mortality rates
RESULTS: A total of 182 patients >14 years of age were enrolled over a 12-month period from April 2017 – March 2018. Patient’s mean age was 42.9 years, males represented 56.6% of the study population and surgical conditions accounted for 46% of diagnostic categories. Sixty percent of the patients were HIV-negative and 12% had no HIV status recorded. The mean APACHE II score was 25 and the mean length of stay in ICU was 10.3 days. Higher APACHE II scores were associated with higher mortality regardless of HIV status. The overall mortality was 42.8% and there was no difference in mortality rates in ICU or at 30 days between HIV-positive and HIV-negative ICU patient groups
CONCLUSIONS: The PMH ICU population is young with a high mean APACHE II score, significant surgical and HIV burdens and a high mortality rate. PMH ICU has significant logistical challenges making comparison with international ICUs challenging, and further research is warranted


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48. Pattern of road traffic Accident and their consequences in Dhaka City

Journal of Z H Sikder Women’s Medical college


Authors: Tasnim Rahman,Muiz Uddin Ahmed Choudhury
Region / country: Southern Asia – Bangladesh
Speciality: Emergency surgery, Health policy

Road traffic injuries (RTIs) are one of the eight burning public health issues worldwide causing 1.3 million death every year. This study aimed to see the pattern of road traffic injuries, their consequences, and factors associated within Dhaka city. A cross-sectional study was conducted among Road Traffic Accident victims attended in three largest and tertiary care hospitals located inside the Dhaka metropolitan area through structured interviews between 25 January and 21 February 2017 with a sample size of 140. The majority of injured patients were between 18-37 years. More than 55% of injuries were severe, and intracranial injury (27.1%) was the most common type. T-junction (32.1%) and highways (31.4%) were most places for RTAs where half of the total victims were passengers. Our study indicates
age, gender, and educational status were significantly associated with consequences of RTAs (p<0.05). Moreover, among the RTAs related variables, type of vehicle, RTA type, injury place, and treatment approach found significantly associated with consequences of RTAs (P<0.05). The findings of this study could play an important role to build awareness on RTAs among policymakers and general peoples to reduce mortality due to RTIs.


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49. World NCD Federation guidelines for prevention, surveillance and management of noncommunicable diseases at primary and secondary health-care for low resource settings

international journal of non-communicable diseases


Authors: JS Thakur, S Kathirvel, Ronika Paika, Nonita Dhirar, Ria Nangia, Kunjan Kunjan, Ajay Duseja, Ankur Gupta, Arun Chockalingam, Ashutosh N Aggarwal, Dheeraj Khurana, Dhirendra Sinha, JP Narain, KR Thankappan, Rajesh Vijayvergiya, Rajveer Singh, Rakesh Kapoor, Renu Madan, Sandeep Grover, Sanjay Jain, Sanjay K Bhadada, SK Jindal, Sunil Taneja, Vivek Kumar, Vivekanand Jha
Region / country: Global
Speciality: Health policy

Noncommunicable diseases (NCDs) have emerged as a major public health problem globally due to demographic, epidemiological, nutritional, and socioeconomic transition. NCDs attributed to 73% of global deaths in 2017 and need urgent action guided by the global action plan for prevention and control of NCDs 2013–2020 to achieve the Sustainable Development Goal (SDG). NCDs also cause premature deaths (≤70 years) and nearly 80% of premature deaths happen in low‑ and middle‑income countries (LMICs). In the global framework of “Public Health Approach” to combat any disease, it needs a standard protocol to screen, diagnose, and manage. However, there are no comprehensive guidelines or
protocols available on the prevention, surveillance, and management of common NCDs at primary and secondary healthcare facilities of low resource settings, except for a few conditions. The current guideline provides simple and comprehensive guidance on the prevention,
surveillance, and management aspects of common NCDs targeting primarily healthcare professionals, including community health workers (CHWs), program managers, policy maker, and implementers at these healthcare settings. These evidence‑based, operational guidelines have been developed by experts from various national and international organizations and are explained under the heads of prevention, surveillance, and management. The management part is developed by nine subgroups one for each NCD, namely type 2 diabetes mellitus (DM), hypertension, cardiovascular diseases (CVDs), chronic respiratory diseases (CRDs), cancers, mental health disorders, cerebrovascular diseases/Stroke, chronic kidney diseases (CKDs), and chronic liver diseases (alcoholic liver disease [ALD] and nonalcoholic fatty liver disease [NAFLD]). The guidelines describe the policy and non-policy interventions for the prevention of NCDs, management strategies separately for primary and secondary healthcare settings including when to refer to tertiary healthcare facility, and an implementation framework for uptake of these guidelines at gross root level. These guidelines will serve as a basic tool for the practicing physician and CHWs at every level of healthcare to deliver quality NCD prevention and care. It has been developed taking the primary and secondary health settings and the provisions
and strategies under the National NCD Program.
The World NCD Federation envisions appropriate and effective implementation of these guidelines for reduction of premature NCD mortality, especially in the context of the low resource setting. In a way, this will help to reorient the existing health systems to combat the NCDs. The guidelines will be helpful to take further steps in capacity building for various cadres of healthcare staff on prevention, surveillance, and management of NCDs and evaluation at national, regional, and international levels.


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50. One Health Approach and Antimicrobial Resistance: From Global to Ethiopian Context

EC Pharmacology and Toxicology – ECronicon


Authors: Dejen Nureye, Mohammed Salahaddin, Workineh Woldeselassie
Region / country: Eastern Africa – Ethiopia
Speciality: Health policy

Recently, antimicrobial resistance is considered as a global health crisis. Some are thought that we are now in post-antibiotic era. Despite data gaps are largest; it creates particularly significant intimidation to low- and middle-income countries. Many factors are responsible for the development of resistance to antimicrobials by microorganisms. Weak regulations and usage inaccuracies are the major causes for the occurrence of antibiotic resistance. In the last three decades, greater than thirty new infectious diseases, most originated from animals, have been emerged. There is also rising of antimicrobial consumption across the world. The growth
of human populations and an increase in contact with wildlife contribute to the spread of resistance and making it a global health concern. Since there are many routes by which drug metabolites and resistant microbes can disseminate among humans, animals and the environment, One Health Approach is urgently required to address antimicrobial resistance in global, national and local level, including Ethiopia. Internationally, the worst threat comes from the emergence and rapid spread of multi-drug resistant Gramnegative bacteria. Once again, an intercontinental, interdisciplinary and multiple approaches should be taken to combat this problem among worldwide nations with special emphasis in developing countries encompassing Africa and Ethiopia.


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51. Evaluation of global health capacity building initiatives in low-and middle-income countries: A systematic review

Journal of global health


Authors: Hady Naal, Maria El Kouss, Melissa El Hamouch, Layal Hneiny, Shadi Saleh
Region / country: Global
Speciality: Health policy

Background
Low-and middle-income countries (LMICs) are in dire need to improve their
health outcomes. Although Global Health Capacity Building (GHCB) initiatives are
recommended approaches, they risk being ineffective in the absence of standardized evaluation
methods. This study systematically reviews evaluation approaches for GHCB initiatives in
LMICs.
Methods
We searched the Medline (OVID), PubMed, Scopus, and Embase.com databases for
studies reporting evaluation of a GHCB initiative in a LMIC from January 1st, 2009 until
August 15th, 2019. To differentiate them from intervention, prevention, and awareness
initiatives, included articles reported at least one approach to evaluate their learning modality.
We excluded cross-sectional studies, reviews, and book chapters that only assessed the effect
of interventions. Data identifying the learning modality, and evaluation method, level, time
interval, and approach were extracted from articles as primary outcomes.
Results
Of the 8,324 identified studies, 63 articles were eligible for analysis. Most studies
stemmed from Africa and Asia (69.8%), were delivered and evaluated face-to-face (74.6% and
76.2%), mainly to professionals (57.1%) and community workers (20.6%). Although the use
of online and blended modalities showed an increase over the past 4 years, only face-to-face
initiatives were evaluated long-term beyond individual-level. GHCB evaluations in general
lacked standardization especially regarding the tools.
Conclusion:
This is an important resource for evaluating GHCB initiatives in LMICs. It
synthesizes evaluation approaches, offers recommendations for improvement, and calls for the
standardization of evaluations, especially for long-term and wider impact assessment of online
and blended modalities.


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52. Simulation Based Training in Basic Life Support for Medical and Non-medical Personnel in Resource Limited Settings

International Journal of Anesthesia and Clinical Medicine


Authors: Christopher Nyirenda, Samuel Phiri, Boniface Kawimbe
Region / country: Southern Africa – Zambia
Speciality: Anaesthesia

Medical and non-medical personnel commonly encounter victims of life threatening injuries inflicted by various causes in diverse settings. More than 90% of global deaths and disability adjusted life-years (DALYs) lost because of injuries reportedly occur in low-income and middle-income countries (LMICs). The degree of readiness and competence to manage victims of accidents is likely to vary among individual care givers for knowledge, skill and confidence which would also depend on their training status. It would thus be justified that training in basic life support and other emergency clinical skills be administered to enhance competences in resuscitating the accident victims. Whatever the scale of a mass casualty incident, the first response will be carried out by members of the local community-not just health care staff and designated emergency workers,but also many ordinary citizens. Therefore, both medical and non-medical personnel should be targeted to receive training in basic life support (BLS). In medical training, the traditional (didactic) approach has been suggested to be an efficient and well-experienced training method while with the advances in technology the use of simulation-based medical training (SBMT) is increasing since SBMT provides a safe and supportive educational setting, so that students can improve their performance without causing adverse clinical outcomes. Similarly, the use of simulation based training in BLS would not only reduce the procedural associated risks but also benefit more participants from the public domain than would be the case if the training was conducted on human subjects. Compared with the developed world set-up simulation based training in resource constrained settings may not be that well established. This paper will therefore seek to examine the role of medical simulation as a necessary advancement and supplementary method of training in basic life support for medical and non-medical personnel in resource limited settings


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53. Barriers and facilitators of research in Cameroon (Part II) – an e-survey of medical students

panafrican medical journal


Authors: Ulrick Sidney Kanmounye, Joel Noutakdie Tochie, Mazou Temgoua, Aimé Noula Mbonda, Francky Teddy Endomba, Jan René Nkeck, Cynthia Wafo, Ferdinand Ndom Ntock, Desmond Tanko Jumbam
Region / country: Central Africa, Western Africa – Cameroon
Speciality: Health policy, Surgical Education

Introduction: research fosters critical thinking and prepares students for a career in academic medicine. This study aimed to identify the facilitators and barriers to research among Cameroonian medical students.

Methods: an electronic survey was distributed between May 23, 2020, and June 07, 2020. The survey was made of closed-, opened-, and Likert scale questions. A Preference Score (PS) was used to quantify the medical students’ perception of barriers and facilitators to research. The Kruskal-Wallis H and Fisher’s Exact tests were used to evaluate bivariate relationships

Results: one hundred and eighty-eight (188) students with a mean age of 24.1 ± 2.3 years were enrolled. Most respondents were male (56.9%), francophone (69.1%), and in their final year of medical school (46.8%). Twenty-one students (11.1%) had a peer-reviewed article, and all the published students were in their sixth- or seventh-year of undergraduate medical studies. Barriers to research included lack of funding (PS=203), obsolete patient information management systems (PS=198), and limited understanding of biostatistics (PS=197). Facilitators to research included research focused on the student’s interests (PS=255), the study’s capacity to improve practice (PS=247), and scientific recognition (PS=198).
Conclusion: barriers to research among Cameroonian medical students are mainly institutional. However, facilitators are primarily linked to career goals. To improve research activities among these undergraduates, initiatives must target institutional barriers and incentives that foster career development.


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54. Oral cancer: Clinicopathological features and associated risk factors in a high risk population presenting to a major tertiary care center in Pakistan

pLOS one


Authors: Namrah Anwar,Shahid Pervez,Qurratulain Chundriger,Sohail Awan,Tariq Moatter,Tazeen Saeed Ali
Region / country: South-eastern Asia – Pakistan
Speciality: ENT surgery, Surgical oncology

Oral squamous cell carcinoma (OSCC) has the highest prevalence in head and neck cancers and is the first and second most common cancer in males and females of Pakistan respectively. Major risk factors include peculiar chewing habits like areca nut, betel quid, and tobacco. The majority of OSCC presents at an advanced stage with poor prognosis. On the face of such a high burden of this preventable cancer, there is a relative lack of recent robust data and its association with known risk factors from Pakistan. The aim of this study was to identify the socioeconomic factors and clinicopathological features that may contribute to the development of OSCC. A total of 186 patients diagnosed and treated at a tertiary care hospital, Karachi Pakistan were recruited. Clinicopathological and socioeconomic information was obtained on a structured questionnaire. Descriptive analysis was done for demographics and socioeconomic status (SES) while regression analysis was performed to evaluate the association between SES and chewing habits, tumor site, and tumor stage. The majority of patients were males and the mean age of OSCC patients was 47.62±12.18 years. Most of the patients belonged to low SES (68.3%) and 77.4% were habitual of chewing. Gender (male) and SES were significantly associated with chewing habits (p<0.05). Odds of developing buccal mucosa tumors in chewers (of any type of substance) and gutka users were 2 and 4 times higher than non-chewers respectively. Middle age, chewing habits, and occupation were significantly associated with late stage presentation of OSCC (p<0.05). In conclusion, male patients belonging to low SES in their forties who had chewing habits for years constituted the bulk of OSCC. Buccal mucosa was the most common site in chewers and the majority presented with late stage tumors.


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55. The Cervical Cancer (CC) Epidemiology and Human Papillomavirus (HPV) in the Middle East

International Journal of Environment, Engineering & Education


Authors: Abduladheem Turki Jalil, Aleksandr Karevskiy
Region / country: Middle East – Belarus
Speciality: Obstetrics and Gynaecology, Surgical oncology

Viral infections contribute 15–20 percent of all human cancers as a cause. Oncogenic virus infection may spur various stages of carcinogenesis. For several forms for HPV, about 15 associated with cancer. Following successful test techniques, cervical cancer remains a significant public health issue. Prevalence and mortality of per geographic area of cervical cancer were vastly different. The fourth most common cause of death from cancer among women is cervical cancer (CC). Human papillomavirus (HPV) infection in the cervix is the most significant risk factor for forming cervical cancer. Inflammation is a host-driven defensive technique that works rapidly to stimulate the innate immune response against pathogens such as viral infections. Inflammation is advantageous if it is brief and well-controlled; however, it can cause adverse effects if the inflammation is prolonged or is chronic in duration. HPV proteins are involved in the production of chronic inflammation, both directly and indirectly. Also, the age-specific prevalence of HPV differs significantly. Two peaks of HPV positive in younger and older people have seen in various populations. A variety of research has performed worldwide on the epidemiology of HPV infection and oncogenic properties due to specific HPV genotypes. Nevertheless, there are still several countries where population-dependent incidences have not yet identified. Additionally, the methods of screening for cervical cancer differ among countries.


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56. How to Implement a Small Blood Bank in Low and Middle-Income Countries Work in Progress?

Tropical Medicine & Surgery


Authors: Pierre Zachee and Philippe Vandekerckhove
Region / country: Global
Speciality: Emergency surgery, General surgery

Compared to High-Income countries (HIC), a shortfall in the provision of blood remains a multifaceted problem in Low and Middle-Income Countries (LMIC) with a direct negative effect on clinical care. The reasons are multifactorial: not only lack of knowledge, skills, and resources, but also huge differences in environment climate, endemic transfusion transmittable infections, clinical set-up, availability of clean water, electricity. It is therefore obvious that simple translation of guidelines, standards, experiences, and the total organization from HIC to LMIC is not the best way to proceed. Adapted, but not less adequate methods for blood transfusion training, organization, and accreditation are required. The Global Advisory Panel (GAP) already formulated an adapted specific answer in terms of training and accreditation. But this is not enough. Academic centres, the GAP, countries, non-governmental organizations, and others need to test current and innovative diagnostic, production, and storage methods in a joint venture with the industry. Also, medical decisions focused on transfusion must be tested before implementation in facilities allowing pre-qualification of tests and devices. The entire transfusion chain needs to be simulated in a competence and training centre, focusing on the region where it will be applied. One of the renowned tropical institutes, currently fulfilling all these requirements could be the ideal place for such a competence centre. This review highlights this and suggests possible ways and solutions.


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57. Adult cardiac surgical cost variation around the world: Protocol for a systematic review

International Journal of Surgery Protocols


Authors: Dominique Vervoort, Camila R.Guetter, Lena Trager, Priyansh Shah, Carlos Eduardo Diaz-Castrillon, Eric W. Etchill, Rawn Salenger
Region / country: Global
Speciality: Cardiothoracic surgery

Introduction: Globally, over one million cardiac operations occur each year, whereas cardiac surgery is expensive and largely inaccessible without insurance or philanthropic support. Substantial cost variation has been reported within cardiac surgery in the United States and among non-cardiac surgical procedures globally, but little is known on the global procedural cost variation for common adult cardiac surgical procedures.

Objectives and significance: This review seeks to assess variation in procedural costs of coronary artery bypass grafting (CABG), mitral valve repair, mitral valve replacement, aortic valve repair, aortic valve replacement, and combined CABG-mitral or CABG-aortic valve procedures between and within countries. Results may give insights in the scope and drivers of cost variation around the world, posing cost reduction lessons. Results may further inform the potential of economies of scale in reducing procedural costs, benefiting patients, hospitals, governments, and insurers.

Methods and analysis: A systematic review will be performed using the EconLit, Embase, PubMed/MEDLINE, Web of Science, and WHO Global Index Medicus databases to identify articles published between January 1, 2000 and June 1, 2020. Studies describing procedural costs for CABG, mitral valve repair, mitral valve replacement, aortic valve repair, aortic valve replacement, and combined CABG-mitral or CABG-aortic valve procedures will be identified. Articles describing other types of cardiac surgery, concomitant aortic surgery, only describing costs related to non-surgical care, or with incomplete cost data will be excluded from the analysis. No exclusion will be based solely on article type or language. Identified costs will be converted to 2019 USD to account for local currency unit inflation and exchange fluctuations.

Ethics and dissemination: This study protocol has been prospectively registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols. This review requires no institutional review board approval. Results of this study will be summarized and disseminated in a peer-review journal.


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58. Caesarean section rates in South Africa: A case study of the health systems challenges for the proposed National Health Insurance

South African Medical Journal


Authors: G C SolankiI, J E Cornell, E Daviaud, S Fawcus
Region / country: Southern Africa – South Africa
Speciality: Obstetrics and Gynaecology

Broader policy research and debate on the issues related to the planning of National Health Insurance (NHI) in South Africa (SA) need to be complemented by case studies to examine and understand the issues that will have to be dealt with at micro and macro levels. The objective of this article is to use caesarean section (CS) as a case study to examine the health systems challenges that NHI would need to address in order to ensure sustainability. The specific objectives are to: (i) provide an overview of the key clinical considerations related to CS; (ii) assess the CS rates in the SA public and private sectors; and (iii) use a health systems framework to examine the drivers of the differences between the public and private sectors and to identify the challenges that the proposed NHI would need to address on the road to implementation.


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59. Negative Pressure Wound Therapy in the Treatment of Surgical Site Infection in Cardiac Surgery

Revista Brasileira de Enfermagem


Authors: Mayra de Castro Oliveira, Alessandra Yuri Takehana de Andrade, Ruth Natalia Teresa Turrini, Vanessa de Brito Poveda
Region / country: South America – Brazil
Speciality: Cardiothoracic surgery

Objectives
To describe the relationship between epidemiological and clinical characteristics of postoperative cardiac surgery patients undergoing negative pressure wound therapy for the treatment of surgical site infection.
Methods
An observational, cross-sectional analytical study including a convenience sample consisting of medical records of patients undergoing sternal cardiac surgery with surgical site infection diagnosed in medical records treated by negative pressure wound therapy.
Results
Medical records of 117 patients, mainly submitted to myocardial revascularization surgery and with deep incisional surgical site infection (88; 75.2%). Negative pressure wound therapy was used on mean for 16 (±9.5) days/patient; 1.7% had complications associated with therapy and 53.8% had discomfort, especially pain (93.6%). The duration of therapy was related to the severity of SSI (p=0.010) and the number of exchanges performed (p=0.045).
Conclusions
Negative pressure wound therapy has few complications, but with discomfort to patients.


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60. Factors Associated With the Uptake of Cataract Surgery and Interventions to Improve Uptake in Low- And Middle-Income Countries: A Systematic Review

PLOSE ONE


Authors: Eunice Wandia Mailu, Bhavisha Virendrakumar, Stevens Bechange, Emma Jolley, Elena Schmidt
Region / country: Global
Speciality: Ophthalmology

Despite significant evidence around barriers hindering timely access to cataract surgery in low- and middle-income countries (LMICs), little is known about the strategies necessary to overcome them and the factors associated with improved access. Despite significant evidence that certain groups, women for example, experience disproportionate difficulties in access, little is known about how to improve the situation for them. Two reviews were conducted recently: Ramke et al., 2018 reported experimental and quasi-experimental evaluations of interventions to improve access of cataract surgical services, and Mercer et al., 2019 investigated interventions to improve gender equity. The aim of this systematic review was to collate, appraise and synthesise evidence from studies on factors associated with uptake of cataract surgery and strategies to improve the uptake in LMICs. We performed a literature search of five electronic databases, google scholar and a detailed reference review. The review identified several strategies that have been suggested to improve uptake of cataract surgery including surgical awareness campaigns; use of successfully operated persons as champions; removal of patient direct and indirect costs; regular community outreach; and ensuring high quality surgeries. Our findings provide the basis for the development of a targeted combination of interventions to improve access and ensure interventions which address barriers are included in planning cataract surgical services. Future research should seek to examine the effectiveness of these strategies and identify other relevant factors associated with intervention effects.


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61. Cancellation of Elective Surgical Cases in a Nigerian Teaching Hospital: Frequency and Reasons

nigerian journal of clinical practice


Authors: C J Okeke, A O Obi, K H Tijani, U E Eni, C O Okorie
Region / country: Western Africa – Nigeria
Speciality: General surgery

Background: Dwindling economic resources and reduced manpower in the health sector require efficient use of the available resources. Day of surgery cancellation has far reaching consequences on the patients and the theatre staff involved. Full use of the theatre space should be pursued by every theatre user.

Objective: The study aimed to report on the rates and causes of day of surgery cancellation of elective surgical cases in our hospital as a means towards proffering solutions.

Materials and methods: It was a retrospective study of all elective cases that were booked over a 15-month period from January 2016 to March 2017. Cancellation was said to have occurred when the planned surgery did not take place on the proposed day of surgery. Cancellations were categorized into patient-related, surgeon-related, hospital-related and anesthetist-related. Reasons for the cancellations were documented. Data were analyzed using Statistical Package for the Social Sciences (SPSS) software program, version 22. Variables were compared using Chi-square tests. A value of P < 0.05 was considered statistically significant.

Results: During the 15-month period, a total of 1296 elective surgeries were booked. Of this, 118 (9.1%) cases were cancelled. Patient-related factor was the most common reason (47.5%) followed by surgeon-related factor (28%). Lack of funds was the most common patient related-reason for cancellation. Majority of the cancelled cases were general surgical cases (36.4%) followed by orthopedics (25.4%) and urology (11%). Seventy percent of the cancelled cases were first and second on the elective list.

Conclusion: The cancellation rate in this study is high. The reasons for these cancellations are preventable. To ensure effective use of the theatre, efforts should be made to tackle these reasons.


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62. Investing in Surgery: A Value Proposition for African Leaders

Lancet


Authors: Desmond T Jumbam , Ché L Reddy , Emmanuel Makasa , Adeline A Boatin , Khama Rogo , Kathryn M Chu , Benetus Nangombe , Olufemi T Oladapo , John G Meara , Salome Maswime
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Health policy

Globally, poor access to high-quality surgical, obstetric, and anaesthesia care remains a main contributor to global disease burden accounting for about a third of deaths worldwide. The need for strengthening surgical care systems is especially urgent in sub-Saharan Africa, where access is strikingly limited, leading to the highest mortality and morbidity from surgically preventable and treatable conditions in the world. Approximately 93% of the population of sub-Saharan Africa lacks access to safe, affordable, and timely surgical care, compared with less than 10% in high-income countries.2 Despite the immense and growing need for surgical services in sub-Saharan Africa, investments by African public sector leaders to improve surgical systems on the subcontinent have been inadequate. The current COVID-19 pandemic has disrupted health care globally, with an estimation by the CovidSurg Collaborative showing that more than 28 million surgeries will be postponed or cancelled worldwide during the 12 weeks of peak disruption. There is a basic ethical responsibility to provide surgical care as a fundamental human right, in keeping with the principles espoused in the Universal Declaration of Human Rights. Additionally, improved access to high-quality surgical care is an essential component of universal health coverage and will contribute to good health and wellbeing, leading to improved human capital—all of which are vital for poverty reduction and economic growth on the continent.


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63. Toward a complete estimate of physical and psychosocial morbidity from prolonged obstructed labour: a modelling study based on clinician survey

BMJ Global Health


Authors: Lina Roa , Luke Caddell , Gabriel Ganyaglo , Vandana Tripathi , Nazmul Huda , Lauri Romanzi , Blake C Alkire
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, South-eastern Asia, Southern Africa, Western Africa
Speciality: Obstetrics and Gynaecology

Introduction: Prolonged obstructed labour often results from lack of access to timely obstetrical care and affects millions of women. Current burden of disease estimates do not include all the physical and psychosocial sequelae from prolonged obstructed labour. This study aimed to estimate the prevalence of the full spectrum of maternal and newborn comorbidities, and create a more comprehensive burden of disease model.

Methods: This is a cross-sectional survey of clinicians and epidemiological modelling of the burden of disease. A survey to estimate prevalence of prolonged obstructed labour comorbidities was developed for prevalence estimates of 27 comorbidities across seven categories associated with prolonged obstructed labour. The survey was electronically distributed to clinicians caring for women who have suffered from prolonged obstructed labour in Asia and Africa. Prevalence estimates of the sequelae were used to calculate years lost to disability for reproductive age women (15 to 49 years) in 54 low- and middle-income countries that report any prevalence of obstetric fistula.

Results: Prevalence estimates were obtained from 132 participants. The median prevalence of reported sequelae within each category were: fistula (6.67% to 23.98%), pelvic floor (6.53% to 8.60%), genitourinary (5.74% to 9.57%), musculoskeletal (6.04% to 11.28%), infectious/inflammatory (5.33% to 9.62%), psychological (7.25% to 24.10%), neonatal (13.63% to 66.41%) and social (38.54% to 59.88%). The expanded methodology calculated a burden of morbidity associated with prolonged obstructed labour among women of reproductive age (15 to 49 years old) in 2017 that is 38% more than the previous estimates.

Conclusions: This analysis provides estimates on the prevalence of physical and psychosocial consequences of prolonged obstructed labour. Our study suggests that the burden of disease resulting from prolonged obstructed labour is currently underestimated. Notably, women who suffer from prolonged obstructed labour have a high prevalence of psychosocial sequelae but these are often not included in burden of disease estimates. In addition to preventative and public health measures, high quality surgical and anaesthesia care are urgently needed to prevent prolonged obstructed labour and its sequelae.


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64. Cancer incidence and treatment utilization patterns at a regional cancer center in Tanzania from 2008-2016: Initial report of 2,772 cases

Cancer Epidemiology


Authors: Adam C Olson , Franco Afyusisye , Joe Egger , David Noyd , Beda Likonda , Nestory Masalu , Gita Suneja , Nelson Chao , Leah L Zullig , Kristin Schroeder
Region / country: Eastern Africa – Tanzania
Speciality: Surgical oncology

Purpose: To describe cancer incidence and treatment utilization patterns at the regional cancer referral center for the Lake Zone of northwestern Tanzania from 2008 to 2016.

Methods: This descriptive, retrospective study reviewed all cancer cases recorded in the Bugando Cancer Registry (BCR), a clinical and pathology based registry at the only cancer referral hospital in the region. Primary tumor site, method of diagnosis, HIV status, and cancer treatment were reported. Using census data, the 2012 GLOBOCAN estimates for Tanzania were scaled to the Lake Zone and adjusted for 2016 population growth. These estimates were then compared to BCR cases using one-sample tests of proportion.

Results: A total of 2772 cases were reported from 2008-2016. Among these, the majority of cases (82.5 %, n = 2286) were diagnosed among adults. Most cases (85 %, n = 1923) were diagnosed by histology or cytology. Among adults, the most common cancers diagnosed were cervix (22.7 %, n=520), breast (12.6 %, n=288), and prostate (8.5 %, n=195). Among children, the most common cancers were non-Burkitt non-Hodgkin lymphoma (17.3 %, n=84), Burkitt lymphoma (16.5 %, n=80), and Wilms tumor (14.6 %, n=71). The 1116 BCR cases represent 12.2 % of the 9165 expected number of cancer cases for the Lake Zone (p < 0.001). 1494 cases (53.9 %) received some form of treatment – surgery, chemotherapy, radiation, or hormone therapy – while 1278 cases (46.1 %) had no treatment recorded.

Conclusions: This comprehensive report of the BCR reveals cancer epidemiology and treatment utilization patterns typical of hospitals in low-resource settings. Despite being the only cancer center in the Lake Zone, BMC evaluates a small percentage of the expected number of cancer patients for the region. The BCR remains an important resource to guide clinical care and academic activities for the Lake Zone.


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65. Oxygen availability in sub-Saharan African countries: a call for data to inform service delivery

Lancet Global Health


Authors: Sowmya Mangipudi , Andrew Leather , Ahmed Seedat , Justine Davies
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa – Democratic Republic of the Congo, Malawi, Senegal, Tanzania
Speciality: Other

Oxygen is central to the management of patients admitted to hospital with severe COVID-19. Furthermore, the availability of oxygen therapy is just as important for the management of other patients who are acutely ill. However, despite recognition from most health-care providers that oxygen is a fundamental component of a health-care system, it has not been a focus of health-care delivery in sub-Saharan African countries, as shown by the lack of data collected on oxygen availability.


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66. Trauma team conformation in a war-influenced middle-income country in South America: is it possible?

International Journal of Emergency Medicine


Authors: Sandra Carvajal, Francisco L Uribe-Buritica, Ana Maria Ángel-Isaza, María Camila López-Girón, Andres González, Julian Chica, Manuel Benitez & Alberto F García
Region / country: South America – Colombia
Speciality: Emergency surgery, Trauma surgery

Introduction: Trauma teams (TTs) improve outcomes in trauma patients. A multidisciplinary TT was conformed in September 2015 in a tertiary level I trauma university hospital in southwestern Colombia, a middle-income war-influenced country.

Objective: To evaluate the impact of a TT in admission-tomography and admission-surgery times as well as mortality in a tertiary center university hospital in a middle-income country war-influenced country.

Material and methods: Retrospective analytical study. Patients older than 17 years admitted to the emergency room 15 months prior and 15 months after the TT implementation were included. Patients prior to the TT implementation were taken as controls. No exclusion criteria. Four hundred sixty-four patients were included, 220 before the TT implementation (BTT) and 244 after (ATT). Demographic data, trauma characteristics, admission-tomography, and admission-surgery time interval as well as mortality were recorded. Requirement of CT scan or surgery was based on physician decision. The analysis was made on Stata 15.1®. Categorical variables were described as quantities and proportions, and continuous variables as mean and standard deviation or median and interquartile range (IQR). Categorical variables were compared using χ2 or Fisher’s test and continuous variables using Student’s T test or Wilcoxon-Mann-Whitney. A multiple logistic regression model was created to evaluate the impact of being treated in the ATT group on mortality, adjusted by age, trauma severity, and physiological response upon admission.

Results: The admission-tomography time interval was 56 min (IQR 39-100) in the BTT group and 40 min (IQR 24-76) in the ATT group, p < 0.001. The admission-surgery time interval was 116 min (IQR 63-214) in the BTT group and 52 min (IQR 24-76) in the ATT group, p < 0.001. Mortality in the BTT group was 18.1% and 13.1% in the ATT group. Adjusted OR was 0.406 (0.215-0.789) p = 0.006 CONCLUSIONS: A trauma team conformation in a war-influenced middle-income country is feasible and reduces mortality as well as admission-surgery and admission-tomography time intervals in trauma patients.


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67. The Effectiveness of Burn Scar Contracture Release Surgery in Low- and Middle-income Countries

Plastic and Reconstructive Surgery – Global Open


Authors: Matthijs Botman MD, Thom C. C. Hendriks MD, Louise E. M. de Haas MD, Grayson S. Mtui MD, Emanuel Q. Nuwass MD, Mariëlle E. H. Jaspers MD PhD, Anuschka S. Niemeijer PhD, Marianne K. Nieuwenhuis MD PhD, Henri A. H. Winters MD PhD, Paul P. M. Van Zuijlen MD PhD
Region / country: Eastern Africa – Tanzania
Speciality: Plastic surgery, Trauma surgery

Background:
Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC.

Methods:
This pre-/postintervention study was conducted in a rural regional referral hospital in Tanzania. All patients undergoing contracture release surgery during surgical missions were eligible. ROM data were indexed to normal values to compare various joints. Surgery was considered effective if the ROM of all planes of motion of a single joint increased at least 25% postoperatively or if the ROM reached 100% of normal ROM. Follow-ups were at discharge and at 1, 3, 6, and 12 months postoperatively.

Results:
A total of 70 joints of 44 patients were included. Follow-up rate at 12 months was 86%. Contracture release surgery was effective in 79% of the joints (P < 0.001) and resulted in a mean ROM improvement from 32% to 90% of the normal value (P < 0.001). A predictive factor for a quicker rehabilitation was lower age (R2 = 11%, P = 0.001). Complication rate was 52%, consisting of mostly minor complications.

Conclusions:
This is the first study to evaluate the long-term effectiveness of contracture release surgery in an LMIC. The follow-up rate was high and showed that contracture release surgery is safe, effective, and sustainable. We call for the implementation of outcome research in future surgical missions.


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68. Impact of the coronavirus disease 2019 (COVID‐19) pandemic on pediatric oncology care in the Middle East, North Africa, and West Asia Region: A report from the Pediatric Oncology East and Mediterranean (POEM) Group

Cancer


Authors: Raya Saab MD, Anas Obeid MD, Fatiha Gachi MD, Houda Boudiaf MD, Lilit Sargsyan MD, Khulood Al‐Saad MD, Tamar Javakhadze MD, Azim Mehrvar MD, Sawsan Sati Abbas MD, Yasir Saadoon Abed Al‐Agele MD, Salma Al‐Haddad MD, Mouroge Hashim Al Ani MD, Suleiman Al‐Sweedan MD, Amani Al Kofide MD, Wasil Jastaniah MD, Nisreen Khalifa MD, Elie Bechara MD, Malek Baassiri MD, Peter Noun MD, Jamila El‐Houdzi MD, Mohammed Khattab MD, Krishna Sagar Sharma MD, Yasser Wali MD, Naureen Mushtaq MD, Aliya Batool MD, Mahwish Faizan MD, Muhammad Rafie Raza MD, Mohammad Najajreh MD, Mohammed Awad Mohammed Abdallah MD, Ghada Sousan MD, Khaled M. Ghanem MD, Ulker Kocak MD, Tezer Kutluk MD, Hacı Ahmet Demir MD, Hamoud Hodeish MD, Samar Muwakkit MD, Asim Belgaumi MD, Abdul‐Hakim Al‐Rawas MD, Sima Jeha MD
Region / country: Global
Speciality: Paediatric surgery, Surgical oncology

Background
Childhood cancer is a highly curable disease when timely diagnosis and appropriate therapy are provided. A negative impact of the coronavirus disease 2019 (COVID‐19) pandemic on access to care for children with cancer is likely but has not been evaluated.

METHODS
A 34‐item survey focusing on barriers to pediatric oncology management during the COVID‐19 pandemic was distributed to heads of pediatric oncology units within the Pediatric Oncology East and Mediterranean (POEM) collaborative group, from the Middle East, North Africa, and West Asia. Responses were collected on April 11 through 22, 2020. Corresponding rates of proven COVID‐19 cases and deaths were retrieved from the World Health Organization database.

Results
In total, 34 centers from 19 countries participated. Almost all centers applied guidelines to optimize resource utilization and safety, including delaying off‐treatment visits, rotating and reducing staff, and implementing social distancing, hand hygiene measures, and personal protective equipment use. Essential treatments, including chemotherapy, surgery, and radiation therapy, were delayed in 29% to 44% of centers, and 24% of centers restricted acceptance of new patients. Clinical care delivery was reported as negatively affected in 28% of centers. Greater than 70% of centers reported shortages in blood products, and 47% to 62% reported interruptions in surgery and radiation as well as medication shortages. However, bed availability was affected in <30% of centers, reflecting the low rates of COVID‐19 hospitalizations in the corresponding countries at the time of the survey.

Conclusions
Mechanisms to approach childhood cancer treatment delivery during crises need to be re‐evaluated, because treatment interruptions and delays are expected to affect patient outcomes in this otherwise largely curable disease.


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69. Surgical Management of Urolithiasis of the Upper Tract – Current Trend of Endourology in Africa

Research and Reports in Urology


Authors: Cassell A III, Jalloh M, Ndoye M, Mbodji M, Gaye O, Thiam NM, Diallo A, Labou I, Niang L, Gueye S
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Urology surgery

Urolithiasis is a global pathology with increasing prevalence rate. The lifetime recurrence of urolithiasis ranges from 10– 75% creating a public health crisis in affected regions. The epidemiology of urolithiasis in most parts of Africa and Asia remains poorly documented as incidence and prevalence rates in these settings are extrapolated from hospital admissions. The surgical management of kidney and ureteral stones is based on the stone location, size, the patient’s preference and the institutional capacity. To date, the available modalities in the management of urolithiasis includes external shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureterorenoscopy (URS) including flexible and semirigid ureteroscopy. However, regarding the lack of endourological equipment and expertise in most parts of Sub-Saharan Africa (SSA), most urological centers in these regions still consider open surgery for kidney and ureteral stones. This review explores the current trend and surgical management of upper tract urolithiasis in SSA with insight on the available clinical guidelines


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70. Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa—a scoping review

Human Resources for Health


Authors: Phylisha van Heemskerken, Henk Broekhuizen, Jakub Gajewski, Ruairí Brugha & Leon Bijlmakers
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Other

Background
Sub-Saharan Africa (SSA) faces the highest burden of disease amenable to surgery while having the lowest surgeon to population ratio in the world. Some 25 SSA countries use surgical task-shifting from physicians to non-physician clinicians (NPCs) as a strategy to increase access to surgery. While many studies have investigated barriers to access to surgical services, there is a dearth of studies that examine the barriers to shifting of surgical tasks to, and the delivery of safe essential surgical care by NPCs, especially in rural areas of SSA. This study aims to identify those barriers and how they vary between surgical disciplines as well as between countries.

Methods
We performed a scoping review of articles published between 2000 and 2018, listed in PubMed or Embase. Full-text articles were read by two reviewers to identify barriers to surgical task-shifting. Cited barriers were counted and categorized, partly based on the World Health Organization (WHO) health systems building blocks.

Results
Sixty-two articles met the inclusion criteria, and 14 clusters of barriers were identified, which were assigned to four main categories: primary outcomes, NPC workforce, regulation, and environment and resources. Malawi, Tanzania, Uganda, and Mozambique had the largest number of articles reporting barriers, with Uganda reporting the largest variety of barriers from empirical studies only. Obstetric and gynaecologic surgery had more articles and cited barriers than other specialties.

Conclusion
A multitude of factors hampers the provision of surgery by NPCs across SSA. The two main issues are surgical pre-requisites and the need for regulatory and professional frameworks to legitimate and control the surgical practice of NPCs.


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71. A review of the epidemiology, post-neurosurgical closure complications and outcomes of neonates with open spina bifida

South African Journal of Child Health


Authors: P C Mashiloane, R Masekela
Region / country: Southern Africa – South Africa
Speciality: Neurosurgery, Paediatric surgery

Background. Spina bifida (SB) is a neural tube defect (NTD) that has an increased risk of fatal and disabling effects if not repaired early, i.e. within the first 24 to 48 hours of life. Its diagnosis holds an increased burden for the patient and the caregiver owing to secondary complications. The effects of the disease are detrimental even with early repair, because of the long-term disabling nature of the disease.

Objective. This retrospective study aimed to assess the effects of demographics, immediate post-surgical complications and impact of time to surgical intervention on the outcome of neonates with open SB (OSB) admitted to the neonatal intensive care unit (NICU) at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal, South Africa (SA), between January 2011 and December 2015.

Methods. A retrospective chart review was conducted at the NICU of IALCH. All neonates diagnosed with SB were identified. The study period was from 1 January 2011 to 31 December 2015. Data were collected from the IALCH electronic database. All neonates with SB admitted to the IALCH NICU were included; any patient who presented beyond the neonatal period (i.e. >28 days) was excluded from the study. Data collected included maternal demographics. Additionally, neonatal history was reviewed and post surgery complications evaluated. Outpatient management post discharge was reviewed.

Results. One hundred and fifty neonates were included (58% male). The mean (standard deviation) maternal age was 26.7 (6.6) years. Only 10% had an antenatal diagnosis of OSB. Seventy-eight percent were born at term and 22% prematurely. The lumbar/sacral region was the most commonly affected. More males (14%) had thoraco/lumbar lesions than females (7.8%). Forty-eight percent presented before 3 days of life (early presentation). In the late-presentation group, there was an association with wound sepsis (p=0.003). Twenty-five percent were repaired between days 0 and 3 of life and 75% after 3 days. Postoperative complications in patients whose open SBs were repaired beyond 3 days of life were not statistically significant compared with those with early repair; all were p>0.05. There was a borderline association of prolonged hospitalisation with wound sepsis (p=0.07). Long-term outcomes showed that 68% had lower limb dysfunction, 18% urological complications, 14% limb deformity, and 11% hydrocephalus. A minority had psychomotor (7%) and developmental (15%) disorders. Ten percent required readmission secondary to shunt complications, and 7% died.

Conclusion. SB remains a significant disease burden that affects outcome and survival of neonates in SA. Lack of good antenatal care, which includes early ultrasound and timely referral to centres, are barriers to good outcomes. Long-term follow-up is also necessary to prevent morbidity.


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72. Trauma in pregnancy at a major trauma centre in South Africa

South African Medical Journal


Authors: S E Moffatt, B Goldberg, V Y Kong, J-P Da Costa, M T D Smith, J L Bruce, G L Laing, D L Clarke
Region / country: Southern Africa – South Africa
Speciality: Obstetrics and Gynaecology, Trauma surgery

Background. Trauma in pregnancy poses a unique challenge to clinicians. Literature on this topic is limited in South Africa (SA).

Objectives. To review our institution’s experience with the management of trauma in pregnancy in a developing-world setting.

Methods. This study was based at Grey’s Hospital, Pietermaritzburg, SA. All pregnant patients who were admitted to our institution following trauma between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry (HEMR).

Results. During the 6-year study period, 2 990 female patients were admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS), of whom 89 were pregnant. The mean age of these patients was 25.64 (range 17 – 43) years. The mechanism of injury was road traffic crash (RTC) in 39, stab wounds (SW) in 19, assault other than SW or gunshot wounds (GSW) in 19, GSW in 8, snake bite in 5, impalement in 1, dog bite in 1, hanging in 1, sexual assault in 1 and a single case of a patient being hit by a falling object. A subset of patients sustained >1 mechanism of injury. Thirty patients were managed operatively. The mean time of gestation was 19.16 (5 – 36) weeks. Three patients died, and there were 16 fetal deaths (including 3 lost after the mother’s death). Forty-five fetuses were recorded as surviving at discharge, while 25 fetal outcomes were not specifically recorded. There were 2 threatened miscarriages and/or patients with vaginal bleeding, 1 positive pregnancy test with no recorded outcome and no premature births as a result of trauma.

Conclusions. Trauma in pregnancy is relatively uncommon and mostly due to a RTC or deliberately inflicted trauma. Fetal outcome is largely dependent on the severity of the maternal injury, with injuries requiring laparotomy leading to a high fetal mortality rate.


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73. Foreign body ingestion in children presenting to a tertiary paediatric centre in South Africa: A retrospective analysis focusing on battery ingestion

South African Medical Journal


Authors: J A Chabilall, J Thomas, R Hofmeyr
Region / country: Southern Africa – South Africa
Speciality: Anaesthesia, Paediatric surgery

Background. Ingestion of foreign bodies remains a frequent reason for presentation to paediatric emergency departments worldwide. Among the variety of objects ingested, button batteries are particularly harmful owing to their electrochemical properties, which can cause extensive injuries if not diagnosed and treated rapidly. International trends show an increasing incidence of button battery ingestion, leading to concern that this pattern may be occurring in South Africa. Limited local data on paediatric foreign body ingestion have been published.

Objectives. To assess battery ingestion rates in a tertiary paediatric hospital. We hypothesised that the incidence has increased, in keeping with international trends. Secondary objectives included describing admission rates, requirements for anaesthesia and surgery, and promoting awareness of the problems associated with battery ingestion.

Methods. We performed a retrospective, descriptive analysis of the Red Cross War Memorial Children’s Hospital trauma database, including all children under 13 years of age seen between 1 January 2010 and 31 December 2015 with suspected ingestion of a foreign body. The ward admissions database was then examined to find additional cases in which children were admitted directly. After exclusion of duplicate records, cases were classified by type of foreign body, management, requirement for admission, anaesthesia and surgery. Descriptive statistics were used to analyse the data in comparison with previous studies published from this database.

Results. Patient age and gender patterns matched the literature, with a peak incidence in children under 2 years of age. Over the 6-year period, 180 patients presented with food foreign bodies, whereas 497 objects were classified as non-food. After exclusion of misdiagnosed cases, the remaining 462 objects were dominated by coins (44.2%). Batteries were the causative agent in 4.8% (22/462). Although the subtypes of batteries were not reliably recorded, button batteries accounted for at least 64% (14/22). Most children who ingested batteries presented early, but more required admission, anaesthesia and surgery than children who ingested other forms of foreign body.

Conclusions. The study demonstrated that the local incidence of button battery ingestion may be increasing, although data are still limited.Admission, anaesthesia and surgery rates for batteries were higher in this cohort than for all other foreign bodies. As button batteries can mimic coins, with much more dire consequences on ingestion, our ability to expedite diagnosis and management hinges on a high index of suspicion. It is imperative to increase awareness among healthcare workers and parents.


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74. Is AJCC/UICC Staging Still Appropriate for Head and Neck Cancers in Developing Countries?

OTO Open


Authors: Johannes J Fagan, Julie Wetter, Jeffrey Otiti , Joyce Aswani , Anna Konney , Evelyne Diom , Kenneth Baidoo, Paul Onakoya , Rajab Mugabo , Patrick Noah , Victor Mashamba , Innocent Kundiona , Chege Macharia , Mohammed Garba Mainasara , Melesse Gebeyehu , Mesele Bogale , Khaled Twier , Marco Faniriko , Getachew Beza Melesse , Mark G Shrime
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: ENT surgery, Surgical oncology

By 2030, 70% of cancers will occur in developing countries. Head and neck cancers are primarily a developing world disease. While anatomical location and the extent of cancers are central to defining prognosis and staging, the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) have incorporated nonanatomic factors that correlate with prognosis into staging (eg, p16 status of oropharyngeal cancers). However, 16 of 17 head and neck surgeons from 13 African countries cannot routinely test for p16 status and hence can no longer apply AJCC/UICC staging to oropharyngeal cancer. While the AJCC/UICC should continue to refine staging that best reflects treatment outcomes and prognosis by incorporating new nonanatomical factors, they should also retain and refine anatomically based staging to serve the needs of clinicians and their patients in resource-constrained settings. Not to do so would diminish their global relevance and in so doing also disadvantage most of the world’s cancer patients.


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75. Perioperative serum albumin as a predictor of adverse outcomes in abdominal surgery: prospective cohort hospital based study in Northern Tanzania

BMC Surgery


Authors: Christian Ephata Issangya, David Msuya, Kondo Chilonga, Ayesiga Herman, Elichilia Shao, Febronia Shirima, Elifaraja Naman, Henry Mkumbi, Jeremia Pyuza, Emmanuel Mtui, Leah Anku Sanga, Seif Abdul, Beatrice John Leyaro, Samuel Chugulu
Region / country: Eastern Africa – Tanzania
Speciality: General surgery

Background: Albumin is an important protein that transports hormones, fatty acids, and exogenous drugs; it also maintains plasma oncotic pressure. Albumin is considered a negative active phase protein because it decreases during injuries and sepsis. In spite of other factors predicting surgical outcomes, the effect of pre and postoperative serum albumin to surgical complications can be assessed by calculating the percentage decrease in albumin (delta albumin). This study aimed to explore perioperative serum albumin as a predictor of adverse outcomes in major abdominal surgeries.

Methods: All eligible adult participants from Kilimanjaro Christian Medical Centre Surgical Department were enrolled in a convenient manner. Data were collected using a study questionnaire. Full Blood Count (FBP), serum albumin levels preoperatively and on postoperative day 1 were measured in accordance with Laboratory Standard Operating Procedures (SOP). Data was entered and analyzed using STATA version 14. Association and extent of decrease in albumin levels as a predictor of surgical site infection (SSI), delayed wound healing and death within 30 days of surgery was determined using ordinal logistic regression models. In determining the diagnostic accuracy, a Non-parametric Receiver Operating Curve (ROC) model was used. We adjusted for ASA classification, which had a negative confounding effect on the predictive power of the percent drop in albumin to adverse outcomes.

Results: Sixty one participants were studied; the mean age was 51.6 (SD16.3), the majorities were males 40 (65.6%) and post-operative adverse outcomes were experienced by 28 (45.9%) participants. In preoperative serum albumin values, 40 (67.8%) had lower than 3.4 g/l while 51 (91%) had postoperative albumin values lower than 3.4 g/l. Only 15 (27.3%) had high delta albumin with the median percentage value of 14.77%. Delta albumin was an independent significant factor associated with adverse outcome (OR: 6.68; 95% CI: 1.59, 28.09); with a good predictive power and area under ROC curve (AUC) of 0.72 (95% CI 0.55 0.89). The best cutoff value was 11.61% with a sensitivity of 76.92% and specificity of 51.72%.

Conclusion: Early perioperative decreases in serum albumin levels may be a good, simple and cost effective tool to predict adverse outcomes in major abdominal surgeries.


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76. National approaches to trichiasis surgical follow-up, outcome assessment and surgeon audit in trachoma-endemic countries in Africa

British Journal of ophthalmology


Authors: Grace Mwangi, Paul Courtright, Anthony W Solomon
Region / country: Central Africa, Eastern Africa, Western Africa
Speciality: Ophthalmology

Background: Poor outcomes of trichiasis surgery, including postoperative trichiasis, are common in many trachoma-endemic countries in Africa. To improve outcomes, WHO recommends regular follow-up and outcome assessment of surgical cases plus audit of trichiasis surgeons.

Aims: To assess national approaches to trichiasis surgical follow-up, outcome assessment and audit, and identify national targets for good surgical outcome (defined as the percentage of patients undergoing surgery for trichiasis remaining free of post-operative trichiasis for a defined interval after surgery).

Methods: A cross-sectional survey was carried out between May and July 2018, involving all 29 known-trachoma-endemic countries in Africa. An emailed questionnaire was used to collect information on national targets for surgical outcomes, policies, monitoring and strategies to address underperformance by surgeons.

Results: All national programmes provided information; 2 of the 29 had not yet implemented trichiasis surgery as part of their trachoma elimination programme. Findings from 27 countries are therefore reported. Only four countries reported having a national policy for trichiasis surgery follow-up and outcome assessment and only two had a national policy for conducting audits of trichiasis surgeons. Only 9 of the 27 countries had a cut-off point at which poorly performing surgeons would be instructed to discontinue surgery until retraining or other interventions had been undertaken.

Discussion: To address the challenge of post-operative trichiasis and other poor outcomes, national trachoma programmes should create and implement policies and systems to follow up patients, assess surgical outcomes and monitor the performance of individual surgeons through post-surgical audits.


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77. Awake Craniotomy in a Child: Assessment of Eligibility with a Simulated Theatre Experience

case reports in anesthesiology


Authors: Jason Labuschagne, Clover-Ann Lee, Denis Mutyaba, Tatenda Mbanje, Cynthia Sibanda
Region / country: Southern Africa – South Africa
Speciality: Neurosurgery, Paediatric surgery, Surgical oncology

Background: Awake craniotomy is a useful surgical approach to identify and preserve eloquent areas during tumour resection, during surgery for arteriovenous malformation resections and for resective epilepsy surgery. With decreasing age, a child’s ability to cooperate and mange an awake craniotomy becomes increasingly relevant. Preoperative screening is essential to identify the child who can undergo the procedure safely. Case Description. A 11-year-old female patient presented with a tumour in her right motor cortex, presumed to be a dysembryoplastic neuroepithelial tumour (DNET). We had concerns regarding the feasibility of performing awake surgery in this patient as psychological testing revealed easy distractibility and an inability to follow commands repetitively. We devised a simulated surgical experience to assess her ability to manage such a procedure. During the simulated theatre experience, attempts were made to replicate the actual theatre experience as closely as possible. The patient was dressed in theatre attire and brought into the theatre on a theatre trolley. She was then transferred onto the theatre bed and positioned in the same manner as she would be for the actual surgery. Her head was placed on a horseshoe headrest, and she was made to lie in a semilateral position, as required for the surgery. A blood pressure cuff, pulse oximeter, nasal cannula with oxygen flow, and calf pumps were applied. She was then draped precisely as she would have been for the procedure. Theatre lighting was set as it would be for the surgical case. The application of the monitoring devices, nasal cannula, and draping was meant not only to prepare her for the procedure but to induce a mild degree of stress such that we could assess the child’s coping skills and ability to undergo the procedure. The child performed well throughout the simulated run, and surgery was thus offered. An asleep-awake-asleep technique was planned and employed for surgical removal of the tumour. Cortical and subcortical mapping was used to identify the eloquent tissue. Throughout the procedure, the child was cooperative and anxiety free. Follow-up MRI revealed gross total removal of the lesion.

Conclusion: A simulated theatre experience allowed us to accurately determine that this young patient, despite relative contraindications, was indeed eligible for awake surgery. We will continue to use this technique for all our young patients in assessing their eligibility for these procedures.


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78. Salome Maswime: dynamic leader in global surgery

Lancet


Authors: Richard Lane
Region / country: Southern Africa – South Africa
Speciality: Other

As Associate Professor and Head of Global Surgery at the University of Cape Town (UCT), South Africa, Salome Maswime is aware of the scale of the job in front of her. “For me the big problem is the disconnect between health systems and clinical care in low and middle income countries, especially concerning surgical care. Outcomes are often poor, there being not enough focus on the quality of surgery, and how it relates to integrated health care and overarching health systems performance”, she explains. Maswime saw such shortcomings first hand in her clinical career in obstetrics and gynaecology, before she took up the new post as Head of Global Surgery at UCT in July, 2019.


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79. Implementation of Surgical Site Infection Surveillance in Low- and Middle-Income Countries A Position Statement for the International Society for Infectious Diseases

International Journal of Infectious Diseases


Authors: Shaheen Mehtar, Anthony Wanyoro , Folasade Ogunsola , Emmanuel A Ameh , Peter Nthumba , Claire Kilpatrick , Gunturu Revathi , Anastasia Antoniadou , Helen Giamarelou , Anucha Apisarnthanarak, John W Ramatowski, Victor D xsRosenthal, Julie Storr, Tamer Saied Osman, Joseph S Solomkin
Region / country: Global
Speciality: Health policy

Surgical site infection (SSI) rates in low- and middle-income countries (LMICs) range from 8 to 30% of procedures, making them the most common healthcare acquired infection (HAI) with substantial morbidity, mortality, and economic impacts. Presented here is an approach to surgical site infection prevention based on surveillance and focused on five key areas as identified by international experts. These five areas include: Collecting valid, high-quality data; Linking HAIs to economic incapacity, underscoring the need to prioritize infection prevention activities; Implementing SSI surveillance within infection prevention and control (IPC) programs to enact structural changes, develop procedural skills, and alter healthcare worker behaviors; Priotiziation of IPC training for healthcare workers in LMICs to conduct broad-based surveillance coupled with the development and implementation of locally applicable IPC programs; Developing a highly accurate and objective international system for defining SSIs that can be translated globally in a straightforward manner. Finally, we present a clear, unambiguous framework for successful SSI guideline implementation that supports the development of sustainable IPC programs in LMICs. This entails: i) identifying index operations for targeted surveillance; ii) identifying IPC “champions” and empowering healthcare workers; iii) using multimodal improvement measures; iv) positioning hand hygiene programs as the basis for IPC initiatives; and v), use of telecommunication devices for surveillance and healthcare outcome follow-ups. Additionally, special considerations for pediatric SSIs, antimicrobial resistance development, and antibiotic stewardship programs are addressed.


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80. Cost-effectiveness of inhaled oxytocin for prevention of postpartum haemorrhage: a modelling study applied to two high burden settings

BMC Medicine


Authors: Natalie Carvalho, Mohammad Enamul Hoque, Victoria L. Oliver, Abbey Byrne, Michelle Kermode, Pete Lambert, Michelle P. McIntosh and Alison Morgan
Region / country: Eastern Africa, South-eastern Asia – Bangladesh, Ethiopia
Speciality: Health policy, Obstetrics and Gynaecology

Background: Access to oxytocin for prevention of postpartum haemorrhage (PPH) in resource-poor settings is limited by the requirement for a consistent cold chain and for a skilled attendant to administer the injection. To overcome these barriers, heat-stable, non-injectable formulations of oxytocin are under development, including oxytocin for inhalation. This study modelled the cost-effectiveness of an inhaled oxytocin product (IHO) in Bangladesh and Ethiopia.

Methods: A decision analytic model was developed to assess the cost-effectiveness of IHO for the prevention of PPH compared to the standard of care in Bangladesh and Ethiopia. In Bangladesh, introduction of IHO was modelled in all public facilities and home deliveries with or without a skilled attendant. In Ethiopia, IHO was modelled in all public facilities and home deliveries with health extension workers. Costs (costs of introduction, PPH prevention and PPH treatment) and effects (PPH cases averted, deaths averted) were modelled over a 12-month program. Life years gained were modelled over a lifetime horizon (discounted at 3%). Cost of maintaining the cold chain or effects of compromised oxytocin quality (in the absence of a cold chain) were not modelled.

Results: In Bangladesh, IHO was estimated to avert 18,644 cases of PPH, 76 maternal deaths and 1954 maternal life years lost. This also yielded a cost-saving, with the majority of gains occurring among home deliveries where IHO would replace misoprostol. In Ethiopia, IHO averted 3111 PPH cases, 30 maternal deaths and 767 maternal life years lost. The full IHO introduction program bears an incremental cost-effectiveness ratio (ICER) of between 2 and 3 times the per-capita Gross Domestic Product (GDP) ($1880 USD per maternal life year lost) and thus is unlikely to be considered cost-effective in Ethiopia. However, the ICER of routine IHO administration considering recurring cost alone falls under 25% of per-capita GDP ($175 USD per maternal life-year saved).

Conclusions: IHO has the potential to expand access to uterotonics and reduce PPH-associated morbidity and mortality in high burden settings. This can facilitate reduced spending on PPH management, making the product highly cost-effective in settings where coverage of institutional delivery is lagging.


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81. Systematic review of barriers to, and facilitators of, the provision of high‐quality midwifery services in India

birth


Authors: Alison McFadden RM PhD, Sunanda Gupta MBBS MS MPH, Joyce L. Marshall RM MPH PhD, Shona Shinwell RM MSc, Bharati Sharma PhD, Fran McConville SRN SCM MA , Steve MacGillivray PhD
Region / country: South-eastern Asia – India
Speciality: Obstetrics and Gynaecology

Background
The Indian government has committed to implementing high‐quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high‐quality midwifery care in India.

Methods
We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high‐quality midwifery care in India.

Results
Thirty‐two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands‐on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women’s experiences of maternity care, and improving health system infrastructure.

Conclusions
The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India’s plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.


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82. Comprehending the lack of access to maternal and neonatal emergency care: Designing solutions based on a space-time approach

pLOS One


Authors: Núbia Cristina da Silva, Thiago Augusto Hernandes Rocha , Pedro Vasconcelos Amaral, Cyrus Elahi, Elaine Thumé, Erika Bárbara Abreu Fonseca Thomaz, Rejane Christine de Sousa Queiroz, João Ricardo Nickenig Vissoci, Catherine Staton, Luiz Augusto Facchini
Region / country: South America – Brazil
Speciality: Emergency surgery, Obstetrics and Gynaecology

Objective
The objective of this study was to better understand how the lack of emergency child and obstetric care can be related to maternal and neonatal mortality levels.

Methods
We performed spatiotemporal geospatial analyses using data from Brazilian municipalities. An emergency service accessibility index was derived using the two-step floating catchment area (2SFCA) for 951 hospitals. Mortality data from 2000 to 2015 was used to characterize space-time trends. The data was overlapped using a spatial clusters analysis to identify regions with lack of emergency access and high mortality trends.

Results
From 2000 to 2015 Brazil the overall neonatal mortality rate varied from 11,42 to 11,71 by 1000 live births. The maternal mortality presented a slightly decrease from 2,98 to 2,88 by 100 thousand inhabitants. For neonatal mortality the Northeast and North regions presented the highest percentage of up trending. For maternal mortality the North region exhibited the higher volume of up trending. The accessibility index obtained highlighted large portions of the rural areas of the country without any coverage of obstetric or neonatal beds.

Conclusions
The analyses highlighted regions with problems of mortality and access to maternal and newborn emergency services. This sequence of steps can be applied to other low and medium income countries as health situation analysis tool.

Significance statement
Low and middle income countries have greater disparities in access to emergency child and obstetric care. There is a lack of approaches capable to support analysis considering a spatiotemporal perspective for emergency care. Studies using Geographic Information System analysis for maternal and child care, are increasing in frequency. This approach can identify emergency child and obstetric care saturated or deprived regions. The sequence of steps designed here can help researchers, and policy makers to better design strategies aiming to improve emergency child and obstetric care.


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83. The international discussion and the new regulations concerning transvaginal mesh implants in pelvic organ prolapse surgery

International Urogynecology Journal


Authors: Nathalie Ng-Stollmann, Christian Fünfgeld, Boris Gabriel & Achim Niesel
Region / country: Global
Speciality: Obstetrics and Gynaecology

The use of transvaginal mesh implants for POP and urinary incontinence is currently being extensively debated among experts as well as the general public. Regulations surrounding the use of these implants differ depending on the country. Although in the USA, the UK, in Canada, Australia, New Zealand, and France, transvaginal mesh implants have been removed from the market, in most mainland European countries, Asia, and South America, they are still available as a surgical option for POP correction. The aim of this review is to provide an overview of the historical timeline and the current situation worldwide, as well as to critically discuss the implications of the latest developments in urogynecological patient care and the training of doctors.


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84. Changes in surgical practice in 85 South African hospitals during COVID-19 hard lockdown

South African Medical Journal


Authors: K M Chu, M Smith, E Steyn, P Goldberg, H Bougard, I Buccimazza
Region / country: Southern Africa – South Africa
Speciality: Health policy

Background. In preparation for the COVID-19 pandemic, South Africa (SA) began a national lockdown on 27 March 2020, and many hospitals implemented measures to prepare for a potential COVID-19 surge.

Objectives. To report changes in SA hospital surgical practices in response to COVID-19 preparedness.

Methods. In this cross-sectional study, surgeons working in SA hospitals were recruited through surgical professional associations via an online survey. The main outcome measures were changes in hospital practice around surgical decision-making, operating theatres, surgical services and surgical trainees, and the potential long-term effect of these changes.

Results. A total of 133 surgeons from 85 hospitals representing public and private hospitals nationwide responded. In 59 hospitals (69.4%), surgeons were involved in the decision to de-escalate surgical care. Access was cancelled or reduced for non-cancer elective (n=84; 99.0%), cancer (n=24; 28.1%) and emergency operations (n=46; 54.1%), and 26 hospitals (30.6%) repurposed at least one operating room as a ventilated critical care bed. Routine postoperative visits were cancelled in 33 hospitals (36.5%) and conducted by telephone or video in 15 (16.6%), 74 hospitals (87.1%) cancelled or reduced new outpatient visits, 64 (75.3%) reallocated some surgical inpatient beds to COVID-19 cases, and 29 (34.1%) deployed some surgical staff (including trainees) to other hospital services such as COVID-19 testing, medical/COVID-19 wards, the emergency department and the intensive care unit.

Conclusions. Hospital surgical de-escalation in response to COVID-19 has greatly reduced access to surgical care in SA, which could result in a backlog of surgical needs and an excess of morbidity and mortality.


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85. Trends and determinants of health facility childbirth service utilization among mothers in urban slums of Nairobi, Kenya

global epidemiology


Authors: Catherine Atahigwa, Damazo T.Kadengye, Samuel Iddi, Steven Abrams, Annelies Van Rie for the NUHDSS
Region / country: Eastern Africa – Kenya
Speciality: Obstetrics and Gynaecology

High maternal mortality remains a challenge for the attainment of the third Sustainable Development Goal in Sub-Saharan Africa. In Kenya, maternal mortality ratio remains high at 362 deaths per 100,000 live births. Utilization of health facility childbirth services ensures safe birth and is vital for the reduction of maternal mortality. However, this can be greatly affected by socioeconomic and geographical inequalities. In this study, we assess the trends and determinants of health facility childbirth service utilization among women giving birth in the urban slums of Nairobi, Kenya. Data were obtained from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) comprising 19,469 births observed between 2003 and [19]. A logistic regression model, with parameter estimation using a generalized estimating equations (GEE) approach, was used to assess factors associated with health facility childbirth. About 81% of the births occurred at health facilities while 19% were occurring at home or outside a health facility. The results further indicated that, education, parity, and relationship to head of households were associated with health facility childbirth. Increasing awareness of the mothers about the benefits of health facility childbirth service utilization and the risks of home childbirth should be given extra attention by health practitioners during antenatal care visits.


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86. The ratio of shock index to pulse oxygen saturation predicting mortality of emergency trauma patients

PLOS One


Authors: Junfang Qi ,Li Ding ,Long Bao,Du Chen
Region / country: South-eastern Asia – China
Speciality: Emergency surgery, Trauma surgery

Objective: To test the following hypothesis: the ratio of shock index to pulse oxygen saturation can better predict the mortality of emergency trauma patients than shock index.

Methods: 1723 Patients of trauma admitted to the Emergency Department of the First Affiliated Hospital of Soochow University from 1 November 2016 to 30 November 2019 were retrospectively evaluated. We defined SS as the ratio of SI to SPO2, and the mortality of trauma patients in the emergency department as end-point of outcome. We calculated the crude HR of SS and adjusted HR with the adjustment for risk factors including sex, age, revised trauma score (RTS) by Cox regression model. ROC curve analyses were performed to compare the area under the curve (AUC) of SS and SI.

Results: The crude HR of SS was: 4.31, 95%CI (2.89-6.42) and adjusted HR: 3.01, 95%CI(1.86-4.88); ROC curve analyses showed that AUC of SS was higher than that of shock index (SI), and the difference was statistically significant: 0.69, 95%CI(0.55-0.83) vs 0.65, 95%CI (0.51-0.79), P = 0.001.

Conclusion: The ratio of shock index to pulse oxygen saturation is good predictor for emergency trauma patients, which has a better prognostic value than shock index.


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87. Barriers and facilitators to implementing trauma registries in low- and middle-income countries: Qualitative experiences from Tanzania

African Journal of Emergency Medicine


Authors: Hendry R.Sawe, Nathanael Sirili, Ellen Weber, Timothy J.Coats, Lee A.Wallis, Teri A.Reynolds
Region / country: Eastern Africa – Tanzania
Speciality: Emergency surgery, Trauma surgery

Background
The burden of trauma in low and middle-income countries (LMICs) is disproportionately high: LMICs account for nearly 90% of the global trauma deaths. Lack of trauma data has been identified as one of the major challenges in addressing the quality of trauma care and informing injury-preventing strategies in LMICs. This study aimed to explore the barriers and facilitators of current trauma documentation practices towards the development of a national trauma registry (TR).

Methods
An exploratory qualitative study was conducted at five regional hospitals between August 2018 and December 2018. Five focus group discussions (FGDs) were conducted with 49 participants from five regional hospitals. Participants included specialists, medical doctors, assistant medical officers, clinical officers, nurses, health clerks and information communication and technology officers. Participants came from the emergency units, surgical and orthopaedic inpatient units, and they had permanent placement to work in these units as non-rotating staff. We analysed the gathered information using a hybrid thematic analysis.

Results
Inconsistent documentation and archiving system, the disparity in knowledge and experience of trauma documentation, attitudes towards documentation and limitations of human and infrastructural resources in facilities we found as major barriers to the implementation of trauma registry. Health facilities commitment to standardising care, Ministry of Health and medicolegal data reporting requirements, and insurance reimbursements criteria of documentation were found as major facilitators to implementing trauma registry.

Conclusions
Implementation of a trauma registry in regional hospitals is impacted by multiple barriers related to providers, the volume of documentation, resource availability for care, and facility care flow processes. However, financial, legal and administrative data reporting requirements exist as important facilitators in implementing the trauma registry at these hospitals. Capitalizing in the identified facilitators and investing to address the revealed barriers through contextualized interventions in Tanzania and other LMICs is recommended by this study.


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88. Inequalities in caesarean section in Burundi: evidence from the Burundi Demographic and Health Surveys (2010–2016)

BMC Health Services Research


Authors: Sanni Yaya, Betregiorgis Zegeye, Dina Idriss-Wheeler and Gebretsadik Shibre
Region / country: Eastern Africa – Burundi
Speciality: Health policy, Obstetrics and Gynaecology

Background
Despite caesarean section (CS) being a lifesaving intervention, there is a noticeable gap in providing this service, when necessary, between different population groups within a country. In Burundi, there is little information about CS coverage inequality and the change in provision of this service over time. Using a high-quality equity analysis approach, we aimed to document both magnitude and change of inequality in CS coverage in Burundi over 7 years to investigate disparities.

Methods
For this study, data were extracted from the 2010 and 2016 Burundi Demographic and Health Surveys (BDHS) and analyzed through the recently updated Health Equity Assessment Toolkit (HEAT) of the World Health Organization. CS delivery was disaggregated by four equity stratifiers, namely education, wealth, residence and sub-national region. For each equity stratifier, relative and absolute summary measures were calculated. We built a 95% uncertainty interval around the point estimate to determine statistical significance.

Main findings
Disparity in CS was present in both survey years and increased over time. The disparity systematically favored wealthy women (SII = 10.53, 95% UI; 8.97, 12.10), women who were more educated (PAR = 8.89, 95% UI; 8.51, 9.26), women living in urban areas (D = 12.32, 95% UI; 9.00, 15.63) and some regions such as Bujumbura (PAR = 11.27, 95% UI; 10.52, 12.02).

Conclusions
Burundi had not recorded any progress in ensuring equity regarding CS coverage between 2010 and 2016. It is important to launch interventions that promote justified use of CS among all subpopulations and discourage overuse among high income, more educated women and urban dwellers.


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89. Resuming elective surgeries in Corona pandemic from the perspective of a developing country

Journal of Pediatric and Adolescent Surgery


Authors: Yogesh Kumar Sarin
Region / country: South-eastern Asia – India
Speciality: Other

Since the COVID-19 pandemic, healthcare facilities have entered into a “crisis mode”. One of the measures used to allow hospitals to surge their capacity and serve the patient population with COVID-19 infection was the suspension of elective activity, most importantly elective surgery and other procedures. Now as the infection is fading, efforts are being made to resume elective surgical services keeping in mind the safety of the patient and health care workers. Resuming surgical services in developing countries is an uphill task.


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90. Perceptions of Non-Communicable Disease and War Injury Management in the Palestinian Health System: A Qualitative Study of Healthcare Providers Perspectives

Journal of Multidisciplinary Healthcare


Authors: Marwan Mosleh, Yousef Aljeesh, Koustuv Dalal, Charli Eriksson, Heidi Carlerby, Eija Viitasara
Region / country: Middle East – Palestinian Territories
Speciality: Emergency surgery, Trauma surgery

Background: Palestine, like other low-income countries, is confronting an increasing epidemic of non-communicable disease (NCD) and trend of war injury. The management of health problems often presents a critical challenge to the Palestinian health system (PHS). Understanding the perceptions of healthcare providers is essential in exploring the gaps in the health system to develop an effective healthcare intervention. Unfortunately, health research on management of NCD and war injury has largely been neglected and received little attention. Therefore, the study aimed to explore the perspectives of healthcare providers regarding NCD and war injury management in the PHS in the Gaza Strip.
Methods: A qualitative study approach was used, based on four focus group discussions (FGDs) involving a purposive sampling strategy of 30 healthcare providers from three main public hospitals in Gaza Strip. A semi-structured topic guide was used, and the focus group interviews data were analyzed using manifest content analysis. The study was approved by the Palestinian Health Research Council (PHRC) for ethics approval.
Results: From the healthcare providers perspective, four main themes and several sub-themes have emerged from the descriptive manifest content analysis: functioning of healthcare system; system-related challenges; patients-related challenges; strategies and actions to navigating the challenges and improving care. Informants frequently discussed that despite some positive aspects in the system, fundamental changes and significant improvements are needed. Some expressed serious concerns that the healthcare system needs complete rebuilding to facilitate the management of NCD and war-related injury. They perceived important barriers to effective management of NCD and war injury such as poor hospital infrastructure and logistics, shortage of micro and sub-specialities and essential resources. Participants also expressed a dilemma and troubles in communication and interactions, especially during emergencies or crises. The informants stressed the unused of updated clinical management guidelines. There was a consensus regarding poor shared-care/task sharing, partnership, and cooperation among healthcare facilities.
Conclusion: Our findings suggest that fundamental changes and significant reforms are needed in the health system to make healthcare services more effective, timely, and efficient. The study disclosed the non-use of clinical guidelines as well as suboptimal sectorial task-sharing among different stakeholders and healthcare providers. A clear and comprehensive healthcare policy considering the gaps in the system must be adopted for the improvement and development of care in the PHS.


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91. Usability of Mobile Health Apps for Postoperative Care: Systematic Review

JMIR Perioperative Medicine


Authors: Ben Patel BA BMBCh, Arron Thind BA BMBCh
Region / country: Global
Speciality: Other

Background: Mobile health (mHealth) apps are increasingly used postoperatively to monitor, educate, and rehabilitate. The usability of mHealth apps is critical to their implementation.

Objective: This systematic review evaluates the (1) methodology of usability analyses, (2) domains of usability being assessed, and (3) results of usability analyses.

Methods: The A Measurement Tool to Assess Systematic Reviews checklist was consulted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline was adhered to. Screening was undertaken by 2 independent reviewers. All included studies were assessed for risk of bias. Domains of usability were compared with the gold-standard mHealth App Usability Questionnaire (MAUQ).

Results: A total of 33 of 720 identified studies were included for data extraction. Of the 5 included randomized controlled trials (RCTs), usability was never the primary end point. Methodology of usability analyses included interview (10/33), self-created questionnaire (18/33), and validated questionnaire (9/33). Of the 3 domains of usability proposed in the MAUQ, satisfaction was assessed in 28 of the 33 studies, system information arrangement was assessed in 11 of the 33 studies, and usefulness was assessed in 18 of the 33 studies. Usability of mHealth apps was above industry average, with median System Usability Scale scores ranging from 76 to 95 out of 100.

Conclusions: Current analyses of mHealth app usability are substandard. RCTs are rare, and validated questionnaires are infrequently consulted. Of the 3 domains of usability, only satisfaction is regularly assessed. There is significant bias throughout the literature, particularly with regards to conflicts of interest. Future studies should adhere to the MAUQ to assess usability and improve the utility of mHealth apps.


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92. The Effectiveness and Challenges of E-learning in Surgical Training in Low- and Middle-Income Countries: A Systematic Review

Global Health: Annual Review


Authors: Justin Di Lu, Brian H. Cameron
Region / country: Global
Speciality: Surgical Education

E-learning encompasses the use of electronic media, online tools, and technologies in education and has been shown to be generally effective and satisfying for students, compared to traditional methods such as didactic lectures. Within surgical education, there is growing demand for e-learning platforms in low- and middle-income countries (LMICs). A systematic review was conducted to evaluate the effectiveness and challenges of e-learning for surgical trainees in LMICs. Out of 87 studies, five studies met the inclusion criteria and reported either neutral or positive improvements in cognitive and procedural skills, compared to baselines or controls for surgical trainees in LMICs. Using a qualitative synthesis approach, the researchers identified common challenges and barriers, such as low bandwidth, limited connectivity, and poor surgical details, which led to poor knowledge synthesis. This suggests that more emphasis needs to be placed on developing a strong online foundation that could be easily accessed and is user-friendly and intuitive, especially in LMICs. However, the research was limited by the lack of literature surrounding surgical e-learning interventions in LMICs and more research is required in this area.


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93. Mechanical and surgical interventions for treating primary postpartum haemorrhage

Cochrane Systematic Review – Intervention


Authors: Frances J Kellie, Julius N Wandabwa, Hatem A Mousa, Andrew D Weeks
Region / country: Global
Speciality: Emergency surgery, Obstetrics and Gynaecology

Background: Primary postpartum haemorrhage (PPH) is commonly defined as bleeding from the genital tract of 500 mL or more within 24 hours of birth. It is one of the most common causes of maternal mortality worldwide and causes significant physical and psychological morbidity. An earlier Cochrane Review considering any treatments for the management of primary PPH, has been split into separate reviews. This review considers treatment with mechanical and surgical interventions.

Objectives: To determine the effectiveness and safety of mechanical and surgical interventions used for the treatment of primary PPH.

Search methods: We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 July 2019) and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (RCTs) of mechanical/surgical methods for the treatment of primary PPH compared with standard care or another mechanical/surgical method. Interventions could include uterine packing, intrauterine balloon insertion, artery ligation/embolism, or uterine compression (either with sutures or manually). We included studies reported in abstract form if there was sufficient information to permit risk of bias assessment. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not.

Data collection and analysis: Two review authors independently assessed studies for inclusion and risk of bias, independently extracted data and checked data for accuracy. We used GRADE to assess the certainty of the evidence.

Main results: We included nine small trials (944 women) conducted in Pakistan, Turkey, Thailand, Egypt (four trials), Saudi Arabia, Benin and Mali. Overall, included trials were at an unclear risk of bias. Due to substantial differences between the studies, it was not possible to combine any trials in meta-analysis. Many of this review’s important outcomes were not reported. GRADE assessments ranged from very low to low, with the majority of outcome results rated as very low certainty. Downgrading decisions were mainly based on study design limitations and imprecision; one study was also downgraded for indirectness. External uterine compression versus normal care (1 trial, 64 women) Very low-certainty evidence means that we are unclear about the effect on blood transfusion (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.66 to 8.23). Uterine arterial embolisation versus surgical devascularisation plus B-Lynch (1 trial, 23 women) The available evidence for hysterectomy to control bleeding (RR 0.73, 95% CI 0.15 to 3.57) is unclear due to very low-certainty evidence. The available evidence for intervention side effects is also unclear because the evidence was very low certainty (RR 1.09; 95% CI 0.08 to 15.41). Intrauterine Tamponade Studies included various methods of intrauterine tamponade: the commercial Bakri balloon, a fluid-filled condom-loaded latex catheter (‘condom catheter’), an air-filled latex balloon-loaded catheter (‘latex balloon catheter’), or traditional packing with gauze. Balloon tamponade versus normal care (2 trials, 356 women) One study(116 women) used the condom catheter. This study found that it may increase blood loss of 1000 mL or more (RR 1.52, 95% CI 1.15 to 2.00; 113 women), very low-certainty evidence. For other outcomes the results are unclear and graded as very low-certainty evidence: mortality due to bleeding (RR 6.21, 95% CI 0.77 to 49.98); hysterectomy to control bleeding (RR 4.14, 95% CI 0.48 to 35.93); total blood transfusion (RR 1.49, 95% CI 0.88 to 2.51); and side effects. A second study of 240 women used the latex balloon catheter together with cervical cerclage. Very low-certainty evidence means we are unclear about the effect on hysterectomy (RR 0.14, 95% CI 0.01 to 2.74) and additional surgical interventions to control bleeding (RR 0.20, 95% CI 0.01 to 4.12). Bakri balloon tamponade versus haemostatic square suturing of the uterus (1 trial, 13 women) In this small trial there was no mortality due to bleeding, serious maternal morbidity or side effects of the intervention, and the results are unclear for blood transfusion (RR 0.57, 95% CI 0.14 to 2.36; very low certainty). Bakri balloon tamponade may reduce mean ‘intraoperative’ blood loss (mean difference (MD) -426 mL, 95% CI -631.28 to -220.72), very low-certainty evidence. Comparison of intrauterine tamponade methods (3 trials, 328 women) One study (66 women) compared the Bakri balloon and the condom catheter, but it was uncertain whether the Bakri balloon reduces the risk of hysterectomy to control bleeding due to very low-certainty evidence (RR 0.50, 95% CI 0.05 to 5.25). Very low-certainty evidence also means we are unclear about the results for the risk of blood transfusion (RR 0.97, 95% CI 0.88 to 1.06). A second study (50 women) compared Bakri balloon, with and without a traction stitch. Very low-certainty evidence means we are unclear about the results for hysterectomy to control bleeding (RR 0.20, 95% CI 0.01 to 3.97). A third study (212 women) compared the condom catheter to gauze packing and found that it may reduce fever (RR 0.47, 95% CI 0.38 to 0.59), but again the evidence was very low certainty. Modified B-Lynch compression suture versus standard B-Lynch compression suture (1 trial, 160 women) Low-certainty evidence suggests that a modified B-Lynch compression suture may reduce the risk of hysterectomy to control bleeding (RR 0.33, 95% CI 0.11 to 0.99) and postoperative blood loss (MD -244.00 mL, 95% CI -295.25 to -192.75).

Authors’ conclusions: There is currently insufficient evidence from RCTs to determine the relative effectiveness and safety of mechanical and surgical interventions for treating primary PPH. High-quality randomised trials are urgently needed, and new emergency consent pathways should facilitate recruitment. The finding that intrauterine tamponade may increase total blood loss > 1000 mL suggests that introducing condom-balloon tamponade into low-resource settings on its own without multi-system quality improvement does not reduce PPH deaths or morbidity. The suggestion that modified B-Lynch suture may be superior to the original requires further research before the revised technique is adopted. In high-resource settings, uterine artery embolisation has become popular as the equipment and skills become more widely available. However, there is little randomised trial evidence regarding efficacy and this requires further research. We urge new trial authors to adopt PPH core outcomes to facilitate consistency between primary studies and subsequent meta-analysis.


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94. Frugal innovation for global surgery: leveraging lessons from low- and middle-income countries to optimise resource use and promote value-based care

RCS Bulletin


Authors: A Steyn, A Cassels-Brown, DF Chang, H Faal, R Vedanthan, R Venkatesh, CL Thiel
Region / country: Global
Speciality: Health policy, Other

Limited or inconsistent access to necessary resources creates many challenges for delivering quality medical care in low- and middle-income countries (LMICs). These include funding and revenue, skilled clinical and allied health professionals, administrative expertise, reliable community infrastructure (eg water, electricity), functioning capital equipment and sufficient surgical supplies. Despite these challenges, some surgical care providers manage to provide cost effective, high quality care, offering lessons not only for other LMICs but also for high-income countries (HICs) that are working towards increasing value-based care. Examples would be how to optimise the consumption of resources, and reduce the environmental and public health burden of surgical care.

Owing to the liberal utilisation of capital equipment and single-use supplies, surgical care in HICs is increasingly recognised as a significant source of greenhouse gases and other environmental impacts that adversely affect human health. Regulations require many potentially reusable supplies and drugs to be discarded after single use. Supply manufacturers may label drugs or products as single-use to increase profit, reduce liability or facilitate regulatory approval. Many HICs struggle to increase the value of care while maximising quality and outcomes, and minimising cost and resource use.


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95. Establishing a Sustainable Training Program for Laparoscopy in Resource-Limited Settings: Experience in Ghana

Annals of Global Health


Authors: Mee Joo Kang, Kwabena Breku Apea-Kubi , Kojo Assoku Kwarko Apea-Kubi , Nyabenda-Gomwa Adoula , James Nii Noi Odonkor and Alfred Korbia Ogoe
Region / country: Western Africa – Ghana
Speciality: General surgery, Surgical Education

Background:
Healthcare equipment funded by international partners is often not properly utilized in many developing countries due to low levels of awareness and a lack of expertise. A long-term on-site training program for laparoscopic surgery was established at a regional hospital in Ghana upon request of the Ghana Health Service and local surgeons.

Objective:
The authors report the initial 32-month experience of implementing laparoscopic surgery focusing on the trainees’ response, technical independence, and factors associated with the successful implementation of a “new” surgical practice.

Methods:
Curricular structure and feedback results of the trainings for doctors and nurses, and characteristics of laparoscopic procedures performed at the Greater Accra Regional Hospital between January 2017 and September 2019 were retrospectively reviewed.

Findings:
Comprehensive training including two weeks of simulation workshops followed by animal labs were regularly provided for the doctors. Among the 97 trainees, 27.9% had prior exposure in laparoscopic surgery, 95% were satisfied with the program. Eleven nurses attained professional competency over 15 training sessions where none had prior exposure to laparoscopic surgery. Since the first laparoscopic cholecystectomy in February 2017, 82 laparoscopic procedures were performed. The scope of the surgery was expanded from general surgery (n = 46) to gynecology (n = 33), pediatric surgery (n = 2), and urology (n = 1). The volume of local doctors as primary operators increased from 0% (0/17, February to December 2017) to 41.9% (13/31, January to October 2018) and 79.4% (27/34, November 2018 to September 2019), with 72.5% of the cases being assisted by the expatriate surgeon. There were no open conversions, technical complications, or mortalities. Local doctors independently commenced endoscopic surgical procedures including cystoscopies, hysteroscopies, endoscopic neurosurgeries and arthroscopies.

Conclusion:
Sensitization and motivation of the surgical workforce through long-term continuous on-site training resulted in the successful implementation of laparoscopic surgery with a high level of technical independence.


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96. Patterns of Endoscopy During COVID-19 Pandemic: A Global Survey of Interventional Inflammatory Bowel Disease Practice

intestinal research


Authors: Yan Chen , Qiao Yu , Francis A Farraye , Gursimran S Kochhar , Charles N Bernstein , Udayakumar Navaneethan , Kaicun Wu , Jie Zhong , David A Schwartz , Hao Wu , Jing-Jing Zheng, Marietta Iacucci, Ravi P Kiran, Bo Shen
Region / country: Global
Speciality: General surgery

Background/aims: Performance of diagnostic or therapeutic endoscopic procedures in inflammatory bowel disease (IBD) patients can be challenging during a viral pandemic; the main concerns being the safety and protection of patients and health care providers (HCP). The aim of this study is to identify endoscopic practice patterns and outcomes of IBD and coronavirus disease 19 (COVID-19) with a worldwide survey of HCP.

Methods: The 20-item survey questionnaire was sent to physician members of the American Society for Gastrointestinal Endoscopy Special Interest Group in Interventional IBD, Chinese IBD Society Endoscopy Interest Group, and the China Crohn’s and Colitis Foundation.

Results: A total of 141 respondents submitted valid responses. Nighty-five respondents (67.9%) reported that at least 25% of their scheduled emergent endoscopic procedures were canceled or postponed during the pandemic. Fifty-six respondents (40.0%) have performed emergent endoscopy during the pandemic. A few respondents (9/140, 6.4%) estimated that more than 25% of their patients had worsened disease due to delayed or canceled emergent endoscopy procedures. More than 80% of respondents believed that personal protective equipment (PPE) for the endoscopy team, room sterilization, and pre-procedure screening of patients for COVID-19 were necessary. Out of 140 respondents, 16 (11.4%) reported that several of their patients had COVID-19. Eight clinicians (5.7%) reported that they or their endoscopy colleagues developed work-related COVID-19.

Conclusions: Cancellation of elective and emergent endoscopy in IBD care during the pandemic was common. Few respondents reported that their patients’ disease conditions worsened due to the cancellation of the endoscopy procedure. Most respondents voiced the need for proper PPE during the procedure regardless of patients’ COVID-19 status and screening the patients for COVID-19.


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97. Resurgence of “Bow and Arrow” Related Ocular Trauma: Collateral Damage Arising From COVID-19 Lockdown in India?

indian journal of ophthalmology


Authors: Maneesh M Bapaye , Akshay Gopinathan Nair , Pankaj P Mangulkar , Charuta M Bapaye , Meena M Bapaye
Region / country: South-eastern Asia – India
Speciality: Ophthalmology, Trauma surgery

Penetrating ocular trauma in children often presents late and may be associated with complications due to delayed presentation as children are not always able to verbalize their injuries. Previous studies have shown that children aged 5 and above were more frequently affected and it was also noted that boys were more frequently affected than girls. Children involved in unsupervised games often get injured and “bow and arrow” injuries were known to be a fairly common cause of penetrating trauma in children, in the past.


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98. All India Ophthalmological Society – Oculoplastics Association of India Consensus Statement on Preferred Practices in Oculoplasty and Lacrimal Surgery During the COVID-19 Pandemic

indian journal of opthalmology


Authors: Mohammad Javed Ali , Raghuraj Hegde , Akshay Gopinathan Nair , Mandeep S Bajaj , Subhash M Betharia , Kasturi Bhattacharjee , Apjit K Chhabra , Jayanta K Das , Gagan Dudeja , Ashok K Grover , Santosh G Honavar , Usha Kim , Lakshmi Mahesh , Bipasha Mukherjee , Anita Sethi , Mukesh Sharma , Usha Singh
Region / country: South-eastern Asia – India
Speciality: Ophthalmology

Oculoplastic surgeries encompass both emergency surgeries for traumatic conditions and infectious disorders as well as elective aesthetic procedures. The COVID-19 pandemic has brought about a drastic change in this practice. Given the highly infectious nature of the disease as well as the global scarcity of medical resources; it is only prudent to treat only emergent conditions during the pandemic as we incorporate evidence-based screening and protective measures into our practices. This manuscript is a compilation of evidence-based guidelines for surgical procedures that oculoplastic surgeons can employ during the COVID-19 pandemic. These guidelines also serve as the basic framework upon which further recommendations may be based on in the future, as elective surgeries start being performed on a regular basis.


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99. Surgical Site Infection and Costs in Low- And Middle-Income Countries: A Systematic Review of the Economic Burden

PLoS One


Authors: Mark Monahan , Susan Jowett , Thomas Pinkney , Peter Brocklehurst , Dion G Morton , Zainab Abdali , Tracy E Roberts
Region / country: Global
Speciality: General surgery, Other

Background: Surgical site infection (SSI) is a worldwide problem which has morbidity, mortality and financial consequences. The incidence rate of SSI is high in Low- and Middle-Income countries (LMICs) compared to high income countries, and the costly surgical complication can raise the potential risk of financial catastrophe.

Objective: The aim of the study is to critically appraise studies on the cost of SSI in a range of LMIC studies and compare these estimates with a reference standard of high income European studies who have explored similar SSI costs.

Methods: A systematic review was undertaken using searches of two electronic databases, EMBASE and MEDLINE In-Process & Other Non-Indexed Citations, up to February 2019. Study characteristics, comparator group, methods and results were extracted by using a standard template.

Results: Studies from 15 LMIC and 16 European countries were identified and reviewed in full. The additional cost of SSI range (presented in 2017 international dollars) was similar in the LMIC ($174-$29,610) and European countries ($21-$34,000). Huge study design heterogeneity was encountered across the two settings.

Discussion: SSIs were revealed to have a significant cost burden in both LMICs and High Income Countries in Europe. The magnitude of the costs depends on the SSI definition used, severity of SSI, patient population, choice of comparator, hospital setting, and cost items included. Differences in study design affected the comparability across studies. There is need for multicentre studies with standardized data collection methods to capture relevant costs and consequences of the infection across income settings.


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100. Exploring the Impact of COVID-19 on Progress Towards Achieving Global Surgery Goals

World Journal of Surgery


Authors: Dennis Mazingi , Sergio Navarro , Matthew C Bobel , Andile Dube , Chenesa Mbanje , Chris Lavy
Region / country: Global
Speciality: Health policy

Introduction: In the 5 months since it began, the COVID-19 pandemic has placed extraordinary demands on health systems around the world including surgery. Competing health objectives and resource redeployment threaten to retard the scale-up of surgical services in low- and middle-income countries where access to safe, affordable and timely care is low. The key aspiration of the Lancet Commission on global surgery was promotion of resilience in surgical systems. The current pandemic provides an opportunity to stress-test those systems and identify fault-lines that may not be easily apparent outside of times of crisis.

Methods: We endeavoured to explore vulnerable points in surgical systems learning from the experience of past outbreaks, using examples from the current pandemic, and make recommendations for future health emergencies. The 6-component framework for surgical systems planning was used to categorise the effects of COVID-19 on surgical systems, with a particular focus on low- and middle-income countries. Key vulnerabilities were identified and recommendations were made for the current pandemic and for the future.

Results: Multiple stress points were identified throughout all of the 6 components of surgical systems. The impact is expected to be highest in the workforce, service delivery and infrastructure domains. Innovative new technologies should be employed to allow consistent, high-quality surgical care to continue even in times of crisis.

Conclusions: If robust progress towards global surgery goals for 2030 is to continue, the stress points identified should be reinforced. An ongoing process of reappraisal and fortification will keep surgical systems in low- and middle-income countries responsive to “old threats and new challenges”. Multiple opportunities exist to help realise the dream of surgical systems resilient to external shocks.


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101. Impact of COVID-19 on Urology Practice: A Global Perspective and Snapshot Analysis

journal of clinical medicine


Authors: Stavros Gravas , Damien Bolton , Reynaldo Gomez , Laurence Klotz , Sanjay Kulkarni , Simon Tanguay , Jean de la Rosette
Region / country: Global
Speciality: Urology surgery

The global impact of the 2019 novel coronavirus disease (COVID-19) pandemic on urology practice remains unknown. Self-selected urologists worldwide completed an online survey by the Société Internationale d’Urologie (SIU). A total of 2494 urologists from 76 countries responded, including 1161 (46.6%) urologists in an academic setting, 719 (28.8%) in a private practice, and 614 (24.6%) in the public sector. The largest proportion (1074 (43.1%)) were from Europe, with the remainder from East/Southeast Asia (441 (17.7%)), West/Southwest Asia (386 (15.5%)), Africa (209 (8.4%)), South America (198 (7.9%)), and North America (186 (7.5%)). An analysis of differences in responses was carried out by region and practice setting. The results reveal significant restrictions in outpatient consultation and non-emergency surgery, with nonspecific efforts towards additional precautions for preventing the spread of COVID-19 during emergency surgery. These restrictions were less notable in East/Southeast Asia. Urologists often bear the decision-making responsibility regarding access to elective surgery (40.3%). Restriction of both outpatient clinics and non-emergency surgery is considerable worldwide but is lower in East/Southeast Asia. Measures to control the spread of COVID-19 during emergency surgery are common but not specific. The pandemic has had a profound impact on urology practice. There is an urgent need to provide improved guidance for this and future pandemics.


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102. Incidence and Mortality Trend of Congenital Heart Disease at the Global, Regional, and National Level, 1990-2017

medicine


Authors: Weiliang Wu , Jinxian He , Xiaobo Shao
Region / country: Global
Speciality: Cardiothoracic surgery, Paediatric surgery

Congenital heart disease (CHD) is the most commonly diagnosed congenital disorder in newborns. The incidence and mortality of CHD vary worldwide. A detailed understanding of the global, regional, and national distribution of CHD is critical for CHD prevention.We collected the incidence and mortality data of CHD from the Global Burden of Disease study 2017 database. Average annual percentage change was applied to quantify the temporal trends of CHD incidence and mortality at the global, regional, and national level, 1990-2017. A sociodemographic index (SDI) was created for each location based on income per capita, educational attainment, and fertility.The incidence of CHD was relatively high in developing countries located in Africa and Asia, while low in most developed countries. Between 1990 and 2017, the CHD incidence rate remained stable at the global level, whereas increased in certain developed countries, such as Germany and France. The age-standardized mortality rate of CHD declined substantially over the last 3 decades, regardless of sex, age, and SDI region. The decline was more prominent in developed countries. We also detected a significant positive correlation between CHD incidence and CHD mortality in both 1990 and 2017, by SDI.The incidence of CHD remained stable over the last 3 decades, suggesting little improvement in CHD prevention strategies and highlighting the importance of etiological studies. The mortality of CHD decreased worldwide, albeit the greatly geographical heterogeneity. Developing countries located in Africa and Asia deserve more attention and priority in the global CHD prevention program.


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103. Mitigating the impact of COVID-19 on children’s surgery in Africa

BMJ Global Health


Authors: Dennis Mazingi, George Ihediwa, Kathryn Ford, Adesoji O Ademuyiwa, Kokila Lakhoo
Region / country: Central Africa, Eastern Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Paediatric surgery

An outbreak of the disease known as COVID-19, which originated in Wuhan in the Hubei province of China, has rapidly spread to all continents of the globe. First detected via local hospital surveillance systems as a ‘pneumonia of unknown aetiology’ in late December 2019, the disease has since been declared a public health emergency of international concern by the WHO and reached pandemic status.

It is uncertain what the eventual toll of the pandemic will be in Africa; however, there has been a suspicion that the looming pandemic may hit harder than it has the rest of the world. Africa has baseline weaknesses in healthcare resource allocation, and her fragile healthcare systems are particularly vulnerable to being overwhelmed by this illness. Available statistics, to date, however, seem to show that the pandemic has been slow to begin. As of 26 May, 115 346 cases and 3471 deaths have been reported across the whole African continent, constituting 2% of all cases in the globe. African nations have had an opportunity to prepare for the coming onslaught, learn from the experience in other countries and choose interventions that are tailor-made for the unique socioeconomic context.

Full text continued on open access link


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104. Gynecological hysterectomy in Northern Tanzania: a cross- sectional study on the outcomes and correlation between clinical and histological diagnoses

BMC Women’s Health


Authors: Daniel Michael, Alex Mremi, Patricia Swai, Benjamin C Shayo, Bariki Mchome
Region / country: Eastern Africa – Tanzania
Speciality: Obstetrics and Gynaecology

Background
Hysterectomy is one of the most common gynaecological procedures performed worldwide. The magnitude of the complications related to hysterectomy and their risk factors are bound to differ based on locations, availability of resources and level of surgical training. Documented complications rates and their correlates are reported from high income countries while data from low- and middle-income countries including Tanzania is scare.
Methods
This was a hospital based cross-sectional study conducted at a tertiary facility in northern Tanzania where 178 women who underwent elective gynecological hysterectomies in the department of obstetrics and gynecology within the study period were enrolled. Logistic regression was performed to determine the association between risk factors and occurrence of surgical complication where p-value of  2 h) (OR 5.02; 95% CI 2.18–11.5). Both uterine fibroid and adenomyosis had good correlation of clinical and histological diagnosis (p-value < 0.001).
Conclusion
Bleeding and blood transfusion were the most common complications observed in this study. Obesity, previous abdominal operation and prolonged duration of operation were the most significant risk factors for the complications. Local tailored interventions to reduce surgical complications of hysterectomy are thus pivotal. Clinicians in this locality should have resources at their disposal to enhance definitive diagnosis attainment before surgical interventions.


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105. Innovative Financing to Fund Surgical Systems and Expand Surgical Care in Low-Income and Middle-Income Countries

BMJ


Authors: Ché L Reddy , Alexander W Peters , Desmond Tanko Jumbam , Luke Caddell , Blake C Alkire , John G Meara , Rifat Atun
Region / country: Global
Speciality: Health policy

Strong surgical systems are necessary to prevent premature death and avoidable disability from surgical conditions. The epidemiological transition, which has led to a rising burden of non-communicable diseases and injuries worldwide, will increase the demand for surgical assessment and care as a definitive healthcare intervention. Yet, 5 billion people lack access to timely, affordable and safe surgical and anaesthesia care, with the unmet demand affecting predominantly low-income and middle-income countries (LMICs). Rapid surgical care scale-up is required in LMICs to strengthen health system capabilities, but adequate financing for this expansion is lacking. This article explores the critical role of innovative financing in scaling up surgical care in LMICs. We locate surgical system financing by using a modified fiscal space analysis. Through an analysis of published studies and case studies on recent trends in the financing of global health systems, we provide a conceptual framework that could assist policy-makers in health systems to develop innovative financing strategies to mobilise additional investments for scale-up of surgical care in LMICs. This is the first time such an analysis has been applied to the funding of surgical care. Innovative financing in global surgery is an untapped potential funding source for expanding fiscal space for health systems and financing scale-up of surgical care in LMICs.


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106. Cervical Cancer Screening With Human Papillomavirus Self-Sampling Among Transgender Men in El Salvador

lGBT Health


Authors: Mauricio Maza , Mario Meléndez , Alejandra Herrera , Xavier Hernández , Bryan Rodríguez , Montserrat Soler, Karla Alfaro , Rachel Masch , Gabriel Conzuelo-Rodríguez , Juno Obedin-Maliver , Miriam Cremer
Region / country: Central America – El Salvador
Speciality: Obstetrics and Gynaecology

Purpose: Sexual and gender minority persons in low-income countries have very limited access to routine health services. This study evaluated the feasibility of using a self-sampled human papillomavirus (HPV) test to increase access to screening for cervical cancer among transgender men in El Salvador. Methods: We partnered with a local advocacy organization for recruitment. A total of 24 transgender men (men assigned female at birth) ages 19-55 were enrolled and provided consent. Questionnaires assessed sociodemographics, health and sexual histories, and knowledge about HPV and cervical cancer. Screening was performed with a self-sampled HPV test. Participants with a positive test were offered colposcopy and cryotherapy treatment, if appropriate. Those with a negative test were advised to return in 5 years for rescreening. Results: Out of 24 consenting participants, 23 (95.83%) agreed to conduct HPV self-sampling, and 22/23 (95.65%) expressed willingness to self-sample in the future. Among self-sampled individuals, 3/23 (13%) tested positive and accepted colposcopy and biopsy. Analyses of biopsied tissue revealed one case of cervical intraepithelial neoplasia grade 1. Conclusion: HPV self-sampling and subsequent procedures were accepted by the majority of participants. This screening method may be a viable alternative to cytology among transgender men in El Salvador.


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107. Improving standard of pediatric surgical care in a low resource setting: the key role of academic partnership

Italian Journal of Pediatrics


Authors: Pierluigi Lelli Chiesa, Osman T M Osman, Antonio Aloi, Mariagrazia Andriani, Alberto Benigni, Claudio Catucci, Paolo Giambelli, Gabriele Lisi, Faisal M Nugud, Paola Presutti, Viviana Prussiani, Vincenzo Racalbuto, Fabio Rossi, Giuliana Santoponte, Bruno Turchetta, Diaa Eldinn Yaseen Mohammed Salman, Francesco Chiarelli, Alessandro Calisti
Region / country: Northern Africa – Sudan
Speciality: Paediatric surgery

Background: An epidemiological transition is interesting Sub-Saharan Africa increasing the burden of non-communicable diseases most of which are of surgical interest. Local resources are far from meeting needs and, considering that 50% of the population is less than 14 years of age, Pediatric surgical coverage is specially affected. Efforts are made to improve standards of care and to increase the number of Pediatric surgeons through short-term specialist surgical Missions, facilities supported by humanitarian organization, academic Partnership, training abroad of local surgeons. This study is a half term report about three-years Partnership between the University of Chieti- Pescara, Italy and the University of Gezira, Sudan to upgrade standard of care at the Gezira National Centre for Pediatric Surgery (GNCPS) of Wad Medani. Four surgical Teams per year visited GNCPS. The Program was financed by the Italian Agency for Development Cooperation.
Methods: The state of local infrastructure, current standard of care, analysis of caseload, surgical activity and results are reported. Methods utilized to assess local needs and to develop Partnership activities are described.
Results: Main surgical task of the visiting Team were advancements in Colorectal procedures, Epispadias/Exstrophy Complex management and Hypospadias surgery (20% of major surgical procedures at the GNCPS). Intensive care facilities and staff to assist more complex cases (i.e. neonates) are still defective. Proctoring, training on the job of junior surgeons, anaesthetists and nurses, collaboration in educational programs, advisorship in hospital management, clinical governance, maintenance of infrastructure together with training opportunities in Italy were included by the Program. Despite on-going efforts, actions have not yet been followed by the expected results. More investments are needed on Healthcare infrastructures to increase health workers motivation and prevent brain drain.
Conclusions: The key role that an Academic Partnership can play, acting through expatriated Teams working in the same constrained contest with the local workforce, must be emphasized. Besides clinical objectives, these types of Global Health Initiatives address improvement in management and clinical governance. The main obstacles to upgrade standard of care and level of surgery met by the Visiting Team are scarce investments on health infrastructure and a weak staff retention policy, reflecting in poor motivation and low performance.


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108. Management of cervical cancer patients during the COVID-19 pandemic: a challenge for developing countries

E cancer medical science


Authors: Maria del Pilar Estevez-Diz,Renata Colombo Bonadio, Vanessa Costa Miranda, Jesus Paula Carvalho
Region / country: Global
Speciality: Surgical oncology

During the COVID-19 pandemic, health services worldwide are going through important adaptations to assist patients infected with COVID-19, at the same time as continuing to provide assistance to other potentially life-threatening diseases. Although patients with cancer may be at increased risk for severe events related to COVID-19 infection, their oncologic treatments frequently cannot be delayed for long periods without jeopardising oncologic outcomes. Considering this, a careful consideration for treatment management of different malignancies is required.

Cervical cancer is concentrated mainly in low-middle income countries (LMICs), which face particular challenges during the COVID-19 pandemic due to the scarcity of health resources in many places. Although cervical cancer is the fourth cause of cancer death among women, it receives little attention from international Oncology societies and scientific research studies. In this review paper, we discuss the cervical cancer landscape and provide specialists recommendations for its management during the COVID-19 pandemic, particularly focused on LMICs’ reality.


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109. The Millennial Generation Plastic Surgery Trainees in sub-Saharan Africa and Social Media: A Review of the Application of Blogs, Podcasts, and Twitter as Web-Based Learning Tools

annals of african medicine


Authors: Abdulrasheed Ibrahim, Lawal M Abubakar, Daniel J Maina, Wasiu O Adebayo, Abdullatif M Kabir, Malachy E Asuku
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Plastic surgery

The delivery of education and training in plastic surgery in Sub-Saharan Africa face increasing challenges. These include endemic shortages of plastic surgeons within postgraduate medical school faculties, the erosion of financial and clinical resources for teaching, and more recently, the millennial generation paradigm shift. It is generally accepted that the millennial generation will be more discerning and comfortable in their requirements for web-based learning content to support their education and training in plastic surgery. We reviewed current literature including original and review articles obtained through a search of PubMed database, Medline, Google Scholar, and hand searching of bibliographies of published articles using the keywords: social media, Blogs, Twitter, plastic surgery, and millennial generation. This article defines and explores Blogs, Podcasts, and Twitter, as web-based learning tools, and discusses how to leverage social media to maximize their educational value and effectiveness.


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110. Surgical Care at Rural District Hospitals in Low- And Middle-Income Countries: An Essential Component of Universal Health Coverage

Rural and Remote Health


Authors: Kathryn M Chu , Priyanka Naidu , Hans J Hendriks , Jennifer Nash , Francois J Coetzee , Martene Esteves , Steve Reid , Ian Couper
Region / country: Southern Africa – South Africa
Speciality: Health policy

Surgical care has long been considered too exclusive and uneconomical to be a public health priority, despite one third of the total global burden of disease being attributed to surgical conditions. Furthermore, five billion people worldwide do not have access to safe and timely surgical care, the majority of whom live in low- and middle-income countries (LMICs) including sub-Saharan Africa.
The Lancet Commission on Global Surgery has highlighted surgical care as an important component of universal health coverage, urging the world to make surgical, anaesthetic and obstetric services a priority on the global health agenda. In 2015, the World Health Assembly passed a declaration stating that timely and safe essential and emergency surgical care (EESC) was a key component of universal health coverage and that district hospitals should be the backbone of EESC. The World Bank further described 44 EESC procedures, 28 of which were categorised as district-level procedures. In order to achieve equitable access to EESC, strengthening surgical health systems, especially at the district level, requires prioritisation.


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111. Recommendations for Head and Neck Surgical Oncology Practice in a Setting of Acute Severe Resource Constraint During the COVID-19 Pandemic: An International Consensus

Lancet Oncology


Authors: Hisham Mehanna , John C Hardman , Jared A Shenson , Ahmad K Abou-Foul , Michael C Topf , Mohammad AlFalasi , Jason Y K Chan , Pankaj Chaturvedi , Velda Ling Yu Chow , Andreas Dietz , Johannes J Fagan , Christian Godballe , Wojciech Golusiński , Akihiro Homma , Sefik Hosal, N Gopalakrishna Iyer , Cyrus Kerawala, Yoon Woo Koh , Anna Konney , Luiz P Kowalski , Dennis Kraus , Moni A Kuriakose , Efthymios Kyrodimos, Stephen Y Lai , C Rene Leemans, Paul Lennon , Lisa Licitra , Pei-Jen Lou , Bernard Lyons , Haitham Mirghani , Anthonny C Nichols , Vinidh Paleri , Benedict J Panizza , Pablo Parente Arias , Mihir R Patel , Cesare Piazza , Danny Rischin , Alvaro Sanabria , Robert P Takes , David J Thomson , Ravindra Uppaluri , Yu Wang , Sue S Yom , Yi-Ming Zhu , Sandro V Porceddu , John R de Almeida , Chrisian Simon , F Christopher Holsinger
Region / country: Global
Speciality: ENT surgery, Surgical oncology

The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.


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112. Aetiologies and Outcomes of Patients With Abdominal Pain Presenting to an Emergency Department of a Tertiary Hospital in Tanzania: A Prospective Cohort Study

BMC Gastroentrology


Authors: Kilalo M Mjema , Hendry R Sawe , Irene Kulola , Amour S Mohamed , Erasto Sylvanus , Juma A Mfinanga , Ellen J Weber
Region / country: Eastern Africa – Tanzania
Speciality: Emergency surgery

Background: Abdominal pain in adults represents a wide range of illnesses, often warranting immediate intervention. This study is to fill the gap in the knowledge about incidence, presentation, causes and mortality from abdominal pain in an established emergency department of a tertiary hospital in Tanzania.

Methods: This was a prospective cohort study of adult (age ≥ 18 years) patients presenting to the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH) in Dar Es Salaam, Tanzania with non-traumatic abdominal pain from September 2017 to October 2017. A case report form was used to record data on demographics, clinical presentation, management, diagnosis, outcomes and patient follow-up. The primary outcome of mortality was summarized using descriptive statistics; secondary outcome was, risks for mortality.

Results: Among 3381 adult patients present during the study period, 288 (8.5%) presented with abdominal pain, and of these 199 (69%) patients were enrolled in our study. Median age was 47 years (IQR 35-60 years), 126 (63%) were female, and 118 (59%) were referred from another hospital. Most common final diagnoses were malignancies 71 (36%), intestinal obstruction 11 (6%) and peptic ulcer disease 9 (5%). Most common EMD interventions given were intravenous fluids 57 (21%), analgesia 49 (25%) and antibiotics 40 (20%). 160 (80%) were admitted of which 15 (8%) underwent surgery directly from EMD. 24-h and 7-day mortality were 4 (2%) and 7 (4%) respectively, while overall in hospital-mortality was 16 (8%). Among the risk factors for mortality were male sex Relative Risk (RR) 2.88 (p = 0.03), hypoglycemia (RR) 5.7 (p = 0.004), ICU admission (RR) 14 (p < 0.0001), receipt of IV fluids (RR) 3.2 (p = 0.0151) and need for surgery (RR) 6.6 (p = 0.0001).

Conclusion: Abdominal pain was associated with significant morbidity and mortality as evidenced by a very high admission rate, need for surgical intervention and a high in-hospital mortality rate. Future studies and quality improvement efforts should focus on identifying why such differences exist and how to reduce the mortality.


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113. Psychological Status of Surgical Staff During the COVID-19 Outbreak

Psychiatry Research


Authors: Jian Xu , Qian-Hui Xu , Chang-Ming Wang , Jun Wang
Region / country: Eastern Asia – China
Speciality: Other

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which appeared in early December 2019, had an atypical viral pneumonia outbreak in Wuhan, Hubei, China. And there is a high risk of global proliferation and impact. The sudden increase in confirmed cases has brought tremendous stress and anxiety to frontline surgical staff. The results showed that the anxiety and depression of surgical staff during the outbreak period were significantly higher and mental health problems appeared, so psychological interventions are essential.


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114. Doctor-patient Communication in Surgical Practice During the Coronavirus (COVID-19) Pandemic

BJS


Authors: M. Hamza H. S. Khan Z. A. Sattar M. Hanif
Region / country: South-eastern Asia – Pakistan
Speciality: Other

COVID‐19 is a new respiratory disease that has become a pandemic, involving whole world. Hospitals are now a hub for this disease and patients are advised to avoid hospitals as far as possible. Many healthcare workers are infected with SARS‐CoV‐2. This virus can spread from an infected doctor to patients or colleagues and does not respect any boundaries. Moreover, immunocompromized patients are at a greater risk of this potentially life‐threatening contagious disease. Recommendations of social distancing and home isolation to limit the spread of coronavirus are major factors limiting patients’ communication with doctors regarding their disease.


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115. Assessment of Eustachian Tube Functioning Following Surgical Intervention of Oral Submucus Fibrosis by Using Tympanometry & Audiometry

Journal of Oral Biology and Craniofacial Research


Authors: Sreea Roy , Abhay Taranath Kamath , Manish Bhagania , Adarsh Kudva , Kishan Madikeri Mohan
Region / country: South-eastern Asia – India
Speciality: ENT surgery, Maxillofacial and oral surgery

Oral Submucus fibrosis has been reported to cause variation in hearing sensitivity & changes in middle ear function. This study was conducted to validate the influence of OSMF and its surgical correction on middle ear function and hearing sensitivity. In this study, 20 patients (40 ears) suffering from biopsy proven OSMF (Group 2 & 3) were tested for Middle ear dysfunction and hearing sensitivity using Tympanometry & Audiometry. On Tympanometry, Type A curve was obtained in 29 ears, Type B curve in 11 ears preoperatively. Immediate postoperatively TYPE A curve was obtained in 27 ears, TYPE B curve in 13 ears. After 1 month and 3 month Type B curve was not obtained in any ear. On Audiometry,28 ears showed normal hearing and 12 ears showed minimal conductive hearing loss preoperatively and Immediate postoperatively. Tests after 1 month and 3 months showed all 40 ears having normal hearing. Results were found statistically significant with p value 0.000 and F value of 11.331 in Tympanometry and 11.143 in Audiometry. Pearson correlation test revealed that results from both the test are highly co related (0.902). OSMF causes fibrotic changes in paratubal muscles which in addition with restricted mouth opening hampers proper Eustachian tube functioning in turn causing changes in Middle ear function. This feature is seldom/infrequently found in Group 2 and 3 and if encountered can be dealt effectively with surgical intervention.


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116. The Influence of Cervical Spondylolisthesis on Clinical Presentation and Surgical Outcome in Patients With DCM: Analysis of a Multicenter Global Cohort of 458 Patients

Global Spine Journal


Authors: Aria Nouri , So Kato , Jetan H Badhiwala , Michael Robinson , Juan Mejia Munne , George Yang , William Jeong , Rani Nasser , David A Gimbel , Joseph S Cheng , Michael G Fehlings
Region / country: Global
Speciality: Neurosurgery

Study design: Ambispective study with propensity matching.

Objective: To assess the impact of cervical spondylolisthesis (CS) on clinical presentation and surgical outcome in patients with degenerative cervical myelopathy (DCM).

Methods: A total of 458 magnetic resonance images (MRIs) from the AOSpine CSM-NA and CSM-I studies were reviewed and CS was identified. Patients with DCM were divided into 2 cohorts, those with CS and those without, and propensity matching was performed. Patient demographics, neurological and functional status at baseline and 2-year follow-up were compared.

Results: Compared with nonspondylolisthesis (n = 404), CS patients (n = 54) were 8.8 years older (P < .0001), presented with worse baseline neurological and functional status (mJOA [modified Japanese Orthopaedic Association Assessment Scale], P = .008; Nurick, P = .008; SF-36-PCS [Short Form-36 Physical Component Score], P = .01), more commonly presented with ligamentum flavum enlargement (81.5% vs 53.5%, P < .0001), and were less commonly from Asia (P = .0002). Surgical approach varied between cohorts (P = .0002), with posterior approaches favored in CS (61.1% vs 37.4%). CS patients had more operated levels (4.3 ± 1.4 vs 3.6 ± 1.2, P = .0002) and tended to undergo longer operations (196.6 ± 89.2 vs 177.2 ± 75.6 minutes, P = .087). Neurological functional recovery was lower with CS (mJOA [1.5 ± 3.6 vs 2.8 ± 2.7, P = .003]; Nurick [-0.8 ± 1.4 vs -1.5 ± 1.5, P = .002]), and CS was an independent predictor of worse mJOA recovery ratio at 2 years (B = -0.190, P < .0001). After propensity matching, improvement of neurological function was still lower in CS patients (mJOA [1.5 ± 3.6 vs 3.2 ± 2.8, P < .01]; Nurick [-0.8 ± 1.4 vs -1.4 ± 1.6, P = .02]).

Conclusions: CS patients are older, present with worse neurological/functional impairment, and receive surgery on more levels and more commonly from the posterior. CS may indicate a more advanced state of DCM pathology and is more likely to result in a suboptimal surgical outcome.


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117. Epidemiological Characteristics of Spinal Cord Injury in Northwest China: A Single Hospital-Based Study

Journal of Orthopaedic Surgery and Research


Authors: Zhi-Meng Wang, Peng Zou, Jun-Song Yang, Ting-Ting Liu, Lei-Lei Song, Yao Lu, Hao Guo, Yuan-Ting Zhao, Tuan-Jiang Liu & Ding-Jun Hao
Region / country: Eastern Asia – China
Speciality: Neurosurgery, Trauma and orthopaedic surgery

Background: While the cities in China in which spinal cord injury (SCI) studies have been conducted previously are at the forefront of medical care, northwest China is relatively underdeveloped economically, and the epidemiological characteristics of SCI have rarely been reported in this region.

Methods: The SCI epidemiological survey software developed was used to analyze the data of patients treated with SCI from 2014 to 2018. The sociodemographic characteristics of patients, including name, age, sex, and occupation, were recorded. The following medical record data, obtained from physical and radiographic examinations, were included in the study: data on the cause of injury, fracture location, associated injuries, and level of injury. Neurological function was evaluated using the American Spinal Injury Association (ASIA) impairment scale. In addition, the treatment and complications during hospitalization were documented.

Results: A total of 3487 patients with SCI with a mean age of 39.5 ± 11.2 years were identified in this study, and the male to female ratio was 2.57:1. The primary cause of SCI was falls (low falls 47.75%, high falls 37.31%), followed by traffic accidents (8.98%), and impact with falling objects (4.39%). Of all patients, 1786 patients (51.22%) had complications and other injuries. According to the ASIA impairment scale, the numbers of grade A, B, C, and D injuries were 747 (21.42%), 688 (19.73%), 618 (17.72%), and 1434 (41.12%), respectively. During the hospitalization period, a total of 1341 patients experienced complications, with a percentage of 38.46%. Among all complications, pulmonary infection was the most common (437, 32.59%), followed by hyponatremia (326, 24.31%), bedsores (219, 16.33%), urinary tract infection (168, 12.53%), deep venous thrombosis (157, 11.71%), and others (34, 2.53%). Notably, among 3487 patients with SCI, only 528 patients (15.14%) received long-term rehabilitation treatment.

Conclusion: The incidence of SCI in northwest China was on the rise with higher proportion in males; fall and the MCVs were the primary causes of SCI. The occupations most threatened by SCI are farmers and workers. The investigation and analysis of the epidemiological characteristics of SCI in respiratory complications are important factors leading to death after SCI, especially when the SCI occurs in the cervical spinal cord. Finally, the significance of SCI rehabilitation should be addressed.


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118. Breast Cancer messaging in Vietnam: an online media content analysis

BMC Public Health


Authors: Chris Jenkins, Dinh Thu Ha, Vu Tuyet Lan, Hoang Van Minh, Lynne Lohfeld, Paul Murphy & Le Thi Hai Ha
Region / country: South-eastern Asia – Vietnam
Speciality: Surgical oncology

Background: Breast cancer incidence is increasing in Vietnam with studies indicating low levels of knowledge and awareness and late presentation. While there is a growing body of literature on challenges faced by women in accessing breast cancer services, and for delivering care, no studies have sought to analyse breast cancer messaging in the Vietnamese popular media. The aim of this study was to investigate and understand the content of messages concerning breast cancer in online Vietnamese newspapers in order to inform future health promotional content.

Methods: This study describes a mixed-methods media content analysis that counted and ranked frequencies for media content (article text, themes and images) related to breast cancer in six Vietnamese online news publications over a twelve month period.

Results: Media content (n = 129 articles & n = 237 images) sampled showed that although information is largely accurate, there is a marked lack of stories about Vietnamese women’s personal experiences. Such stories could help bridge the gap between what information about breast cancer is presented in the Vietnamese media, and what women in Vietnam understand about breast cancer risk factors, symptoms, screening and treatment.

Conclusions: Given findings from other studies indicating low levels of knowledge and women with breast cancer experiencing stigma and prejudice, more nuanced and in-depth narrative-focused messaging may be required.


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119. Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury

African Journal of Emergency Medicine


Authors: Miriam Gamble, Tonny Stone Luggya , Jacqueline Mabweijano , Josephine Nabulimed, Hani Mowafia
Region / country: Eastern Africa – Uganda
Speciality: Emergency surgery, Neurosurgery

Introduction
Throughout the world, traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality. Low-and middle-income countries experience an especially high burden of TBI. While guidelines for TBI management exist in high income countries, little is known about the optimal management of TBI in low resource settings. Prevention of secondary injuries is feasible in these settings and has potential to improve mortality.

Methods
A pragmatic quasi-experimental study was conducted in the emergency centre (EC) of Mulago National Referral Hospital to evaluate the impact of TBI nursing education and use of a monitoring tool on mortality. Over 24 months, data was collected on 541 patients with moderate (GCS9-13) to severe (GCS≤8) TBI. The primary outcome was in-hospital mortality and secondary outcomes included time to imaging, time to surgical intervention, time to advanced airway, length of stay and number of vital signs recorded.

Results
Data were collected on 286 patients before the intervention and 255 after. Unadjusted mortality was higher in the post-intervention group but appeared to be related to severity of TBI, not the intervention itself. Apart from number of vital signs, secondary outcomes did not differ significantly between groups. In the post-intervention group, vital signs were recorded an average of 2.85 times compared to 0.49 in the pre-intervention group (95% CI 2.08-2.62, p ≤ 0.001). The median time interval between vital signs in the post-intervention group was 4.5 h (IQR 2.1-10.6).

Conclusion
Monitoring of vital signs in the EC improved with nursing education and use of a monitoring tool, however, there was no detectable impact on mortality. The high mortality among patients with TBI underscores the need for treatment strategies that can be implemented in low resource settings. Promising approaches include improved monitoring, organized trauma systems and protocols with an emphasis on early aggressive care and primary prevention.


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120. Using critical care physicians to deliver anesthesia and boost surgical caseload in austere environments: the Critical Care General Anesthesia Syllabus (CC GAS)

Heliyon


Authors: Quincy K.Tran, Natalie M.Mark, Lia I.Losonczy, Michael T.McCurdy, James H.LantryIII, Marc E.Augustin, Lovely N.Colas, Richard Skupski, Arthur S.Toth, Bhavesh M.Patel, Donald F.Zimmer, Rebecca Tracy, Mark Walsh
Region / country: Caribbean – Haiti
Speciality: Anaesthesia

Background
Despite an often severe lack of surgeons and surgical equipment, the rate-limiting step in surgical care for the nearly five billion people living in resource-limited areas is frequently the absence of safe anesthesia. During disaster relief and surgical missions, critical care physicians (CCPs), who are already competent in complex airway and ventilator management, can help address the need for skilled anesthetists in these settings.

Methods
We provided a descriptive analysis that CCPs were trained to provide safe general anesthesia, monitored anesthesia care (MAC), and spinal anesthesia using a specifically designed and simple syllabus.

Results
Six CCPs provided anesthesia under the supervision of a board-certified anesthesiologist for 58 (32%) cases of a total of 183 surgical cases performed by a surgical mission team at St. Luc Hospital in Port-au-Prince, Haiti in 2013, 2017, and 2018. There were no reported complications.

Conclusions
Given CCPs’ competencies in complex airway and ventilator management, a CCP, with minimal training from a simple syllabus, may be able to act as an anesthesiologist-extender and safely administer anesthesia in the austere environment, increasing the number of surgical cases that can be performed. Further studies are necessary to confirm our observation.


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121. The global burden of musculoskeletal injury in low and lower-middle income countries

Orthopaedic Trauma Association International


Authors: Cordero, Daniella M. BSa; Miclau, Theodore A. BS, MSb; Paul, Alexandra V. BSc; Morshed, Saam MDc; Miclau, Theodore III MDc; Martin, Claude MD, MBAd; Shearer, David W. MD, MPHc,
Region / country: Global
Speciality: Trauma and orthopaedic surgery

Background:
While the global burden of musculoskeletal injury is increasingly recognized, few epidemiologic studies have specifically recorded its incidence or prevalence, particularly in low- and middle-income countries. Understanding the burden of musculoskeletal injury relative to other health conditions is critical to effective allocation of resources to mitigate the disability that results from trauma. The current study aims to systematically review the existing primary literature on the incidence and prevalence of pelvic and appendicular fractures, a major component of musculoskeletal injury, in low- and lower-middle income countries (LMICs).

Methods:
This study conforms to the systematic review and traditional meta-analysis guidelines outlined in the PRISMA-P statement. Incidence rates were calculated as the occurrence of new fracture cases per 100,000 person-years, and prevalence as total fracture cases per population sample, reported as percentages.

Results:
The literature search yielded 3497 total citations. There were 21 full-text articles, representing 14 different countries, selected for data extraction. Included studies reported a wide range of incidence and prevalence rates, with an overall mean fracture incidence ranging from 779 (95% CI: 483.0–1188.7) to 1574 (95% CI: 1285.1–1915.1) per 100,000 person-years.

Conclusion:
Better understanding the unmet burden of musculoskeletal injury in LMICs is critical to effectively allocating resources and advocating for underserved populations. To address existing gaps and heterogeneity within the literature, future research should incorporate population-based sampling with broader geographic representation in LMICs to more accurately capture the burden of disease.


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122. Emergency department management of traumatic brain injuries: A resource tiered review

African Journal of Emergency Medicine


Authors: Julia Dixon, Grant Comstock, Jennifer Whitfield, David Richards, Taylor W.Burkholder, Noel Leifer, Nee-KofiMould-Millman, Emilie J.Calvello Hynes
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Emergency surgery, Neurosurgery, Trauma surgery

Introduction
Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20–30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma.

Objectives
Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework.

Methods
A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings.

Key recommendations
Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.


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123. Predictors of prolonged length of hospital stay and in-hospital mortality among adult patients admitted at the surgical ward of Jimma University medical center, Ethiopia: prospective observational study

Journal of Pharmaceutical Policy and Practice volume


Authors: Gosaye Mekonen Tefera, Beshadu Bedada Feyisa, Gurmu Tesfaye Umeta & Tsegaye Melaku Kebede
Region / country: Eastern Africa – Ethiopia
Speciality: General surgery

Background
Data regarding prolonged length of hospital stay (PLOS) and in-hospital mortality are paramount to evaluate efficiency and quality of surgical care as well as for rational resource utilization, allocation, and administration. Thus, PLOS and in-hospital mortality have been used as a surrogate indicator of satisfactory treatment outcome and efficient utilization of resources for a given health institution. However, there was a scarcity of data regarding these issues in Ethiopia. Therefore, this study aimed to assess treatment outcome, length of hospital stay, in-hospital mortality, and their determinants.

Methods
Health facility-based prospective observational study was used for three consecutive months among adult patients hospitalized for the surgical case. Socio-demographic, clinical history, medication history, in-hospital complications, and overall treatment outcomes were collected from the medical charts’ of the patients, using a checklist from the day of admission to discharge. PLOS is defined as hospital stay > 75th percentile (≥33 days for the current study). To identify predictor variables for both PLOS and in-hospital mortality, multivariate logistic regression was performed at p-value  2 antibiotic exposure (p  7 days (p < 0.0001) were independent predictors for PLOS.

Conclusion
In-hospital mortality rate was almost comparable to reports from developing countries, though it was higher than the developed countries. However, the length of hospital stay was extremely higher than that of reports from other parts of the world. Besides, different socio-demographic, health facility’s and patients’ clinical conditions (baseline and in-hospital complications) were identified as independent predictors for both in-hospital mortality and PLOS. Therefore, the clinician and stakeholders have to emphasize to avoid the modifiable factors to reduce in-hospital mortality and PLOS in the study area; to improve the quality of surgical care.


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124. Considerations for Newborn Screening for Critical Congenital Heart Disease in Low- and Middle-Income Countries

international journal of neonatal screening


Authors: Bistra Zheleva, Sreehari M. Nair , Adriana Dobrzycka and Annamarie Saarinen
Region / country: Global
Speciality: Cardiothoracic surgery, Paediatric surgery

We propose several considerations for implementation of critical congenital heart disease (CCHD) screening for low- and middle-income countries to assess health system readiness for countries that may not have all the downstream capacity needed for treatment of CCHD. The recommendations include: (1) assessment of secondary and tertiary level CHD health services, (2) assessment of birth delivery center processes and staff training needs, (3) data collection on implementation and quality surgical outcomes, (4) budgetary consideration, and (5) consideration of the CCHD screening service as part of the overall patient care continuum.


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125. Prevalence and Factors Associated With Caesarean Section in Four Hard-to-Reach Areas of Bangladesh: Findings From a Cross-Sectional Survey

PLOS One


Authors: Farhana Karim , Nazia Binte Ali , Abdullah Nurus Salam Khan , Aniqa Hassan , Mohammad Mehedi Hasan , Dewan Md Emdadul Hoque , Sk Masum Billah , Shams El Arifeen , Mohiuddin Ahsanul Kabir Chowdhury
Region / country: South-eastern Asia – Bangladesh
Speciality: Obstetrics and Gynaecology

Background: Caesarean section (C-section) is a major obstetric life-saving intervention for the prevention of pregnancy and childbirth related complications. Globally C-section is increasing, as well as in Bangladesh. This study identifies the prevalence of C-section and socio-economic and health care seeking related determinants of C-section among women living in hard-to-reach (HtR) areas in Bangladesh.

Methods: A cross-sectional survey was conducted using a structured questionnaire between August and December 2017 at four distinct types of HtR areas of Bangladesh, namely coastal, hilly, haor (wetland), and char areas (shallow land-mass rising out of a river). Total 2,768 women of 15-49 years of age and who had delivery within one year prior to data collection were interviewed. For the analysis of determinants of C- section, the explanatory variables were maternal age, educational status of women and their husbands, women’s religion, employment status and access to mobile phone, wealth index of the household, distance to the nearest health facility from the household, the number of ANC visits and presence of complications during pregnancy and the last childbirth. Logistic regression model was run among 850 women, who had facility delivery. Variables found significantly associated with the outcome (C-section) in bivariate analysis were included in the multivariable logistic model. A p-value <0.05 was considered as statistically significant in the analyses.

Results: Of the 2,768 women included in the study, 13% had C-sections. The mean (±SD) age of respondents was 25.4 (± 0.1) years. The adjusted prevalence of C-section was 13.1 times higher among women who had their delivery in private facilities than women who delivered in public facilities (Adjusted Odds Ratio, AOR: 13.1; 95% CI 8.6-19.9; p-value: <0.001). Women from haor area and coastal area had 4.7 times (AOR: 4.7; 95% CI 2.4-9.4; p value: <0.001) and 6.8 times (AOR: 6.8; 95% CI 3.6-12.8; p value: <0.001) more chance of having C-section, respectively, than women living in char area. Among women who reported complications during the last childbirth, the AOR of C-section was 3.6 times higher than those who did not report any complication (AOR: 3.6; 95% CI 2.4-5.4; p value: <0.001).

Conclusions: The study identifies that the prevalence of C-sections in four HtR areas of Bangladesh in substantially below the national average, although, the prevalence was higher in coastal areas than three other HtR regions. Both public and private health services for C-section should be made available and accessible in remote HtR areas for women with pregnancy complications. Establishment of an accreditation system for regulating private hospitals are needed to ensure rational use of the procedure.


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126. Perspectives on how to navigate cancer surgery in the breast, head and neck, skin, and soft tissue tumor in limited-resource countries during COVID-19 pandemic

International Journal of Surgery


Authors: Sumadi Lukman Anwar, Wirsma Arif Harahap, Teguh Aryandono
Region / country: Global
Speciality: Surgical oncology

The rapidly spreading coronavirus infection (COVID-19) worldwide has contracted all aspects of health systems. Developing countries that mostly have a weaker healthcare system and insufficient resources are likely to be the most hardly affected by the pandemic. Cancers are frequently diagnosed in late stages with higher case-fatality rates compared to those in high-income countries. Delayed diagnosis, lack of cancer awareness, low adherence to treatment, and unequal or limited access to treatment are among the challenging factors of cancer management in developing countries. Elective cancer surgeries are often considered to be postponed during COVID-19 pandemic to preserve valuable hospital resources such as personal protection equipment, hospital bed, intensive care unit capacity, and manpower to screen and treat the affected individuals. However, specific considerations to defer cancer surgery in developing countries might need to be carefully adjusted to counterbalance between preventing COVID-19 transmission and preserving patients ‘long-term life expectancy and quality of life.


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127. The Impact of Cleft Lip/Palate and Surgical Intervention on Adolescent Life Outcomes: Evidence from Operation Smile in India

UC Berkeley: Center for Effective Global Action


Authors: Wydick, BruceZahid, MustafaManning, SamMaller, JeremiahEvsanaa, KiraSkjoldhorne, SusannBloom, MatthewDas, AbhishekDeshpande, Gaurav
Region / country: South-eastern Asia – India
Speciality: ENT surgery, Maxillofacial and oral surgery

Cleft Lip/Palate (CLP) is a congenital orofacial anomaly appearing in approximately one in 700 births worldwide. While in high-income countries CLP is normally addressed surgically during infancy, in developing countries CLP is often left unoperated, potentially impacting multiple dimensions of life quality. Previous research has frequently compared CLP outcomes to those of the general population. But because local environmental and genetic factors both contribute to the risk of CLP and also may influence life outcomes, such studies may present a downward bias in estimates of both CLP status and restorative surgery. Working with the non- profit organization Operation Smile, this research uses quasi-experimental causal methods on a novel data set of 1,118 Indian children to study the impact of CLP status and CLP correction on the physical, psychological, and social well-being of Indian teenagers. Our results indicate that adolescents with median-level CLP severity show statistically significant losses in indices of speech quality (-1.55), academic and cognitive ability (-0.43), physical well-being (-0.35), psychological well-being (-0.23), and social inclusion (-0.35). We find that CLP surgery improves speech if carried out at an early age, and that it significantly restores social inclusion.


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128. Outcomes Associated With Anaesthetic Techniques for Caesarean Section in Low- And Middle-Income Countries: A Secondary Analysis of WHO Surveys

scientific reports


Authors: Pisake Lumbiganon , Hla Moe , Siriporn Kamsa-Ard , Siwanon Rattanakanokchai , Malinee Laopaiboon , Chumnan Kietpeerakool , Nampet Jampathong , Monsicha Somjit , José Guilherme Cecatti , Joshua P Vogel , Ana Pilar Betran , Suneeta Mittal , Maria Regina Torloni
Region / country: Global
Speciality: Anaesthesia, Obstetrics and Gynaecology

Associations between anaesthetic techniques and pregnancy outcomes were assessed among 129,742 pregnancies delivered by caesarean section (CS) in low- and middle-income countries (LMICs) using two WHO databases. Anaesthesia was categorized as general anaesthesia (GA) and neuraxial anaesthesia (NA). Outcomes included maternal death (MD), maternal near miss (MNM), severe maternal outcome (SMO), intensive care unit (ICU) admission, early neonatal death (END), neonatal near miss (NNM), severe neonatal outcome (SNO), Apgar score <7 at 5 minutes, and neonatal ICU (NICU) admission. A two-stage approach of individual participant data meta-analysis was used to combine the results. Adjusted odds ratio (OR) with 95% confidence intervals (CIs) were presented. Compared to GA, NA were associated with decreased odds of MD (pooled OR 0.28; 95% CI 0.10, 0.78), MNM (pooled OR 0.25; 95% CI 0.21, 0.31), SMO (pooled OR 0.24; 95% CI 0.20,0.28), ICU admission (pooled OR 0.17; 95% CI 0.13, 0.22), NNM (pooled OR 0.63; 95% CI 0.55, 0.73), SNO (pooled OR 0.55; 95% CI 0.48, 0.63), Apgar score <7 at 5 minutes (pooled OR 0.35; 95% CI 0.29, 0.43), and NICU admission (pooled OR 0.53; 95% CI 0.45, 0.62). NA therefore was associated with decreased odds of adverse pregnancy outcomes in LMICs.


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129. Hashtag Global Surgery: The Role of Social Media in Advancing the Field of Global Surgery

Cureus


Authors: Dominique Vervoort , Jessica G Luc
Region / country: Global
Speciality: Other

Introduction: Surgery is increasingly recognized as an indispensable part of healthcare, but lack of awareness about its cost-effectiveness and cross-cutting impact remain. Social media has become an important resource for healthcare professionals in a variety of settings due to its instant global reach in a non-discriminatory and low-threshold manner. In 2010, #globalsurgery was first used on Twitter to spread awareness, foster international collaborations, and raise voices of advocates around the world. Here, we examine the role of social media in the field of global surgery.

Methods: The use of #globalsurgery on Twitter was analyzed through Tweetreach from July 31 to December 31, 2018. Additional analysis of hashtags in Spanish, Japanese, Malay, and Portuguese was done to determine the number of tweets, retweets, impressions, and users using #globalsurgery or translated hashtags. Sentiment analysis was performed to determine the affective state of tweets.

Results: A total of 4,519 tweets and 15,861 retweets were posted by 4,449 different contributors. Tweets totalled 58,733,406 potential direct impressions and 46,560,293 potential amplified impressions, with potential reach of 11,272,014. English was the major language (99.47%), followed by Spanish (0.49%) and Japanese (0.04%). Portuguese and Malay hashtags were not used during the study period.

Conclusion: #globalsurgery provides an innovative way to overcome barriers and strengthen collaboration among advocates, and more effectively raise awareness about global surgery.


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130. Inverted flap technique with air tamponade and one day face down positioning for posttraumatic macular hole surgery in a young male patient in sub-Saharan Africa

Journal of Case Reports and Images in Ophthalmology


Authors: Olufemi Oderinlo, Adekunle Olubola Hassan, Ogugua Okonkwo
Region / country: Western Africa – Nigeria
Speciality: Ophthalmology

Introduction: Surgery has been the mainstay of macular hole treatment since the first description of its success. Different techniques are, however, described. Our case report looks into the use of the inverted flap technique for managing patients with posttraumatic full thickness macular holes with a single day supervised face down positioning and air tamponade.

Case Report: A 32-year-old young man sustained blunt ocular trauma to his left eye while under training seven months prior to presentation with reduced central vision and metamorphopsia. On examination visual acuities were best corrected 6/6 in the right and 6/60 in the left, anterior segments were normal. Fundoscopy revealed flat retinae, and extensive linear chorioretina scars in the posterior pole suggestive of healed choroidal ruptures and a posttraumatic stage 4 full thickness macular hole (FTMH) in the left. The FTMH measured 877 μm on optical coherence tomography (OCT). The patient had a macular hole surgery using the inverted flap technique with one-day face down positioning and air tamponade. Significant hole closure was seen in the first postoperative week and by six weeks after surgery, the macular hole was fully closed and vision improved to 6/6 best corrected. The inverted flap technique with air tamponade and one day face down positioning can offer another option to retina surgeons treating complex macular holes. Early visual recovery and ability to undertake air travel immediately after surgery is an additional advantage.

Conclusion: Using the inverted flap technique for surgery provides surgeons with another option for repair of complex FTMHs, like those secondary to trauma that have been known to respond poorly to initial standard repair.


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131. Minimizing Delays in the Breast Cancer Pathway by Integrating Breast Specialty Care Services at the Primary Health Care Level in Zambia

JCO Global Oncology


Authors: Mutumba Songiso MBChB, MMED, Leeya F. Pinder MD, MPH, Jabulani Munalula, MD, Anna Cabanes PhD, MPH, Sarah Rayne MBChB, PhD, Sharon Kapambwe MD, Aaron Shibemba MBChB and Groesbeck P. Parham, MD
Region / country: Eastern Africa – Zambia
Speciality: Surgical oncology

PURPOSE
In Zambia, more than two-thirds of female patients with breast cancer present with late-stage disease, leading to high mortality rates. Most of the underlying causes are associated with delays in symptom recognition and diagnosis. By implementing breast care specialty services at the primary health care level, we hypothesized that some of the delays could be minimized.

METHODS
In March 2018, we established a breast care specialty clinic for women with symptomatic disease within 1 of the 5 district hospitals in Lusaka. The clinic offers breast self-awareness education, clinical breast examination, breast ultrasound, ultrasound-guided breast biopsy, surgery, referral for chemoradiation, follow-up care, and electronic medical records.

RESULTS
Between March 2018 and April 2019, of 1,790 symptomatic women who presented to the clinic, 176 (10%) had clinical and/or ultrasound indications for histologic evaluation. Biopsy specimens were obtained using ultrasound-guided core-needle procedures, all of which were performed on the same day as the initial visit. Of the 176 women who underwent biopsy, 112 (64%) had pathologic findings compatible with a primary breast cancer, and of these, 42 (37%) were early-stage (stage I/II) disease. Surgery for early-stage cancers was performed at the district hospital within 2 weeks of the time of definitive pathologic diagnosis. Patients with advanced disease were referred to the national cancer center for multimodality therapy, within a similar time frame.

CONCLUSION
Breast care specialty services for symptomatic women were established in a district-level hospital in a resource-constrained setting in Africa. As a result, the following time intervals were minimized: initial presentation and performance of clinical diagnostics; receipt of a definitive pathologic diagnosis and initiation of surgery; receipt of a definitive pathologic diagnosis and referral.


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132. Maximizing the potential of trauma registries in low-income and middle-income countries

Trauma Surgery & Acute Care Open


Authors: Leah Rosenkrantz, Nadine Schuurman, Claudia Arenas, Andrew Nicol, Morad S. Hameed
Region / country: Global
Speciality: Trauma surgery

Injury is a major global health issue, resulting in millions of deaths every year. For decades, trauma registries have been used in wealthier countries for injury surveillance and clinical governance, but their adoption has lagged in low-income and middle-income countries (LMICs). Paradoxically, LMICs face a disproportionately high burden of injury with few resources available to address this pandemic. Despite these resource constraints, several hospitals and regions in LMICs have managed to develop trauma registries to collect information related to the injury event, process of care, and outcome of the injured patient. While the implementation of these trauma registries is a positive step forward in addressing the injury burden in LMICs, numerous challenges still stand in the way of maximizing the potential of trauma registries to inform injury prevention, mitigation, and improve quality of trauma care. This paper outlines several of these challenges and identifies potential solutions that can be adopted to improve the functionality of trauma registries in resource-poor contexts. Increased recognition and support for trauma registry development and improvement in LMICs is critical to reducing the burden of injury in these settings.


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133. The feasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review

Trauma Surgery & Acute Care Open


Authors: Isabelle Feldhaus, Melissa Carvalho, Ghazel Waiz, Joel Igu, Zachary Matthay, Rochelle Dicker, Catherine Juillard
Region / country: Global
Speciality: Trauma surgery

Background: About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings.

Materials and methods: This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized.

Results: Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessments observed mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility.

Conclusions: The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective.


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134. Global Neurosurgery in the Time of COVID-19

Neurospine


Authors: Kee B Park, Ulrick Sidney Kanmounye, Jean Wilguens Lartigue
Region / country: Global
Speciality: Neurosurgery

In this editorial, the term global surgery includes neurosurgical care delivery as an integral component of surgical systems and the broader health systems.
While there are many stories about the impact of the coronavirus disease 2019 (COVID-19) pandemic on the delivery of surgical care and the clinical management of neurosurgical cases in high-income countries (HICs), less attention has been directed toward the impact of COVID-19 in low- and middle-income countries (LMICs). Nine-in-ten spine cases are in LMICs, and spine diseases make up 39.0% of operative cases in LMICs. The pandemic will stretch the resources of the already fragile surgical systems in LMICs and thereby worsen the disparities in access to neurosurgical care. As priorities are readjusted and unprecedented resources are made available to battle the new coronavirus, we need to explore the shared interests between global surgery and pandemic response and preparedness.


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

PLoS one


Authors: Taiwo Obembe, Sharon Fonn
Region / country: Western Africa – Nigeria
Speciality: Emergency surgery

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


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136. Significant Improvement in Quality of Life Following Surgery for Hydrocoele Caused by Lymphatic Filariasis in Malawi: A Prospective Cohort Study

PLoS neglected Tropical diseases


Authors: Hannah Betts, Sarah Martindale, John Chiphwanya, Square Z Mkwanda, Dorothy E Matipula, Paul Ndhlovu, Charles Mackenzie, Mark J Taylor, Louise A Kelly-Hope
Region / country: Southern Africa – Malawi
Speciality: General surgery

Background
Lymphatic filariasis (LF) is a mosquito-borne parasitic infection that causes significant disabling and disfiguring clinical manifestations. Hydrocoele (scrotal swelling) is the most common clinical condition, which affects an estimated 25 million men globally. The recommended strategy is surgical intervention, yet little is known about the impact of hydrocoele on men’s lives, and how it may change if they have access to surgery.
Methodology/principal findings
We prospectively recruited and followed-up men who underwent surgery for hydrocoele at six hospitals in an LF endemic area of Malawi in December 2015. Men were interviewed at hospitals pre-surgery and followed-up at 3-months and 6-months post-surgery. Data on demographic characteristics, clinical condition, barriers to surgery, post-surgery symptoms/complications and quality of life indicators were collected and analysed pre- and post-surgery, by age group and stage of disease (mild/moderate vs. severe), using chi-square tests and student’s t test (paired). 201 men were interviewed pre-surgery, 152 at 3-months and 137 at 6-months post-surgery. Most men had unilateral hydrocoeles (65.2%), mild/moderate stages (57.7%) with an average duration of 11.4 years. The most reported cause of hydrocoele was it being sexually transmitted (22.4%), and the main barrier to surgery was the cost (36.3%). Pre-surgery, a significant difference in the scrotum side affected was found by age group (X2 = 5.978, p = 0.05), and men with severe stage hydrocoele reported more problems with their quality of life than those with mild/moderate stage (t = 2.793; p = 0.0006). Post-surgery, around half of the men reported some pain/discomfort (55.9%), swelling (8.6%), bleeding (3.3%) and infection (5.9%), most of which had resolved at 3-months when the most significant improvements in their quality of life were found (t = 21.3902; p = 0.000). Post-surgery at 6 months all men reported no physical, social, psychological problems and took no time off work.
Conclusion/significance
Surgery had a significant positive impact on many aspects of a patient’s life, and the expansion of this treatment to all those affected in LF endemic areas would greatly improve the quality of men’s and their families’ lives, and greatly contribute to the global goal of providing universal health care.


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137. Surgery for Radiologically Normal-Appearing Temporal Lobe Epilepsy in a Centre With Limited Resources

Scientific reports


Authors: Muhamad Thohar Arifin, Yuriz Bakhtiar, Erie B P S Andar, Happy Kurnia B, Dody Priambada, Ajid Risdianto, Gunadi Kusnarto, Krisna Tsaniadi, Jacob Bunyamin, Ryosuke Hanaya, Kazunori Arita, Aris Catur Bintoro, Koji Iida, Kaoru Kurisu, Rofat Askoro, Surya P Briliantika, Zainal Muttaqin
Region / country: South-eastern Asia – Indonesia
Speciality: Neurosurgery

Approximately 26-30% of temporal lobe epilepsy (TLE) cases display a normal-appearing magnetic resonance image (MRI) leading to difficulty in determining the epileptogenic focus. This causes challenges in surgical management, especially in countries with limited resources. The medical records of 154 patients with normal-appearing MRI TLE who underwent epilepsy surgery between July 1999 and July 2019 in our epilepsy centre in Indonesia were examined. The primary outcome was the Engel classification of seizures. Anterior temporal lobectomy was performed in 85.1% of the 154 patients, followed by selective amygdalo-hippocampectomy and resection surgery. Of 82 patients (53.2%), Engel Class I result was reported in 69.5% and Class II in 25.6%. The median seizure-free period was 13 (95% CI,12.550-13.450) years, while the seizure-free rate at 5 and 12 years follow-up was 96.3% and 69.0%, respectively. Patients with a sensory aura had better seizure-free outcome 15 (11.575-18.425) years. Anterior temporal lobectomy and selective amygdala-hippocampectomy gave the same favourable outcome. Despite the challenges of surgical procedures for normal MRI TLE, our outcome has been favourable. This study suggests that epilepsy surgery in normal MRI TLE can be performed in centres with limited resources.


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138. Troponin I as a Mortality Marker After Lung Resection Surgery – A Prospective Cohort Study

BMC Anesthesiology


Authors: Ricardo B Uchoa, Bruno Caramelli
Region / country: South America – Brazil
Speciality: Cardiothoracic surgery

Background
Cardiovascular complications associated with thoracic surgery increase morbidity, mortality, and treatment costs. Elevated cardiac troponin level represents a predictor of complications after non-cardiac surgeries, but its role after thoracic surgeries remains undetermined. The objective of this study was to analyze the relationship between troponin I elevation and morbidity and mortality after one year in patients undergoing lung resection surgery.
Methods
This prospective cohort study evaluated 151 consecutive patients subjected to elective lung resection procedures using conventional and video-assisted thoracoscopic techniques at a University Hospital in Brazil, from July 2012 to November 2015. Preoperative risk stratification was performed using the scores obtained by the American College of Physicians (ACP) and the Society of Cardiology of the state of São Paulo (EMAPO) scoring systems. Troponin I levels were measured in the immediate postoperative period (POi) and on the first and second postoperative days.
Results
Most patients had a low risk for complications according to the ACP (96.7%) and EMAPO (82.8%) scores. Approximately 49% of the patients exhibited increased troponin I (≥0.16 ng/ml), at least once, and 22 (14.6%) died in one year. Multivariate analysis showed that the elevation of troponin I, on the first postoperative day, correlated with a 12-fold increase in mortality risk within one year (HR 12.02, 95% CI: 1.82-79.5; p = 0.01).
Conclusions
In patients undergoing lung resection surgery, with a low risk of complications according to the preoperative evaluation scores, an increase in troponin I levels above 0.16 ng/ml in the first postoperative period correlated with an increase in mortality within one year.


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139. The Trauma and Acute Care Surgeon in the COVID-19 Pandemic Era

Revista do Colégio Brasileiro de Cirurgiões


Authors: Marcelo Augusto Fontenelle Ribeiro, Tercio DE-Campos, Daniel Souza Lima, Antonio C Marttos-Jr, Bruno M Pereira
Region / country: South America – Brazil
Speciality: Emergency surgery, Trauma surgery

The World Health Organization recognized in March 2020 the existence of a pandemic for the new coronavirus that appeared in China, in late 2019, and whose disease was named COVID-19. In this context, the SBAIT (Brazilian Society of Integrated Care for Traumatized Patients) conducted a survey with 219 trauma and emergency surgeons regarding the availability of personal protective equipment (PPE) and the role of the surgeon in this pandemic by means of an electronic survey. It was observed that surgeons have been acting under inadequate conditions, with a lack of basic supplies as well as more specific equipment such as N95 masks and facial shields for the care of potential victims who may be contaminated. The latter increases the risk of contamination of professionals, resulting in potential losses in the working teams. Immediate measures must be taken to guarantee access to safety equipment throughout the country, since all trauma victims and/or patients with emergency surgical conditions must be treated as potential carriers of COVID-19.


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140. Delays in hospital admissions in patients with fractures across 18 LMIC (INORMUS): a prospective observational study

lancet Global health


Authors: P Pouramin , C Silvia Li , J W Busse , S Sprague , P J Devereaux , J Jagnoor , R Ivers , M Bhandari , INORMUS investigators
Region / country: Global
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Background: The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. Methods: In this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Findings: Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31-62), of whom 19 937 (63·8%) were men, and 14 524 (46·5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71·9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27·5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88·7%] of 195 patients with open fractures; 426 [44·7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47·7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50·5%]), while Second Delays (delays in reaching care) were the least common (423 [5·4%]). Compared with other methods of transportation (eg, walking, rickshaw), ambulances led to delay in transporting patients with open fractures to a treating hospital (adjusted RR 0·66, 99% CI 0·46-0·93)…(abstract continued on full journal site)


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141. Management guidelines of penile cancer- a contemporary review of sub-Saharan Africa

Infectious Agents and Cancer


Authors: Ayun Cassell, Bashir Yunusa, Burgess Manobah, and Desire Wambo
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Surgical oncology, Urology surgery

Background
Penile cancer is a rare malignancy with prevalence higher in areas of high Human Papilloma Virus (HPV) such as Africa, Asia and South America. In middle- and low-income countries where circumcision is not routinely practiced, the rate of penile cancer could be ten times higher.

Main body of the abstract
A literature review was conducted from 1992 to 2019 using PubMed, Google Scholar, African Journal Online and Google with inclusion of 27 publications with emphasis on the Sub-Saharan literature. Findings revealed that most men with penile cancer in Sub-Saharan Africa (SSA) present with locally advanced to advanced disease with devastating consequences. The option of penile sparing procedure is reduced with most treatment option directed to mutilating surgeries. The lack of appropriate chemotherapy and radiotherapy worsens the prognosis in the region.

Short conclusion
Human Papilloma Virus (HPV) vaccination may not be cost-effective for most regions in SSA. Therefore, early childhood circumcision might be the best advocated alternative for prevention.


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142. Outcomes in the management of high-risk gestational trophoblastic neoplasia in trophoblastic disease centers in South America

International Journal of Gynecologic Cancer


Authors: Izildinha Maestá, Marjory de Freitas Segalla Moreira, Jorge Rezende-Filho, Maria Inés Bianconi, Gustavo Jankilevich, Silvina Otero, Luz Angela Correa Ramirez, Sue Yazaki Sun, Kevin Elias, Neil Horowitz, Antonio Braga and Ross Berkowitz
Region / country: South America – Argentina, Brazil
Speciality: Obstetrics and Gynaecology

Background: South America has a higher incidence of gestational trophoblastic disease than North America or Europe, but whether this impacts chemotherapy outcomes is unclear. The purpose of this study was to evaluate outcomes among women with high-risk gestational trophoblastic neoplasia (GTN) treated at trophoblastic disease centers in developing South American countries.

Methods: This retrospective cohort study included patients with high-risk GTN treated in three trophoblastic disease centers in South America (Botucatu and Rio de Janeiro, Brazil, and Buenos Aires, Argentina) from January 1990 to December 2014. Data evaluated included demographics, clinical presentation, FIGO stage, WHO prognostic risk score, and treatment-related information. The primary treatment outcome was complete sustained remission by 18 months following completion of therapy or death.

Results: Among 1264 patients with GTN, 191 (15.1%) patients had high-risk GTN and 147 were eligible for the study. Complete sustained remission was ultimately achieved in 87.1% of cases overall, including 68.4% of ultra high-risk GTN (score ≥12). Early death (within 4 weeks of initiating therapy) was significantly associated with ultra high-risk GTN, occurring in 13.8% of these patients (p=0.003). By Cox’s proportional hazards regression, factors most strongly related to death were non-molar antecedent pregnancy (RR 4.35, 95% CI 1.71 to 11.05), presence of liver, brain, or kidney metastases (RR 4.99, 95% CI 1.96 to 12.71), FIGO stage (RR 3.14, 95% CI 1.52 to 6.53), and an ultra-high-risk prognostic risk score (RR 7.86, 95% CI 2.99 to 20.71). Median follow-up after completion of chemotherapy was 4 years. Among patients followed to that timepoint, the probability of survival was 90% for patients with high-risk GTN (score 7-11) and 60% for patients with ultra-high-risk GTN (score ≥12).

Conclusion: Trophoblastic disease centers in developing South American countries have achieved high remission rates in high-risk GTN, but early deaths remain an important problem, particularly in ultra-high-risk GTN.


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143. Use of vital signs in Predicting surgical intervention in a South African population: A cross-sectional study

International Journal of Surgery


Authors: Amee D.Azad, Victor Y.Kong, Damian L.Clark, Grant L.Laing, John L.Bruce, Tiffany E.Chao
Region / country: Southern Africa – South Africa
Speciality: Emergency surgery, Trauma surgery

Background
While vital signs are widely obtained for trauma patients around the world, the association of these signs with need for surgical intervention has yet to be defined. Early detection of preventable outcomes is essential to timely intervention and reduction of morbidity and mortality.

Objective
The aim of this study was to determine the association of vital signs and surgical intervention in a population of patients in South Africa.

Methods
This retrospective cohort included 8722 trauma patients admitted at **** Hospital in Pietermaritzburg, South Africa over a five-year period December 2012-April 2018. Exclusion criteria included missing key data points. Variables for analysis included sex, mechanism of injury, admission Glasgow Coma Scale (GCS), systolic blood pressure, diastolic blood pressure, temperature, heart rate, and respiratory rate. Surgical intervention was defined by the need for treatment requiring time in the operating room. Data were analyzed using a univariate and multivariate logistic regression to determine an association between admission vital signs and surgical intervention and compared to the association of the Revised Trauma Score to surgical intervention.

Results
Of the 8722 trauma patient records available, exclusion of patients with incomplete data resulted in 7857 patient records available for analysis. Two thousand two hundred and ninety-six (29.2%) patients required surgical intervention in the operating room. Multivariate analysis revealed that male sex [odds ratio (OR) 1.25, 95% confidence interval (CI) 1.06-1.48], stab wound (OR 3.42, CI 2.99-3.09), gunshot wound (OR 4.27, CI 3.58-5.09), systolic hypotension (OR 1.81, CI 1.32- 2.48), hypothermia(OR 1.77, CI 1.34-2.34), tachycardia (OR 1.84, CI 1.61- 2.10), and tachypnea (OR 1.26, CI 1.08-1.45) as factors ssociated withan increased likelihood of surgical intervention.

Conclusions
In this cohort of patients, the need for surgical intervention was best predicted by penetrating mechanisms of injury, tachycardia, and systolic hypotension. These data show that rapid and focused patient assessments should be used to triage patients foremergency surgery to avoid delays at any stage.


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144. 2020 Update of the WSES Guidelines for the Management of Acute Colonic Diverticulitis in the Emergency Setting

world journal of emergency surgery


Authors: Massimo Sartelli, Dieter G. Weber, Yoram Kluger, Luca Ansaloni, Federico Coccolini, Fikri Abu-Zidan, Goran Augustin, Offir Ben-Ishay, Walter L. Biffl, Konstantinos Bouliaris, Rodolfo Catena, Marco Ceresoli, Osvaldo Chiara, Massimo Chiarugi, Raul Coimbra, Francesco Cortese, Yunfeng Cui, Dimitris Damaskos, Gian Luigi de’ Angelis, Samir Delibegovic, Zaza Demetrashvili, Belinda De Simone, Francesco Di Marzo, Salomone Di Saverio, Therese M. Duane, Mario Paulo Faro, Gustavo P. Fraga, George Gkiokas, Carlos Augusto Gomes, Timothy C. Hardcastle, Andreas Hecker, Aleksandar Karamarkovic, Jeffry Kashuk, Vladimir Khokha, Andrew W. Kirkpatrick, Kenneth Y. Y. Kok, Kenji Inaba, Arda Isik, Francesco M. Labricciosa, Rifat Latifi, Ari Leppäniemi, Andrey Litvin, John E. Mazuski, Ronald V. Maier, Sanjay Marwah, Michael McFarlane, Ernest E. Moore, Frederick A. Moore, Ionut Negoi, Leonardo Pagani, Kemal Rasa, Ines Rubio-Perez, Boris Sakakushev, Norio Sato, Gabriele Sganga, Walter Siquini, Antonio Tarasconi, Matti Tolonen, Jan Ulrych, Sannop K. Zachariah, and Fausto Catena
Region / country: Global
Speciality: Emergency surgery, General surgery

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.


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145. COVID-19 and Neurosurgical Education in Africa: Making Lemonade From Lemons

world neurosurgery


Authors: Ulrick Sidney Kanmounye , Ignatius N Esene
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Neurosurgery, Surgical Education

Never in history has the fabric of African Neurosurgery been challenged as it is today with the advent of covid-19. Even the most robust and resilient neurosurgical educational systems in the continent have been brought to their knees with Neurosurgical trainees and young neurosurgeons bearing the brunt. In the face of this new reality, and in order to limit the impact of the current COVID-19 pandemic, multiple programs have implemented physical distancing which reduces in-person interactions. In some cases, residents have been asked to stay home at least till they are instructed otherwise. This unfortunate event presents an innovative opportunity for neurosurgical education in Africa. Herein, we detail the framework of an online neurosurgical education initiative to advance the education of African residents and young Neurosurgeons during and after the COVID-19 pandemic.


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146. Mapping Global Evidence on Strategies and Interventions in Neurotrauma and Road Traffic Collisions Prevention: A Scoping Review

Systematic Reviews


Authors: Santhani M Selveindran , Tamara Tango , Muhammad Mukhtar Khan , Daniel Martin Simadibrata , Peter J A Hutchinson , Carol Brayne , Christine Hill , Franco Servadei , Angelos G Kolias , Andres M Rubiano , Alexis J Joannides, Hamisi K Shabani
Region / country: Global
Speciality: Emergency surgery, Neurosurgery, Trauma surgery

Background
Neurotrauma is an important global health problem. The largest cause of neurotrauma worldwide is road traffic collisions (RTCs), particularly in low- and middle-income countries (LMICs). Neurotrauma and RTCs are preventable, and many preventative interventions have been implemented over the last decades, especially in high-income countries (HICs). However, it is uncertain if these strategies are applicable globally due to variations in environment, resources, population, culture and infrastructure. Given this issue, this scoping review aims to identify, quantify and describe the evidence on approaches in neurotrauma and RTCs prevention, and ascertain contextual factors that influence their implementation in LMICs and HICs.

Methods
A systematic search was conducted using five electronic databases (MEDLINE, EMBASE, CINAHL, Global Health on EBSCO host, Cochrane Database of Systematic Reviews), grey literature databases, government and non-government websites, as well as bibliographic and citation searching of selected articles. The extracted data were presented using figures, tables, and accompanying narrative summaries. The results of this review were reported using the PRISMA Extension for Scoping Reviews (PRISMA-ScR).

Results
A total of 411 publications met the inclusion criteria, including 349 primary studies and 62 reviews. More than 80% of the primary studies were from HICs and described all levels of neurotrauma prevention. Only 65 papers came from LMICs, which mostly described primary prevention, focussing on road safety. For the reviews, 41 papers (66.1%) reviewed primary, 18 tertiary (29.1%), and three secondary preventative approaches. Most of the primary papers in the reviews came from HICs (67.7%) with 5 reviews on only LMIC papers. Fifteen reviews (24.1%) included papers from both HICs and LMICs. Intervention settings ranged from nationwide to community-based but were not reported in 44 papers (10.8%), most of which were reviews. Contextual factors were described in 62 papers and varied depending on the interventions.

Conclusions
There is a large quantity of global evidence on strategies and interventions for neurotrauma and RTCs prevention. However, fewer papers were from LMICs, especially on secondary and tertiary prevention. More primary research needs to be done in these countries to determine what strategies and interventions exist and the applicability of HIC interventions in LMICs.


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147. Emergency and Essential Surgical Healthcare Services During COVID-19 in Low- And Middle-Income Countries: A Perspective

international Journal of surgery


Authors: Xiya Ma, Dominique Vervoort, Ché L. Reddy, Kee B. Park, and Emmanuel Makasa
Region / country: Global
Speciality: Emergency surgery

The COVID-19 pandemic resulted in significant changes in health care systems worldwide, with low- and middle-income countries (LMIC) sustaining important repercussions. Specifically, alongside cancellation and postponements of non-essential surgical services, emergency and essential surgical care delivery may become affected due to the shift of human and material resources towards fighting the pandemic. For surgeries that do get carried through, new difficulties arise in protecting surgical personnel from contracting SARS-CoV-2. This scarcity in LMIC surgical ecosystems may result in higher morbidity and mortality, in addition to the COVID-19 toll. This paper aims to explore the potential consequences of COVID-19 on the emergency and essential surgical care in LMICs, to offer recommendations to mitigate damages and to reflect on preparedness for future crises. Reducing the devastating consequences of the COVID-19 pandemic on LMIC emergency and essential surgical services can be achieved through empowering communities with accurate information and knowledge on prevention, optimizing surgical material resources, providing quality training of health care personnel to treat SARS-CoV-2, and ensuring adequate personal protection equipment for workers on the frontline. While LMIC health systems are under larger strain, the experience from previous outbreaks may aid in order to innovate and adapt to the current pandemic. Protecting LMIC surgical ecosystems will be a pivotal process in ensuring that previous health system strengthening efforts are preserved, comprehensive care for populations worldwide are ensured, and to allow for future developments beyond the pandemic.


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148. Remote Monitoring of Clubfoot Treatment With Digital Photographs in Low Resource Settings: Is It Accurate?

PLoS One


Authors: Tracey Smythe , Marie-Caroline Nogaro , Laura J Clifton , Debra Mudariki , Tim Theologis , Chris Lavy
Region / country: Southern Africa – Zimbabwe
Speciality: Surgical Education, Trauma and orthopaedic surgery

Background: Clinical examination and functional assessment are often the first steps to assess outcome of clubfoot treatment. Clinical photographs may be an adjunct used to assess treatment outcomes in lower resourced settings where physical review by a specialist is limited. We aimed to evaluate the diagnostic performance of photographic images of patients with clubfoot in assessing outcome following treatment.

Methods: In this single-centre diagnostic accuracy study, we included all children with clubfoot from a cohort treated between 2011 and 2013, in 2017. Two physiotherapists trained in clubfoot management calculated the Assessing Clubfoot Treatment (ACT) score for each child to decide if treatment was successful or if further treatment was required. Photographic images were then taken of 79 feet. Two blinded orthopaedic surgeons assessed three sets of images of each foot (n = 237 in total) at two time points (two months apart). Treatment for each foot was rated as ‘success’, ‘borderline’ or ‘failure’. Intra- and inter-observer variation for the photographic image was assessed. Sensitivity, specificity, positive and negative predictive values were calculated for the photographic image compared to the ACT score.

Results: There was perfect correlation between clinical assessment and photographic evaluation of both raters at both time-points in 38 (48%) feet. The raters demonstrated acceptable reliability with re-scoring photographs (rater 1, k = 0.55; rater 2, k = 0.88). Thirty percent (n = 71) of photographs were assessed as poor quality image or sub-optimal patient position. Sensitivity of outcome with photograph compared to ACT score was 83.3%-88.3% and specificity ranged from 57.9%-73.3%.

Conclusion: Digital photography may help to confirm, but not exclude, success of clubfoot treatment. Future work to establish photographic parameters as an adjunct to assessing treatment outcomes, and guidance on a standardised protocol for photographs, may be beneficial in the follow up of children who have treated clubfoot in isolated communities or lower resourced settings.


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149. Giant Mesenteric Cyst: Successful Management in Low-Resource Setting

International Journal of Surgery Case Reports


Authors: Mario Antunes , Damiano Pizzol , Marcella Schiavone , Anna Claudia Colangelo
Region / country: Eastern Africa, Western Europe – Italy, Mozambique
Speciality: Cardiothoracic surgery, General surgery, Paediatric surgery

Introduction: Mesenteric cysts are rare, generally benign intra-abdominal lesions with a wide range of presentation in terms of size, clinical presentation, etiology, radiological features, and pathological characteristics.

Presentation of case: We reported a case of giant mesenteric cyst in a 16-month-old girl successfully managed in a low-resource setting.

Discussion: This case is particularly important not only due to the rarity of the presented case, but also for the highlighted aspects from a public health point of view. We faced of the problem of a late stage disease and the lack of preoperative diagnosis due to cultural and economic reasons and the weaknesses of healthcare systems, as in the majority of low- and middle-income countries.

Conclusion: Despite all these limitation, this case illustrates that complex, rare diseases can also be managed successfully in a low-resource setting. It is mandatory to strengthen and improve the health system both in terms of equipment both in terms of public health policies in order to offer a better and more effective quality of care to patients also in low-income countries.


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150. Primary Hydatid Cyst of the Adrenal Gland: A Case Report and a Review of the Literature

International Journal of Surgery Case Reports


Authors: Skander Zouari , Chakroun Marouene , Hana Bibani , Ahmed Saadi , Anis Sellami , Linda Haj Kacem , Ahlem Blel , Abderrazek Bouzouita , Amine Derouiche , Riadh Ben Slama , Soumaya Rammeh , Haroun Ayed , Mohamed Chebil
Region / country: Northern Africa – Tunisia
Speciality: General surgery

Introduction: In North Africa which is an endemic region for Hydatid Cyst, Tunisia is considered as an endemic country. The liver and lungs are common locations for Hydatid Cysts, whereas the Adrenal Glands are unusual and rare locations.

Presentation of case: Here is a report of primary Hydatid Cyst in a 55-year old patient, with left hypochondrium pain as chief complain. No remarkable findings were revealed by physical examination and blood analysis showed normal range. Hydatid serology was negative. The diagnosis of Hydatid Cyst was suspected based on CT Scan results which showed a well-circumscribed, non-enhanced, multi-cystic, 12 cm mass with scattered calcifications located in the left adrenal gland. Therefore, the patient underwent an open surgery with resection of the protruding dome of the cyst as it was attached to the renal pedicle, the pancreatic tail, the spleen and the jejunum. The final pathological examination of the specimen led to a Hydatid Cyst.

Discussion: Throughout an extensive literature review that we have made, we have analyzed 54 reported cases, with their clinical presentations, biological exams, radiological features and surgical managements. The treatment should be surgical and has to be as conservative as possible. The prevention of the parasite transmission has to be the cornerstone of the disease management.

Conclusion: The hydatid cyst of the adrenal gland remains a rare diagnosis that has to be evoked in case of an adrenal gland cyst, especially in an endemic country.


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151. Improving Quality of Surgical and Anaesthesia Care at Hospital Level in sub-Saharan Africa: A Systematic Review Protocol of Health System Strengthening Interventions

BMJ Open


Authors: Nataliya Brima , Justine Davies , Andrew Jm Leather
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Anaesthesia, General surgery

Introduction: Over 5 billion people in the world do not have access to safe, affordable surgical and anaesthesia care when needed. In order to improve health outcomes in patients with surgical conditions, both access to care and the quality of care need to be improved. A recent commission on high-quality health systems highlighted that poor-quality care is now a bigger barrier than non-utilisation of the health system for reducing mortality.

Aim: To carry out a systematic review to provide an evidence-based summary of hospital-based interventions associated with improved quality of surgical and anaesthesia care in sub-Saharan African countries (SSACs).

Methods and analysis: Three search strings (1) surgery and anaesthesia, (2) quality improvement hospital-based interventions and (3) SSACs will be combined. The following databases EMBASE, Global Health, MEDLINE, CINAHL, Web of Science and Scopus will be searched. Further relevant studies will be identified from national and international health organisations and publications and reference lists of all selected full-text articles. The review will include all type of original articles in English published between 2008 and 2019. Article screening, data extraction and assessment of methodological quality will be done by two reviewers independently and any disputes will be resolved by a third reviewer or team consensus. Three types of outcomes will be collected including clinical, process and implementation outcomes. The primary outcome will be mortality. Secondary outcomes will include other clinical outcomes (major and minor complications), as well as process and implementation outcomes. Descriptive statistics and outcomes will be summarised and discussed. For the primary outcome, the methodological rigour will be assessed.

Ethics and dissemination: The results will be published in a peer reviewed open access journal and presented at national and international conferences. As this is a review of secondary data no formal ethical approval is required.


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152. Association of Health Care Use and Economic Outcomes After Injury in Cameroon

JAMA Network Open


Authors: S Ariane Christie , Drusia Dickson , Susana N Mbeboh , Frida N Embolo , William Chendjou , Emerson Wepngong , Ahmed N Fonje , Eunice Oben , Kareen Azemfac , Alain Chichom Mefire , Theophile Nana , M Agbor Mbianyor , Patrick Stern , Rochelle Dicker , Catherine Juillard
Region / country: Central Africa – Cameroon
Speciality: Emergency surgery, Trauma surgery

Importance: Despite the highest injury rates worldwide, formal medical care is not often sought after injuries in Sub-Saharan Africa. Unaffordable costs associated with trauma care might inhibit injured patients from seeking care.

Objectives: To (1) determine the injury epidemiology in Cameroon using population-representative data, (2) identify the barriers to use of formal health care after injury, and (3) determine the association between use of care and economic outcomes after injury.

Design, setting, and participants: This mixed-methods, cross-sectional study included a population-representative, community-based survey and nested qualitative semistructured interviews in the urban-rural Southwest Region of Cameroon. Three-stage cluster sampling was used to select target households. Data were collected from January 3 to March 14, 2017, and analyzed from March 3, 2017, to March 3, 2019.

Exposures: Injuries occurring in the preceding 12 months.

Main outcomes and measures: Postinjury use of health care services, disability, and economic outcomes. All survey data were adjusted for cluster sampling.

Results: Of 1551 total households approached, 1287 (83.0%) were surveyed for a total sample size of 8065 participants. The 8065 individuals surveyed included 4181 women (52.0%), with a mean age of 23.9 (standard error [SE], 0.2) years. A total of 503 injuries were identified among 471 unique participants, including 494 nonfatal injuries. Among these, 165 (34.6%) did not seek formal medical services. Disability occurred after 345 injuries (68.6%) and resulted in 11 941 lost days of work in the sample. Family economic hardship after injury was substantially increased among the injured cohort who used formal medical care. Injuries brought to formal medical care, compared with those that were note, incurred higher mean treatment costs ($101.08 [SE, $236.23] vs $12.13 [SE, $36.78]; P < .001), resulted in higher rates of lost employment (19.9% [SE, 3.6%] vs 5.6% [SE, 1.6%]; P = .004), and more frequently led affected families to use economic coping strategies, such as borrowing money (26.2% [SE, 2.7%] vs 7.1% [SE, 1.2%]; P < .001). After adjusting for age and severity, use of formal medical care in Cameroon was independently associated with severe economic hardship after injury, defined as a new inability to afford food or rent (adjusted odds ratio, 1.67; 95% CI, 1.05-2.65).

Conclusions and relevance: In this study, injury in Southwestern Cameroon was associated with significant disability and lost productivity. Formal medical treatment of injury was associated with significant financial consequences for households of injured patients. Primary prevention of road traffic injuries and financial restructuring of emergency care could improve trauma care access in Cameroon and reduce the societal effects of injury.


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153. Tuberculous Aortitis as a Rare Cause of Aortobronchial Fistula With Massive Haemoptysis: A Case Report

International Journal of Surgery Case Reports


Authors: Joseph Motshedi Sekgololo , Chauke Risenga Frank , Vally Moinuddeen , Dehghan-Dehnavi Alireza , Khaba Moshawa Calvin
Region / country: Southern Africa – South Africa
Speciality: Cardiothoracic surgery

Background: Aortobronchial fistula is a rare condition, which is difficult to diagnose. It is fatal if misdiagnosed or not well treated. Massive haemoptysis is usually the first common symptom. Computed tomography angiogram (CTA) is the best non-invasive diagnostic modality. Treatment options include open repair procedure or Transthoracic Endovascular Aortic Repair (TEVAR) and resection of the destroyed lung tissue. The recurrent rate is high.

Case presentation: This report is a case of a 26-year-old African female patient who presented with massive haemoptysis. She had been treated for pulmonary tuberculosis two years before. The patient was diagnosed with retroviral disease and had been on treatment for two years. She underwent a 2-stage repair procedure. The initial treatment was TEVAR, which was followed by lung resection after two weeks. Both operations were uneventful. Histopathology analysis confirmed tuberculous aortitis as aetiology. The patient had been followed up for a year, with no recurrence.

Discussion: Aortobronchial is divided into primary and secondary subtypes. Primary aortobronchial fistula is commonly caused by inflammatory disease and atherosclerosis. Secondary aortobronchial fistula is a complication of surgery for thoracic aorta and congenital cardiac disease. Tuberculous fistula is an uncommon cause of aortobronchial fistula. Surgery for aortobronchial fistula should include controlling both aortic and pulmonary fistula sites. A healthy tissue or muscle flap should be used between the repaired sites to prevent refistulisation. Recurrence is common; hence, long-term follow up is important.

Conclusion: Early diagnosis and adequate treatment are important. A high index of suspicion is important for diagnosis, because the diagnosis is difficult.


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154. Rehabilitation of an Irradiated Marginal Mandibulectomy Patient Using Immediately Loaded Basal Implant-Supported Fixed Prostheses and Hyperbaric Oxygen Therapy: A 2-year Follow-Up

International Journal of Surgery Case Reports


Authors: Fadia Awadalkreem , Nadia Khalifa , Abdelnasir G Ahmad , Ahmed Mohamed Suliman , Motaz Osman
Region / country: Northern Africa – Sudan
Speciality: ENT surgery, Maxillofacial and oral surgery

Introduction: The prosthetic rehabilitation of mandibular defects owing to tumor resection is challenging, especially when the patient has undergone subsequent radiotherapy.

Presentation of case: A 46-year old male presented with a marginal mandibular resection. Following surgery, the patient received adjunctive radiation therapy with a total dose of 70 grays. On clinical examination, the patient presented with severely resorbed edentulous jaws, with an anterior marginal mandibular resection and an obliterated vestibular sulcus. The panoramic radiograph showed a hypocellularity of the maxillary and mandibular bones. A multidisciplinary team was formed, and a treatment plan was formulated which involved the construction of a vestibuloplast stent, and the application of 20 hyperbaric oxygen sessions before implant treatment and 10 more sessions after implant insertion. A total of 16 basal cortical screw implants were inserted to support the fixed prostheses, and a vestibuloplasty was performed to improve esthetics. No complications were observed, and at the 2-year follow-up, the patient presented with excellent peri-implant soft tissue health; increased bone-implant contact; and stable, well-functioning prostheses.

Discussion: The construction of a stable, retentive, well-supported removable prosthesis may be complicated in cases of comprehensive mandibular resection. Basal implants can eliminate the need for bone grafting, and reduce the treatment period required for providing a fixed prosthesis.

Conclusion: To our knowledge this is the first evidence reporting the use of fixed basal implant-supported prostheses in irradiated bone, in conjunction with hyperbaric oxygen therapy. A treatment modality that significantly improves the peri-implant tissue health, and ensures an excellent implant-bone contact.


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155. Current Efforts and Challenges Facing Responses to 2019-nCoV in Africa

global health research and policy


Authors: Don Eliseo Lucero-Prisno , Yusuff Adebayo Adebisi , Xu Lin
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Health policy, Other

The novel coronavirus is a pandemic that has started to creep into Africa thus making the virus a truly global, health security threat. The number of new 2019-nCoV cases has been rising in Africa, though currently lower than the cases reported outside the region. African countries have activated their Emergency Operations Centres to coordinate responses and preparedness activities to the pandemic. A series of measures such as restricting travel, case detection and contact tracing, mandatory quarantine, guidance and information to the public among other efforts are being implemented across Africa. However, the presence of porous borders, the double burden of communicable and non-communicable diseases, poverty, poor health literacy, infodemic and family clustering, and most of all, weak health systems, may make containment challenging. It is important for African countries to continue to intensify efforts and address the challenges to effectively respond to the uncertainty the pandemic poses.


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156. Association of Gynecological Endoscopy Surgeons of Nigeria (AGES) Advisory on Laparoscopic and Hysteroscopic Procedures During the COVID-19 Pandemic

Nigerian Journal of Clinical Practice


Authors: O C Alabi , J E Okohue , A A Adewole , J I Ikechebelu
Region / country: Western Africa – Nigeria
Speciality: Obstetrics and Gynaecology

Coronavirus 2, or SARS-CoV-2 disease (COVID-19) is a global public health concern. Although there is a paucity of evidence to advise on the best practice, we recommend postponement of elective gynecological endoscopic surgeries until the pandemic is contained. Emergency surgeries should preferably be done through open surgeries than laparoscopy or hysteroscopy approach. However, if or when laparoscopy or hysteroscopy is considered, health personnel in theatre must wear appropriate personal protective equipment (PPE) and all standard precautions should be observed to prevent COVID-19 infection. When COVID-19 is highly suspected or confirmed, the patient should be referred to centers equipped in taking care of such cases.


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157. Morbidity and Mortality of Typhoid Intestinal Perforation Among Children in Sub-Saharan Africa 1995-2019: A Scoping Review

world journal of surgery


Authors: Megan Birkhold , Yacaria Coulibaly , Oumar Coulibaly , Philadelphie Dembélé , Daniel S Kim , Samba Sow , Kathleen M Neuzil
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: General surgery, Paediatric surgery

Background: Typhoid fever incidence and complications, including intestinal perforation, have declined significantly in high-income countries, with mortality rates <1%. However, an estimated 10.9 million cases still occur annually, most in low- and middle-income countries. With the availability of a new typhoid conjugate vaccine licensed for children and recommended by the World Health Organization, understanding severe complications, including associated mortality rates, is essential to inform country-level decisions on introduction of this vaccine. This scoping review summarizes over 20 years of the literature on typhoid intestinal perforation in sub-Saharan Africa.

Methods: We searched EMBASE, PubMed, Medline, and Cochrane databases for studies reporting mortality rates due to typhoid intestinal perforation in children, under 18 years old, in sub-Saharan Africa published from January 1995 through June 2019.

Results: Twenty-four papers from six countries were included. Reported mortality rates ranged from 4.6-75%, with 16 of the 24 studies between 11 and 30%. Thirteen papers included postoperative morbidity rates, ranging from 16-100%. The most documented complications included surgical site infections, intra-abdominal abscesses, and enterocutaneous fistulas. High mortality rates can be attributed to late presentation to tertiary centers, sepsis and electrolyte abnormalities requiring preoperative resuscitation, prolonged perforation-to-surgery interval, and lack of access to critical care or an intensive care unit postoperatively.

Conclusions: Current estimates of mortality related to typhoid intestinal perforation among children in sub-Saharan Africa remain unacceptably high. Prevention of typhoid fever is essential to reduce mortality, with the ultimate goal of a comprehensive approach that utilizes vaccination, improvements in water, sanitation, and hygiene, and greater access to surgical care.


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158. Travel/Tropical Medicine and Pandemic Considerations for the Global Surgeon

Oral and Maxillofacial Surgery Clinics of North America


Authors: Christian Sandrock , Shahid R Aziz
Region / country: Global
Speciality: Other

International travel goes hand in hand with medical delivery to underserved communities. The global health care worker can be exposed to a wide range of infectious diseases during their global experiences. A pretravel risk assessment visit and all appropriate vaccinations and education must be performed. Universal practices of water safety, food safety, and insect avoidance will prevent most travel-related infections and complications. Region-specific vaccinations will further reduce illness risk. An understanding of common travel-related illness signs and symptoms is helpful. Emerging pathogens that can cause a pandemic should be understood to avoid health care worker infection and spread.


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159. Orthopedic Healthcare in the Time of COVID-19: Experience of the Orthopedic Surgery Department at Mustapha Bacha Hospital, Algeria

annals of medicine and Surgery


Authors: Nadhir Meraghni , Riad Benkaidali , Mohamed Derradji , Zoubir Kara
Region / country: Northern Africa – Algeria
Speciality: Trauma and orthopaedic surgery

In response to the global health emergency, which has been raised to its highest level as a consequence of the coronavirus disease 2019 (COVID-19), urgent and aggressive actions were taken by health institutions across the world to stop the spread of the disease while ensuring continuity of vital care. This article outlines the urgent measures put in place by the orthopedic surgery department at Mustapha Bacha Hospital in response to the COVID-19 pandemic.


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160. COVID 19 and Laparoscopic Surgeons, the Indian Scenario – Perspective

international journal of surgery


Authors: Nikhil Gupta , Himanshu Agrawal
Region / country: South-eastern Asia – India
Speciality: Other

Coronavirus Disease 2019(COVID 19) had emerged as a global pandemic in recent times. The healthcare sector is at the epicentre of this unprecedented global pandemic challenge. Hospitals all over the world have reduced the number of non-emergency surgeries in order to utilize the staff and resources in a more efficient way. Severe acute respiratory syndrome coronavirus (SARS-CoV-2) is most transmitted via respiratory droplets, but risk of transmission is hugely increased while doing aerosol generating procedures (AGPs). Laparoscopy remains the preferred surgical approach for most surgical indications. There is theoretical possibility of generation of aerosols contaminated with COVID-19 from leaked CO2 and smoke generation after energy device use. The aim of this paper is to review available evidence evaluating the risk of spread of COVID-19 during necessary laparoscopic procedures and to compile guidelines from relevant professional organizations to minimize this risk.


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161. Mitigating the risks of surgery during the COVID-19 pandemic

Lancet


Authors: Paul S Mylesa and Salome Maswime
Region / country: Global
Speciality: Emergency surgery, Other

In response to the evolving COVID-19 pandemic, most governments and professional bodies recommended cancellation of elective surgery. This action was important to free up hospital bed capacity and ensure supplies of personal protective equipment (PPE), as well as to protect patients and health-care workers. In The Lancet, The COVIDSurg Collaborative1 report 30-day results of an international cohort study assessing postoperative outcomes in 1128 adults with COVID-19 who were undergoing a broad range of surgeries (605 [53·6%] men and 523 [46·4%] women; 214 [19·0%] aged <50 years, 353 [31·3%] aged 50–69 years, and 558 [49·5%] aged ≥70 years). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed postoperatively in more than two-thirds of the patients (806 [71·5%]). The primary outcome was overall postoperative mortality at 30 days and the rate was high at 23·8% (268 of 1128 patients). Pulmonary complications occurred in 577 (51·2%) patients and 30-day mortality in these patients was 38·0% (219 of 577), accounting for 82·6% (219 of 265) of all deaths. Risk factors for mortality were patient age of 70 years or older, male sex, poor preoperative physical health status, emergency versus elective surgery, malignant versus benign or obstetric diagnosis, and more extensive (major vs minor) surgery. The high proportion of these patients who were diagnosed with SARS-CoV-2 infection in the postoperative period is of interest. These patients probably acquired their infection before being admitted to hospital, thus reflecting the high prevalence of SARS-CoV-2 in the community.


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162. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

lancet


Authors: COVIDSurg Collaborative
Region / country: Global
Speciality: General surgery, Other

Background
The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection.

Methods
This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation.

Findings
This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 82·6% (219 of 265) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047).

Interpretation
Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery.

Funding
National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.


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163. Scoring System to Triage Patients for Spine Surgery in the Setting of Limited Resources: Application to the COVID-19 Pandemic and Beyond

world Neurosurgery


Authors: Daniel M Sciubba , Jeff Ehresman , Zach Pennington , Daniel Lubelski , James Feghali , Ali Bydon , Dean Chou , Benjamin D Elder , Aladine A Elsamadicy , C Rory Goodwin , Matthew L Goodwin , James Harrop , Eric O Klineberg , Ilya Laufer , Sheng-Fu L Lo , Brian J Neuman , Peter G Passias , Themistocles Protopsaltis , John H Shin , Nicholas Theodore , Timothy F Witham , Edward C Benzel
Region / country: Global
Speciality: Neurosurgery

Background: As of May 04, 2020, the COVID-19 pandemic has affected over 3.5 million people and touched every inhabited continent. Accordingly, it has stressed health systems the world over leading to the cancellation of elective surgical cases and discussions regarding healthcare resource rationing. It is expected that rationing of surgical resources will continue even after the pandemic peak, and may recur with future pandemics, creating a need for a means of triaging emergent and elective spine surgery patients.

Methods: Using a modified Delphi technique, a cohort of 16 fellowship-trained spine surgeons from 10 academic medical centers constructed a scoring system for the triage and prioritization of emergent and elective spine surgeries. Three separate rounds of videoconferencing and written correspondence were used to reach a final scoring system. Sixteen test cases were used to optimize the scoring system so that it could categorize cases as requiring emergent, urgent, high-priority elective, or low-priority elective scheduling.

Results: The devised scoring system included 8 independent components: neurological status, underlying spine stability, presentation of a high-risk post-operative complication, patient medical comorbidities, expected hospital course, expected discharge disposition, facility resource limitations, and local disease burden. The resultant calculator was deployed as a freely-available web-based calculator (https://jhuspine3.shinyapps.io/SpineUrgencyCalculator/).

Conclusion: Here we present the first quantitative urgency scoring system for the triage and prioritizing of spine surgery cases in resource-limited settings. We believe that our scoring system, while not all-encompassing, has potential value as a guide for triaging spine surgical cases during the COVID pandemic and post-COVID period.


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164. Critical Adjustments in a Department of Orthopaedics Through the COVID-19 Pandemic

international Orthopaedics


Authors: Gonzalo Luengo-Alonso , Fernando García-Seisdedos Pérez-Tabernero , Miguel Tovar-Bazaga , José Manuel Arguello-Cuenca , Emilio Calvo
Region / country: Western Europe – Spain
Speciality: Health policy, Trauma and orthopaedic surgery

Purpose: SARS-CoV-2’s new scenario has forced health systems to work under extreme stress urging to perform a complete reorganization of the way our means and activities were organized. The orthopaedic and trauma units have rescheduled their activities to help SARS-CoV-2 units, but trauma patients require also treatment, and no standardized protocols have been established.

Methods: A single-centre cross-sectional study was performed in a tertiary hospital. Two different periods of time were analyzed: a two week period of time in March 2019 (pre-SARS-CoV-2) and the same period in March 2020 (SARS-CoV-2 pandemic time). Outpatient’s data, emergency activity, surgical procedures, and admissions were evaluated. Surgeons’ and patient’s opinion was also evaluated using a survey.

Results: A total of ~ 16k (15,953) patients were evaluated. Scheduled clinical appointments decreased by ~ 22%. Urgent consultations and discharge from clinics also descended (~ 37% and ~ 20% respectively). Telemedicine was used in 90% of outpatient clinical evaluations. No elective surgical procedures during SARS-CoV-2 time were scheduled, and subtracting the effect of elective surgeries, there was a reduction of inpatient surgeries, from ~ 85% to ~ 59%. Patients delayed trauma assistance more than 48 hours in 13 cases (35%). Pre-operative admission for hip fractures decreased in ten hours on average. Finally, surveys stated that patients were more in favour than surgeons were to this new way to evaluate orthopaedic and trauma patients based strongly on telemedicine.

Conclusion: Detailed protocols should be standardized for surgical departments during the pandemic. This paper offers a general view in how this virus affects an orthopaedic unit and could serve as a protocol and example for orthopaedic and trauma units. Even in the worst scenario, an orthopaedic and trauma unit could offer an effective, efficient, and quality service. SARS-CoV-2 will set up a new paradigm for health care in orthopaedics and trauma.


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165. Management Strategies and Role of Telemedicine in a Surgery Unit During COVID-19 Outbreak

international journal of surgery


Authors: Giuseppe Palomba , Vincenza Paola Dinuzzi , Giovanni Aprea , Giovanni Domenico De Palma
Region / country: Western Europe – Italy
Speciality: General surgery, Other

At the end of 2019, in Wuhan, the capital of Hubei (China) were reported 27 cases of death caused by “severe acute respiratory virus coronavirus 2” (SARS-CoV-2) [1]. The World Health Organization (WHO) on March 11, 2020, has declared the COVID-19 outbreak a global pandemic [2]. Officially, Italian lockdown started on March 10th and ended on May 3rd, 2020. From 4 May a new phase of coexistence with the coronavirus began. This is characterized by a gradual reopening of commercial activities and by persistence of some important rules such as social distancing and use of masks in public transport. At the 20/05/2020 in Italy there are 226.699 total cases and 32.169 deaths, while in Campania region, total cases are 4.707 with 400 deaths [3]. In this situation, there was a rapid reorganization of public health system and hospitals. Also, for surgery there have been several changes. As part of COVID-19 containment strategy and with Intensive Care Unit (ICU) near collapse, elective operations were suspended while emergency surgery and the operative therapy of oncological patients continued. Moreover, have been deleted all non-urgent outpatients visits and endoscopic procedures.


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166. Perianesthetic Concerns for the non-COVID-19 Patients Requiring Surgery During the COVID-19 Pandemic Outbreak: An Observational Study

journal of clinical anesthesia


Authors: Gilles Boccara , David Cassagnol , Laurent Bargues , Thierry Guenoun , Benjamin Aubier , Ivan Goldstein , Stéphane Romano , Dan Longrois
Region / country: Western Europe – France
Speciality: Anaesthesia

The global health crisis caused by the COVID-19 virus, has being marked by a rapid spread, numerous severe respiratory cases and an elevated mortality rate [1]. It has forced World Health Organization to declare global emergency and governments to apply confinement measures and stop the scheduled medical activities [2]. Recommendations have been developed for the management of patients with COVID-19 requiring endotracheal intubation and critical cares [3]. In addition of surgical emergencies and cesarean sections, certain surgical or diagnostic procedures cannot be postponed due to the risk of unacceptable morbidity. Therefore, Health Ministries have authorized the performance of these procedures in accordance with specific rules. Data on this type of perioperative management for COVID-19 negative patients are rare.


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167. A Case Report With COVID-19 During Perioperative Period of Lobectomy

medicine


Authors: Peng Han , Fan Li, Peng Cao, Shan Hu, Kangle Kong, Yu Deng, Yukun Zu, Bo Zhao
Region / country: Eastern Asia – China
Speciality: Neurosurgery

Rationale: Currently, COVID-19 has made a significant impact on many countries in the world. However, there have been no reported cases of pulmonary lobectomy with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) infection. We are the first to report such a case.

Patient concerns: We report a 63-year-old Wuhan male patient with smoking history of 40 cigarettes per day for 40 years. He sought medical consultation for right lower lung nodules found by CT scan.

Diagnoses and interventions: The patient’s postoperative pathological diagnosis was squamous cell carcinoma of the right lower lung. On the fourth day after the operation, the real-time reverse transcription polymerase chain reaction test showed a positive result. After the operation, we routinely give symptomatic treatments such as anti-infection, nebulization and oxygen inhalation. We also change antibiotics several times depending on the patient’s condition.

Outcomes: The patient’s condition continued to deteriorate. On the fifth day after surgery, the patient died despite medical treatment.

Lessons: We are the first to report the diagnosis and treatment process of patients with COVID-19 during perioperative period of lobectomy. It provides a case for the postoperative management of such patients.


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168. Uro-oncology in Times of COVID-19: The Available Evidence and Recommendations in the Indian Scenario

indian journal of cancer


Authors: Tushar A Narain , Gagan Gautam , Amlesh Seth , Vikas K Panwar , Sudhir Rawal , Puneet Dhar , Harkirat S Talwar , Amitabh Singh , Jiten Jaipuria , Ankur Mittal
Region / country: Southern Asia – India
Speciality: Surgical oncology, Urology surgery

The Corona Virus Disease-2019 (COVID-19), one of the most devastating pandemics ever, has left thousands of cancer patients to their fate. The future course of this pandemic is still an enigma, but health care services are expected to resume soon in a phased manner. This might be a long drawn process and we need to have policies in place, to be able to fight both, the SARS-CoV-2 virus and cancer, simultaneously, and emerge triumphant. An extensive literature search for impact of delay in management of various urological malignancies was carried out. Expert opinions were sought wherever there was paucity of evidence, in order to reach a consensus and come up with recommendations for directing uro-oncology services in the times of COVID-19. The panel recommends deferring treatment of patients with renal cell carcinoma by 3 to 6 months, except for those with ongoing hematuria and/or inferior vena cava thrombus, which warrant immediate surgery. Metastatic renal cell cancers should be started on targeted therapy. Low grade non-muscle invasive bladder cancers can be kept on active surveillance while high risk non-muscle invasive bladder cancers and muscle invasive bladder cancers should be treated within 3 months. Neoadjuvant chemotherapy should be avoided. Management of low and intermediate risk prostate cancer can be deferred for 3 to 6months while high risk prostate cancer patients can be initiated on neoadjuvant androgen deprivation therapy. Patients with testicular tumors should undergo high inguinal orchiectomy and be treated according to stage without delay, with stage I patients being offered surveillance. Penile cancers should undergo penectomy, while clinically negative groins can be kept on surveillance. Neoadjuvant chemotherapy should be avoided and adjuvant therapy should be deferred. We need to tailor our treatment strategies to the prevailing present conditions, so as to fight and defeat both, the SARS-CoV-2 virus and cancer. Protection of health care workers, judicious use of available resources, and a rational and balanced outlook towards different malignancies is the need of the hour.


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169. Pearls of Experience for Safe and Efficient Hospital Practices in Otorhinolaryngology-Head and Neck Surgery in Hong Kong During the 2019 Novel Coronavirus Disease (COVID-19) Pandemic

Journal of Otolaryngology – Head & Neck Surgery


Authors: Ryan H W Cho , Zenon W C Yeung , Osan Y M Ho , Jacky F W Lo , Alice K Y Siu , Wendy M Y Kwan , Zion W H To , Anthony W H Chan , Becky Y T Chan, Kitty S C Fung , Victor Abdullah , Michael C F Tong , Peter K M Ku
Region / country: Eastern Asia – China
Speciality: ENT surgery

The 2019 novel coronavirus disease (COVID-19) epidemic originated in Wuhan, China and spread rapidly worldwide, leading the World Health Organization to declare an official global COVID-19 pandemic in March 2020. In Hong Kong, clinicians and other healthcare personnel collaborated closely to combat the outbreak of COVID-19 and minimize the cross-transmission of disease among hospital staff members. In the field of otorhinolaryngology-head and neck surgery (OHNS) and its various subspecialties, contingency plans were required for patient bookings in outpatient clinics, surgeries in operating rooms, protocols in wards and other services. Infected patients may shed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) particles into their environments via body secretions. Therefore, otolaryngologists and other healthcare personnel in this specialty face a high risk of contracting COVID-19 and must remain vigilant when performing examinations and procedures involving the nose and throat. In this article, we share our experiences of the planning and logistics undertaken to provide safe and efficient OHNS practices over the last 2 months, during the COVID-19 pandemic. We hope that our experiences will serve as pearls for otolaryngologists and other healthcare personnel working in institutes that serve large numbers of patients every day, particularly with regard to the sharing of clinical and administrative tasks during the COVID-19 pandemic.


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170. General Thoracic Surgery Services Across Asia During the 2020 COVID-19 Pandemic

Asian Cardiovascular and Thoracic Annals


Authors: Sanghoon Jheon , Aneez Db Ahmed , Vincent Wt Fang , Woohyun Jung , Ali Zamir Khan , Jang-Ming Lee , Jun Nakajima , Alan Dl Sihoe , Punnarerk Thongcharoen , Masahiro Tsuboi , Akif Turna
Region / country: Central Asia, Eastern Asia, South-eastern Asia, Southern Asia, Western Asia
Speciality: Cardiothoracic surgery

The COVID-19 pandemic of 2020 posed an historic challenge to healthcare systems around the world. Besides mounting a massive response to the viral outbreak, healthcare systems needed to consider provision of clinical services to other patients in need. Surgical services for patients with thoracic disease were maintained to different degrees across various regions of Asia, ranging from significant reductions to near-normal service. Key determinants of robust thoracic surgery service provision included: preexisting plans for an epidemic response, aggressive early action to “flatten the curve”, ability to dedicate resources separately to COVID-19 and routine clinical services, prioritization of thoracic surgery, and the volume of COVID-19 cases in that region. The lessons learned can apply to other regions during this pandemic, and to the world, in preparation for the next one.


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171. Cost-effectiveness of Emergency Care Interventions in Low and Middle-Income Countries: A Systematic Review

Bulletin of World Health Organization


Authors: Kalin Werner , Nicholas Risko , Taylor Burkholder , Kenneth Munge , Lee Wallis , Teri Reynolds
Region / country: Global
Speciality: Emergency surgery

Objective: To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries.

Methods: Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low- and middle-income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies.

Results: Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied.

Conclusion: We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low- and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research.


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172. Retrospective Analysis of Chilean and Mexican GI Stromal Tumor Registries: A Tale of Two Latin American Realities

JCO Global Oncology


Authors: Germán Calderillo , Matías Muñoz-Medel , Edelmira Carbajal , Miguel Córdova-Delgado , Doris Durán , Ignacio N Retamal , Piga Fernández , Absalón Espinoza , Rodrigo Salas , María de la Paz Mastretta , Héctor Galindo , Bruno Nervi , Jorge Madrid , Cesar Sánchez , Carolina Ibáñez , José Peña , Sebastián Mondaca , Francisco Acevedo , Erica Koch , Mauricio P Pinto , Marcelo Garrido
Region / country: South America – Chile, Mexico
Speciality: Surgical oncology

Purpose: Like other malignancies, GI stromal tumors (GIST) are highly heterogeneous. This not only applies to histologic features and malignant potential, but also to geographic incidence rates. Several studies have reported GIST incidence and prevalence in Europe and North America. In contrast, GIST incidence rates in South America are largely unknown, and only a few studies have reported GIST prevalence in Latin America.

Patients and methods: Our study was part of a collaborative effort between Chile and Mexico, called Salud con Datos. We sought to determine GIST prevalence and patients’ clinical characteristics, including survival rates, through retrospective analysis.

Results: Overall, 624 patients were included in our study. Our results found significant differences between Mexican and Chilean registries, such as stage at diagnosis, primary tumor location, CD117-positive immunohistochemistry status, mitotic index, and tumor size. Overall survival (OS) times for Chilean and Mexican patients with GIST were 134 and 156 months, respectively. No statistically significant differences in OS were detected by sex, age, stage at diagnosis, or recurrence status in both cohorts. As expected, patients categorized as being at high risk of recurrence displayed a trend toward poorer progression-free survival in both registries.

Conclusion: To the best of our knowledge, this is the largest report from Latin America assessing the prevalence, clinical characteristics, postsurgery risk of recurrence, and outcomes of patients with GIST. Our data confirm surgery as the standard treatment of localized disease and confirm a poorer prognosis in patients with regional or distant disease. Finally, observed differences between registries could be a result of registration bias.


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173. The epidemiology and outcome of patients admitted for elective brain tumour surgery at a single neurosurgical centre in South Africa

Interdisciplinary Neurosurgery


Authors: Adrian Kelly,Patrick Lekgwara, Siyazi Mda
Region / country: Southern Africa – South Africa
Speciality: Neurosurgery

Introduction
Many countries, including South Africa, do not have a national brain tumour registry. Despite this limitation several institutional studies report age, gender, and histological tumour types that are in-line with the findings of the large established national brain tumour registries from the United States and Europe.

Materials and methods
We conducted a prospective study consecutively enrolling all elective subjects admitted to our Unit with a neoplastic brain tumor from the 01 July 2018–31 March 2020. The data collected included age, gender, admission Glasgow Coma Score, HIV status, admission absolute CD4 count in all patients, radiological tumour diagnosis, pre-operative steroid treatment, length of in-hospital stay prior to surgery, time between prophylactic antibiotic administration and skin incision, intra-operative blood loss, length of surgery, extent of resection, histological diagnosis, post-operative nosocomial infection incidence, and Glasgow Outcome Score.

Results
The mean age of our subjects was 48 (±14.56) years. Significance was demonstrated between age and histological tumour diagnosis (p = 0.031). With regards gender 72/101 (72%) were males and 29/101 (29%) were females. Considering admission HIV status 65/101 (64%) were HIV negative and 36/101 (36%) were HIV positive. Of the 101 subjects enrolled in the study 78/101 (77%) were taken for operative intervention. The mean intra-operative blood loss in our study was 505 (±336) millilitres. The mean length of surgery was 278 (±80.33) minutes. Considering nosocomial infection 30/78 (38%) subjects developed this complication. Considering outcome 29/78 (37%) subjects in our study had a favourable outcome (GOS 4/5), and 49/78 (63%) had an unfavourable outcome (GOS 1–3).

Conclusion
Patients with brain tumours, whether HIV positive or not, show characteristic histological tumour types that are age specific. While being HIV positive does have a detrimental influence, the primary histology of the lesion and the extent of resection are the major determinants of outcome.


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174. Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: A web-based survey

PLoS ONE


Authors: Kanmounye US, Mbonda AN, Djiofack D, Daya L, Pokam OF, Ghomsi NC
Region / country: Central Africa – Cameroon
Speciality: Other

Introduction
Global surgery is a growing field studying the determinants of safe and affordable surgical care and advocating to gain the global health community’s attention. In Cameroon, little is known about the level of knowledge and attitudes of students. Our survey aimed to describe the knowledge and attitudes of Cameroonian medical students towards global surgery.

Materials and methods
We performed an anonymous online survey of final-year Cameroonian medical students. Mann-Whitney U test and Spearman correlation analysis were used for bivariate analysis, and the alpha value was set at 0.05. Odds ratios and their 95% confidence intervals were calculated.

Results
204 respondents with a mean age of 24.7 years (±2.0) participated in this study. 58.3% were male, 41.6% had previously heard or read about global surgery, 36.3% had taken part in a global surgery study, and 10.8% had attended a global surgery event. Mercy Ships was well known (46.5%), and most students believed that surgical interventions were more costly than medical treatments (75.0%). The mean score of the global surgery evaluation was 47.4% (±29.6%), and being able to recognize more global surgery organizations was correlated with having assumed multiple roles during global surgery studies (p = 0.008) and identifying more global surgery indicators (p = 0.04). Workforce, infrastructure, and funding were highlighted as the top priorities for the development of global surgery in Cameroon.

Conclusion
Medical students are conscious of the importance of surgical care. They lack the opportunities to nurture their interest and should be taught global surgery concepts and skills


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175. Designing and implementing a practical prehospital emergency trauma care curriculum for lay first responders in Guatemala

Trauma Surgery & Acute Care Open


Authors: Peter G Delaney, Jose A Figueroa, Zachary J Eisner, Rudy Erik Hernandez Andrade, Monita Karmakar, John W Scott, Krishnan Raghavendran
Region / country: Central America – Guatemala
Speciality: Emergency surgery, Trauma surgery

Background: Injury disproportionately affects low-income and middle-income countries, yet robust emergency medical services are often lacking to effectively address the prehospital injury burden. A half-day prehospital emergency trauma care curriculum was designed for first responders and piloted in the Sacatepéquez, Chimaltenango, and Escuintla departments in Guatemala.

Methods: Three hundred and fifty-four law enforcement personnel, firefighters, and civilians volunteered to participate in a 5-hour emergency care course teaching scene safety, triage, airway management, cardiopulmonary resuscitation, fracture management, and victim transport. A validated 26-question pretest/post-test study instrument was contextually adapted and used to measure overall test performance, the primary study outcome, as well as test performance stratified by occupation, the secondary study outcome. Pretest/post-test score distributions were compared using a Wilcoxon signed-rank test. For test evaluation, knowledge acquisition on a by-question and by-category basis was examined using McNemar’s χ² test, whereas item difficulty indices used frequency-of-distribution tests and item discrimination indices used point biserial correlation.

Results: Two hundred and eighty-seven participants qualified for inclusion. Participant mean pretest versus post-test scores improved 24 percentage points after course completion (43% vs 68%, p<0.001). Cronbach’s alpha yielded values of 0.86 (pretest) and 0.94 (post-test), suggesting testing instrument reliability. Between-group analyses demonstrated law enforcement and civilian participants improved more than firefighters (p<0.001). Performance on 23 of 26 questions improved significantly. All test questions except one showed an increase in their PPDI.

Discussion: A 1-day, contextually adapted, 5-hour course targeting laypeople demonstrates significant improvements in emergency care knowledge. Future investigations of similar curricula should be trialed in alternate low-resource settings with increased civilian participation to evaluate efficacy and replicability as adequate substitutes for longer courses. This study suggests future courses teaching emergency care for lay first responders may be reduced to 5 hours duration.


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176. Delivering trauma and rehabilitation interventions to women and children in conflict settings: a systematic review

BMJ Global Health


Authors: Reena P Jain, Sarah Meteke, Michelle F Gaffey, Mahdis Kamali, Mariella Munyuzangabo, Daina Als, Shailja Shah, Fahad J Siddiqui, Amruta Radhakrishnan, Anushka Ataullahjan, Zulfiqar A Bhutta
Region / country: Global
Speciality: Trauma surgery

Background: In recent years, more than 120 million people each year have needed urgent humanitarian assistance and protection. Armed conflict has profoundly negative consequences in communities. Destruction of civilian infrastructure impacts access to basic health services and complicates widespread emergency responses. The number of conflicts occurring is increasing, lasting longer and affecting more people today than a decade ago. The number of children living in conflict zones has been steadily increasing since the year 2000, increasing the need for health services and resources. This review systematically synthesised the indexed and grey literature reporting on the delivery of trauma and rehabilitation interventions for conflict-affected populations.

Methods: A systematic search of literature published from 1 January 1990 to 31 March 2018 was conducted across several databases. Eligible publications reported on women and children in low and middle-income countries. Included publications provided information on the delivery of interventions for trauma, sustained injuries or rehabilitation in conflict-affected populations.

Results: A total of 81 publications met the inclusion criteria, and were included in our review. Nearly all of the included publications were observational in nature, employing retrospective chart reviews of surgical procedures delivered in a hospital setting to conflict-affected individuals. The majority of publications reported injuries due to explosive devices and remnants of war. Injuries requiring orthopaedic/reconstructive surgeries were the most commonly reported interventions. Barriers to health services centred on the distance and availability from the site of injury to health facilities.

Conclusions: Traumatic injuries require an array of medical and surgical interventions, and their effective treatment largely depends on prompt and timely management and referral, with appropriate rehabilitation services and post-treatment follow-up. Further work to evaluate intervention delivery in this domain is needed, particularly among children given their specialised needs, and in different population displacement contexts.


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177. The Hidden Risk of Ionizing Radiation in the Operating Room: A Survey Among 258 Orthopaedic Surgeons in Brazil

Patient Safety in Surgery


Authors: Robinson Esteves Pires, Igor Guedes Nogueira Reis, Ângelo Ribeiro Vaz de Faria, Vincenzo Giordano, Pedro José Labronici, William Dias Belangero
Region / country: South America – Brazil
Speciality: Trauma and orthopaedic surgery

Background: This study aims to assess orthopaedic surgeon knowledge in Brazil about ionizing radiation and its health implications on surgical teams and patients.
Methods: A 15-question survey on theoretical and practical concepts of ionizing radiation was administered during the 23rd Brazilian Orthopaedic Trauma Association annual meeting. The survey addressed issues within orthopedic surgery, such as radiation safety concepts, protection, exposure, as well as the participant gender. Participants were either orthopedic surgeons or orthopedic surgery residents working at institutions in Brazil.
Results: One thousand surveys were distributed at the moment of the meeting registration, and 258 were answered completely (25.8% response rate). Only 5.8% of participants used basic radiation protection equipment; 47.3% used a dosimeter; 2.7% reached the annual maximum permissible radiation dose; 10.5% knew the period of increased risk to fetal gestation; 5.8% knew the maximum permissible radiation dose during pregnancy; 58.5% knew that the hands, eyes, and thyroid are the most exposed areas and at greater risk of radiation-related lesions; 25.2% knew the safe distance from a radiation-emitting tube is 3 m or more; 44.2% knew the safest positioning of the radiation-emitting tube; 25.2% knew that smaller tubes emit greater radiation at the entrance dose to magnify the image; and 55.4% knew that the surgery team receives more scattered radiation in surgical procedures performed on obese patients.
Conclusion: This study revealed inadequate theoretical and practical knowledge about radiation exposure among orthopaedic surgeons in Brazil. Only a minority of orthopaedic surgeons used basic radiation protection equipment. No significant differences in knowledge were found when comparing all orthopedic surgery specialties. Our findings indicate an urgent need for education to increase knowledge among orthopaedic surgeons about the hazards of ionizing radiation. Personal protection and implementation of the ALARA (as low as reasonably achievable) protocol in daily practice are important behaviors to prevent the harmful effects of ionizing radiation.


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

Annals of Medicine and Surgery


Authors: Harissou Adamou, Ibrahim Amadou Magagi, Ousseini Adakal, Mahamadou Doutchi, Oumarou Habou, Mamane Boukari, Lassey James Didier, Rachid Sani
Region / country: Western Africa – Niger
Speciality: General surgery

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


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179. Mitral valve replacement in mitral stenosis; the problem of small left ventricle

Journal of Cardiothoracic Surgery


Authors: Hesham Alkady, Ahmed Saber, Sobhy Abouramadan, Ahmed Elnaggar, Sherif Nasr, Eman Mahmoud
Region / country: Northern Africa – Egypt
Speciality: Cardiothoracic surgery

Background
Mitral valve stenosis in adults especially due to rheumatic heart disease may be associated with a smaller than normal left ventricular cavity. Mitral valve replacement in such cases may lead to hemodynamic instability either during weaning from cardiopulmonary bypass or in the early postoperative period manifested by the need for inotropic support and even mortality due to low cardiac output syndrome.
Patients and methods
184 patients with predominately severe stenotic mitral valves who underwent elective isolated mitral valve replacement in the period between January 2012 and January 2018 at our hospital were included in this study. Patients were divided into 2 matched groups; (small LV group) consisting of 86 cases and (normal or dilated LV group) consisting of 98 cases.
Results
There were no statistically significant differences in operative details among both groups apart from the need for inotropic support and intra-aortic balloon pump due to low cardiac output which were statistically significantly higher in (small LV group) than (normal or dilated LV group) with a p-values of 0.01 and 0.03 respectively. Within the ICU stay only the incidence of occurrence of heart failure was significantly higher in (small LV group) with a p-value of 0.008. No statistically significant difference could be elicited in the in-hospital mortality between both groups (p-value = 0.1).
Conclusion
Patients with mitral valve stenosis and small left ventricular cavity are in a higher need for inotropic and even mechanical support after mitral valve replacement as well as at a higher risk for the development of heart failure before hospital discharge than patients with mitral stenosis and normal-sized left ventricular cavity.


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180. A Glimpse of Hope: Cardiac Surgery in Low- And Middle-Income Countries (LMICs)

Cardiovascular Diagnosis and therapy


Authors: Peter Zilla, R Morton Bolman, Percy Boateng, Karen Sliwa
Region / country: Global
Speciality: Cardiothoracic surgery

Currently, more than five times more people live in low- and middle-income countries (LMICs) than in high-income countries (HICs). As such, the downward trend in cardiac surgical needs in HICs reflects only the situation of one sixth of the world population while the vast majority living in LMICs has still no or limited access to life saving heart operations. In these countries, rheumatic heart disease (RHD) still accounts for a significant proportion of cardiac surgical needs. In low- and lower-middle income countries it remains the single most common cardiovascular disease in young adult and adolescent patients in need of heart surgery outweighing other indications such as congenital cardiac defects almost 4-fold. Compared to HICs with their predominance of calcific aortic stenosis in the elderly mitral valve surgery is required in >90% of the largely young patients with RHD in low-income countries (LICs) and still in 70% of the often middle aged patients in middle-income countries (MICs). Although recent government initiatives in LICs led to the establishment of local, independent cardiac surgical services gradually replacing fly-in missions, these centers still only cover less than 2% of the needs of their populations. In MICs, cardiac surgical needs continually grow with the emergence of degenerative diseases. As such, in spite of the concomitant growth of cardiac surgical capacity, significantly less than half the estimated patients in need have access. Capacities in LICs range from 0.5 to 7 cardiac operations/million population; 100-481/million in MICs and >1,200/million in HICs such as the USA and Germany. While a new level of awareness of the scope and magnitude of the problem has begun to emerge in LICs and the establishment of local cardiac surgical capacity has given rise to a glimpse of hope, the challenges of expanding these fledgling services to a significant proportion of the population still seem insurmountable. Challenges in MICs are on the other hand the widening gap between private cardiac medicine for the affluent few and overwhelmed public services for the many and the rural urban divide with the underappreciation of the ongoing dominance of RHD in the rural and indigent population on the other. Overshadowing all LMICs is the low level of valve-repair skills associated with insufficient cardiac surgical capacity and the unavailability of suitable replacement valves which address the young age of the patients and the difficulties of anticoagulation in a socioeconomic environment distinctly different from the elderly patients of HICs.


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181. Ultrasound-guided Thrombin Injection for Treatment of Iatrogenic Femoral Artery Pseudoaneurysms Compared With Open Surgery: First Experiences From a Single Institution

Annals of Surgical Treatment and Research


Authors: Onur Saydam, Deniz Serefli, A Yaprak Engin, Mehmet Atay
Region / country: Western Asia – Turkey
Speciality: Vascular surgery

Purpose
The frequency of iatrogenic femoral artery pseudoaneurysm (FAP) diagnoses has recently increased due to the growing use of diagnostic and interventional procedures involving large diameter sheaths, as well as more potent anticoagulation procedures. In this study, we aimed to present our experience with ultrasound-guided thrombin injection (UGTI) in patients with iatrogenic FAP.
Methods
We studied patients with FAP who were under anticoagulant or antiplatelet therapies preoperatively, or who had received a loading dose during an interventional procedure. The outcomes of patients with FAP treated with UGTI were compared with those of patients who underwent open surgical repair for pseudoaneurysms.
Results
Among the 55 patients included in this study, 24 had UGTI while 31 had open surgery. The success rate was 95.8% when taking into consideration primary and secondary attempts. The mean duration of the procedure was shorter in patients with UGTI (10.1 ± 3.54 minutes) when compared with those who underwent open surgery (76.55 ± 26.74 minutes, P ≤ 0.001). In addition, the total complication frequency was significantly higher in the open surgery group (P = 0.005), as was their length of hospital stay (P < 0.001). Cost analysis showed significant differences between UGTI ($227.50 ± $82.90) and open surgery ($471.20 ± $437.60, P = 0.01).
Conclusion
We have found that UGTI is the safer and more effective choice of treatment in appropriate patients with FAP, as opposed to surgery


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182. Role of Surgical Modality and Timing of Surgery as Clinical Outcome Predictors Following Acute Subdural Hematoma Evacuation

Pakistan journal of medical sciences


Authors: Imran Altaf, Shahzad Shams, Anjum Habib Vohra
Region / country: Southern Asia – Pakistan
Speciality: Neurosurgery

Background & objective
A Craniotomy (CO) or decompressive craniectomy (DC) are the two main surgical procedures employed for evacuation of acute traumatic subdural hematoma (ASDH). However, the optimal surgical procedure remains controversial. The beneficial effect of early surgical evacuation of acute subdural hematoma in improving outcome also remains unclear. Our objective was to study the role of these two parameters in determining the outcome in patients undergoing surgical evacuation of acute traumatic subdural hematoma.
Methods
A retrospective analysis of 58 patients presenting with acute traumatic subdural hematoma and with presenting Glasgow Coma Scale (GCS) ≤ 8 that had been operated in Lahore General Hospital between June 2014 and July 2015 was performed. The demographic data, preoperative GCS, type of surgical procedure performed and timing of surgery were analysed.
Results
Forty (69%) patients underwent CO, and eighteen (31%) patients underwent DC. The CO and DC groups showed no difference in the demographic data and preoperative GCS. Six patients survived in the craniotomy group, while none survived in the decompressive craniectomy group (p=0.083). The relationship of timing of surgery with survival in the craniotomy group was found not to be clinically significant (p=0.87).
Conclusion
In this study craniotomy was associated with a better outcome as compared to decompressive craniectomy, however, the difference did not reach statistical significance. Early surgery was also found not to be associated with an improved outcome.


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183. Changes in Electrical Activity of the Masseter Muscle and Masticatory Force After the Use of the Masseter Nerve as Donor in Facial Reanimation Surgery

indian journal of plastic surgery


Authors: Jose E Telich-Tarriba, Alejandro Orihuela-Rodríguez, Adriana de Lourdes Rivera-Priego, Fernando Ángeles-Medina, Julio Morales-González, Ignacio Mora-Magaña, Adriana Fentanes-Vera, Damian Palafox, Alexander Cárdenas-Mejía
Region / country: Northern America – Mexico
Speciality: Plastic surgery

Introduction
The masseter nerve has been used as a donor nerve for facial reanimation procedures due to the multiple advantages it offers; it has been generally considered that sacrifice of the masseter nerve does not alter the masticatory apparatus; however, there are no objective studies to support this claim.
Objective
To evaluate the impact that the use of the masseter nerve in dynamic facial reconstruction has on the electrical activity of the masseter muscle and on bite force.
Materials and Methods
An observational and prospective longitudinal study was performed measuring bite force and electrical activity of the masseter muscles before and 3 months after dynamic facial reconstructive surgery using the masseter nerve. An occlusal analyzer and surface electromyography were employed for measurements.
Results
The study included 15 patients with unilateral facial paralysis, with a mean age of 24.06 ± 23.43. Seven patients were subjected to a masseter-buccal branch nerve transfer, whereas in eight patients, the masseter nerve was used as a donor nerve for gracilis free functional muscle transfer. Electrical activity of the masseter muscle was significantly reduced after surgery in both occlusal positions: from 140.86 ± 65.94 to 109.68 ± 68.04 ( p = 0.01) in maximum intercuspation and from 123.68 ± 75.64 to 82.64 ± 66.56 ( p = 0.01) in the rest position. However, bite force did not show any reduction, changing from 22.07 ± 15.66 to 15.56 ± 7.91 ( p = 0.1) after the procedure
Conclusion
Masseter nerve transfer causes a reduction in electromyographic signals of the masseter muscle; however, bite force is preserved and comparable to preoperative status.


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184. Comparison on Frequencies of Pericardial Effusion and Tamponade Following Open Heart Surgery in Patients With or Without Low Negative Pressure Suction on Chest Tube

american journal of cardiovascular disease


Authors: Farinaz Khodadadi, Sasan Gilani, Pouria Shoureshi
Region / country: Western Asia – Iran
Speciality: Cardiothoracic surgery

Introduction
Pericardial effusion and tamponade are accounted as the two most important complications following open-heart surgeries which are known to increase mortality and morbidity rates. Putting a low negative pressure suction on the chest tube of patients might be a useful way for better drainage and also reducing the occurrence of pericardial effusion and tamponade. In the present study, we aimed to compare the prevalence of pericardial effusion and tamponade in patients undergoing open-heart surgeries with and without low negative pressure suction on the chest tube.
Methods
This clinical trial was performed in 2018-2019 in Tehran, Iran. 100 patients who were candidates for open-heart surgery were entered. After surgeries, patients were divided into two groups: group 1 had a low negative pressure suction on their chest tube and group 2 had no suction. Patients were then observed for clinical and imaging characteristics of pleural effusion and tamponade. Data were gathered and analyzed using SPSS software.
Results
In the present study, we indicated that the prevalence of pericardial effusion is significantly lower in patients with low negative pressure on their chest tube (P=0.04). No significant differences were observed between two groups regarding to: frequency of tamponade and post-operative ejection fraction (P> 0.05).
Conclusion
The usage of a low negative pressure suction on the chest tube following open cardiac surgeries is associated with a lower prevalence of pericardial effusion. We suggest that such systems could be commonly used in cardiac surgeries or surgeries of the thorax.


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185. Blood Transfusion and Lung Surgeries in Pediatric Age Group: A Single Center Retrospective Study

annals of cardiac anaesthesia


Authors: Ahmed S Elgebaly, Sameh M Fathy, Mona B Elmorad, Ayman A Sallam
Region / country: Northern Africa – Egypt
Speciality: Cardiothoracic surgery, Paediatric surgery

Background
Blood transfusion is not without harm, and recent studies suggest association between transfusion and poor outcome in critically ill patients. Although it is prescribed for many reasons based on the firm belief that blood transfusion improves oxygen carrying capacity, it carries notable adverse hazards. Importantly, lung surgeries are counted as moderate to high-risk operations and take a significant risk of blood loss.
Aim
This study aims to reveal the association between blood transfusion and poor clinical outcomes and characterize the epidemiology of blood transfusion after pediatric chest surgery.
Settings and design
Retrospective cohort study, done throughout 3 years.
Materials and methods
A total of 248 patients who underwent open thoracotomy and lung surgery and aged ≤18 years were classified according to the need of intraoperative or postoperative blood transfusion into two groups: Group I (non-transfused = 130) and Group II (transfused = 118).
Statistical analysis
SPSS v25 was used for analysis.
Results
Transfusion probability ranged between 42.8% and 50% according to type of surgery. As regard to postoperative variables, there was no significant difference between both groups regarding the duration of analgesia, allergic reactions, need of re-operation and in-hospital mortality. However, transfused group showed significant increase in duration of antibiotic, persistent postoperative fever, time to remove chest drains, ICU stays, hospital stay and pneumonia. Incidence of pneumonia had a relative risk 1.82 with transfused compared to non-transfused group.
Conclusion
Transfusion group in pediatrics undergoing lung surgeries in our study was more prone to adverse outcomes such as pneumonia, delayed time to remove chest drains, prolonged ICU stay, and hospital stay.


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186. Cardioprotective Effects of Propofol-Dexmedetomidine in Open-Heart Surgery: A Prospective Double-Blind Study

Annals of cardiac anaesthesia


Authors: Ahmed Said Elgebaly, Sameh Mohamad Fathy, Ayman Ahmed Sallam, Yaser Elbarbary
Region / country: Northern Africa – Egypt
Speciality: Anaesthesia, Cardiothoracic surgery

Background
Myocardial protection in cardiac surgeries is a must and requires multimodal approaches in perioperative period to decrease and prevent the increase of myocardial oxygen demand and consumption that lead to postoperative cardiac complications including myocardial ischemia, dysfunction, and heart failure.
Study design
Prospective, controlled, randomized, double-blinded study.
Aims
This study aims to study the effect of propofol-dexmedetomidine continuous infusion cardioprotection during open-heart surgery in adult patients.
Materials and methods
Sixty adult patients of both sexes aged from 30 to 60 years old belonging to the American Society of Anesthesiologists III or IV undergoing open-heart surgery were randomly divided into two equal groups: Group P (control group) received continuous infusion of propofol at a rate of 2 mg/kg/h and 50 cc 0.9% sodium chloride solution infused at a rate of 0.4 μg/kg/h (used as a placebo) and Group PD received continuous infusion of propofol at a rate of 2 mg/kg/h and dexmedetomidine 200 μg diluted in 50 cc 0.9% sodium chloride solution infused at a rate of 0.4 μg/kg/h. Infusion for all patients started immediately preoperative till skin closure. Hemodynamic measurements of heart rate (HR), invasive mean arterial pressure, and oxygen saturation were recorded at baseline before induction of anesthesia, immediately after intubation, at skin incision, at sternotomy and every 15 min in the 1st h then every 30 min during the prebypass period then every 15 min in the 1st h then every 30 min after weaning from CPB till the end of the surgery. Serum biomarkers; cardiac troponin (cTnI) and creatine kinase-myocardial bound (CK-MB) samples were measured basally (T1), 15 min after unclamping of the aorta (T2), immediate postoperative (T3), and 24 h postoperative (T4). Intraoperative data were also recorded including the number of coronary grafts, aortic cross-clamping duration, duration of cardiopulmonary bypass (CPB), duration of surgery, and rhythm of reperfusion. Fentanyl requirement, extubation time, and length of intensive care unit (ICU) stay were also recorded for every case.
Results
There was no statistically significant differences as regard to demographic data between the studied two groups. HR and blood pressure recorded was lower in the PD group than the control group, and this difference was noted to be statistically significant. Furthermore, the PD group showed lower levels of myocardial enzymes (cTnI and CK-MB), decreased total fentanyl requirement, earlier postoperative extubation, and shorter ICU stay than the P(control) group.
Conclusion
The use of propofol-dexmedetomidine in CPB surgeries offers more cardioprotective effects than the use of propofol alone.


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187. Utility of Tranexamic acid to minimize blood loss in brain tumour surgery

Journal of the Pakistan Medical Association


Authors: Bukhari SS, Shamim MS
Region / country: South-eastern Asia – Pakistan
Speciality: Neurosurgery, Surgical oncology

Tranexamic acid is emerging as a useful option for a number of clinical indications, by virtue of its anti-fibrinolytic properties that allow better haemostasis and lesser blood loss. Herein, the authors have attempted to summarize the existing evidence on the possible role of tranexamic acid in brain tumour surgeries.


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188. Burden and Factors Associated with Refractive Errors Post Cataract Surgery at Kilimanjaro Christian Medical Center: A Hospital Based Retrospective Cross-sectional Study

Ophthalmology Research: An international Journal


Authors: Livin Uwemeye, William U. Makupa
Region / country: Eastern Africa – Tanzania
Speciality: Ophthalmology

Aims: To determine the burden and factors associated with refractive errors after cataract surgery in a training institution.

Study Design: A retrospective cross-sectional study.

Place and Duration of the Study: Kilimanjaro Christian Medical Center Eye department. Northern Tanzania, from January 2016 to December 2017.

Methods: A review of files of all adult patients who have had cataract surgery in 2016 and 2017 was conducted. A total of 626 eyes of 554 patients who had post-operative refraction by experienced optometrists were included. Information were extracted from patients’ files then entered into SPSS version 20 for analysis. The main outcomes were post-operative refraction and best corrected visual acuity.

Results: Mean age was 69.3 years (SD=10.7) and ECCE accounted for 76% of surgeries. At least 84.6% had post-operative refractive error and astigmatism was the most common refractive error (56.8%). Spherical error accounted for 27.8%. Spherical error ranged from -12 to 4DS, mean = -0.42 (SD=1.3) DS and median = 0.00DS. The maximum cylindrical error was -7.5 DC, mean = -1.15 (SD=1.36) DC and median = -1.0DC. At least 56% had spherical equivalent within 1D of emmetropia. A BCVA of 6/18 or better was achieved in 92.8%. Age, poor pre-operative VA, poor presenting VA, astigmatism on keratometry, difference between recommended and inserted IOL, ECCE, grade of surgeon and suturing were associated with refractive errors.

Conclusion: Refractive errors following cataract surgery are common. Best corrected visual acuity outcome was in normal recommended range; however, the magnitude of refractive errors was high and the proportion of patients who achieved a final refraction within 1D of emmetropia was below the recommended range. An effort should be made to lower the prevalence and magnitude of refractive errors associated with cataract surgery in training institutions.


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189. Managing the soft tissue defects over the dorsum of hand: Our experience with Posterior Interosseous Artery (PIA) flap

Journal of Pakistan Orthopaedic Association


Authors: Khalid Masood, Belal Saadat, Khalid Zulfiqar Qureshi, Karam Rasool Basra, Hafiz Muhammad Kashif Shafi
Region / country: South-eastern Asia – Pakistan
Speciality: Plastic surgery, Trauma and orthopaedic surgery

Objective: To determine the outcome of posterior interosseous artery (PIA) flap in terms of coverage of the defects and survival of the flap in patients with complex defects over the dorsum of hand and distal forearm.

Methods: This descriptive study was conducted in Hand and Upper Limb Surgery (HULS) CMH Lahore Medical College, Lahore, Pakistan from 15th July 2017 to 15th August 2019.All patients with complex defects of the dorsum of the hand and distal forearm were treated with posterior interosseous artery (PIA) flap. Post operatively the grafts were observed for coverage of the defects and graft survival.

Results: The total number of patients were 24 with 19(79.1%) males and 05(20.8%) females. The mean age was 37±7SD(range 21 to 56 years). Right hand was involved in 17(70.8%) patients and left in 7(29.1%) patients. Complete coverage of the defects were achieved in all cases. Successful graft survival and uptake was seen in 20(83.3%) flaps. Partial loss was seen in 03 (12.5%) flaps which required debridement and subsequent Split Thickness Skin Grafting. Complete graft loss was seen in 01 (4.1%) flap

Conclusion: Posterior interosseous artery flap (PIA) had higher survival rates and larger area of the dorsum of the hand and distal forearm were entirely covered with this graft. We recommend posterior interosseous artery flap as first line surgical technique to treat complex tissue defects of the dorsum of the hand and distal forearm


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190. Designing and implementing a practical prehospital emergency trauma care curriculum for lay first responders in Guatemala

Trauma Surgery & Acute Care Open


Authors: Peter G Delaney, Jose A Figueroa, Zachary Eisner, Rudy Erik Hernandez Andrade, Monita Karmakar, John W Scott, Krishnan Raghavendran
Region / country: Central America – Guatemala
Speciality: Surgical Education, Trauma surgery

Background Injury disproportionately affects low-income and middle-income countries, yet robust emergency medical services are often lacking to effectively address the prehospital injury burden. A half-day prehospital emergency trauma care curriculum was designed for first responders and piloted in the Sacatepéquez, Chimaltenango, and Escuintla departments in Guatemala.

Methods Three hundred and fifty-four law enforcement personnel, firefighters, and civilians volunteered to participate in a 5-hour emergency care course teaching scene safety, triage, airway management, cardiopulmonary resuscitation, fracture management, and victim transport. A validated 26-question pretest/post-test study instrument was contextually adapted and used to measure overall test performance, the primary study outcome, as well as test performance stratified by occupation, the secondary study outcome. Pretest/post-test score distributions were compared using a Wilcoxon signed-rank test. For test evaluation, knowledge acquisition on a by-question and by-category basis was examined using McNemar’s χ² test, whereas item difficulty indices used frequency-of-distribution tests and item discrimination indices used point biserial correlation.

Results Two hundred and eighty-seven participants qualified for inclusion. Participant mean pretest versus post-test scores improved 24 percentage points after course completion (43% vs 68%, p<0.001). Cronbach’s alpha yielded values of 0.86 (pretest) and 0.94 (post-test), suggesting testing instrument reliability. Between-group analyses demonstrated law enforcement and civilian participants improved more than firefighters (p<0.001). Performance on 23 of 26 questions improved significantly. All test questions except one showed an increase in their PPDI.

Discussion A 1-day, contextually adapted, 5-hour course targeting laypeople demonstrates significant improvements in emergency care knowledge. Future investigations of similar curricula should be trialed in alternate low-resource settings with increased civilian participation to evaluate efficacy and replicability as adequate substitutes for longer courses. This study suggests future courses teaching emergency care for lay first responders may be reduced to 5 hours duration.

Level of evidence Level II.


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191. Ethical Considerations in Global Surgery: A Scoping Review

bMJ Global Health


Authors: Chantalle Lauren Grant, Tessa Robinson , Alreem Al Hinai , Cheryl Mack , Regan Guilfoyle , Abdullah Saleh
Region / country: Global
Speciality: Other

Introduction: An unmet burden of surgical disease exists worldwide and is disproportionately shouldered by low-income and middle-income countries (LMICs). As the field of global surgery grows to meet this need, ethical considerations need to be addressed. Currently, there are no formal guidelines to help inform relevant stakeholders of the ethical challenges and considerations facing global surgical collaborations. The aim of this scoping review is to synthesise the existing literature on ethics in global surgery and identify gaps in the current knowledge.

Methods: A scoping review of relevant databases to identify the literature pertaining to ethics in global surgery was performed. Eligible articles addressed at least one ethical consideration in global surgery. A grounded theory approach to content analysis was used to identify themes in the included literature and guide the identification of gaps in existing literature.

Results: Four major ethical domains were identified in the literature: clinical care and delivery; education and exchange of trainees; research, monitoring and evaluation; and engagement in collaborations and partnerships. The majority of published literature related to issues of clinical care and delivery of the individual patient. Most of the published literature was published exclusively by authors in high-income countries (HICs) (80%), and the majority of articles were in the form of editorials or commentaries (69.1%). Only 12.7% of articles published were original research studies.

Conclusion: The literature on ethics in global surgery remains sparse, with most publications coming from HICs, and focusing on clinical care and short-term surgical missions. Given that LMICs are frequently the recipients of global surgical initiatives, the relative absence of literature from their perspective needs to be addressed. Furthermore, there is a need for more literature focusing on the ethics surrounding sustainable collaborations and partnerships.


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192. Validating the Global Surgery Geographical Accessibility Indicator: Differences in Modeled Versus Patient-Reported Travel Times

World Journal of Surgery


Authors: Niclas Rudolfson, Magdalena Gruendl, Theoneste Nkurunziza, Frederick Kateera, Kristin Sonderman, Edison Nihiwacu, Bahati Ramadhan, Robert Riviello & Bethany Hedt-Gauthier
Region / country: Eastern Africa – Rwanda
Speciality: Emergency surgery, Obstetrics and Gynaecology

Background: Since long travel times to reach health facilities are associated with worse outcomes, geographic accessibility is one of the six core global surgery indicators; this corresponds to the second of the “Three Delays Framework,” namely “delay in reaching a health facility.” Most attempts to estimate this indicator have been based on geographical information systems (GIS) algorithms. The aim of our study was to compare GIS derived estimates to self-reported travel times for patients traveling to a district hospital in rural Rwanda for emergency obstetric care.

Methods: Our study includes 664 women who traveled to undergo a Cesarean delivery in Kirehe, Rwanda. We compared self-reported travel time from home to the hospital (excluding waiting time) with GIS estimated travel times, which were computed using the World Health Organization tool AccessMod, using linear regression.

Results: The majority of patients used multiple modes of transportation (walking = 48.5%, public transport = 74.2%, private transport = 2.9%, and ambulance 70.6%). Self-reported times were longer than GIS estimates by a factor of 1.49 (95% CI 1.40-1.57). Concordance was higher when the GIS model took into account that all patients in Rwanda are referred via their health center (β = 1.12; 95% CI 1.05-1.18).

Conclusions: To our knowledge, in this largest to date GIS validation study for geographical access to healthcare in low- and middle-income countries, a standard GIS model was found to significantly underestimate real travel time, which likely is in part because it does not model the actual route patients are travelling. Therefore, previous studies of 2-h access to surgery will need to be interpreted with caution, and future studies should take local travelling conditions into account.


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193. The impact of COVID-19 on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study

Acta Neurochirurgica


Authors: Walter C Jean , Natasha T Ironside , Kenneth D Sack , Daniel R Felbaum , Hasan R Syed
Region / country: Global
Speciality: Neurosurgery

Object: The COVID-19 pandemic has disrupted all aspects of society globally. As healthcare resources had to be preserved for infected patients, and the risk of in-hospital procedures escalated for uninfected patients and staff, neurosurgeons around the world have had to postpone non-emergent procedures. Under these unprecedented conditions, the decision to defer cases became increasingly difficult as COVID-19 cases skyrocketed.

Methods: Data was collected by self-reporting surveys during two discrete periods: the principal survey accrued responses during 2 weeks at the peak of the global pandemic, and the supplemental survey accrued responses after that to detect changes in opinions and circumstances. Nine hypothetical surgical scenarios were used to query neurosurgeons’ opinion on the risk of postponement and the urgency to re-schedule the procedures. An acuity index was generated for each scenario, and this was used to rank the nine cases.

Results: There were 494 respondents to the principal survey from 60 countries. 258 (52.5%) reported that all elective cases and clinics have been shut down by their main hospital. A total of 226 respondents (46.1%) reported that their operative volume had dropped more than 50%. For the countries most affected by COVID-19, this proportion was 54.7%. There was a high degree of agreement among our respondents that fast-evolving neuro-oncological cases are non-emergent cases that nonetheless have the highest risk in postponement, and selected vascular cases may have high acuity as well.

Conclusion: We report on the impact of COVID-19 on neurosurgeons around the world. From their ranking of the nine case scenarios, we deduced a strategic scheme that can serve as a guideline to triage non-emergent neurosurgical procedures during the pandemic. With it, hopefully, neurosurgeons can continue to serve their patients without endangering them either neurologically or risking their exposure to the deadly virus.


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194. Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: A web-based survey

PLOS One


Authors: Ulrick S. Kanmounye ,Aimé N. Mbonda ,Dylan Djiofack ,Leonid Daya ,Ornella F. Pokam ,Nathalie C. Ghomsi
Region / country: Central Africa – Cameroon
Speciality: Surgical Education

Introduction: Global surgery is a growing field studying the determinants of safe and affordable surgical care and advocating to gain the global health community’s attention. In Cameroon, little is known about the level of knowledge and attitudes of students. Our survey aimed to describe the knowledge and attitudes of Cameroonian medical students towards global surgery.

Materials and methods: We performed an anonymous online survey of final-year Cameroonian medical students. Mann-Whitney U test and Spearman correlation analysis were used for bivariate analysis, and the alpha value was set at 0.05. Odds ratios and their 95% confidence intervals were calculated.

Results: 204 respondents with a mean age of 24.7 years (±2.0) participated in this study. 58.3% were male, 41.6% had previously heard or read about global surgery, 36.3% had taken part in a global surgery study, and 10.8% had attended a global surgery event. Mercy Ships was well known (46.5%), and most students believed that surgical interventions were more costly than medical treatments (75.0%). The mean score of the global surgery evaluation was 47.4% (±29.6%), and being able to recognize more global surgery organizations was correlated with having assumed multiple roles during global surgery studies (p = 0.008) and identifying more global surgery indicators (p = 0.04). Workforce, infrastructure, and funding were highlighted as the top priorities for the development of global surgery in Cameroon.

Conclusion: Medical students are conscious of the importance of surgical care. They lack the opportunities to nurture their interest and should be taught global surgery concepts and skills.


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195. Prevalence of pelvic organ prolapse in women, associated factors and impact on quality of life in rural Pakistan: population-based study

BMC Women’s Health


Authors: Abdul Hakeem Jokhio, Raheela Mohsin Rizvi & Christine MacArthur
Region / country: South-eastern Asia – Pakistan
Speciality: Obstetrics and Gynaecology

Background: Pelvic organ prolapse (POP) is a gynecological condition resulting from pelvic floor dysfunction in women. The objective of this study is to estimate “the prevalence of pelvic organ prolapse” associated factors, duration and impact on women’s quality of life in rural Pakistan.

Methods: A cross-sectional study was conducted with a three stage random sampling strategy. Three health centers were selected and selected Lady Health Workers from each health center interviewed a random sample of women in their households. The interview used a structured questionnaire to collect symptom data. Female gynaecologists then conducted a clinical examination at the local health center on women who reported symptoms of prolapse to verify and grade pelvic organ prolapse using Baden-Walker classification system.

Results: Among the 5064 women interviewed (95.8% response rate), 521 women had clinically confirmed POP, a prevalence of 10.3% (95% CI 9-11%). Among women with POP 37.8% had grade III or IV prolapse. Women with four or more children had the highest proportion of pelvic organ prolapse (75%) followed by women aged 36-40 years (25%).Among women with POP, 60.8% reported their quality of life as greatly or moderately affected; 44.3% had it for more than 5 years; and 78.7% never consulted a doctor.

Conclusions: Pelvic organ prolapse is highly prevalent in rural Pakistan, impacts on women’s everyday lives and remains mainly untreated. Measures should be taken to provide health care services to reduce this burden of disease among women.


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196. Perioperative Anticoagulation Management in Spine Surgery: Initial Findings From the AO Spine Anticoagulation Global Survey

global spine journal


Authors: Philip Louie, MD , Garrett Harada, MD , James Harrop, MD , Thomas Mroz, MD , Khalid Al-Saleh, PhD , Giovanni Brodano, MD , Jens Chapman, MD, Michael Fehlings, MD, PhD , Serena Hu, MD , Yoshiharu Kawaguchi, MD, PhD, Michael Mayer, MD, PhD, Venugopal Menon, MD , Jong-Beom Park, PhD, Sheeraz Qureshi, MD, MBA, Shanmuganathan Rajasekaran, PhD, Marcelo Valacco, MD, Luiz Vialle, PhD, Jeffrey C. Wang, MD, Karsten Wiechert, MD, Daniel Riew, MD, and Dino Samartzis, DSc
Region / country: Global
Speciality: Neurosurgery

Study Design: Cross-sectional, international survey.
Objectives: This study addressed the global perspectives concerning perioperative use of pharmacologic thromboprophylaxis
during spine surgery along with its risks and benefits.
Methods: A questionnaire was designed and implemented by expert members in the AO Spine community. The survey was
distributed to AO Spine’s spine surgeon members (N ¼ 3805). Data included surgeon demographic information, type and region
of practice, anticoagulation principles, different patient scenarios, and comorbidities.
Results: A total of 316 (8.3% response rate) spine surgeons completed the survey, representing 64 different countries. Completed surveys were primarily from Europe (31.7%), South/Latin America (19.9%), and Asia (18.4%). Surgeons tended to be 35 to
44 years old (42.1%), fellowship-trained (74.7%), and orthopedic surgeons (65.5%) from academic institutions (39.6%). Most
surgeons (70.3%) used routine anticoagulation risk stratification, irrespective of geographic location. However, significant differences were seen between continents with anticoagulation initiation and cessation methodology. Specifically, the length of a
procedure (P ¼ .036) and patient body mass index (P ¼ .008) were perceived differently when deciding to begin anticoagulation,
while the importance of medical clearance (P < .001) and reference to literature (P ¼ .035) differed during cessation. For specific
techniques, most providers noted use of mobilization, low-molecular-weight heparin, and mechanical prophylaxis beginning on
postoperative 0 to 1 days. Conversely, bridging regimens were bimodal in distribution, with providers electing anticoagulant
initiation on postoperative 0 to 1 days or days 5-6
Conclusion: This survey highlights the heterogeneity of spine care and accentuates geographical variations. Furthermore, it
identifies the difficulty in providing consistent perioperative anticoagulation recommendations to patients, as there remains no
widely accepted, definitive literature of evidence or guidelines.


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197. Delays to diagnosis and barriers to care for breast cancer in Mexico and Peru: a cross sectional study

global health


Authors: Karla Unger-Saldaña, Manuel Cedano Guadiamos, Ana Maria Burga Vega, Benjamin O Anderson, Anya Romanoff
Region / country: South America – Mexico, Peru
Speciality: General surgery, Surgical oncology

Background
Delays to breast cancer diagnosis and treatment initiation are associated with worsened outcomes. However, population-based screening is impractical in many low-income and middle-income countries (LMICs) because of resource constraints and a lack of capacity to effectively diagnose and treat screen-detected disease. Mexico and Peru have similar mortality-to-incidence ratios for breast cancer. Unlike Peru, Mexico has attempted to implement mammography screening, although it remains opportunistic with low (20%) national coverage rates. The aim of this study was to compare delays and describe barriers to care among breast cancer patients in Mexico and Peru.

Methods
This international cross-sectional study included breast cancer patients interviewed at four public cancer hospitals in Mexico City between 2009 and 2011, and a federally-funded regional cancer institute in Trujillo, Peru in 2015. A Breast Cancer Delays Questionnaire, developed and validated in Mexico and modified for Peru, was administered to breast cancer patients during routine hospital visits at each location. Patient-related, diagnostic, and treatment delays were quantified, and barriers to care identified.

Findings
We included data from 597 Mexican women and 113 Peruvian women. Age at diagnosis did not differ between countries (53 years [Mexico] vs 54 years [Peru], p=0·266). Most women in both countries had breast cancer detected by symptoms (84% [Mexico] vs 93% [Peru]; p<0·001), although more women in Mexico were diagnosed by mammography screening (12% vs 6%) and screening clinical breast examination (4% vs 1%). Of patients with available stage information, the majority of disease was AJCC stage II or III at diagnosis (76% [n=597, Mexico] vs 91% [93, Peru]; p=0·014). More women in Mexico were diagnosed at an early stage (AJCC stage 0 or I) (14% [Mexico] vs 4% [Peru]). Total delay (symptom discovery or screening to initiation of treatment) did not differ between the two countries (median 210 days [IQR 128–415; n=597] Mexico vs 201 days [82–442; n=74] Peru; [p=0·71]). Diagnostic delay (first medical consultation to diagnosis) was the greatest contributor to overall delay (113 days [59–250; n=597, Mexico] vs 174 days [40–396; n=95, Peru]; p=0·105). Approximately 60% of all patients had diagnostic delays greater than 3 months. Less than half (44%) of Mexican patients visited more than two health-care facilities before the cancer centre, compared with 71% of Peruvian patients (p<0·001). Patients in both countries reported that barriers to prompt arrival at the cancer centre were: not knowing where to go, lack of money, spread out appointments, and diagnostic errors.

Interpretation
Improved diagnostic and referral systems are necessary to reduce delays to breast cancer care in Mexico and Peru. Such improvements are prerequisites to the establishment of maximally effective mammography screening programmes in LMICs.


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198. Nonoperative Treatment of Traumatic Spinal Injuries in Tanzania: Who Is Not Undergoing Surgery and Why?

spinal cord


Authors: Noah L Lessing, Albert Lazaro, Scott L Zuckerman, Andreas Leidinger, Nicephorus Rutabasibwa, Hamisi K Shabani, Roger Härtl
Region / country: Eastern Africa – Tanzania
Speciality: Neurosurgery, Trauma surgery

Study design: Retrospective, cohort study of a prospectively collected database.

Objectives: In a cohort of patients with traumatic spine injury (TSI) in Tanzania who did not undergo surgery, we sought to: (1) describe this nonoperative population, (2) compare outcomes to operative patients, and (3) determine predictors of nonoperative treatment.

Setting: Tertiary referral hospital.

Methods: All patients admitted for TSI over a 33-month period were reviewed. Variables included demographics, fracture morphology, neurologic exam, indication for surgery, length of hospitalization, and mortality. Regression analyses were used to report outcomes and predictors of nonoperative treatment.

Results: 270 patients met inclusion criteria, of which 145 were managed nonoperatively. Demographics between groups were similar. The nonoperative group was young (mean = 35.5 years) and primarily male (n = 125, 86%). Nonoperative patients had 7.39 times the odds of death (p = 0.003). Patients with AO type A0/1/2/3 fractures (p < 0.001), ASIA E exams (p = 0.016), cervical spine injuries (p = 0.005), and central cord syndrome (p = 0.016) were more commonly managed nonoperatively. One hundred and twenty-four patients (86%) had indications for but did not undergo surgery. After multivariate analysis, the only predictor of nonoperative management was sustaining a cervical injury (p < 0.001).

Conclusions: Eighty-six percent of nonoperative TSI patients had an indication for surgery. Nonoperative management was associated with an increased risk of mortality. Cervical injury was the single independent risk factor for not undergoing surgery. The principle reason for nonoperative management was cost of implants. While a causal relationship between nonoperative management and inferior outcomes cannot be made, efforts should be made to provide surgery when indicated, regardless of a patient's ability to pay.


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199. Post-Tuberculosis (TB) Treatment: The Role of Surgery and Rehabilitation

applied Sciences


Authors: Dina Visca, Simon Tiberi, Rosella Centis, Lia D’Ambrosio, Emanuele Pontali, Alessandro Wasum Mariani, Elisabetta Zampogna, Martin van den Boom, Antonio Spanevello and Giovanni Battista Migliori
Region / country: Global
Speciality: Cardiothoracic surgery

Even though the majority of tuberculosis (TB) programmes consider their work completed when a patient is ‘successfully’ cured, patients often continue to suffer with post-treatment or surgical sequelae. This review focuses on describing the available evidence with regard to the diagnosis and management of post-treatment and surgical sequelae (pulmonary rehabilitation). We carried out a non-systematic literature review based on a PubMed search using specific key-words, including various combinations of ‘TB’, ‘MDR-TB’, ‘XDR-TB’, ‘surgery’, ‘functional evaluation’, ‘sequelae’ and ‘pulmonary rehabilitation’. References of the most important papers were retrieved to improve the search accuracy. We identified the main areas of interest to describe the topic as follows: 1) ‘Surgery’, described through observational studies and reviews, systematic reviews and meta-analyses, IPD (individual data meta-analyses), and official guidelines (GRADE (Grading of Recommendations Assessment, Development and Evaluation) or not GRADE-based); 2) Post-TB treatment functional evaluation; and 3) Pulmonary rehabilitation interventions. We also highlighted the priority areas for research for the three main areas of interest. The collection of high-quality standardized variables would allow advances in the understanding of the need for, and effectiveness of, pulmonary rehabilitation at both the individual and the programmatic level. The initial evidence supports the importance of the adequate functional evaluation of these patients, which is necessary to identify those who will benefit from pulmonary rehabilitation.


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200. A Review of State Guidelines for Elective Orthopaedic Procedures During the COVID-19 Outbreak

Journal Of Bone And Joint Surgery, INCORPORATED


Authors: Nikolas J. Sarac, BS, Benjamin A. Sarac, BS, Anna R. Schoenbrunner, MD, MAS, Jeffrey E. Janis, MD, Ryan K. Harrison, MD, Laura S. Phieffer, MD, Carmen E. Quatman, MD, PhD, and Thuan V. Ly, MD
Region / country: Northern America – United States of America
Speciality: Trauma and orthopaedic surgery

Background:
The SARS-CoV-2 (COVID-19) pandemic has resulted in widespread cancellation of elective orthopaedic procedures. The guidance coming from multiple sources frequently has been difficult to assimilate as well as dynamic, with constantly changing standards. We seek to communicate the current guidelines published by each state, to discuss the impact of these guidelines on orthopaedic surgery, and to provide the general framework used to determine which procedures have been postponed at our institution.

Methods:
An internet search was used to identify published state guidelines regarding the cancellation of elective procedures, with a publication cutoff of March 24, 2020, 5:00 p.m. Eastern Daylight Time. Data collected included the number of states providing guidance to cancel elective procedures and which states provided specific guidance in determining which procedures should continue being performed as well as to orthopaedic-specific guidance.

Results:
Thirty states published guidance regarding the discontinuation of elective procedures, and 16 states provided a definition of “elective” procedures or specific guidance for determining which procedures should continue to be performed. Only 5 states provided guidelines specifically mentioning orthopaedic surgery; of those, 4 states explicitly allowed for trauma-related procedures and 4 states provided guidance against performing arthroplasty. Ten states provided guidelines allowing for the continuation of oncological procedures.

Conclusions:
Few states have published guidelines specific to orthopaedic surgery during the COVID-19 outbreak, leaving hospital systems and surgeons with the responsibility of balancing the benefits of surgery with the risks to public health.


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201. Non-endoscopic management of a giant ureterocele: a case report in resource poor African hospital

international surgery journal


Authors: Usman Mohammed Tela, Babatunde David Olajide, Abdu Mohammed Lawan
Region / country: Western Africa – Nigeria
Speciality: Urology surgery

Ureterocele is a cystic dilatation of the distal sub mucosal part of the ureter. It is a congenital anomaly that may co-exist with other anomalies. It has an incidence 1 in 4000 live births. Patients present with symptoms at paediatric age or may remain asymptomatic till adulthood. Our 30 year old female patient was assessed for a giant orthotropic right ureterocele with obstructive uropathy, in a hospital that has no modern facilities for endoscopic treatment. She then had successful open surgical repair of the ureterocele with satisfactory outcome. Minimally invasive endoscopic treatment options remains the gold standard. Patients from poor resource regions can as well be treated successfully by open surgical repair like our index case presented.


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202. m-Health for Burn Injury Consultations in a Low-Resource Setting: An Acceptability Study Among Health Care Providers

Telemedicine and e-Health


Authors: Anders Klingberg, Hendry Robert Sawe, Ulf Hammar, Lee Alan Wallis, and Marie Hasselberg
Region / country: Eastern Africa – Tanzania
Speciality: Emergency surgery, Plastic surgery

Introduction:The rapid adoption of smartphones, especially in low- and middle-income countries, has opened up novel ways to deliver health care, including diagnosis and management of burns. This study was conducted to measure acceptability and to identify factors that influence health care provider’s attitudes toward m-health technology for emergency care of burn patients.

Methods:An extended version of the technology acceptance model (TAM) was used to assess the acceptability toward using m-health for burns. A questionnaire was distributed to health professionals at four hospitals in Dar Es Salaam, Tanzania. The questionnaire was based on several validated instruments and has previously been adopted for the sub-Saharan context. It measured constructs, including acceptability, usefulness, ease of use, social influences, and voluntariness. Univariate analysis was used to test our proposed hypotheses, and structural equation modeling was used to test the extended version of TAM.

Results:In our proposed test-model based on TAM, we found a significant relationship between compatibility—usefulness and usefulness—attitudes. The univariate analysis further revealed some differences between subgroups. Almost all health professionals in our sample already use smartphones for work purposes and were positive about using smartphones for burn consultations. Despite participants perceiving the application to be easy to use, they suggested that training and ongoing support should be available. Barriers mentioned include access to wireless internet and access to hospital-provided smartphones.


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203. The Occurrence and Contributing Factors of Needle Stick and Sharp Injuries Among Dental Students in a South African University

The Open Public Health Journal


Authors: Emma Musekene, Perpetua Modjadji, Sphiwe Madiba
Region / country: Southern Africa – South Africa
Speciality: Maxillofacial and oral surgery, Surgical Education

Background:
Needle stick and sharp injuries are a global public health issue, mainly due to exposure to infectious diseases. Dental students, in particular, are at a high risk of needle stick and sharp injuries attributed to the restricted working space of the oral cavity and the routine use of sharp instruments, among other risks. Despite this growing body of knowledge on needle stick and sharp injuries in the dental setting, data is limited among dental students in South Africa.

Objective:
The study aimed to determine the occurrence and contributing factors of needle stick and sharp injuries among dental undergraduate students in a university in South Africa.

Methods:
A university based cross-sectional study was conducted among 248 dental students in the School of Oral Health Sciences using a census sampling. An anonymous self-administered questionnaire was used to collect data on prevalence, procedures, instruments, reporting, contributing factors, training, protective strategies, and hepatitis B immunization. Data was analysed using STATA 14.

Results:
The response rate was 99% and the mean age of students was 24 years (SD=±4). Male students were 43% (107), while females constituted 57% (141) of the sample. One-hundred and one (41%) students reported being exposed to needle stick and sharps injuries. Most injuries (45%) occurred among students studying Bachelor of Dental and Surgery and among students in the 4th year (57%). The people at the departments of periodontology (39%), and maxillofacial and oral Surgery (25%) experienced most injuries. The main tools causing injuries were the syringe needle (52%) and the scaler (31%) while injecting a patient (34%), and scaling and polishing (26%) were common procedures. Eight (8%) students did not report their injury, even though the use of prophylaxis exposure was minimal (8%). Very few students (5%) were tested for a blood-borne virus after injury, while 23% did nothing with their injury and 43% opted to wash the injury under tap water. Lack of concentration (36%) and anxiety (19%) were reported as major contributing factors to injuries. Two hundred and forty six (99%) students were fully vaccinated against hepatitis B. Two hundred and nineteen (86%) students were aware of full details on the use of universal precautions. One hundred and eighty six (75%) students practiced needle recapping. Being in the 3rd year (AOR = 3.0, 95%CI: 1.4 – 6.3), 4th year (AOR = 5.0, 95%CI: 1.9 – 11) and 5th year (AOR=4.6, 95%CI: 2 -12.5) was significantly associated to injuries compared to students in the 2nd year of the study.

Conclusion:
The needle stick and sharp injuries were prevalent in this study, and factors implicated were lack of concentration and anxiety, as well as, age, academic year of study and training on handling of instruments. The burden of needle stick and sharps injuries among the dental professionals can be reduced by adhering to the current and universally accepted standard precautionary measures against needle stick and sharp injuries.


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204. COVID-19 Preparedness Within the Surgical, Obstetric and Anesthetic Ecosystem in Sub Saharan Africa

annals of surgery


Authors: Adesoji O Ademuyiwa , Abebe Bekele , Atakltie Baraki Berhea , Eric Borgstein , Nina Capo-Chichi , Miliard Derbew , Faye M Evans , Mekdes Daba Feyssa , Moses Galukande , Atul A Gawande , Serigne Magueye Gueye , Ewen Harrison , Pankaj Jani , Neema Kaseje , Louis Litswa , Tihitena Negussie Mammo , Jannicke Mellin-Olsen , Godfrey Muguti , Mary T Nabukenya , Eugene Ngoga , Faustin Ntirenganya , Stephen Rulisa , Nichole Starr , Stephen Tabiri , Mahelet Tadesse , Isabeau Walker , Thomas G Weiser , Sherry M Wren
Region / country: Central Africa, Eastern Africa, Southern Africa, Western Africa
Speciality: General surgery

Community transmission of COVID-19 is already being reported in Africa. Most countries on the continent will have +10,000 confirmed cases within the month. The population, while generally younger than in Europe and North America, has much higher rates of poverty, malnutrition, HIV, and TB, which could shift the demographics of lethality. For surgeons, obstetricians, and anesthesiologists, the major challenge will be maintaining provision of emergency and essential surgery and obstetric care while preserving precious resources, minimizing exposure of health care workers, and preventing onward transmission (Table ​(Table11). The human skill sets, resources, and supply chains supporting surgical services are also those needed for responding to the crisis.


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205. COVID-19: Initial experience of an international group of hand surgeons

hand surgery rehabilitation


Authors: F Ducournau , M Arianni , S Awwad , E-M Baur , J-Y Beaulieu , M Bouloudhnine , M Caloia , K Chagar , Z Chen , A Y Chin , E C Chow , T Cobb , Y David , P J Delgado , M Woon Man Fok , R French , I Golubev , J R Haugstvedt , S Ichihara , R A Jorquera , S C J J Koo , J Y Lee , Y K Lee , Y J Lee , B Liu , T Kaleli , G R Mantovani , C Mathoulin , J C Messina , C Muccioli , S Nazerani , C Y Ng , M C Obdeijn , L Van Overstraeten , T O H Prasetyono , M Ross , J T Shih , N Smith , F A Suarez R , P-T Chan , H Tiemdjo , A Wahegaonkar , M C Wells , W-Y Wong , F Wu , X F Yang , D Yanni , J Yao , P A Liverneaux
Region / country: Global
Speciality: Plastic surgery, Trauma and orthopaedic surgery

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.


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206. Impact of capnography on patient safety in high- and low-income settings: a scoping review

British Journal of Anaesthesia


Authors: Elliot Wollner , Maziar M Nourian , William Booth , Sophia Conover , Tyler Law , Maytinee Lilaonitkul , Adrian W Gelb , Michael S Lipnick
Region / country: Global
Speciality: Anaesthesia

Background: Capnography is universally accepted as an essential patient safety monitor in high-income countries (HICs) yet is often unavailable in low and middle-income countries (LMICs). Increasing capnography availability has been proposed as one of many potential approaches to improving perioperative outcomes in LMICs. This scoping review summarises the existing literature on the effect of capnography on patient outcomes to help prioritise interventions and guide expansion of capnography in LMICs.

Methods: We searched MEDLINE and EMBASE databases for articles published between 1980 and March 2019. Studies that assessed the impact of capnography on morbidity, mortality, or the use of airway interventions both inside and outside the operating room were included.

Results: The search resulted in 7445 unique papers, and 31 were included for analysis. Retrospective and non-randomised data suggest capnography use may improve outcomes in the operating room, ICU, and emergency department, and during resuscitation. Prospective data on capnography use for procedural sedation suggest earlier detection of hypoventilation and a reduction in haemoglobin desaturation events. No randomised studies exist that assess the impact of capnography on patient outcomes.

Conclusion: Despite widespread endorsement of capnography as a mandatory perioperative monitor, rigorous data demonstrating its impact on patient outcomes are limited, especially in LMICs. The association between capnography use and a reduction in serious airway complications suggests that closing the capnography gap in LMICs may represent a significant opportunity to improve patient safety. Additional data are needed to quantify the global capnography gap and better understand the barriers to capnography scale-up in LMICs.


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

Journal of Global Antimicrobial Resistance


Authors: Bhakht Sarang, Anurag Tiwary, Anita Gadgil, Nobhojit Roy
Region / country: Southern Asia – India
Speciality: General surgery

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


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208. The challenge of safe anesthesia in developing countries: defining the problems in a medical center in Cambodia.

BMC Health Services Research


Authors: Kun-ming Tao, Sann Sokha, Hong-bin Yuan
Region / country: South-eastern Asia – Cambodia, Singapore, Thailand, Vietnam
Speciality: Anaesthesia

The International Standards for a Safe Practice of Anesthesia (ISSPA) were developed on behalf of the World Federation of Societies of Anaesthesiologists and the World Health Organization. It has been recommend as an assessment tool that allows anesthetic providers in developing countries to assess their compliance and needs. This study was performed to describe the anesthesia service in one main public hospital during an 8-month medical mission in Cambodia and evaluate its anesthetic safety issues according to the ISSPA. We conduct a retrospective study involving 1953 patients at the Preah Ket Mealea hospital. Patient demographics, anesthetic techniques, and complications were reviewed according to the registers of the anesthetic services and questionnaires. The inadequacies in personnel, facilities, equipment, medications, and conduct of anesthesia drugs were recorded using a checklist based on the ISSPA. A total of 1792 patients received general and regional anesthesia in the operating room, while 161 patients receiving sedation for gastroscopy. The patients’ mean age was 45.0 ± 16.6 years (range, 17-87 years). The three most common surgical procedures were abdominal (52.0%; confidence interval [CI], 49.3-54.7), orthopedic (27.6%; CI, 25.2-29.9), and urological surgery (14.7%; CI, 12.8-16.6). General anesthesia, spinal anesthesia, and brachial plexus block were performed in 54.3% (CI, 51.7-56.8), 28.2% (CI, 25.9-30.5), and 9.4% (CI, 7.9-10.9) of patients, respectively. One death occurred. Twenty-six items related to professional aspects, monitoring, and conduct of anesthesia did not meet the ISSPA-recommended standards. A lack of commonly used drugs and monitoring equipment was noted, posing major threats to the safety of anesthesia practice, especially in emergency situations. This study adds to the scarce literature on anesthesia practice in low- and middle-income countries such as Cambodia. Future medical assistance should help to strengthen these countries’ inadequacies, allowing for the adoption of international standards for the safe practice of anesthesia.


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209. Reversal of Hartmann’s procedure is still a high-morbid surgery?

Turkish Journal Trauma and Emergency surgery


Authors: Ozan Akıncı, Müge Yurdacan, Başar Can Turgut, Server Sezgin Uludağ, Osman Şimşek
Region / country: Western Asia – Turkey
Speciality: Emergency surgery, Surgical oncology

BACKGROUND: This study evaluated the outcome of the reversal of Hartmann’s procedure based on preoperative and intraoperative risk factors.
METHODS: We retrospectively reviewed 78 cases, whom we applied the Hartmann’s procedure either electively or under emergency conditions in our clinic between the years 2010 and 2016.
RESULTS: Of the cases reviewed in this study, 45 patients were males, and 33 patients were females. Of all cases included in this study, 32 cases were operated due to malignancies, 15 cases were operated due to a perforated diverticulum, and 11 cases were operated due to sigmoid volvulus. Reversal of Hartmann’s was performed in 32 cases. The morbidity and mortality rates for the reversal of Hartmann’s procedure were 37.5% and 0.0%, respectively.
CONCLUSION: The reversal of Hartmann’s procedure appears to be a safe operation with acceptable morbidity rates. If the correct patient selection, correct operation timing and meticulous surgical preparation are performed, the risk of morbidity and mortality of the reversal of Hartmann’s procedure can be minimized.


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210. Lessons From Developing, Implementing and Sustaining a Participatory Partnership for Children’s Surgical Care in Tanzania

BMJ Global Health


Authors: Godfrey Sama Philipo , Shobhana Nagraj , Zaitun M Bokhary , Kokila Lakhoo
Region / country: Eastern Africa, Global – Tanzania
Speciality: Paediatric surgery

Global surgery is an essential component of Universal Health Coverage. Surgical conditions account for almost one-third of the global burden of disease, with the majority of patients living in low-income and middle-income countries (LMICs). Children account for more than half of the global population; however, in many LMIC settings they have poor access to surgical care due to a lack of workforce and health system infrastructure to match the need for children’s surgery. Surgical providers from high-income countries volunteer to visit LMICs and partner with the local providers to deliver surgical care and trainings to improve outcomes. However, some of these altruistic efforts fail. We aim to share our experience on developing, implementing and sustaining a partnership in global children’s surgery in Tanzania. The use of participatory methods facilitated a successful 17-yearlong partnership, ensured a non-hierarchical environment and encouraged an understanding of the context, local needs, available resources and hospital capacity, including budget constraints, when codesigning solutions. We believe that participatory approaches are feasible and valuable in developing, implementing and sustaining global partnerships for children’s surgery in LMICs.


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211. Cross-sectional study of surgical quality with a novel evidence-based tool for low-resource settings

BMJ Global Health


Authors: Lina Roa , Isabelle Citron, Jania A Ramos, Jessica Correia, Berenice Feghali, Julia R Amundson, Saurabh Saluja, Nivaldo Alonso, Rodrigo Vaz Ferreira
Region / country: South America – Brazil
Speciality: Other, Surgical Education

Background: Adverse events from surgical care are a major cause of death and disability, particularly in low-and-middle-income countries. Metrics for quality of surgical care developed in high-income settings are resource-intensive and inappropriate in most lower resource settings. The purpose of this study was to apply and assess the feasibility of a new tool to measure surgical quality in resource-constrained settings.

Methods: This is a cross-sectional study of surgical quality using a novel evidence-based tool for quality measurement in low-resource settings. The tool was adapted for use at a tertiary hospital in Amazonas, Brazil resulting in 14 metrics of quality of care. Nine metrics were collected prospectively during a 4-week period, while five were collected retrospectively from the hospital administrative data and operating room logbooks.

Results; 183 surgeries were observed, 125 patient questionnaires were administered and patient charts for 1 year were reviewed. All metrics were successfully collected. The study site met the proposed targets for timely process (7 hours from admission to surgery) and effective outcome (3% readmission rate). Other indicators results were equitable structure (1.1 median patient income to catchment population) and equitable outcome (2.5% at risk of catastrophic expenditure), safe outcome (2.6% perioperative mortality rate) and effective structure (fully qualified surgeon present 98% of cases).

Conclusion: It is feasible to apply a novel surgical quality measurement tool in resource-limited settings. Prospective collection of all metrics integrated within existing hospital structures is recommended. Further applications of the tool will allow the metrics and targets to be refined and weighted to better guide surgical quality improvement measures.


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212. Is Quality of Life After Mastectomy Comparable to That After Breast Conservation Surgery? A 5-year Follow Up Study From Mumbai, India

quality of life research


Authors: K V Deepa , A Gadgil , Jenny Löfgren , S Mehare , Prashant Bhandarkar , N Roy
Region / country: South-eastern Asia – India
Speciality: Plastic surgery, Surgical oncology

Purpose
Breast cancer is the commonest cancer in women worldwide. Surgery is a central part of the treatment. Modified radical mastectomy (MRM) is often replaced by breast conserving therapy (BCT) in high-income countries. MRM is still the standard choice, in low- and middle-income countries (LMICs) as radiotherapy, a mandatory component of BCT is not widely available. It is important to understand whether quality of life (QOL) after MRM is comparable to that after BCT. This has not been studied well in LMICs. We present, 5-year follow-up of QOL scores in breast cancer patients from India.

Methods
We interviewed women undergoing breast cancer surgery preoperatively, at 6 months after surgery, and at 1 year and 5 years, postoperatively. QOL scores were evaluated using FACT B questionnaire. Average QOL scores of women undergoing BCT were compared with those undergoing MRM. Total scores, domain scores and trends of scores over time were analyzed.

Results
We interviewed 54 women with a mean age of 53 years (SD 9 ± years). QOL scores in all the women, dipped during the treatment period, in all subscales but improved thereafter and even surpassed the baseline in physical, emotional and breast-specific domains (p < 0.05) at 5 years. At the end of 5 years, there was no statistically significant difference between the MRM and BCT groups in any of the total or domain scores.

Conclusion
QOL scores in Indian women did not differ significantly between MRM and BCT in the long term. Both options are acceptable in the study setting.


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213. 14 Years’ Experience of Esophageal Replacement Surgeries

Pediatric Surgery International


Authors: Muhammad Saleem, Asif Iqbal, Uzma Ather, Naveed Haider, Nabila Talat, Imran Hashim, Muhammad Bilal Mirza, Jamal Butt, Hassan Mahmud, and Fatima Majeed
Region / country: South-eastern Asia – Pakistan
Speciality: Paediatric surgery

Background
Esophageal replacement is a challenge to the therapeutic skills of surgeons and a technically demanding operation in the pediatric age group. Various conduits and routes have been described in the literature, each with their specific advantages and disadvantages. We carried out this retrospective study to share our experience of esophageal replacement.

Methodology
This study was conducted at the department of pediatric surgery The Children’s Hospital and The Institute of Child Health, Lahore. The records of patients treated for esophageal replacement were reviewed. The patients under follow-up were called for clinical evaluation and assessed of long terms complications if any.

Results
A total of 93 patients with esophageal replacement were included in the study. Esophageal replacement was done with gastric transposition in 84 cases (90%), colon interposition in 7 cases (7.5%) including one case of redo colonic interposition, and jejunal interposition in 2 cases (2%). Routes of esophageal replacement were trans-hiatal in 71 (76%), retrosternal in 13 (14%), and trans-hiatal with thoracotomy in 9 (10%) patients. Postoperatively, all of the conduits maintained viability. Wound infection was seen in 10 (11%), wound dehiscence in 5 (5%), anastomotic leak in 9 (10%), anastomotic stenosis in 12 (13%), fistula formation in 4 (4%), aortic injury 1 (1%), dumping syndrome 8 (9%), reflux 18 (19%), dysphagia 15 (16%) and death occurred in 12 patients (13%).

Conclusion
There are problems with esophageal replacement in developing countries. In this context, gastric conduit appeared as the best conduit for esophageal replacement, using the trans-hiatal route for replacement, in the authors’ experience.


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214. Economic benefits and costs of surgery for filarial hydrocele in Malawi

Plos Neglected Tropical Diseases


Authors: Larry Sawers,Eileen Stillwaggon,John Chiphwanya,Square Z. Mkwanda,Hannah Betts,Sarah Martindale,Louise A. Kelly-Hope
Region / country: Southern Africa – Malawi
Speciality: Urology surgery

Background
Lymphatic filariasis (LF) is endemic in 72 countries of Africa, Asia, Oceania, and the Americas. An estimated 25 million men live with the disabling effects of filarial hydrocele. Hydrocele can be corrected with surgery with few complications. For most men, hydrocelectomy reduces or corrects filarial hydrocele and permits them to resume regular activities of daily living and gainful employment.

Methodology and principal findings
This study measures the economic loss due to filarial hydrocele and the benefits of hydrocelectomy and is based on pre- and post-operative surveys of patients in southern Malawi. We find the average number of days of work lost due to filarial hydrocele and daily earnings for men in rural Malawi. We calculate average annual lost earnings and find the present discounted value for all years from the time of surgery to the end of working life. We estimate the total costs of surgery. We compare the benefit of the work capacity restored to the costs of surgery to determine the benefit-cost ratio. For men younger than 65 years old, the average annual earnings loss attributed to hydrocele is US$126. The average discounted present value of lifetime earnings loss for those men is US$1684. The average budgetary cost of the hydrocelectomy is US$68. The ratio of the benefit of surgery to its costs is US$1684/US$68 or 24.8. Sensitivity analysis demonstrates that the results are robust to variations in cost of surgery and length of working life.

Conclusion
The lifetime benefits of hydrocelectomy–to the man, his family, and his community–far exceed the costs of repairing the hydrocele. Scaling up subsidies to hydrocelectomy campaigns should be a priority for governments and international aid organizations to prevent and alleviate disability and lost earnings that aggravate poverty among the many millions of men with filarial hydrocele.


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215. Supervision as a tool for building surgical capacity of district hospitals: the case of Zambia

Human Resources for Health


Authors: Jakub Gajewski, Nasser Monzer, Chiara Pittalis, Leon Bijlmakers, Mweene Cheelo, John Kachimba, Ruairi Brugha
Region / country: Southern Africa – Zambia
Speciality: General surgery

Introduction
Many countries in sub-Saharan Africa have adopted task shifting of surgical responsibilities to non-physician clinicians (NPCs) as a solution to address workforce shortages. There is resistance to delegating surgical procedures to NPCs due to concerns about their surgical skills and lack of supervision systems to ensure safety and quality of care provided. This study aimed to explore the effects of a new supervision model implemented in Zambia to improve the delivery of health services by surgical NPCs working at district hospitals.
Methods
Twenty-eight semi-structured interviews were conducted with NPCs and medical doctors at nine district hospitals and with the surgical specialists who provided in-person and remote supervision over an average period of 15 months. Data were analysed using ‘top-down’ and ‘bottom-up’ thematic coding.
Results
Interviewees reported an improvement in the surgical skills and confidence of NPCs, as well as better teamwork. At the facility level, supervision led to an increase in the volume and range of surgical procedures done and helped to reduce unnecessary surgical referrals. The supervision also improved communication links by facilitating the establishment of a remote consultation network, which enabled specialists to provide real-time support to district NPCs in how to undertake particular surgical procedures and expert guidance on referral decisions. Despite these benefits, shortages of operating theatre support staff, lack of equipment and unreliable power supply impeded maximum utilisation of supervision.
Conclusion
This supervision model demonstrated the additional role that specialist surgeons can play, bringing their expertise to rural populations, where such surgical competence would otherwise be unobtainable. Further research is needed to establish the cost-effectiveness of the supervision model; the opportunity costs from surgical specialists being away from referral hospitals, providing supervision in districts; and the steps needed for regular district surgical supervision to become part of sustainable national programmes.


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216. Availability of ENT Surgical Procedures and Medication in Low-Income Nation Hospitals: Cause for Concern in Zambia

biomed research international


Authors: Lufunda Lukama, Chester Kalinda, Warren Kuhn, Colleen Aldous
Region / country: Southern Africa – Zambia
Speciality: ENT surgery

Background
Ear, nose, and throat (ENT) diseases are an oft overlooked global health concern. Despite their high prevalence and associated morbidity and mortality, ENT diseases have remained neglected in health care delivery. In Zambia and many other low-income countries, ENT services are characterized by poor funding, unavailable surgical procedures, and erratic supply of essential drugs.
Objective
To investigate ENT service provision in Zambia with regard to availability of surgical procedures and supply of essential drugs.
Methods
A descriptive cross-sectional survey was conducted using a piloted structured questionnaire between 17 January 2017 and 2 January 2018. Included in the study were the 109 hospitals registered with the Ministry of Health (MoH) across the 10 provinces of Zambia.
Results
Of the participating hospitals, only 5.9% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (n = 1) and 40% (.
Conclusion
ENT service delivery in Zambia is limited with regard to performed surgical procedures and availability of essential drugs, necessitating urgent intervention. The findings from this study may be used to direct national policy on the improvement of provision of ENT services in Zambia.


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217. Incidence of Keratoconus in Refractive Surgery Population of Vojvodina – Single Center Study

materia sociomedica


Authors: Nita Bejdic, Alma Biscevic, Melisa Ahmedbegovic Pjano, Borivoje Ivezic
Region / country: Eastern Europe, Southern Europe – Serbia
Speciality: Ophthalmology

Introduction
Keratoconus (KCN) is known to affect all ethnicities but its incidence exhibits geographical variability plausibly due to subclinical forms of the disease, differences in diagnostic methods and criteria, or differences in genetic variations in populations.
Aim
To examine the prevalence of keratoconus among the refractive surgery population of Vojvodina, who underwent refractive surgery screening at Eye Clinic Svjetlost Novi Sad, Serbia from September 2018 to September 2019. This is a single-center study.
Methods
Retrospective analysis of 876 patients who presented for refractive surgery evaluation. Corneal tomographers represent the gold standard in the detection and classification of corneal ectatic diseases and screening is an essential part of the preoperative diagnostics before any refractive surgery. The corneal tomographer used in this study was a Scheimpflug imaging device (Pentacam AXL, Oculus Optikgeräte GmbH, Wetzlar, Germany). The device was realigned before each measurement.
Results
Out of a total number of patients, 619 (70,7%) were candidates for corneal refractive surgery procedure, and 257 patients (29.3%) were not. Out of 257 patients that were not candidates for the procedure 157 (61,0%) patients had thin corneas, high myopia/hypermetropia or had some retinal disease; 75 patients (29,1) were keratoconus suspect and 25 patients (9,7%) had keratoconus. KCN patients had a mean age of 29.5 ± 7.7 years, 18 patients (72.0%) were male and 7 patients were female (28%)
Conclusion
The most cited annual incidence of KCN is 2 approximately 1 per 2,000. Recent data from the biggest Netherland study revealed many different epidemiological results which deprive keratoconus of the community of rare diseases. The incidence of keratoconus in Vojvodina refractive surgery population presented in our Clinic was 2.9%


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218. Decortication as an Option for Empyema Thoracis

Journal of the College of Physicians and Surgeons–pakistan


Authors: Majeed FA, Zafar U, Chatha SS, Ali A, Raza A
Region / country: South-eastern Asia – Pakistan
Speciality: Cardiothoracic surgery

OBJECTIVE:To analyse the outcome and morbidity associated with decortication in empyema thoracis. STUDY DESIGN:A case series. PLACE AND DURATION OF STUDY:Departments of Surgery, Combined Military Hospitals (CMH) of Rawalpindi, Quetta and Lahore, from January 2006 to March 2018. METHODOLOGY:This is a retrospective study of 812 cases of open and VATS (video-assisted thoracic surgery) decortication for empyema thoracis, operated by the same consultants. Only patients with established empyema were included. Those who were unfit for one-lung ventilation, undergoing local anesthesia procedures like rib resection, clagget window or tube windows, with clotted hemothorax and malignant pathology were excluded. Posterolateral serratus sparing thoracotomy was used in open decortications. Multiportal or uniport VATS was employed for video-assisted thoracoscopic decortications (VATD). Histopathology and microbiological sampling was also done in all cases. RESULTS:There were 537 (66.1%) males and 275 (33.9%) females. Age ranged from 1 to 80 years with a mean of 37 years. Open decortication was done in 650 (80%), standard decortication with posterolateral thoracotomy in 458 (56.4%), minithoracotomy was done in 69 (8.4%) patients with loculated empyema, thoracotomy and open decortication with conventional thoracoplasty was done in 21 patients. Twenty-two patients required open decortications with tailored thoracoplasty and muscle flap. Open decortication with intercostal muscle (ICM) flap or primary closure of bronchopleural fistula was performed in 55 patients. VATD was done in 162 cases, out of which 120 were early empyema, and 42 were of chronic empyema; of which 22 required a further utility thoracotomy. Decortication with lung resection and muscle flap reinforcement to bronchial stump was done in 25 patients. Blood transfusion was required in 331 (40.7%). Twenty-six (3.4%) patients developed residual space and collection requiring intervention; and 384 (47.3%) patients had a histopathology diagnostic for tuberculosis. There were 11 (1.3%) deaths. CONCLUSION:Open decortication is still one of the preferred procedures in developing countries. VATD is also increasingly utilised for empyema.


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219. Percutaneous dilatational tracheostomy: A prospective analysis among ICU patients

Journal of Rawalpindi Medical College


Authors: Khawaja Kamal Nasir, Faraz Mansoor, Shahzad Hussain Waqar, Shahab Zahid Ahmed Khan, Rakhshanda Jabeen
Region / country: South-eastern Asia – Pakistan
Speciality: ENT surgery

Introduction: Percutaneous dilatational tracheostomy (PDT) is a simple bedside procedure, particularly useful in the intensive care units. Over the last few decades, the technique of PDT has gained popularity due to its comparable safety to the more surgical tracheostomy (ST).

Objective: To describe the outcome of PDT using modified Ciaglia’s technique in patients of Surgical ICU.

Methodology: This was a prospective cohort study that analysed the outcomes of PDTs carried out on critically ill patients admitted in the surgical ICU, Pakistan Institute of Medical Sciences, Islamabad from August 2015 to January 2017. All PDTs were performed by the presiding consultant and his team using modified Ciaglia’s (Blue Rhino) technique. The main outcome was the frequency of perioperative and early complications within the first six days. Demographic variables and complications were recorded. Data was analysed using SPSS version 18.

Results: Seventy-four patients underwent PDTs in the surgical ICU with mean age of the patients was 49.17 ± 12.82 years. The commonest indication of tracheostomy was prolonged mechanical ventilation followed by failure to wean. Complications rate was 12.16% of which perioperative bleeding occurred in 6.7% of patients. Early complications within the first six days were wound infection, tube displacement and blocked tube.

Conclusion: PDT is a valuable, efficacious and safe method that can be performed at the bedside with minimal complication rate and needs to be considered more frequently in the intensive care units in developing countries.


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220. Practice Patterns in the Management of Strabismus in Pakistan

pakistan journal of ophthalmology


Authors: Nasir Ahmed, Muhammad Shaheer, Sarmad Zahoor, Salman Hamza, Samran Asim
Region / country: South-eastern Asia – Pakistan
Speciality: Ophthalmology

Purpose: To study the current practice patterns of pediatric ophthalmologists in the management of strabismus in Punjab.

Study Design: Questionnaire based Practice pattern survey.

Place and Duration of Study: Teaching hospitals of Punjab from July 2018 to July 2019.

Material and Methods: This study was conducted at ophthalmology departments of various teaching hospitals of Punjab. A questionnaire was designed to find out the current practice pattern for management of strabismus. Ophthalmologists who were members of Ophthalmological Society of Pakistan (OSP), having their expertise in strabismus surgery for more than 5years and practicing pediatric ophthalmology were selected. Discussion was also held regarding questionnaire and practices being performed after filling the proforma. This data was compiled, analyzed and was converted to a summary in points.

Results: We contacted 90 ophthalmologists out of whom 76 responded to our Questionnaire. Complete Orthoptic Assessment was performed by only 46% (35) of the ophthalmologists. Prism cover test was used as a diagnostic tool by 70 (92%) ophthalmologists. Rest of the ophthalmologists used Synoptophore with it. Percentage of ophthalmologists performing cycloplegic refraction was very low. Only 5 (6.57%) surgeons used adjustable sutures. Only 46% of surgeons used to explain the complications of Anesthesia. More than 90% of surgeons explained the surgical procedures being done, its complications, post-operative care and need to use glasses or need for orthoptic exercises. All the surgeons kept follow up of the patients on 1st post-operative day.

Conclusion: The current practices in strabismus need to be standardized and a consensus should be developed at a national level.


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221. Neurosurgical Education in Egypt and Africa

journal of neurosurgery


Authors: Nasser M F El-Ghandour
Region / country: Northern Africa – Egypt
Speciality: Neurosurgery, Surgical Education

Objective: Africa still significantly lags in the development of neurosurgery. Egypt, located in North Africa, is well-developed in this specialty, with the largest number of neurosurgeons among all African countries. This article provides insight into neurosurgical training in Egypt, the challenges African neurosurgeons are facing, and the requirements needed to enhance neurosurgical education and build up the required neurosurgical capacity in Africa.

Methods: The information presented in the current work was collected from databases of the Egyptian Society of Neurological Surgeons and the World Federation of Neurosurgical Societies.

Results: There are two types of neurosurgical certification in Egypt. The first type is granted by the universities (MD), and the second is awarded by the Ministry of Health (Fellow of Neurosurgery). The program in both types ranges from 6 to 9 years. The number of qualified neurosurgeons in Egypt constitutes one-third of the total number of African neurosurgeons. There is a significant shortage of neurological surgeons in Africa, and the distribution is entirely unbalanced, with the majority of neurosurgeons concentrated in the North and South regions. The most important challenge facing neurosurgery in Africa is lack of resources, which is considered to be the main obstacle to the development of neurosurgery. Other challenges include the limited number of neurosurgeons, lack of training programs, and lack of collaboration among the different regions.

Conclusions: Proper collaboration among the different regions within the African continent regarding neurosurgical education will enhance African neurosurgical capacity and make neurosurgery an independent specialty. The definite functional polarity among different regions, regarding both the number of qualified neurosurgeons and the neurosurgical capacity, is an important factor that could help in the development of neurosurgery in this continent


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222. Neurosurgical Randomized Trials in Low- and Middle-Income Countries

Neurosurgery


Authors: Griswold DP, Khan AA, Chao TE, Clark DJ, Budohoski K, Devi BI, Azad TD, Grant GA, Trivedi RA, Rubiano AM, Johnson WD, Park KB, Broekman M, Servadei F, Hutchinson PJ, Kolias AG
Region / country: Global
Speciality: Neurosurgery

BACKGROUND:The setting of a randomized trial can determine whether its findings are generalizable and can therefore apply to different settings. The contribution of low- and middle-income countries (LMICs) to neurosurgical randomized trials has not been systematically described before. OBJECTIVE:To perform a systematic analysis of design characteristics and methodology, funding source, and interventions studied between trials led by and/or conducted in high-income countries (HICs) vs LMICs. METHODS:From January 2003 to July 2016, English-language trials with >5 patients assessing any one neurosurgical procedure against another procedure, nonsurgical treatment, or no treatment were retrieved from MEDLINE, Scopus, and Cochrane Library. Income classification for each country was assessed using the World Bank Atlas method. RESULTS:A total of 73.3% of the 397 studies that met inclusion criteria were led by HICs, whereas 26.7% were led by LMICs. Of the 106 LMIC-led studies, 71 were led by China. If China is excluded, only 8.8% were led by LMICs. HIC-led trials enrolled a median of 92 patients vs a median of 65 patients in LMIC-led trials. HIC-led trials enrolled from 7.6 sites vs 1.8 sites in LMIC-led studies. Over half of LMIC-led trials were institutionally funded (54.7%). The majority of both HIC- and LMIC-led trials evaluated spinal neurosurgery, 68% and 71.7%, respectively. CONCLUSION:We have established that there is a substantial disparity between HICs and LMICs in the number of published neurosurgical trials. A concerted effort to invest in research capacity building in LMICs is an essential step towards ensuring context- and resource-specific high-quality evidence is generated.


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223. The Impact of African-trained Neurosurgeons on sub-Saharan Africa

journal of neurosurgery


Authors: Claire Karekezi , Abdeslam El Khamlichi , Abdessamad El Ouahabi , Najia El Abbadi , Semevo Alidegnon Ahokpossi , Kodjo Mensah Hobli Ahanogbe , Ibrahima Berete , Soueilem Mohamed Bouya , Oumar Coulibaly , Ibrahim Dao , Ben Ousmanou Djoubairou , Agbeko Achille Komlan Doleagbenou , Komi Prosper Egu, Hugues Brieux Ekouele Mbaki , Sinclair Brice Kinata-Bambino, Laminou Mahamane Habibou , Adio Nabil Mousse , Trésor Ngamasata , Jeff Ntalaja , Justin Onen, Kisito Quenum , Diawara Seylan , Youssouf Sogoba , Franco Servadei , Isabelle M Germano
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Neurosurgery, Surgical Education

Objective: Sub-Saharan Africa (SSA) represents 17% of the world’s land, 14% of the population, and 1% of the gross domestic product. Previous reports have indicated that 81/500 African neurosurgeons (16.2%) worked in SSA-i.e., 1 neurosurgeon per 6 million inhabitants. Over the past decades, efforts have been made to improve neurosurgery availability in SSA. In this study, the authors provide an update by means of the polling of neurosurgeons who trained in North Africa and went back to practice in SSA.

Methods: Neurosurgeons who had full training at the World Federation of Neurosurgical Societies (WFNS) Rabat Training Center (RTC) over the past 16 years were polled with an 18-question survey focused on demographics, practice/case types, and operating room equipment availability.

Results: Data collected from all 21 (100%) WFNS RTC graduates showed that all neurosurgeons returned to work to SSA in 12 different countries, 90% working in low-income and 10% in lower-middle-income countries, defined by the World Bank as a Gross National Income per capita of ≤ US$995 and US$996-$3895, respectively. The cumulative population in the geographical areas in which they practice is 267 million, with a total of 102 neurosurgeons reported, resulting in 1 neurosurgeon per 2.62 million inhabitants. Upon return to SSA, WFNS RTC graduates were employed in public/private hospitals (62%), military hospitals (14.3%), academic centers (14.3%), and private practice (9.5%). The majority reported an even split between spine and cranial and between trauma and elective; 71% performed between 50 and more than 100 neurosurgical procedures/year. Equipment available varied across the cohort. A CT scanner was available to 86%, MRI to 38%, surgical microscope to 33%, endoscope to 19.1%, and neuronavigation to 0%. Three (14.3%) neurosurgeons had access to none of the above.

Conclusions: Neurosurgery availability in SSA has significantly improved over the past decade thanks to the dedication of senior African neurosurgeons, organizations, and volunteers who believed in forming the new neurosurgery generation in the same continent where they practice. Challenges include limited resources and the need to continue expanding efforts in local neurosurgery training and continuing medical education. Focus on affordable and low-maintenance technology is needed.


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224. Delphi prioritization and development of global surgery guidelines for the prevention of surgical‐site infection

bJS


Authors: National Institute for Health Research Global Research Health Unit on Global Surgery
Region / country: Global
Speciality: General surgery

Background
Most clinical guidelines are developed by high‐income country institutions with little consideration given to either the evidence base for interventions in low‐ and middle‐income countries (LMICs), or the specific challenges LMIC health systems may face in implementing recommendations. The aim of this study was to prioritize topics for future global surgery guidelines and then to develop a guideline for the top ranked topic.

Methods
A Delphi exercise identified and prioritized topics for guideline development. Once the top priority topic had been identified, relevant existing guidelines were identified and their recommendations were extracted. Recommendations were shortlisted if they were supported by at least two separate guidelines. Following two voting rounds, the final recommendations were agreed by an international guideline panel. The final recommendations were stratified by the guideline panel as essential (baseline measures that should be implemented as a priority) or desirable (some hospitals may lack these resources at present, in which case they should plan for future implementation).

Results
Prevention of surgical‐site infection (SSI) after abdominal surgery was identified as the highest priority topic for guideline development. The international guideline panel reached consensus on nine essential clinical recommendations for prevention of SSI. These included recommendations concerning preoperative body wash, use of prophylactic antibiotics, decontamination of scrub teams’ hands, use of antiseptic solutions for surgical site preparation and perioperative supplemental oxygenation. In addition, three desirable clinical recommendations and four recommendations for future research were agreed.

Conclusion
This process led to the development of a global surgery guideline for the prevention of SSI that is both clinically relevant and implementable in LMICs.


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225. Can traditional bonesetters become trained technicians? Feasibility study among a cohort of Nigerian traditional bonesetters

Human Resources for Health


Authors: Ndubuisi Onu Onyemaechi, Ijeoma Uchenna Itanyi, Paulinus Okechukwu Ossai & Echezona Edozie Ezeanolue
Region / country: Western Africa – Nigeria
Speciality: Trauma and orthopaedic surgery

Background
Traditional bonesetters (TBS) provide the majority of primary fracture care in Nigeria and other low- and middle-income countries (LMICs). They are widely patronized and their services are commonly associated with complications. The aim of the study was to establish the feasibility of formal training of TBS and subsequent integration into the healthcare system.

Methods
Two focus group discussions were conducted involving five TBS and eight orthopaedic surgeons in Enugu Nigeria. Audio-recordings made during the focus groups were transcribed verbatim and analysed using a thematic analysis method.

Results
Four themes were identified: Training of TBS, their experiences and challenges; perception of traditional bonesetting by orthopaedic surgeons; need for formal training TBS and willingness to offer and accept formal training to improve TBS practice. Participants (TBS group) acquired their skills through informal training by apprenticeship from relatives and family members. They recognized the need to formalize their training and were willing to accept training support from orthopaedists. The orthopaedists recognized that the TBS play a vital role in filling the gap created by shortage of orthopaedic surgeons and are willing to provide training support to them.

Conclusion
This study demonstrates the feasibility of providing formal training to TBS by orthopaedic surgeons to improve the quality of services and outcomes of TBS treatment. This is critical for integration of TBS into the primary healthcare system as orthopaedic technicians. Undoubtedly, this will transform the trauma system in Nigeria and other LMICs where TBS are widely patronized.


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226. Challenges and Outcome of Management of Gastroschisis at a Tertiary Institution in North-Eastern Nigeria

frontiers in surgery


Authors: Adewale O. Oyinloye, Auwal M. Abubakar, Samuel Wabada and Lateef O. Oyebanji
Region / country: Western Africa – Nigeria
Speciality: Paediatric surgery

Introduction: Gastroschisis is a congenital anterior abdominal wall defect characterized by herniation of abdominal contents through a defect usually located to the right side of the umbilical cord. It occurs in about 1 in 2,000–4,000 live births and is slightly commoner in males. Management has remained challenging in the low and middle-income countries, with high mortality rates. This study highlights the clinical presentation, treatment, outcomes, and challenges in the management of gastroschisis at a tertiary healthcare center in a resource-limited setting.

Methods: This was a retrospective review of the records of all patients with gastroschisis managed over a period of 30 months (January 2016–June 2018). Data on patients’ demographics, age, birth weight, clinical presentation, method of gastroschisis reduction and closure, complications, and outcomes were collated. Statistical analysis was performed using SPSS version 20. A p < 0.05 was considered significant.

Results: Twenty-four patients with gastroschisis were managed. Of these, 18 patients had data available for analysis. There were 14 males, with a male-female ratio of 3.5:1. The median age at presentation was 11.0 h (range 1–36 h). Ten patients (55.6%) were delivered in a medical facility. One patient had type II jejunal atresia and transverse colonic atresia as associated anomalies. Improvised silos were applied by the bedside in 15 (83.3%) patients, while two patients (11.1%) had primary closure under general anesthesia. One patient died before definitive treatment could be done. Sterile urobags and female condoms were used for constructing improvised silos in 9 (60%) and 6 (40%) patients, respectively. Eight patients who had initial silo application had complete bowel reduction over a median time of 8.0 days (mean 10.0 ± 6.5days, range 2–23 days). Total parenteral nutrition was not available. The average time to commencement of feeding was 8.0 days ± 6.6 (median 6.0 days, range 2–22 days). Full feeding was achieved in five patients (two patients in the primary closure group and three from the silo group) over a mean time of 16.8 days ± 10.4 (median 14.0 days). Sepsis was the commonest complication. Four patients (22.2%) survived.


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227. The initial experience of InterSurgeon: an online platform to facilitate global neurosurgical partnerships

journal of neurosurgery


Authors: Jacob R Lepard, S Hassan A Akbari , Faizal Haji , Matthew C Davis , William Harkness , James M Johnston
Region / country: Global
Speciality: Neurosurgery, Surgical Education

Objective: Despite general enthusiasm for international collaboration within the organized neurosurgical community, establishing international partnerships remains challenging. The current study analyzes the initial experience of the InterSurgeon website in partnering surgeons from across the world to increase surgical collaboration.

Methods: One year after the launch of the InterSurgeon website, data were collected to quantify the number of website visits, average session duration, total numbers of matches, and number of offers and requests added to the website each month. Additionally, a 15-question survey was designed and distributed to all registered members of the website.

Results: There are currently 321 surgeon and institutional members of InterSurgeon representing 69 different countries and all global regions. At the time of the survey there were 277 members, of whom 76 responded to the survey, yielding a response rate of 27.4% (76/277). Twenty-five participants (32.9%) confirmed having either received a match email (12/76, 15.8%) or initiated contact with another user via the website (13/76, 17.1%). As expected, the majority of the collaborations were either between a high-income country (HIC) and a low-income country (LIC) (5/18, 27.8%) or between an HIC and a middle-income country (MIC) (9/18, 50%). Interestingly, there were 2 MIC-to-MIC collaborations (2/18, 11.1%) as well as 1 MIC-to-LIC (1/18, 5.6%) and 1 LIC-to-LIC partnership. At the time of response, 6 (33.3%) of the matches had at least resulted in initial contact via email or telephone. One of the partnerships had involved face-to-face interaction via video conference. A total of 4 respondents had traveled internationally to visit their partner’s institution.

Conclusions: Within its first year of launch, the InterSurgeon membership has grown significantly. The partnerships that have already been formed involve not only international visits between HICs and low- to middle-income countries (LMICs), but also telecollaboration and inter-LMIC connections that allow for greater exchange of knowledge and expertise. As membership and site features grow to include other surgical and anesthesia specialties, membership growth and utilization is expected to increase rapidly over time according to social network dynamics.


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228. Pattern of Peri-Operative Antibiotic Use among Surgical Patients in a Regional Referral and Teaching Hospital in Uganda

Surgical Infections


Authors: Hiroki Saito , Kyoko Inoue , James Ditai , Andrew D Weeks
Region / country: Eastern Africa – Uganda
Speciality: General surgery

Background: Prolonged surgical antimicrobial prophylaxis (SAP) to prevent surgical site infection (SSI) is generally discouraged after completion of surgery. However, little is known about the pattern of peri-operative antibiotic use in resource-limited settings. We aimed to describe its use at a typical government hospital in Uganda. Methods: A study was originally conducted in a rural Ugandan regional referral and teaching hospital in 2014 and 2015 to improve hand hygiene practice and measure its impact on health-care-associated infections including SSI (WardGel study). This is a secondary analysis of the data from the WardGel study to assess the frequency of peri-operative antibiotic use among surgical patients. Results: Of 3,627 patients enrolled into the original study, 960 (26.5%) underwent surgery at the hospital and 907 patients (94.5%) received antibiotic agents during hospitalization. Of these, 880 patients (97.0%, of 907 patients) received antibiotic agents on the day of surgery. A combination of ceftriaxone and metronidazole was the most common regimen (609/907 patients, 67.1%). Thirty-six of 907 patients (4.0%) started and completed their antibiotic agents on the day of surgery. The mean length of antibiotic use during hospitalization was 3.5 days (standard deviation, 3.3). After adjusting for covariates, linear regression analysis showed an extra 1.9 days of antibiotic use post-operatively (95% confidence interval = 1.7-2.3). During the total 4,960 inpatient-days for those having surgery, there were 6,503 days of therapy (DOTs) of antibiotic agents and 1,649 antibiotic-free days (AFDs). Conclusions: Most patients received prolonged antibiotic therapy after surgery. Antimicrobial stewardship for SAP can play a major role in combating antimicrobial resistance in resource-limited settings.


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229. Effective Hand Preparation for Surgical Procedures in Low- and Middle-Income Countries

Surgical Infections


Authors: Peter Muli Nthumba
Region / country: Global
Speciality: General surgery, Other

Background: The burden of healthcare-associated infections (HAIs) is greatest in low- and middle-income countries (LMICs); surgical site infections (SSIs) are the most common HAI in LMICs. Hand hygiene is the single most effective strategy for reducing HAIs and the transmission of antimicrobial drug-resistant pathogens. Similarly, effective surgical hand preparation is a critical step in the prevention of SSIs in the surgical patient. Methods: Surgical hand preparation (SHP) is a seemingly simple activity that is easily overlooked. Performed properly, however, along with other measures, it has the potential to reduce SSIs in LMICs. The article reviews the current state of surgical hand preparation in LMICs. Results: Alcohol-based handrubs (ABHRs) have received wide acceptance by healthcare workers for both hand hygiene and SHP; when mixed with emollients, ABHRs retain efficacy against microorganisms and gain skin tolerability and user acceptability. Healthcare institutions in many LMICs face difficulties obtaining the products needed to ensure effective SHP using ABHRs. Conclusion: The ABHRs are the most efficacious surgical hand preparation products available today. They are cost-effective and can safely be prepared locally in hospitals, even in LMICs. The challenge of access to ABHRs should be addressed by national and local governments, through advocacy by healthcare workers coupled with continued lobbying and campaigns by the World Health Organization. Effective surgical hand preparation, like hand hygiene, saves lives.


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230. Neurosurgical Training and Global Health Education: Systematic Review of Challenges and Benefits of In-Country Programs in the Care of Neural Tube Defects

journal of neurosurgery


Authors: Kellen Gandy , Heidi Castillo , Brandon G Rocque , Viachaslau Bradko , William Whitehead , Jonathan Castillo
Region / country: Global
Speciality: Neurosurgery, Surgical Education

Objective: The recognition that neurosurgeons harbor great potential to advocate for the care of individuals with neural tube defects (NTDs) globally has sounded as a clear call to action; however, neurosurgical care and training in low- and middle-income countries (LMICs) present unique challenges that must be considered. The objective of this study was to systematically review publications that describe the challenges and benefits of participating in neurosurgery-related training programs in LMICs in the service of individuals with NTDs.

Methods: Using MEDLINE (PubMed), the authors conducted a systematic review of English- and Spanish-language articles published from 1974 to 2019 that describe the experiences of in-country neurosurgery-related training programs in LMICs. The inclusion criteria were as follows-1) population/exposure: US residents, US neurosurgeons, and local in-country medical staff participating in neurosurgical training programs aimed at improving healthcare for individuals with NTDs; 2) comparison: qualitative studies; and 3) outcome: description of the challenges and benefits of neurosurgical training programs. Articles meeting these criteria were assessed within a global health education conceptual framework.

Results: Nine articles met the inclusion criteria, with the majority of the in-country neurosurgical training programs being seen in subregions of Africa (8/9 [89%]) and one in South/Central America. US-based residents and neurosurgeons who participated in global health neurosurgical training had increased exposure to rare diseases not common in the US, were given the opportunity to work with a collaborative team to educate local healthcare professionals, and had increased exposure to neurosurgical procedures involved in treating NTDs. US neurosurgeons agreed that participating in international training improved their own clinical practices but also recognized that identifying international partners, travel expenses, and interference with their current practice are major barriers to participating in global health education. In contrast, the local medical personnel learned surgical techniques from visiting neurosurgeons, had increased exposure to intraoperative decision-making, and were given guidance to improve postoperative care. The most significant challenges identified were difficulties in local long-term retention of trained fellows and staff, deficient infrastructure, and lower compensation offered for pediatric neurosurgery in comparison to adult care.

Conclusions: The challenges and benefits of international neurosurgical training programs need to be considered to effectively promote the development of neurosurgical care for individuals with NTDs in LMICs. In this global health paradigm, future work needs to investigate further the in-country professionals’ perspective, as well as the related outcomes.


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231. Use of Social Media to Teach Global Reconstructive Surgery: Initiation of a Secret Facebook Group

Plastic and Reconstructive Surgery – Global Open


Authors: Deptula, Peter L. MD, Auten, Brieanne BA, Chang, James MD
Region / country: Global
Speciality: Plastic surgery, Surgical Education

Background:
The ReSurge Global Training Program (RGTP) is a model for building reconstructive surgery capacity in low- and middle-income countries.1 The aim of this study is to assess attitudes toward social media, to develop an initial RGTP Facebook Education Group, and to assess the early results of the group’s implementation.

Methods:
A survey of the RGTP community assessed group demographic, interests, concerns, and familiarity with Facebook from July to August of 2018. A “secret” Facebook group was launched on October 30, 2018. Narrated lectures were posted weekly to the group. Educational cases were shared on the group’s discussion page. Facebook “Group Insights” and individual post review were used to obtain group statistics.

Results:
Senior faculty were less likely to have an existing Facebook account (58% vs 93%, P < 0.05). Trainees were more confident using Facebook (97% vs 54%, P < 0.05) and favored viewing the training curriculum through Facebook (93.0%, P < 0.05). At 6 months, the group enrolled 103 members from 14 countries. Twenty-two lectures were posted, obtaining an average of 59.4 views (range, 36–78). Fourteen cases were presented for group discussion with an average of 61.1 views (range, 43–87).

Conclusions:
The RGTP Facebook group has continued to expand in its early months. This group allows our community to view RGTP’s training curriculum, while providing global access to expert opinion and collaboration. The secret Facebook group can be used as an effective and easy-to-use platform for educational outreach in global reconstructive surgery.


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232. Major abdominal wall defects in the low- and middle-income setting: current status and priorities

Pediatric Surgery International


Authors: Lofty-John Chukwuemeka Anyanwu, Niyi Ade-Ajayi & Udo Rolle
Region / country: Global
Speciality: General surgery, Paediatric surgery

Major congenital abdominal wall defects (gastroschisis and omphalocele) may account for up to 21% of emergency neonatal interventions in low- and middle-income countries. In many low- and middle-income countries, the reported mortality of these malformations is 30-100%, while in high-income countries, mortality in infants with major abdominal wall reaches less than 5%. This review highlights the challenges faced in the management of newborns with major congenital abdominal wall defects in the resource-limited setting. Current high-income country best practice is assessed and opportunities for appropriate priority setting and collaborations to improve outcomes are discussed.


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233. Trauma burden, patient demographics and care-process in major hospitals in Tanzania: A needs assessment for improving healthcare resource management

African Journal of Emergency Medicine


Authors: Michael Mwandri, Timothy Craig Hardcastle, Hendry Sawe, Francis Sakita, Juma Mfinanga, Sarah Urassa, Alex Mremi, Lazaro Nelbert Mboma, Prosper Bashaka
Region / country: Eastern Africa – Tanzania
Speciality: Emergency surgery, Trauma surgery

Background
Appropriate referrals of injured patients could improve clinical outcomes and management of healthcare resources. To gain insights for system development, we interrogated the current situation by assessing burden, patient demography, causes of injury, trauma mortality and the care-process.

Methods
We used an observational, cross-sectional study design and convenience sampling to review patient charts from 3 major hospitals and the death registry in Tanzania.

Results
Injury constitutes 9–13% of the Emergency Centre census. Inpatient trauma-deaths were 8%; however, the trauma death registry figures exceeded the ‘inpatient deaths’ and recorded up to 16%. Most patients arrive through a hospital referral system (82%) and use a hospital transport network (76%). Only 8% of the trauma admissions possessed National Health Insurance. Road traffic collision (RTC) (69%), assault (20%) and falls (9%) were the leading causes of injury. The care process revealed a normal primary-survey rate of 73–90%. Deficiencies in recording were in the assessment of: Airway and breathing (67%), circulation (40%) and disability (80%). Most patients had non-operative management (42–57%) or surgery for wound care or skeletal injuries (43%). Laparotomies were performed in 26%, while craniotomy and chest drain-insertion were each performed in 10%.

Conclusion
The burden of trauma is high, and the leading causes are: RTC, assault, and falls. Deaths recorded in the death registries outweigh in-hospital deaths for up to twofold. There are challenges in the care process, funding and recording. We found a functional hospital referral-network, transport system, and death registry.


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234. Cross-sectional study of surgical quality with a novel evidence-based tool for low-resource settings

BMJ open quality


Authors: Lina Roa, Isabelle Citron, Jania A Ramos, Jessica Correia, Berenice Feghali, Julia R Amundson, Saurabh Saluja, Nivaldo Alonso, Rodrigo Vaz Ferreira
Region / country: South America – Brazil
Speciality: General surgery, Other, Surgical Education

Background Adverse events from surgical care are a major cause of death and disability, particularly in low-and-middle-income countries. Metrics for quality of surgical care developed in high-income settings are resource-intensive and inappropriate in most lower resource settings. The purpose of this study was to apply and assess the feasibility of a new tool to measure surgical quality in resource-constrained settings.

Methods This is a cross-sectional study of surgical quality using a novel evidence-based tool for quality measurement in low-resource settings. The tool was adapted for use at a tertiary hospital in Amazonas, Brazil resulting in 14 metrics of quality of care. Nine metrics were collected prospectively during a 4-week period, while five were collected retrospectively from the hospital administrative data and operating room logbooks.

Results 183 surgeries were observed, 125 patient questionnaires were administered and patient charts for 1 year were reviewed. All metrics were successfully collected. The study site met the proposed targets for timely process (7 hours from admission to surgery) and effective outcome (3% readmission rate). Other indicators results were equitable structure (1.1 median patient income to catchment population) and equitable outcome (2.5% at risk of catastrophic expenditure), safe outcome (2.6% perioperative mortality rate) and effective structure (fully qualified surgeon present 98% of cases).

Conclusion It is feasible to apply a novel surgical quality measurement tool in resource-limited settings. Prospective collection of all metrics integrated within existing hospital structures is recommended. Further applications of the tool will allow the metrics and targets to be refined and weighted to better guide surgical quality improvement measures.


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235. Lagos state ambulance service: a performance evaluation

European Journal of Trauma and Emergency Surgery


Authors: Chinmayee Venkatraman, Aina Olufemi Odusola, Chenchita Malolan, Olusegun Kola-Korolo, Oluwole Olaomi, Jide Idris & Fiemu E. Nwariaku
Region / country: Western Africa – Nigeria
Speciality: Emergency surgery, Trauma surgery

Objectives: The mortality rate from road traffic accidents (RTAs) in Nigeria is almost double that of the USA. In Nigeria, the first emergency medical services (EMS) system was established in March 2001, The Lagos State Ambulance Service (LASAMBUS). The objectives of this study are to (1) determine the burden of RTAs in Lagos, (2) assess RTA call outcomes, and (3) analyze LASAMBUS’s response time and causes for delay.

Methodology: We reviewed completed LASAMBUS intervention forms spanning December 2017 to May 2018. We categorized the call outcomes into five groups: I. Addressed Crash, II. No Crash (False Call), III. Crash Already Addressed, IV. Did Not Respond, and V. Other. We further explored associations between the (1) causes for delay and outcomes and (2) response times and the outcomes.

Results: Overall, we analyzed 1352 intervention forms. We found that LASAMBUS did not address 53% of the RTA calls that they received. Of this, Outcome II. No Crash (False Call) accounted for 26% and Outcome III. Crash Already Addressed accounted for 22%. Self-reported causes for delay were recorded in 180 forms, representing 13.7% of the RTA burden. Traffic congestion accounted for 60% of this distribution.

Conclusion: LASAMBUS response rates are significantly lower than response rates in high-income countries such as the USA and lead to increased RTA mortality rates. Eliminating causes for delay will improve both LASAMBUS effectiveness and RTA victims’ health outcomes. Changing the public perception of LASAMBUS and standardizing LASAMBUS’ contact information will aid this as well.


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236. Tracheoesophageal fistula in the developing world: are we ready for thoracoscopic repair?

Pediatric Surgery International


Authors: Hossam S. Alslaim, Andrew B. Banooni, Ahmad Shaltaf & Nathan M. Novotny
Region / country: Global
Speciality: Cardiothoracic surgery, Paediatric surgery

Purpose: Tracheoesophageal fistula (TEF) is a bellwether for a country’s ability to care for sick newborns. We aim to review the existing literature from low- and middle-income countries in regard to management of those newborns and the possible approaches to improve their outcomes.

Methods: A review of the existing English literature was conducted with the aim of assessing challenges faced by providers in LMIC in terms of diagnostic, preoperative, operative and post-operative care for TEF patients. We also review the limited literature for performing thoracoscopic repair in the developing world context and suggest methods for introduction of advanced thoracoscopic procedures including techniques for providing anesthesia to these challenging babies.

Results: While outcomes related to technique from LMIC are comparable to the developed world, rates of secondary complications like sepsis and pneumonia are higher. In many areas, repairs are conducted in a staged fashion with minimal utilization of thoracoscopic approach. The paucity of resources creates strain on intraoperative and post-operative management.

Conclusion: Clearly, not all developing world contexts are ready to attempt thoracoscopic repair but we outline suggestions for assessing the existing capabilities and a stepwise gradual implementation of advanced thoracoscopy when appropriate.


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237. Travel barriers, unemployment, and external fixation predict loss to follow-up after surgical management of lower extremity fractures in Dar es Salaam, Tanzania

open access journal of Orthopedic trauma


Authors: Patterson, Joseph T. MD, Albright, Patrick D. BS, MS, Jackson, J. Hunter BA, Eliezer, Edmund N. MD, Haonga, Billy T. MD, Morshed, Saam MD, MPH, PhD, Shearer, David W. MD, MPH
Region / country: Eastern Africa – Tanzania
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Objective:
Predict loss to follow-up in prospective clinical investigations of lower extremity fracture surgery.

Design:
Secondary analysis of 2 prospective clinical trials.

Setting:
National public orthopaedic and neurologic trauma tertiary referral hospital in Dar es Salaam, Tanzania, a low-income country in sub-Saharan Africa.

Patients/Participants:
Three hundred twenty-nine femoral shaft and 240 open tibial shaft fracture patients prospectively enrolled in prospective controlled trials of surgical fracture management by external fixation, plating, or intramedullary nailing between June 2015 and March 2017.

Intervention:
Telephone contact for failure to attend scheduled 1-year clinic visit.

Main Outcome Measurements:
Ascertainment of primary trial outcome at 1-year from surgery; post-hoc telephone questionnaire for reasons patient did not attend the 1-year clinic visit.

Results:
One hundred twenty-seven femur fracture (39%) and 68 open tibia fracture (28%) patients did not attend the 1-year clinic visit. Telephone contact significantly improved ascertainment of the primary study outcome by 20% between 6-month and 1-year clinic visits to 82% and 92% respectively at study completion. Multivariable analysis associated unemployment (OR = 2.5 [1.7–3.9], P < .001), treatment with an external fixator (OR = 1.7 [1.0–2.8], P = .033), and each additional 20 km between residence and clinic (OR = 1.03 [1.00–1.06], P = .047] with clinic nonattendance. One hundred eight (55%) nonattending patients completed the telephone questionnaire, reporting travel distance to the hospital (49%), and travel costs to the hospital (46%) as the most prevalent reasons for nonattendance. Sixty-five percent of patients with open tibia fractures cited relocation after surgery as a contributing factor.

Conclusions:
Relocation during recovery, travel distance, travel cost, unemployment, and use of an external fixator are associated with loss to clinical follow-up in prospective investigations of femur and open tibia fracture surgery in this population. Telephone contact is an effective means to assess outcome.


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238. Clinical profile and patterns of extremity fractures among patients visiting orthopedics department in Tikur Anbessa specialized hospital, Ethiopia.

ethiopian medical journal


Authors: Girma Seyoum
Region / country: Eastern Africa – Ethiopia
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Background: Fracture is a loss in the structural continuity of bone which results from injury, repetitive stress, or abnormal weakening of the bone. Globally, fracture injury continues to be an important cause of morbidity and disability both in the developed and developing countries.

Objective: The aim of this study was to assess the clinical profile and patterns of extremity fracture patients visiting orthopedic department at TASH, Ethiopia.

Materials and Method: Institutional based retrospective cross-sectional study was carried out. The sample size was 354 and study participants were extermity fracture cases. The data were analyzed using SPSS 21. Chi-square (χ2) test was applied to see if there was any association between the different variables.

Results: Most of the fracture victims, 111 (32.6%), were between the ages of 15 and 29 years. Lower extremity fracture (65.6%) was more common compared to upper extremity (34.7%). The femur (23.7 %) was the commonest fractured bone. The common patterns of fractures were transverse type which accounted for (35.5 %). The leading causes of fractures were road traffic injuries (RTIs) (42.2%) followed by falling down accidents (29.6%). The Cause of fracture and number of bone fracture were significantly associated with age (p<0.05).

Conclusion: The most commonly fractured bone in the extremities was the femur followed by tibia and fibula. Transverse factures followed by communited-type of fractures were the commonest patterns of fracture. The leading cause of fracture was road traffic injury followed by falling-down accidents.


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239. Severe Acute Multi-Systemic Failure With Bilateral Ocular Toxoplasmosis in Immunocompetent Patients From Urban Settings in Colombia: Case Reports

american journal of ophthalmology case report


Authors: Diana Alejandra Cortés , María Camila Aguilar , Hernán Andres Ríos , Francisco José Rodríguez , Kelly Verónica Montes , Jorge Enrique Gómez-Marín , Alejandra de-la-Torre
Region / country: South America – Colombia
Speciality: Ophthalmology

Propose: To report two cases of severe acute multi-systemic failure with bilateral ocular toxoplasmosis in immunocompetent patients from urban settings in Colombia.

Observations: We report two immunocompetent male patients aged 44- and 67-years-old who, despite not having visited the Amazonian region in Colombia, had severe bilateral posterior uveitis and extensive-bilateral macular lesions and multiple organ failure that required admission to an intensive care unit. Toxoplasma gondii was positive by PCR assay in vitreous humor samples. Patients were treated with intravitreal clindamycin and dexamethasone in addition to systemic treatment with trimethoprim-sulfamethoxazole. In both patients, infection by atypical strains was confirmed; in one case by serotyping and in another one by genotyping (ROP 18 virulent allele). After 2 and 4 months of treatment respectively, the patients showed improvement of the posterior uveitis and its systemic manifestations. However, there was no significant visual acuity improvement due to bilateral extensive macular involvement.

Conclusions and importance: Clinicians should be aware that toxoplasmosis originating from South America could be associated with severe acute multisystemic and intraocular bilateral involvement, even in patients with no history of exposure to jungle environments.


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240. An Analysis of Cross-Continental Scholarship Requirements During Neurosurgical Training and National Research Productivity

journal of neurosurgery


Authors: Michael S Rallo, Omar Ashraf, Fareed Jumah, Gaurav Gupta, Anil Nanda
Region / country: Global
Speciality: Neurosurgery, Surgical Education

Objective: Engagement in research and scholarship is considered a hallmark of neurosurgical training. However, the participation of neurosurgical trainees in this experience has only recently been analyzed and described in the United States, with little, if any, data available regarding the research environment in neurosurgical training programs across the globe. Here, the authors set out to identify requirements for research involvement and to quantify publication rates in leading neurosurgical journals throughout various nations across the globe.

Methods: The first aim was to identify the research requirements set by relevant program-accrediting and/or board-certifying agencies via query of the literature and published guidelines. For the second part of the study, the authors attempted to determine each country’s neurosurgical research productivity by quantifying publications in the various large international neurosurgical journals-World Neurosurgery, Journal of Neurosurgery, and Neurosurgery-via a structured search of PubMed.

Results: Data on neurosurgical training requirements addressing research were available for 54 (28.1%) of 192 countries. Specific research requirements were identified for 39 countries, partial requirements for 8, and no requirements for 7. Surprisingly, the authors observed a trend of increased average research productivity with the absence of designated research requirements, although this finding is not unprecedented in the literature.

Conclusions: A variety of countries of various sizes and neurosurgical workforce densities across the globe have instituted research requirements during training and/or prior to board certification in neurosurgery. These requirements range in intensity from 1 publication or presentation to the completion of a thesis or dissertation and occur at various time points throughout training. While these requirements do not correlate directly to national research productivity, they may provide a foundation for developing countries to establish a culture of excellence in research.


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241. Predictors of Survival After Head and Neck Squamous Cell Carcinoma in South America: The InterCHANGE Study

jCO Global oncology


Authors: Renata Abrahão MD, MSc, PhD, Sandra Perdomo PhD, Luis Felipe Ribeiro Pinto PhD, Flavia Nascimento de Carvalho MSc, Fernando Luis Dias MD, PhD, Jose Roberto V. de Podesta MD, Sandra Ventorin von Zeidler PhD, Priscila Marinho de Abreu PharmD, MSc, Marta Vilensky BSc, Raul Eduardo Giglio MD, Jose Carlos Oliveira PhD, Matinair Siqueira Mineiro RN, Luiz P. Kowalski MD, PhD, Mauro K. Ikeda PhD, Mauricio Cuello MD, Andres Munyo MD, Paula A. Rodrıguez-Urrego MD, Jose Antonio Hakim, MD ´ 4 ; David Alfonso Suarez-Zamora MD, Federico Cayol, MD, Marcelo Fernando Figari MD, Javier Oliver PhD, Valerie Gaborieau DUT, Ruth H. Keogh DPhil, Paul Brennan, PhD and Maria Paula Curado, PhD, MD on behalf of the InterCHANGE Group
Region / country: South America – Argentina, Brazil, Colombia, Uruguay
Speciality: ENT surgery, Surgical oncology

PURPOSE
Head and neck squamous cell carcinoma (HNSCC) incidence is high in South America, where recent data on survival are sparse. We investigated the main predictors of HNSCC survival in Brazil, Argentina, Uruguay, and Colombia.

METHODS
Sociodemographic and lifestyle information was obtained from standardized interviews, and clinicopathologic data were extracted from medical records and pathologic reports. The Kaplan-Meier method and Cox regression were used for statistical analyses.

RESULTS
Of 1,463 patients, 378 had a larynx cancer (LC), 78 hypopharynx cancer (HC), 599 oral cavity cancer (OC), and 408 oropharynx cancer (OPC). Most patients (55.5%) were diagnosed with stage IV disease, ranging from 47.6% for LC to 70.8% for OPC. Three-year survival rates were 56.0% for LC, 54.7% for OC, 48.0% for OPC, and 37.8% for HC. In multivariable models, patients with stage IV disease had approximately 7.6 (LC/HC), 11.7 (OC), and 3.5 (OPC) times higher mortality than patients with stage I disease. Current and former drinkers with LC or HC had approximately 2 times higher mortality than never-drinkers. In addition, older age at diagnosis was independently associated with worse survival for all sites. In a subset analysis of 198 patients with OPC with available human papillomavirus (HPV) type 16 data, those with HPV-unrelated OPC had a significantly worse 3-year survival compared with those with HPV-related OPC (44.6% v 75.6%, respectively), corresponding to a 3.4 times higher mortality.

CONCLUSION
Late stage at diagnosis was the strongest predictor of lower HNSCC survival. Early cancer detection and reduction of harmful alcohol use are fundamental to decrease the high burden of HNSCC in South America.


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242. Sex Disparities in the Global Burden of Surgical Disease

World Journal of Surgery


Authors: Brittany L. Powell, Rebecca Luckett, Abebe Bekele & Tiffany E. Chao
Region / country: Global
Speciality: General surgery, Other

The 2015 Lancet Commission on Global Surgery and 2015 Global Burden of Disease study provide evidence for the increasing relative burden of noncommunicable diseases in low- and middle-income countries (LMICs), including surgical conditions such as injuries, gastrointestinal diseases, and cancer [1, 2]. While many of these conditions affect both men and women, women bear a large burden of sex-specific surgical disease.


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243. A traveling fellowship to build surgical capacity in Ethiopia: the Jimma University specialized hospital and operation smile partnership

International Journal of Surgery: Global Health


Authors: Meghan McCullough, MD, Allison Bradshaw, MSc , Daniel Getachew, MD , Yonas Eshetu, MD , Anjali Raghuram, BA , Jacqueline Stoneburner, BS , Rojine Ariani, MS , William P. Magee, DDS, MD, Per N. Hall, MD, FRCS
Region / country: Eastern Africa – Ethiopia
Speciality: General surgery, Surgical Education

A lack of trained providers is an important contributor to the unmet burden of surgical disease treatment in low- and middle-income countries. The World Health Organization’s Commission on the International Recruitment of Health Personnel lays out guiding principles for addressing this workforce crisis. However, for surgical subspecialties such as plastic surgery, in-country training opportunities remain limited and there is a clear need for effective strategies to retain providers and develop sustainable solutions. We report the design and early implementation of a traveling fellowship in plastic surgery for providers at Jimma University Specialized Hospital in Jimma, Ethiopia. This fellowship is supported by Operation Smile and its network of international surgical volunteers. Since its inception, the program has trained 2 general surgeons with a commitment to helping train a total of 6 surgeons to establish a self-sustaining service. Key innovations include multiple international sites to facilitate broad subspecialty training, commitment of participants to return to Jimma upon completion of the program to establish a local training service, and coordination with national governing bodies to ensure program recognition and support. Ongoing challenges include physical resource limitations and coordination with a wide array of stakeholders. Nongovernmental organizations also have a role to play in supporting the Ministries of Health in scaling up human resources for improved health within their countries. Operation Smile’s traveling fellowship demonstrates a feasible method of addressing the health workforce crisis by providing specialized training and facilitating the development of surgical teaching programs capable of sustainably serving local communities.


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244. Liver Trauma: WSES 2020 Guidelines

World Journal of Emergency Surgery


Authors: Federico Coccolini, Raul Coimbra, Carlos Ordonez, Yoram Kluger, Felipe Vega, Ernest E. Moore, Walt Biffl, Andrew Peitzman, Tal Horer, Fikri M. Abu-Zidan, Massimo Sartelli, Gustavo P. Fraga, Enrico Cicuttin, Luca Ansaloni, Michael W. Parra, Mauricio Millán, Nicola DeAngelis, Kenji Inaba, George Velmahos, Ron Maier, Vladimir Khokha, Boris Sakakushev, Goran Augustin, Salomone di Saverio, Emanuil Pikoulis, Mircea Chirica, Viktor Reva, Ari Leppaniemi, Vassil Manchev, Massimo Chiarugi, Dimitrios Damaskos, Dieter Weber, Neil Parry, Zaza Demetrashvili, Ian Civil, Lena Napolitano, Davide Corbella, Fausto Catena, and the WSES expert panel
Region / country: Global
Speciality: Emergency surgery

Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.


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245. Global Trends of Hand and Wrist Trauma: A Systematic Analysis of Fracture and Digit Amputation Using the Global Burden of Disease 2017 Study

injury prevention


Authors: Crowe CS, Massenburg BB, Morrison SD, Chang J, Friedrich JB, Abady GG, Alahdab F, Alipour V, Arabloo J, Asaad M, Banach M, Bijani A, Borzì AM, Briko NI, Castle CD, Cho DY, Chung MT, Daryani A, Demoz GT, Dingels ZV, Do HT, Fischer F, Fox JT, Fukumoto T, Gebre AK, Gebremichael B, Haagsma JA, Haj-Mirzaian A, Handiso DW, Hay SI, Hoang CL, Irvani SSN, Jozwiak JJ, Kalhor R, Kasaeian A, Khader YS, Khalilov R, Khan EA, Khundkar R, Kisa S, Kisa A, Liu Z, Majdan M, Manafi N, Manafi A, Manda AL, Meretoja TJ, Miller TR, Mohammadian-Hafshejani A, Mohammadpourhodki R, Mohseni Bandpei MA, Mokdad AH, Naimzada MD, Ndwandwe DE, Nguyen CT, Nguyen HLT, Olagunju AT, Olagunju TO, Pham HQ, Pribadi DRA, Rabiee N, Ramezanzadeh K, Ranganathan K, Roberts NLS, Roever L, Safari S, Samy AM, Sanchez Riera L, Shahabi S, Smarandache CG, Sylte DO, Tesfay BE, Tran BX, Ullah I, Vahedi P, Vahedian-Azimi A, Vos T, Woldeyes DH, Wondmieneh AB, Zhang ZJ, James SL.
Region / country: Global
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Background As global rates of mortality decrease, rates of non-fatal injury have increased, particularly in low Socio-demographic Index (SDI) nations. We hypothesised this global pattern of non-fatal injury would be demonstrated in regard to bony hand and wrist trauma over the 27-year study period.

Methods The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 was used to estimate prevalence, age-standardised incidence and years lived with disability for hand trauma in 195 countries from 1990 to 2017. Individual injuries included hand and wrist fractures, thumb amputations and non-thumb digit amputations.

Results The global incidence of hand trauma has only modestly decreased since 1990. In 2017, the age-standardised incidence of hand and wrist fractures was 179 per 100 000 (95% uncertainty interval (UI) 146 to 217), whereas the less common injuries of thumb and non-thumb digit amputation were 24 (95% UI 17 to 34) and 56 (95% UI 43 to 74) per 100 000, respectively. Rates of injury vary greatly by region, and improvements have not been equally distributed. The highest burden of hand trauma is currently reported in high SDI countries. However, low-middle and middle SDI countries have increasing rates of hand trauma by as much at 25%.

Conclusions Certain regions are noted to have high rates of hand trauma over the study period. Low-middle and middle SDI countries, however, have demonstrated increasing rates of fracture and amputation over the last 27 years. This trend is concerning as access to quality and subspecialised surgical hand care is often limiting in these resource-limited regions.


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246. Surgathon: a new model for creating a surgical innovation ecosystem in low-resource settings

BMJ Glob Health


Authors: Shivani Mitra, Joanna Ashby, Arsen Muhumuza, Isaac Ndayishimiye, Isaac Wasserman, Vatshalan Santhirapala, Alexander W Peters, Dominique Vervoort, Oshin Jacob, Jesudian Gnanaraj, Praveen Ganesh, Salim A
Region / country: Global
Speciality: Surgical Education

Innovation ecosystems and emerging technologies can potentially accelerate the access to safe, affordable surgical care in low-resource settings. There is a need to develop localised innovation ecosystems that can establish an initial culture and catalyse the creation, adoption and diffusion of innovation. The surgathon model outlines one approach to seeding surgical innovation ecosystems. International academic institutions collaborated on six global surgery, innovation and ethics-themed hackathons (‘surgathons’) across India and Rwanda between 2016 and 2019. Over 1598 local multidisciplinary students participated, learning about challenges in the delivery of surgical care and ideating solutions that could leverage appropriate technology and resources for impact. Pursuing student ideas and evaluating their implementation past the surgathons continues to be an active effort. Surgathons have unfolded in different permutations based on local faculty, institution and health system context. The surgathon model is a novel method of priority setting challenges in global surgery and utilises locally driven expertise and innovation capacity to derive ethical solutions. The model offers a path for low-resource setting students and faculty to learn, advocate and innovate for improved surgical care.


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247. Management and outcomes following emergency surgery for traumatic brain injury – A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study).

International Journal of Surgery Protocals


Authors: Clark D, Joannides A, Ibrahim Abdallah O, Olufemi Adeleye A, Hafid Bajamal, Bashford T, Bhebhe, Biluts H, Budohoska N, Budohoski K, Cherian I, Marklund N, Fernandez Mendez R, Figaji T, Kumar Gupta D, Iaccarino C, Ilunga A, Joseph M, Khan T, Laeke T, Waran V, Park K, Rosseau G, Rubiano A, Saleh Y, Shabani HK, Smith B, Sichizya K, Tewari M, Tirsit A, Thu M, Tripathi M, Trivedi R, Villar S, Devi Bhagavatula I, Servadei F, Menon D, Kolias A, Hutchinson P; Global Neurotrauma Outcomes Study (GNOS) collaborative.
Region / country: Global – Colombia, Egypt, Ethiopia, India, Indonesia, Italy, Malaysia, Nepal, Nigeria, Pakistan, South Africa, Sweden, Tanzania, United Kingdom, United States of America, Zambia
Speciality: Emergency surgery, Neurosurgery, Trauma surgery

Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.


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248. Emergency chest wall reconstruction in open pneumo-thorax from gunshot chest: A case report

Journal of Pakistan Medical Association


Authors: Naveed Ullah Khan, Zahoor Ahmed, Farooq Malik, Javaid Ahmed, Sarwat Saeed, Inayat Ullah Baig
Region / country: Southern Asia – Pakistan
Speciality: Cardiothoracic surgery, Emergency surgery, Trauma surgery

Chest trauma, penetrating or blunt is common in this era of motor vehicle accidents, violence and terrorism in South Asia. Islamabad is the capital of Pakistan but there is no dedicated chest surgery unit in any government sector hospitals. Gunshot chest, is therefore managed by general surgery team in our tertiary care setting i.e. Federal Government Polyclinic Hospital and Post Graduate Medical Institute, Islamabad. We report a case of gunshot chest with lung contusion and open pneumothorax with a chest wall defect of 10 x 15 cm. in March 2015, this young man presented in emergency department of Federal Government Polyclinic Hospital (FGPC), Post Graduate Medical Institute (PGMI) Islamabad in shock after self-inflicted point blank suicidal gunshot to his left anterolateral chest. After primary resuscitation, the patient was shifted to OR, and a left anterolateral thoracotomy performed. Lung contusion was repaired and chest drain placed. The challenging task of closing the huge chest wall defect was performed by rotating the left latissimus dorsi muscle flap. The patient was shifted to ICU and remained stable postoperatively.


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249. Hydatid cyst of thyroid gland, a rare case report with a literature review

International Journal of Surgery Case Reports


Authors: Abdwlwahid M. Saliha, Zanyar Y. Abdulla b, Dlawar A. Mohammedc,k, Vanya I. Jwamer d, Pshtiwan G. Ali e, Ahmed G. Hamasaeede, Hawar H. Shkur f , Jalal K. Omer g, Rawezh Q. Salihh, Shvan H. Mohammed h, Aso S. Muhialdeenh, Karzan Mohammedi , Snur Othmanh, Fahmi H. Kakamad
Region / country: Middle East – Iraq
Speciality: ENT surgery

Introduction: Although hydatid cysts can affect any organ in the body, reports regarding affection of thyroid gland are scanty in the literature. This report aims to present a case of thyroid hydatid disease with literature review.

Case report: A 48-year-old female presented with painless anterior neck mass of about 2 year duration. There was an ill-defined, central anterior neck mass, with a smooth surface and mobile with deglutition. Ultrasound of the thyroid gland revealed an enlarged left lobe of thyroid gland due to well defined thick wall cystic nodule. The patient underwent left thyroid lobectomy under general anesthesia, the pathology report revealed hydatid cyst of thyroid gland.

Discussion: Liver and lungs are often the end destination for hydatid cysts, while other places like mediastinum, diaphragm, cardiac, smooth and skeletal muscles, abdominal and chest walls are rarely involved. In this case, the cyst affected even a rarer organ which was the left lobe of thyroid gland. Most of the time the disease is asymptomatic and is found accidentally, yet depending on the site and size of the cysts, symptoms can occur.

Conclusion: Hydatid disease of thyroid gland is an extremely rare condition. The main presenting symptom is swelling. Operation under general anesthesia is the only modality of treatment.


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250. The Epidemiology of Traumatic Brain Injury Due to Traffic Accidents in Latin America: A Narrative Review

Journal of Neurosciences in Rural Practice


Authors: Jack Dunne, Gabriel Alexander Quiñones-Ossa  , Ethne Grey Still, María N. Suarez, José A. González-Soto, David S. Vera, Andrés M. Rubiano
Region / country: South America – Colombia
Speciality: Neurosurgery, Trauma surgery

Objective Traumatic brain injuries (TBIs) are devastating injuries and represent a major cause of morbidity and mortality worldwide. Traffic accidents are one of the main causes, especially in low- and middle-income countries. The epidemiology of TBI due to road traffic in Latin America is not clearly documented.

Methods A narrative review was conducted using PubMed, SCOPUS, and Google Scholar, looking for TBI studies in Latin America published between 2000 and 2018. Seventeen studies were found that met the inclusion and exclusion criteria.

Results  It was found that TBI due to road traffic accidents (RTAs) is more frequent in males between the ages of 15 and 35 years, and patients in motor vehicles accounted for most cases, followed by pedestrians, motorcyclists, and cyclists.

Conclusion Road traffic accidents is a common cause of TBI in Latin America. More studies and registries are needed to properly document the epidemiological profiles of TBI related to RTAs.


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251. Comparison of emergency department trauma triage performance of clinicians and clinical prediction models: a cohort study in India

BMJ Open


Authors: Ludvig Wärnberg Gerdin, Monty Khajanchi, Vineet Kumar, Nobhojit Roy, Makhan Lal Saha, Kapil Dev Soni, Anurag Mishra, Jyoti Kamble, Nitin Borle, Chandrika Prasad Verma, Martin Gerdin Wärnberg
Region / country: South-eastern Asia – India
Speciality: Emergency surgery, Trauma surgery

Objective: The aim of this study was to evaluate and compare the abilities of clinicians and clinical prediction models to accurately triage emergency department (ED) trauma patients. We compared the decisions made by clinicians with the Revised Trauma Score (RTS), the Glasgow Coma Scale, Age and Systolic Blood Pressure (GAP) score, the Kampala Trauma Score (KTS) and the Gerdin et al model.

Design: Prospective cohort study.

Setting: Three hospitals in urban India.

Participants: In total, 7697 adult patients who presented to participating hospitals with a history of trauma were approached for enrolment. The final study sample included 5155 patients. The majority (4023, 78.0%) were male.

Main outcome measure The patient outcome was mortality within 30 days of arrival at the participating hospital. A grid search was used to identify model cut-off values. Clinicians and categorised models were evaluated and compared using the area under the receiver operating characteristics curve (AUROCC) and net reclassification improvement in non-survivors (NRI+) and survivors (NRI−) separately.

Results:The differences in AUROCC between each categorised model and the clinicians were 0.016 (95% CI −0.014 to 0.045) for RTS, 0.019 (95% CI −0.007 to 0.058) for GAP, 0.054 (95% CI 0.033 to 0.077) for KTS and −0.007 (95% CI −0.035 to 0.03) for Gerdin et al. The NRI+ for each model were −0.235 (−0.37 to −0.116), 0.17 (−0.042 to 0.405), 0.55 (0.47 to 0.65) and 0.22 (0.11 to 0.717), respectively. The NRI− were 0.385 (0.348 to 0.4), −0.059 (−0.476 to −0.005), −0.162 (−0.18 to −0.146) and 0.039 (−0.229 to 0.06), respectively.

Conclusion: The findings of this study suggest that there are no substantial differences in discrimination and net reclassification improvement between clinicians and all four clinical prediction models when using 30-day mortality as the outcome of ED trauma triage in adult patients.


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252. Investing in Pediatric Surgical Research to Advance Universal Health Coverage for Children in Nigeria

Nigerian Journal of surgery


Authors: Justina O. Seyi-Olajid , Emmanuel A. Ameh
Region / country: Global – Nigeria
Speciality: Paediatric surgery

About 1.7 billion children and adolescents most of whom are in low- and middle-income countries lack access to safe and affordable surgical and anesthesia care when needed. 43% of Nigeria’s population of 199 million are below the age of 15 years. In 2015, Nigeria had a pediatric surgeon workforce deficit of 693 for children <15 years. While threats and constraints to achieving universal health coverage in Nigeria have been highlighted, the role of research is often not included. Over the years, there has been a slow but progressive increase in pediatric surgical workforce and research output, both locally and with international collaborations, and in trainee involvement in research as lead authors. There has unfortunately been a challenge with translation of research findings, outcomes, and recommendations into actions. Despite the various challenges mitigating against pediatric surgery research, efforts must be committed to developing and implementing innovative approaches to address the problems and challenges, as well as implementing quality improvement programs and deploying technology to advance children's care. It is hoped that inclusion of children's surgery in the National Surgical, Obstetrics, Anaesthesia, and Nursing Plan would strengthen pediatric surgical research in Nigeria.


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253. Effect of Dexmedetomidine Combined with Inhalation of Isoflurane on Oxygenation Following One-Lung Ventilation in Thoracic Surgery

ANESTHESIOLOGY AND PAIN MEDICINE


Authors: Somayeh Asri , Hamzeh Hosseinzadeh , Mahmood Eydi , Marzieh Marahem , Abbasali Dehghani , Hassan Soleimanpour
Region / country: Western Asia – Iran
Speciality: Anaesthesia, Cardiothoracic surgery

Background: One-lung ventilation (OLV) is commonly used during thoracic surgery. At this time, hypoxemia is considered one of the remarkable consequences of the anesthesia management. Hypoxic pulmonary vasoconstriction (HPV) is the defense mechanism against hypoxia.
Objectives: The aim of the present study was to investigate the effect of infusion of dexmedetomidine on improving the oxygenation during OLV among the adult patients undergoing thoracic surgery.
Methods: A total of 42 patients undergoing OLV by general anesthesia with isoflurane inhalation were randomly assigned into two groups: IV infusion of dexmedetomidine at 0.3 microgram/kg/h (DISO) and IV infusion of normal saline (NISO). Three Arterial Blood Gas (ABG) samples were obtained throughout the surgery. Hemodynamic parameters, PaO2, PaCO2, and complications at recovery phase were recorded. The collected information was analyzed using SPSS software version 22.
Results: In the dexmedetomidine group, the mean hemodynamic parameters had a significant reduction at 30 and 60 minutes following OLV. Administration of dexmedetomidine resulted in a significant increase in the PaCO2 and a reduction in the PaO2 when changing from two-lung ventilation to OLV, where PaO2 reached its maximum value within 10 minutes after OLV in the DISO group, and it began to gradually increase to the end of operation. The duration of the recovery phase, also complications at the recovery phase decreased significantly in DISO group.
Conclusions: The results of the study showed that, dexmedetomidine may improve arterial oxygenation during OLV in adult patients undergoing thoracic surgery, and can be a suitable anesthetic agent for thoracic surgery.


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254. Decentralization and Regionalization of Surgical Care as a Critical Scale-up Strategy in Low- and Middle-Income Countries; Comment on “Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries

International Journal of Health Policy Management


Authors: Jaymie A. Henry
Region / country: Global
Speciality: Obstetrics and Gynaecology, Other

As global attention to improve the quality, safety and access to surgical care in low- and middle-income countries (LMICs) increases, the need for evidence-based strategies to reliably scale-up the quality and quantity of surgical services becomes ever more pertinent. Iversen et al discuss the optimal distribution of surgical services, whether through decentralization or regionalization, and propose a strategy that utilizes the dimensions of acuity, complexity and prevalence of surgical conditions to inform national priorities. Proposed expansion of this strategy to encompass levels of scale-up prioritization is discussed in this commentary. The decentralization of emergency obstetric services in LMICs shows promising results and should be further explored. The dearth of evidence of regionalization in LMICs, on the other hand, limits extrapolation of lessons learned. Nevertheless, principles from the successful regionalization of certain services such as trauma care in high-income countries (HICs) can be adapted to LMIC settings and can provide the backbone for innovation in service delivery and safety.


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255. Epidemiology and Perioperative Mortality of Exploratory Laparotomy in Rural Ghana

Annals of Global Health


Authors: Brandon S. Hendriksen , Laura Keeney, David Morrell, Xavier Candela, John Oh, Christopher S. Hollenbeak, Temitope E. Arkorful, Richard Ofosu-Akromah, Evans K. Marfo, Forster Amponsah-Manu
Region / country: Western Africa – Ghana
Speciality: General surgery

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

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

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

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


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256. Outcome of Esotropia Surgery in 2 Tertiary Hospitals in Cameroon

Clinical Ophthalmology


Authors: Viola Andin Dohvoma, Stève Robert Ebana Mvogo, Jean Audrey Ndongo, Caroline Tsimi Mvilongo, Côme Ebana Mvogo
Region / country: Western Africa – Cameroon
Speciality: Ophthalmology

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


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

BMC Pregnancy and Childbirth


Authors: Abdul-Aziz Seidu, John Elvis Hagan Jr., Wonder Agbemavi, Bright Opoku Ahinkorah, Edmond Banafo Nartey, Eugene Budu, Francis Sambah & Thomas Schack
Region / country: Western Africa – Ghana
Speciality: Obstetrics and Gynaecology

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

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

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

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


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

SICOT J


Authors: Gerald Chukwuemeka Oguzie, Patrick Albright, Syed Haider Ali, Ndubuisi E. Duru, Emmanuel Chino Iyidobi, Omolade Ayoola Lasebikan, Denning C. Chukwumam, Hao-Hua Wu, and Ikpeme A. Ikpeme
Region / country: Western Africa – Nigeria
Speciality: Trauma and orthopaedic surgery, Trauma surgery

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


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259. Caesarean Section in Low-, Middle- and High-Income Countries

IntechOpen


Authors: Josaphat Byamugisha and Moses Adroma
Region / country: Global
Speciality: Obstetrics and Gynaecology

Caesarean section (CS) refers to delivery of a foetus through surgical incisions made through abdominal and uterine walls. It’s a life-saving procedure when complications arise during pregnancy. It may be an emergency or a planned procedure. Although desirable, CS may be medically unnecessary. CS is a major procedure associated with immediate and long-term maternal and perinatal risks and may have implications for future pregnancies. Since 1985, international healthcare community considers ideal rate for CS to be 10–15%. However, in the last decade, there has been concern about the rising rates of CS from as low as 2% in Africa to as high as 50–60% in Dominican Republic and Latin America. To this effect, there have been attempts to regulate the rates, and the Ten Group Classification System under the Robson criteria is such an attempt. CS rates are on the increase due to varying reasons ranging from patient, institutional, care provider and societal factors. There have been modifications in the CS technique and the drugs used postoperatively from Pitocin to addition of Misoprostol. Need has developed from Reproductive Health Specialists to review indications, rates and terminologies used and evaluate practices in low-, middle- and high-income countries regarding CS.


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260. Changing face of trauma and surgical training in a developing country: A literature review

journal of pakistan medical association


Authors: Qamar Riaz, Sabah uddin Saqib, Rehan Nasir Khan, Nadeem Ahmed Siddiqui
Region / country: South-eastern Asia – Pakistan
Speciality: Emergency surgery, Surgical Education, Trauma surgery

Trauma continues to be the major cause of disability and death globally and surgeons are often involved in immediate care. However there has been an exponential decrease in the number of the trained trauma surgeons. The purpose of the current review article is to summarize the published literature pertaining to trauma education in postgraduate surgical training programmes internationally and in a developing country as Pakistan. Several electronic databases like MEDLINE, PubMed, Google scholar and PakMediNet were searched using the keywords ‘trauma education’ or ‘trauma training’ AND ‘postgraduate medical education’, ‘surgery residency training’, ‘surgery residents’ and ‘surgeons’. The current training in most surgical residency programmes, locally and globally, is suboptimal. Change in trauma management protocols, and decrease in volume of trauma cases results in variable and/ or inadequate exposure and hands-on experience of the surgical trainees in operative and non-operative management of trauma. This warrants collaborative measures for integration of innovative educational interventions at all levels of the surgical educational programmes.


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261. Review of antibiotic prophylaxis for the prevention of surgical site infection in low and middle income countries (LMICs)

Access Microbiology


Authors: Lesley Cooper, Jacqueline Sneddon
Region / country: Global
Speciality: General surgery

Background
The Scottish Antimicrobial Prescribing Group (SAPG) is supporting two hospitals in Ghana via a Fleming Fund healthcare partnership to develop antimicrobial stewardship. Initial intelligence gathering suggests that antibiotic prophylaxis to prevent surgical site infection (SSI) is suboptimal. To inform a quality improvement programme we have reviewed the evidence for use of surgical prophylaxis in LMICs including staff behaviours and attitudes.

Methods
MEDLINE, Embase, Cochrane, CINHAL and Google Scholar were searched from inception to 22 July 2019 for trials, audits, guidelines and systematic review in English. Grey literature, websites and reference lists of included studies were searched. The following data were extracted; study characteristics, interventions, outcomes and recommendations. In view of heterogeneity between studies descriptive analysis was conducted.

Results
Of 185 records screened, 26 studies related to SSI and timing of antibiotic prophylaxis in LMICs were included. The incidence of SSI is significantly higher in LMICs compared with high income countries, recording of infection surveillance data is poor and a lack of local guidelines for antibiotic prophylaxis. Several projects in Africa have reported reduction in SSI with single dose preoperative antibiotic use compared with post-operative prophylaxis and a reduction in cost and nurse time. Despite evidence to the contrary, many surgeons continue to use post-operative antibiotic prophylaxis.

Conclusion
Education to improve incidence of SSI in LMICs through appropriate antibiotic prophylaxis can be successful. Interventions must include local context and address strongly held beliefs. The establishment of local multidisciplinary teams will promote ownership and sustainability of change.


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262. Ventriculoperitoneal shunt complication in pediatric hydrocephalus: Risk factor analysis from a single institution in Nepal

Asian Journal of Neurosurgery


Authors: Prakash Paudel, Prakash Bista, Durga Prasad Pahari, Gopal Raman Sharma
Region / country: Southern Asia – Nepal
Speciality: Neurosurgery, Paediatric surgery

Objective
Ventriculoperitoneal (VP) shunt surgery is one of the commonly performed neurosurgical procedures. Complications due to shunt failure are associated with high morbidity and mortality. We report an analysis of risk factors for shunt failure in pediatric patients from a single institution in Nepal.
Materials and methods
A retrospective analytical study with prospective data was designed. All children younger than 15 years, with first time VP shunting, at a tertiary government hospital in Kathmandu during 2014-2017 were followed up. Association of independent variables with the primary outcome variable (complication of VP shunt) was analyzed using Chi-square test. Bivariate logistic regression was performed to identify unadjusted odds ratio (OR) with 95% confidence interval (CI). Multivariate logistic regression model was designed to calculate adjusted OR with 95% CI.
Results
Of 120 patients, more than half (55.8%) of the patients were male. Mean age was 62.97 months. Maximum duration of follow-up was 30 months. Most common cause of hydrocephalus was congenital aqueductal stenosis (40.8%) followed by tumors (29.2%). Overall shunt complication was found in 26.7% (95% CI 19.0%-35.5%). Shunt infection was seen in 5% while malfunction without infection was found in 21.7%. Bivariate logistic regression showed duration of surgery more than 1 h (OR 2.67, 95% CI 1.11-6.42, P = 0.028) compared to 1 h or less, experienced surgeon (OR 0.37, 95% CI 0.16-0.89, P = 0.026) compared to residents, and emergency surgery (OR 3.97, 95% CI 1.69-9.29, P = 0.001) compared to elective surgery as significant risk factors, while emergency surgery was the only significant variable for shunt failure on multivariate regression analysis (OR 3.3, 95% CI 1.16-9.35, P = 0.025).
Conclusion
Longer duration of surgery, less experience of the surgeon, and the priority of the case (emergency) were independent risk factors for shunt complications.


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

Nigerian Journal Of Surgery


Authors: AbdulGhaffar A Yunus, Euphemia M Ugwu, Yunusa Ali, Ganiyat Olagunju
Region / country: Western Africa – Nigeria
Speciality: Anaesthesia, Emergency surgery, General surgery

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


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

Nigerian Journal Of Clinical Practice


Authors: C Nwachukwu, H O Idehen, N P Edomwonyi, B Umeh
Region / country: Western Africa – Nigeria
Speciality: Anaesthesia, Trauma and orthopaedic surgery, Trauma surgery

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


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265. Impact of Delaying Surgery After Chemoradiation in Rectal Cancer: Outcomes From a Tertiary Cancer Centre in India

Journal of Gastrointestinal Oncology


Authors: Praveen Kammar, Aditi Chaturvedi, Masillamany Sivasanker, Ashwin de’Souza, Reena Engineer, Vikas Ostwal, Avanish Saklani
Region / country: Southern Asia – India
Speciality: Surgical oncology

Background
Delaying surgery after chemoradiation is one of the strategies for increasing tumor regression in rectal cancer. Tumour regression and PCR are known to have positive impact on survival.
Methods
It’s a retrospective study of 161 patients undergoing surgery after neoadjuvant chemoradiation (NCRT) for locally advanced rectal cancer (LARC). Patients were divided into three categories based on the gap between NCRT and surgery, i.e., 12 weeks. Tumor regression grades (TRG), sphincter preservation, post-operative morbidity-mortality and survival were evaluated.
Results
Sphincter preservation was significantly less in >12 weeks group compared to the other two groups (P=0.003). Intraoperative blood loss was significantly higher in >12 weeks group compared to 8-12 weeks group (P=0.001).There was no difference in major postoperative morbidity and hospital stay among the groups. There was no significant correlation between delay and TRG (P=0.644). At Median follow up of 49.5 months the projected 3-year overall survival (OS) and disease free survival (DFS) were not significantly different among the 3 groups (OS: 79.5% vs. 83.3% vs. 76.5%; P=0.849 and DFS 50.4% vs. 70.6% vs. 62%; P=0.270 respectively).
Conclusions
Delaying surgery by more than 12 weeks causes more blood loss but no change in morbidity or hospital stay. Increased time interval between radiation and surgery does not improve tumor regression and has no effect on survival.


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266. Anorectal Malformation Patients’ Outcomes After Definitive Surgery Using Krickenbeck Classification: A Cross-Sectional Study

Heliyon


Authors: Firdian Makrufardi, Dewi Novitasari Arifin, Dwiki Afandy, Dicky Yulianda, Andi Dwihantoro, Gunadi
Region / country: South-eastern Asia – Indonesia
Speciality: Surgical oncology

Background
The survival of anorectal malformation (ARM) patients has been improved in the last 10 years because of the improvement in management of neonatal care and surgical approaches for ARM patients. Thus, the current management of ARM patients are focusing on the functional outcomes after definitive surgery. Here, we defined the type of ARM and assessed the functional outcomes, including voluntary bowel movement (VBM), soiling, and constipation, in our patients following definitive surgery using Krickenbeck classification.
Methods
We conducted a cross-sectional study to retrospectively review medical records of ARM patients who underwent a definitive surgery at Dr. Sardjito Hospital, Indonesia, from 2011 to 2016.
Results
Forty-three ARM patients were ascertained in this study, of whom 30 males and 13 females. Most patients (83.7%) were normal birth weight. There were ARM without fistula (41.9%), followed by rectourethral fistula (25.5%), perineal fistula (18.6%), vestibular fistula (9.3%), and rectovesical fistula (4.7%). The VBM was achived in 53.5% patients, while the soiling and constipation rates were 11.6% and 9.3%, respectively. Interestingly, patients with normal birth weight showed higher frequency of VBM than those with low birth weight (OR = 9.4; 95% CI = 1.0-86.9; p = 0.04), while male patients also had better VBM than females (OR = 3.9; 95% CI = 1.0-15.6) which almost reached a significant level (p = 0.09). However, VBM was not affected by ARM type (p = 0.26). Furthermore, there were no significant associations between gender, birth weight, and ARM type with soiling and constipation, with p-values of 1.0, 1.0, and 0.87; and 0.57, 1.0, and 0.94, respectively.
Conclusions
Functional outcomes of ARM patients in our hospital are considered relatively good with more than half of children showing VBM and only relatively few patients suffering from soiling and constipation. The frequency of VBM might be associated with birth weight and gender, but not ARM type, while the soiling and constipation did not appear to be correlated with birth weight, gender, nor ARM type. Further multicenter study is necessary to compare our findings with other centers.


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267. Global Retinoblastoma Presentation and Analysis by National Income Level

JAMA Oncology


Authors: Global Retinoblastoma Study Group
Region / country: Global
Speciality: Ophthalmology, Surgical oncology

Importance
Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child’s life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives
To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, and Participants
A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes and Measures
Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results
The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle–income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle–income countries vs upper-middle–income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions and Relevance
This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.


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268. Thoracoscopic Surgery Approach to Mediastinal Mature Teratomas: A Single-Center Experience

Journal of Cardiothoracic Surgery


Authors: Lu Huu Pham, Diep Ke Trinh, Anh Viet Nguyen, Lanh Sy Nguyen, Dung Thanh Le, Dinh-Hoa Nguyen, Hung Quoc Doan, Uoc Huu Nguyen
Region / country: South-eastern Asia – Vietnam
Speciality: Cardiothoracic surgery, Surgical oncology

Background
Mediastinal mature teratomas are rare tumors with diverse surgical approaches. The aim of this study is to review our experience of thoracoscopic surgery management in patients with teratomas.
Methods
We retrospectively reviewed 28 consecutive patients with mediastinal mature teratomas who underwent thoracoscopic surgery at Viet Duc University Hospital from January 2008 to August2018. Patients were divided into 2 groups with 2 types of thoracoscopic surgery, closed thoracoscopic surgery (CTS) group and video-assisted thoracoscopic surgery (VATS) group. The selection of sugical approach was based on sizes, locations and characteristics of tumors. Post-operative outcomes were assessed and compared between these 2 groups.
Results
There were 14 female and 14 male patients with a median age of 41.2 ± 13.8 years. A total of 22 teratomas were located on the right side of the chest cavity and 6 on the left side. We performed CTS in 21 patients (75%) and VATS in 7 patients (25%) for tumor resection. There were 3 cases (10.7%) required conversion to minithoracotomy (5 cm in incision length). Skin appendages accounted for the highest rate (96.4%) in pathology. There was no record of mortality or tumor recurrence detected by computerized tomography.
Conclusion
A thoracoscopic surgery for a mediastinal mature teratoma was a feasible choice. Challenging factors such as large tumors, intraoperative bleeding and strong tumor cell adhesion were considered handling by conversion to mini-thoracotomy that could ensure safety procedures and complete removal of tumors. Extraction of tumor contents might be performed for patients with large mature cystic teratomas to facilitate thoracoscopic surgery.


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269. Pediatric Cataract Audit at a Tertiary Care Center in Karachi

Pakistan Journal of Ophthalmology


Authors: Rabia Khawar Chaudhry, Nasar Qamar Khan, Weiji Kumar Dembra, Areej Riaz, Gaintry Vickash
Region / country: South-eastern Asia – Pakistan
Speciality: Ophthalmology

Purpose: To perform pediatric cataract surgery audit at a tertiary care center in Karachi.

Study Design: Descriptive observational study.

Place and Duration of Study: From January, 2016 to July, 2018 at Ophthalmology Department of Jinnah Postgraduate Medical Center, Karachi.

Material and Methods: All patients with congenital cataract were included in study regardless of presence or absence of systemic association. Patients who were lost to follow up at three months were excluded from the study. Hospital records were reviewed retrospectively and data on patient demographics, preoperative presentations, intraoperative complications and postoperative visual outcomes was documented on predesigned proformas. All patients underwent lens aspiration, posterior capsulotomy and anterior vitrectomy. Surgeries were performed under general anesthesia. Preoperative and postoperative visual acuity was assessed with ability to fix and follow light/objects, Kay picture test and Snellen’s chart according to patient’s age.

Results: Three hundred and twenty six eyes underwent surgery for congenital cataract and sixty for traumatic cataract. Number of male patients was 54.93% and female was 45.07%. The average age of patients with congenital cataract was 5.01 years and that for traumatic cataract was 7.8 years. Amblyopia, nystagmus and strabismus were the commonest ocular comorbidities. Uncorrected visual acuity ranged from 6/18 to light perception preoperatively. Postoperatively 55% children with congenital cataract and 15% children with traumatic cataract had visual acuity better than 6/24.

Conclusion: Early surgery in congenital cataract gives good visual outcomes. In traumatic cataract extraction, the final visual outcome depends on other effects of trauma on ocular structures.


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270. Sigmoid volvulus: a rare but unique complication of enteric fever

Journal of Community Hospital Internal Medicine Perspectives


Authors: Muhammad Sohaib Asghar, Abubakar Tauseef, Hiba Shariq, Maryam Zafar, Rumael Jawed, Uzma Rasheed, Mustafa Dawood, Haris Alvi, Saad Aslam & Marium Tauseef
Region / country: South-eastern Asia – Pakistan
Speciality: General surgery

We present a case of sigmoid volvulus in a young male patient with culture-proven Salmonella Typhi in the blood which was sensitive to Meropenem and Azithromycin only, presented with fever, vomiting, loose stools, hematochezia, abdominal distention and tenderness with no signs of perforation on erect chest x-ray. Further, radiological imaging showed signs of sigmoid volvulus. An urgent colonic decompression with untwisting of the mesentery was performed. In our case, it can be said that sigmoid volvulus was developed as a complication of multiple drug-resistant strains of Salmonella Typhi. The resistance is acquired by alteration in the genome sequence. Currently, it is important to control such an unknown outbreak of multiple drug-resistant strains of Salmonella Typhi as it is a serious health care issue of disease control and prevention in Pakistan.


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271. Functional and clinical outcomes of open versus closed radius and ulna shaft fractures in adults: A prospective cohort study

Journal Of Pakistan Medical Association


Authors: Tashfeen Ahmad, Zehra Abdul Muhammad, Pervaiz Hashmi
Region / country: South-eastern Asia – Pakistan
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Objective: To compare functional and clinical outcomes of open versus closed radius ulna shaft fractures in adults treated by internal fixation.

Methods: A prospective cohort study was conducted on patients presenting with traumatic radius and ulna shaft fractures to Aga Khan University and undergoing internal fixation between July 2015 to June 2019. Data was extracted from an ongoing orthopaedic trauma registry. Functional and clinical outcomes were assessed by Price et al. criteria at 6 weeks, 3, 6 and 12 months follow-up. Outcome scores of open versus closed fractures were compared.

Results: Twenty-nine adult patients with isolated radius and ulna shaft fracture were identified. Cause of injury was road traffic accident in 18 (62%) and fall in 11 (38%) patients. Seventeen (59%) were closed and 12 (41%) were open fractures. At 6week follow-up, better outcomes were observed in closed fracture group (p=0.01) with near-full range of motion and activity in 10(83%) patients as compared to 3(27%) in the open fracture group. No significant difference in outcomes was observed at 3 months and thereafter.

Conclusions: Earlier recovery of function at 6 weeks was observed in majority of patients in the closed fracture group. Our data shows that good-excellent functional and clinical results are achievable by internal fixation in both open as well as closed fractures of the shaft of radius and ulna in adults.


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272. Impact of time of arrival in emergency unit on estimation of injuries and overall care of trauma victims

The Journal of the Pakistan Medical Association


Authors: Saqib SU, Zafar H
Region / country: South-eastern Asia – Pakistan
Speciality: Emergency surgery, Trauma surgery

Background: Outcomes of trauma victims largely depends upon available resources, not only in terms of location of high level trauma center near the area where incident takes place but also on staff and equipment available at that particular center at that particular time. This study used retrospective charts review to ascertain whether trauma patients presenting during the night time would have delayed in establishing injuries after necessary investigations and higher in-hospital mortality than those trauma patients arriving during the day time at our hospital.

Methods: This was a cross sectional study, conducted in department of Surgery, Aga Khan University Hospital, Karachi. Data was obtained from patients charts by a single investigator. By random sampling technique, 146 patients admitted between 1st January 2018 to 31st December 2018inthe Emergency Department of the Aga Khan University Hospital, Karachi were included. Patients were placed into two groups. Those arriving in hospital from 7 am to 7 pm were labeled as day time group while those who presented from 7 pm to 7 am were labeled as night time group. Difference in mortality in each group and time required for carrying out investigations and admissions to definite care were recorded and compared among both groups.

Results: A total of 146 patient charts were reviewed, with 73 patients each in both day time (DT) and night time (NT) groups. Out of 146 trauma victims 123(82.2%) were male and 23(17.8%) were female. Mean age in our population was 37.4 years (±14.3). Road traffic accident (RTA) was the most common cause in 121 patients (82.9%). Time required to conduct trauma services was shorter and significant in DT group as compared to NT group. There was significant difference observed in time required for admission in each group, with mean of 6hours and 40 minutes ± 4 hours,22 minutes in DT group and 8 hours, 36 minutes (± 5 hours,11 minutes in NT group (p = 0.03). However there was no significant difference in mortality observed in both groups.

Conclusions: In our hospital time of arrival has no impact on overall mortality of trauma patients. However time to carryout necessary investigations for stable trauma patients and their admissions to definite care is longer as compared to day time arrival of emergency trauma patients.


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273. Perioperative hypothermia in colorectal surgeries: are we doing enough to prevent it?

Journal Of Pakistan Medical Association


Authors: Tanzeela Gala, Noman Shahzad, Ahmed Iqbal Edhi, Tabish Umer Chawla
Region / country: South-eastern Asia – Pakistan
Speciality: General surgery

Objective: To determine the incidence of hypothermia in patients undergoing colorectal surgery, and to identify factors that increase vulnerability to perioperative hypothermia.

Methods: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised medical records from May 2012 to June 2017 related to all patients aged >16 years of either gender who underwent colorectal procedures. Analysis about predictors of perioperative hypothermia was done using Stata 12.

Results: Of the 100 patients, 69(69%) were males. The overall mean age was 50.2±16.7 years. Majority cases had elective presentation 72(72%). Incidence of perioperative hypothermia was noted in 74(74%) patients. Postoperative morbidity was 16(16%), while mortality was 4(4%). Elective presentation and hypothermia before surgery were significantly associated with occurrence of intraoperative hypothermia (odds ratio: 4.5 and 1.3 respectively).

Conclusions: Perioperative incidence of hypothermia was found to be quite high despite appropriate measures. Factors responsible need to be explored and rectified.


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274. Comparison of intraarticular distal humerus fracture outcomes treated with or without olecranon osteotomy – A case series

Journal of the Pakistan Medical Association


Authors: Naveed Baloch , Tashfeen Ahmad , Zehra Abdul Muhammad
Region / country: South-eastern Asia – Pakistan
Speciality: Trauma and orthopaedic surgery, Trauma surgery

A case series was extracted from the trauma registry at Aga Khan University Hospital from the period June 2015 to June 2019. Included were 16 adult patients who presented with intra-articular distal humerus fracture type C2. The functional, clinical and radiological outcomes of fractures treated with or without olecranon osteotomy up to 12 months follow-up were compared. Outcomes were assessed at 6 weeks, 3, 6 and 12 months re-visits. Among the 16 studied patients, 9 (56%) were males and 7 (44%) were females. In the group without osteotomy, there was a good functional and clinical outcome with a mean Quick Disability of the Arm, Shoulder and Hand score of 32±30 at 3 months post-procedure. Bone healing was noticed at 6 months after surgery. In the osteotomy group, 50%-70% bone union was seen at 3 months post-surgery while fair functional and clinical outcome was achieved at 6 months after surgery


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275. The Preferred Management of a Single-Digit Distal Phalanx Amputation

Journal of Reconstructive Microsurgery open


Authors: Soo-Ha Kwon  , William Wei-Kai Lao, Angela Ting-Wei Hsu, Che-Hsiung Lee, Chung-Chen Hsu, Jung-Ju Huang, Shan Shan Qiu, Daniel Tilkorn, Evelyn Ting-Hsuan Tang  , Johnny Chuieng-Yi Lu, Tommy Nai-Jen Chang
Region / country: Global
Speciality: Plastic surgery, Trauma and orthopaedic surgery

Background: Replantation of a single digit at the distal phalanx level is not routinely performed since it is technically challenging with questionable cost-effectiveness. The purpose of this study was to analyze international microsurgeons’ clinical decisions when faced with this common scenario.

Methods: A survey of a right-middle finger distal phalanx transverse complete amputation case was conducted via online and paper questionnaires. Microsurgeons around the world were invited to provide their treatment recommendations. In total, 383 microsurgeons replied, and their responses were stratified and analyzed by geographical areas, specialties, microsurgery fellowship training, and clinical experiences.

Results: Among 383 microsurgeons, 170 (44.3%) chose replantation as their preferred management option, 137 (35.8%) chose revision amputation, 62 (16.2%) chose local flap coverage, 8 (2.1%) chose composite graft, and 6 (1.6%) favored other choices as their reconstruction method for the case study. Microsurgeons from the Asia-Pacific, Middle East/South Asia, and Central/South America regions tend to perform replantation (70.7, 68.8, and 67.4%, respectively) whereas surgeons from North America and Europe showed a lower preference toward replantation (20.5 and 26.8%, respectively p < 0.001). Having completed a microsurgery fellowship increased the attempt rate of replantation by 15.3% (p = 0.004). Clinical experience and the surgeons' specialties did not show statistical significance in clinical decision making.

Conclusion: From the present study, the geographic preferences and microsurgery fellowship experience influence the method of reconstruction for distal phalanx amputation. Multiple factors are taken into consideration in selecting the most suitable reconstructive method for each case scenario. In addition to the technical challenges of the proposed surgery, the cost of the procedure and the type of facility needed are important variables in the decision making process.


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276. Parotid Tumours: A Conservative Investigative and Surgical Approach

Journal of Surgery


Authors: Paul Douglas-Jones, Melesse G Biadgelign, Stuart Burrows and Johannes J Fagan
Region / country: Southern Africa – South Africa
Speciality: ENT surgery

Background: The extent of preoperative investigations for parotid tumours and whether a partial or total parotidectomy should be performed for malignancy remain controversial. In developing countries, limited access to special investigations and their affordability requires careful consideration when investigating parotid tumors.

Aims: This study assesses whether a conservative investigative and surgical approach to parotid malignancies with adjuvant radiation therapy in selected patients is associated with acceptable local control and survival rates.

Methods: A retrospective observational audit was conducted on patients undergoing parotid surgery for parotid masses, by a single surgeon, between 1st January 2004 and 31st December 2012. Outcome measures included local tumour control and five-year disease-specific survival, calculated via Kaplan-Meier analysis.

Results: Three hundred and forty-seven parotidectomies were performed for parotid masses between 2004 and 2012. Fifty-three primary parotid malignancies were diagnosed (15%) and were followed up for a mean of 56.6 months postoperatively. Adopting a conservative investigative and surgical approach to primary parotid malignancies was associated with a local tumour control rate of 92.5%.

Conclusion: A conservative investigative and surgical approach with adjuvant radiation therapy in select patients is associated with excellent local control with primary parotid malignancy.


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277. Venoarterial extracorporeal membrane oxygenation in heart surgery post-operative pediatric patients: A retrospective study at Christus Muguerza Hospital, Monterrey, Mexico

SAGE Open mediine


Authors: Gerardo Vargas-Camacho, Verónica Contreras-Cepeda, Rene Gómez-Gutierrez, Guillermo Quezada-Valenzuela, Adriana Nieto-Sanjuanero, Jesús Santos-Guzmán and Francisco González-Salazar
Region / country: South America – Mexico
Speciality: Cardiothoracic surgery, Paediatric surgery

Objectives:
Extracorporeal membrane oxygenation is a life support procedure developed to offer cardiorespiratory support when conventional therapies have failed. The purpose of this study is to describe the findings during the first years using venoarterial extracorporeal membrane oxygenation in pediatric patients after cardiovascular surgery at Christus Muguerza High Specialty Hospital in Monterrey, Mexico.

Methods:
This is a retrospective, observational, and descriptive study. The files of congenital heart surgery post-operative pediatric patients, who were treated with venoarterial extracorporeal membrane oxygenation from January 2013 to December 2015, were reviewed.

Results:
A total of 11 patients were reviewed, of which 7 (63.8%) were neonates and 4 (36.7%) were in pediatric age. The most common diagnoses were transposition of great vessels, pulmonary stenosis, and tetralogy of Fallot. Survival rate was 54.5% and average life span was 6.3 days; the main complications were sepsis (36.3%), acute renal failure (36.3%), and severe cerebral hemorrhage (9.1%). The main causes of death were multi-organ dysfunction syndrome (27.3%) and cerebral hemorrhage (18.2%).

Conclusion:
The mortality rates found are very similar to those found in a meta-analysis report published in 2013 and the main complication and causes of death are also very similar to the majority of extracorporeal membrane oxygenation reports for these kinds of patients. Although the results are encouraging, early sepsis detection, prevention of cerebral hemorrhage, and renal function monitoring must be improved.


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278. Popliteal fossa reconstruction with medial genicular artery flap in a low resource setting: A report of two cases

International Journal of Surgery Case Reports


Authors: U.U.Nnadozie and C.C.Maduba
Region / country: Western Africa – Nigeria
Speciality: Plastic surgery, Trauma and orthopaedic surgery

Background: Popliteal fossa defects are common arising from several causes. Options of reconstruction around the knee could be limited by the cause of defect or interventions. Medial genicular artery flap is known in the books but not in popular use despite its obvious advantages of superior vascularity, adequate size, suppleness, and hidden donor site.

Aim: To promote the use of this flap due to its advantages and ease of use especially in resource poor settings.

Patients and methods: We report two patients from a low resource setting aged 23 and 20 years respectively. The first case was managed for avulsion wound of the popliteal fossa while the second had post burn knee contracture release. The resultant large popliteal fossa defects on both patients were seen on clinical examination. Both patients were offered popliteal fossa reconstruction for the popliteal fossa defects using medial genicular artery flap with good outcome.

Conclusion: The medial genicular artery flap is a veritable option of popliteal fossa reconstruction especially for defects that are located contiguous to the flap and when other regional flap options are not available. Flap survival is excellent and donor site is hidden


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279. Academic Advancement in Global Surgery Appointment, Promotion, and Tenure Recommendations From the American Surgical Association Working Group on Global Surgery

annals of surgery


Authors: Wren, Sherry M. MD, Balch, Charles M. MD, Doherty, Gerard M. MD, Finlayson, Samuel R. MD, MPH, Kauffman, Gordon L. MD, Kibbe, Melina R. MD, Haider, Adil H. MD, MPH, Minter, Rebecca M. MD, Mock, Charles MD, PhD, MPH, Muguti, Godfrey I. MB, BS, MS; Numann, Patricia J. MD, Olutoye, Oluyinka O. MBChB, PhD, Roy, Nobhojit MD, PhD, Weigel, Ronald J. MD, PhD, MBA
Region / country: Northern America – United States of America
Speciality: Other, Surgical Education

There is growing interest in global surgery among US academic surgical departments. As academic global surgery is a relatively new field, departments may have minimal experience in evaluation of faculty contributions and how they integrate into the existing academic paradigm for promotion and tenure. The American Surgical Association Working Group on Global Surgery has developed recommendations for promotion and tenure in global surgery, highlighting criteria that: (1) would be similar to usual promotion and tenure criteria (eg, publications); (2) would likely be undervalued in current criteria (eg, training, administrative roles, or other activities that are conducted at low- and middle-income partner institutions and promote the partnerships upon which other global surgery activities depend); and (3) should not be considered (eg, mission trips or other clinical work, if not otherwise linked to funding, training, research, or building partnerships).


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280. Risk Factors of Perioperative Mortality From Complicated Peptic Ulcer Disease in Africa: Systematic Review and Meta-Analysis

bMJ Open Gastroenterology


Authors: Sarah Peiffer , Matthew Pelton , Laura Keeney , Eustina G Kwon , Richard Ofosu-Okromah , Yubraj Acharya , Vernon M Chinchilli , David I Soybel , John S Oh , Paddy Ssentongo
Region / country: Central Africa, Eastern Africa, Northern Africa, Southern Africa, Western Africa
Speciality: General surgery

Introduction: In 2013, peptic ulcer disease (PUD) caused over 300 000 deaths globally. Low-income and middle-income countries are disproportionately affected. However, there is limited information regarding risk factors of perioperative mortality rates in these countries.

Objective: To assess perioperative mortality rates from complicated PUD in Africa and associated risk factors.

Design: We performed a systematic review and a random-effect meta-analysis of literature describing surgical management of complicated PUD in Africa. We used subgroup analysis and meta-regression analyses to investigate sources of variations in the mortality rates and to assess the risk factors contributing to mortality.

Results: From 95 published reports, 10 037 patients underwent surgery for complicated PUD. The majority of the ulcers (78%) were duodenal, followed by gastric (14%). Forty-one per cent of operations were for perforation, 22% for obstruction and 9% for bleeding. The operations consisted of vagotomy (38%), primary repair (34%), resection and reconstruction (12%), and drainage procedures (6%). The overall PUD mortality rate was 6.6% (95% CI 5.4% to 8.1%). It increased to 9.7% (95% CI 7.1 to 13.0) when we limited the analysis to studies published after the year 2000. The correlation was higher between perforated PUD and mortality rates (r=0.41, p<0.0001) than for bleeding PUD and mortality rates (r=0.32, p=0.001). Non-significant differences in mortality rates existed between sub-Saharan Africa (SSA) and North Africa and within SSA.

Conclusion: Perioperative mortality rates from complicated PUD in Africa are substantially high and could be increasing over time, and there are possible regional differences.


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281. Review of Testicular Tumor: Diagnostic Approach and Management Outcome in Africa

research and reports in urology


Authors: Ayun Cassell , Mohamed Jalloh , Medina Ndoye , Bashir Yunusa , Mouhamadou Mbodji , Abdourahmane Diallo , Omar Gaye , Issa Labou , Lamine Niang , Serigne Gueye
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Urology surgery

Testicular cancer is a common malignancy in young males with higher incidence in developed nations but with the lowest incidence in Africa (0.3-0.6/100 000). Ironically, the global testicular cancer mortality rate has shown a reverse trend to its incidence with higher rates in low- and middle-income countries (0.5 per 100 000) than in high-income countries. Data from GLOBOCAN 2008 have shown relatively high mortality rates in sub-Saharan countries like Mali, Ethiopia, Niger and Malawi. The prognosis of testicular tumor is good with remarkable chemosensitivity to cisplatin-based regimen. Early diagnosis, careful staging and a multidisciplinary management approach is crucial to achieve this optimal result. These results are achievable in the sub-Saharan region if the relevant resources are appropriated for cancer care and clinical guidelines are formulated in a regional context.


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282. Globalization of national surgical, obstetric and anesthesia plans: the critical link between health policy and action in global surgery

Global Health


Authors: Paul Truché, Haitham Shoman, Ché L. Reddy, Desmond T. Jumbam, Joanna Ashby, Adelina Mazhiqi, Taylor Wurdeman, Emmanuel A. Ameh, Martin Smith, Edwin Lugazia, Emmanuel Makasa, Kee B. Park, and John G. Meara
Region / country: Global
Speciality: Anaesthesia, Health policy, Obstetrics and Gynaecology, Other

Efforts from the developed world to improve surgical, anesthesia and obstetric care in low- and middle-income countries have evolved from a primarily volunteer mission trip model to a sustainable health system strengthening approach as private and public stakeholders recognize the enormous health toll and financial burden of surgical disease. The National Surgical, Obstetric and Anesthesia Plan (NSOAP) has been developed as a policy strategy for countries to address, in part, the health burden of diseases amenable to surgical care, but these plans have not developed in isolation. The NSOAP has become a phenomenon of globalization as a broad range of partners – individuals and institutions – help in both NSOAP formulation, implementation and financing. As the nexus between policy and action in the field of global surgery, the NSOAP reflects a special commitment by state actors to make progress on global goals such as Universal Health Coverage and the United Nations Sustainable Development Goals. This requires a continued global commitment involving genuine partnerships that embrace the collective strengths of both national and global actors to deliver sustained, safe and affordable high-quality surgical care for all poor, rural and marginalized people.


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283. Self-Diagnosis of Surgical Site Infections: Lessons From a Tertiary Care Centre in Karachi, Pakistan

Pakistan Journal of Medical Sciences


Authors: Sana Z Sajun, Katherine Albutt, Umme Salama Moosajee, Gustaf Drevin, Swagoto Mukhopadhyay, and Lubna Samad
Region / country: South-eastern Asia – Pakistan
Speciality: General surgery, Other

Background and Objective: Surgical site infections (SSIs) usually manifest post-discharge, rendering accurate diagnosis and treatment challenging, thereby catalyzing the development of alternate strategies like self-monitored SSI surveillance. This study aimed to evaluate the diagnostic accuracy of patients and Infection Control Monitors (ICMs) to develop a replicable method of SSI-detection.
Methods: A two-year prospective diagnostic accuracy study was conducted in Karachi, Pakistan between 2015 and 2017. Patients were educated about SSIs and provided with questionnaires to elicit symptoms of SSI during post-discharge self-screening. Results of patient’s self-screening and ICM evaluation at followups were compared to surgeon evaluation.
Results: A total of 348 patients completed the study, among whom 18 (5.5%) developed a SSI. Patient selfscreening had a sensitivity of 39%, specificity of 95%, positive predictive value (PPV) of 28%, and negative predictive value (NPV) of 97%. ICM evaluation had a sensitivity of 82%, specificity of 99%, PPV of 82%, and NPV of 99%.
Conclusion: Patients cannot self-diagnose a SSI reliably. However, diagnostic accuracy of ICMs is significantly higher and they may serve as a proxy for surgeons, thereby reducing the burden on specialized surgical workforce in LMICs. Regardless, supplementing post-discharge follow-up with patient self-screening could
increase SSI-detection and reduce burden on health systems.


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284. Endoscopic Third Ventriculostomy With Choroid Plexus Cauterization for the Treatment of Infantile Hydrocephalus in Haiti

Journal of neurosurgery pediatrics


Authors: Ashish H. Shah MD , Yudy LaFortune MD , George M. Ibrahim MD, PhD , Iahn Cajigas MD, PhD , Michael Ragheb MSPH , Stephanie H. Chen MD , Ernest J. Barthélemy MD, MA, MPH , Ariel Henry MD and John Ragheb MD
Region / country: Caribbean – Haiti
Speciality: Neurosurgery, Paediatric surgery

Objective: Untreated hydrocephalus poses a significant health risk to children in the developing world. In response to this risk, global neurosurgical efforts have increasingly focused on endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) in the management of infantile hydrocephalus in low- and middle-income countries (LMICs). Here, the authors report their experience with ETV/CPC at the Hospital Bernard-Mevs/Project Medishare (HBMPM) in Port-au-Prince, Haiti.

Methods: The authors conducted a retrospective review of a series of consecutive children who had undergone ETV/CPC for hydrocephalus over a 1-year period at HBMPM. The primary outcome of interest was time to ETV/CPC failure. Univariate and multivariate analyses using a Cox proportional hazards regression were performed to identify preoperative factors that were associated with outcomes.

Results: Of the 82 children who underwent ETV/CPC, 52.2% remained shunt free at the last follow-up (mean 6.4 months). On univariate analysis, the ETV success score (ETVSS; p = 0.002), success of the attempted ETV (p = 0.018), and bilateral CPC (p = 0.045) were associated with shunt freedom. In the multivariate models, a lower ETVSS was independently associated with a poor outcome (HR 0.072, 95% CI 0.016-0.32, p < 0.001). Two children (2.4%) died of postoperative seizures.

Conclusions: As in other LMICs, ETV/CPC is an effective treatment for hydrocephalus in children in Haiti, with a low but significant risk profile. Larger multinational prospective databases may further elucidate the ideal candidate for ETV/CPC in resource-poor settings.


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285. Operative Treatment of Traumatic Spinal Injuries in Tanzania: Surgical Management, Neurologic Outcomes, and Time to Surgery

Global Spine Journal


Authors: Juma Magogo, MD, MMED , Albert Lazaro, MD , Mechris Mango, MD, MMED , Scott L. Zuckerman, MD, MPH , Andreas Leidinger, MD , Salim Msuya, MD , Nicephorus Rutabasibwa, MD , Hamisi K. Shabani, MD, PhD , and Roger Hartl, MD
Region / country: Eastern Africa – Tanzania
Speciality: Neurosurgery, Trauma and orthopaedic surgery, Trauma surgery

Objective:
Little is known about operative management of traumatic spinal injuries (TSI) in low- and middle-income countries (LMIC). In patients undergoing surgery for TSI in Tanzania, we sought to (1) determine factors involved in the operative decision-making process, specifically implant availability and surgical judgment; (2) report neurologic outcomes; and (3) evaluate time to surgery.

Methods:
All patients from October 2016 to June 2019 who presented with TSI and underwent surgical stabilization. Fracture type, operation, neurologic status, and time-to-care was collected.

Results:
Ninety-seven patients underwent operative stabilization, 23 (24%) cervical and 74 (77%) thoracic/lumbar. Cervical operations included 4 (17%) anterior cervical discectomy and fusion with plate, 7 (30%) anterior cervical corpectomy with tricortical iliac crest graft and plate, and 12 (52%) posterior cervical laminectomy and fusion with lateral mass screws. All 74 (100%) of thoracic/lumbar fractures were treated with posterolateral pedicle screws. Short-segment fixation was used in 86%, and constructs often ended at an injured (61%) or junctional (62%) level. Sixteen (17%) patients improved at least 1 ASIA grade. The sole predictor of neurologic improvement was faster time from admission to surgery (odds ratio = 1.04, P = .011, 95%CI = 1.01-1.07). Median (range) time in days included: injury to admission 2 (0-29), admission to operating room 23 (0-81), and operating room to discharge 8 (2-31).

Conclusions:
In a cohort of LMIC patients with TSI undergoing stabilization, the principle driver of operative decision making was cost of implants. Faster time from admission to surgery was associated with neurologic improvement, yet significant delays to surgery were seen due to patients’ inability to pay for implants. Several themes for improvement emerged: early surgery, implant availability, prehospital transfer, and long-term follow-up.


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286. Hernioplasty Using Low-Cost Mesh Compared to Surgical Mesh in Low- And Middle-Income Countries: A Systematic Review Protocol

JBI Evidence Synthesis


Authors: Ashish Immanuel Vaska, Zachary Munn , Sonal Nagra , Timothy Hugh Barker
Region / country: Global
Speciality: General surgery

Objective: This review aims to assess the differences in surgical outcomes between hernioplasty using low-cost mesh and surgical mesh in adults undergoing elective hernioplasty in low- and middle-income countries.

Introduction: The use of untreated mosquito netting in inguinal hernioplasty in low- and middle-income countries has been well described in the literature, with two recent limited systematic reviews finding equivalent postoperative surgical outcomes. This comprehensive review, across a wider set of databases and gray literature, will assess a broader set of outcomes including patient and surgeon preference and sterility, report more granular complication outcomes, and include other low-cost mesh alternatives such as resterilized surgical mesh and indigenous products, alongside mosquito net mesh.

Inclusion criteria: Adult patients undergoing elective inguinal hernioplasty with mesh in low- and middle-income countries.

Methods: Electronic bibliographic databases (PubMed, Embase, Scopus, Web of Science and the Cochrane Library) and gray literature databases and trial registers will be searched for experimental studies, either randomized or quasi-randomized controlled trials, comparing hernioplasty with surgical mesh versus low-cost mesh, published in any language from 2000 to the present. Two independent reviewers will conduct the literature search, screen titles and abstracts, assess full-text studies for inclusion, assess methodological quality using the Cochrane Risk of Bias 2 tool, and extract data using a custom extraction tool. Synthesis will involve pooling for statistical meta-analysis with either a random-effects or fixed-effects model, as appropriate, and where this is not possible, findings will be presented in narrative form.


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

World Journal of Surgery


Authors: Anip Joshi, Bernardo Borraez-Segura, Mariyah Anwer, Oluwaseun Ladipo-Ajayi, Francisco Schlottmann, Diem Nguyen Ngoc Le, Andrew G. Hill & Michael G. Sarr
Region / country: South America, South-eastern Asia, Southern Asia, Western Africa – Argentina, Colombia, Nepal, Nigeria, Pakistan, Vietnam
Speciality: Surgical Education

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

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

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

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


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288. Global health, global surgery and mass casualties: II. Mass casualty centre resources, equipment and implementation

BMJ Global Health


Authors: Sergio Aguilera, Leonidas Quintana, Tariq Khan, Roxanna Garcia5, Haitham Shoman, Luke Caddell, Rifat Latifi, Kee B Park, Patricia Garcia, Robert Dempsey, Jeffrey V Rosenfeld, Corey Scurlock, Nigel Crisp, Lubna Samad, Montray Smith, Laura Lippa, Rashid Jooma, Russell J Andrews
Region / country: South America, Southern Asia – Chile, Pakistan
Speciality: Emergency surgery, Trauma surgery

Trauma/stroke centres optimise acute 24/7/365 surgical/critical care in high-income countries (HICs). Concepts from low-income and middle-income countries (LMICs) offer additional cost-effective healthcare strategies for limited-resource settings when combined with the trauma/stroke centre concept. Mass casualty centres (MCCs) integrate resources for both routine and emergency care—from prevention to acute care to rehabilitation. Integration of the various healthcare systems—governmental, non-governmental and military—is key to avoid both duplication and gaps. With input from LMIC and HIC personnel of various backgrounds—trauma and subspecialty surgery, nursing, information technology and telemedicine, and healthcare administration—creative solutions to the challenges of expanding care (both daily and disaster) are developed. MCCs are evolving initially in Chile and Pakistan. Technologies for cost-effective healthcare in LMICs include smartphone apps (enhance prehospital care) to electronic data collection and analysis (quality improvement) to telemedicine and drones/robots (support of remote regions and resource optimisation during both daily care and disasters) to resilient, mobile medical/surgical facilities (eg, battery-operated CT scanners). The co-ordination of personnel (within LMICs, and between LMICs and HICs) and the integration of cost-effective advanced technology are features of MCCs. Providing quality, cost-effective care 24/7/365 to the 5 billion who lack it presently makes MCCs an appealing means to achieve the healthcare-related United Nations Sustainable Development Goals for 2030.


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289. Establishment of a road traffic trauma registry for northern Sri Lanka

BMJ Global Health


Authors: Thayasivam Gobyshanger, Alison M Bales, Claire Hardman, Mary McCarthy
Region / country: Southern Asia – Sri Lanka
Speciality: Trauma surgery

Road traffic injuries are a neglected global public health problem. Over 1.25 million people are killed each year, and middle-income countries, which are motorising rapidly, are the hardest hit. Sri Lanka is dealing with an injury-related healthcare crisis, with a recent 85% increase in road traffic fatality rates. Road traffic crashes now account for 25 000 injuries annually and 10 deaths daily. Development of a trauma registry is the foundation for injury control, care and prevention. Five northern Sri Lankan provinces collaborated with Jaffna Teaching Hospital to develop a local electronic registry. The Centre for Clinical Excellence and Research was established to provide organisational leadership, hardware and software were purchased, and data collectors trained. Initial data collection was modified after implementation challenges were resolved. Between 1 June 2017 and 30 September 2017, 1708 injured patients were entered into the registry. Among these patients, 62% were male, 76% were aged 21–50, 71.3% were motorcyclists and 34% were in a collision with another motorcyclist. There were frequent collisions with uncontrolled livestock (12%) and with fixed objects (14%), and most patients were transported by private vehicles without prehospital care. Head (n=315) and lower extremity (n=497) injuries predominated. Establishment of a trauma registry in low-income and middle-income countries is a significant challenge and requires invested local leadership; the most challenging issue is ongoing funding. However, this pilot registry provides a valuable foundation, identifying unique injury mechanisms, establishing priorities for prevention and patient care, and introducing the concept of an organised system to this region.


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290. Availability, procurement, training, usage, maintenance and complications of electrosurgical units and laparoscopic equipment in 12 African countries

BJS Open


Authors: Oosting RM, Wauben LS, Madete JK, Groen RS, Dankelman J
Region / country: Central Africa, Eastern Africa, Southern Africa – Burundi, Ethiopia, Kenya, Malawi, Mozambique, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe
Speciality: General surgery, Other, Surgical Education

Background: Strategies are needed to increase the availability of surgical equipment in low- and middle-income countries (LMICs). This study was undertaken to explore the current availability, procurement, training, usage, maintenance and complications encountered during use of electrosurgical units (ESUs) and laparoscopic equipment.

Methods: A survey was conducted among surgeons attending the annual meeting of the College of Surgeons of East, Central and Southern Africa (COSECSA) in December 2017 and the annual meeting of the Surgical Society of Kenya (SSK) in March 2018. Biomedical equipment technicians (BMETs) were surveyed and maintenance records collected in Kenya between February and March 2018.

Results: Among 80 participants, there were 59 surgeons from 12 African countries and 21 BMETs from Kenya. Thirty-six maintenance records were collected. ESUs were available for all COSECSA and SSK surgeons, but only 49 per cent (29 of 59) had access to working laparoscopic equipment. Reuse of disposable ESU accessories and difficulties obtaining carbon dioxide were identified. More than three-quarters of surgeons (79 per cent) indicated that maintenance of ESUs was available, but only 59 per cent (16 of 27) confirmed maintenance of laparoscopic equipment at their centre.

Conclusion: Despite the availability of surgical equipment, significant gaps in access to maintenance were apparent in these LMICs, limiting implementation of open and laparoscopic surgery.


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291. Care Bundle Approach to Reduce Surgical Site Infections in Acute Surgical Intensive Care Unit, Cairo, Egypt

Infection and Drug Resistance


Authors: Mona Wassef, Ahmed Mukhtar, Ahmed Nabil, Moushira Ezzelarab, Doaa Ghaith
Region / country: Eastern Africa – Egypt, Sri Lanka
Speciality: Emergency surgery, General surgery, Other

Introduction
Surgical site infections (SSIs) are one of the most frequently reported hospital acquired infections associated with significant spread of antibiotic resistance.

Purpose
We aimed to evaluate a bundle-based approach in reducing SSI at acute surgical intensive care unit of the Emergency Hospital of Cairo University.

Patients and Methods
Our prospective study ran from March 2018 to February 2019 and used risk assessment. The study was divided into three phases. Phase I: (pre-bundle phase) for 5 months; data collection, active surveillance of the SSIs, screening for OXA-48 producing Enterobacteriaceae and multidrug resistant Acinetobacter baumannii colonizers using Chrom agars were carried out. Phase II: (bundle-implementation) a 6-S bundle approach included education, training and postoperative bathing with Chlorhexidine Gluconate in collaboration with the infection control team. Finally, Phase III: (post-implementation) for estimation of compliance, rates of colonization, and infection.

Results
Phase I encompassed 177 patients, while Phase III included 93 patients. A significant reduction of colonization from 24% to 15% (p<0.001) was observed. Similarly, a decrease of SSI from 27% to 15% (p=0.02) was noticed. A logistic regression was performed to adjust for confounding in the implementation of the bundle and we found a 70% reduction of SSI odd’s ratio (OR’s ratio = 0.3) confidence interval (95% CI 0.14–0.6) with significant Apache II (p=0.04), type of wound; type II (p=0.002), type III (p=0.001) and duration of surgery (p=0.04) as independent risk factors for SSI. Klebsiella pneumoniae was the most prevalent organism during phase I (34.7%). On the other hand, A. baumannii was the commonest organism to be isolated during phase III with (38.5%) preceding K. pneumoniae (30%).

Conclusion
Our study demonstrated that the implementation of a multidisciplinary bundle containing evidence-based interventions was associated with a significant reduction of colonization and SSIs and was met with staff approval and acceptable compliance.


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292. Frequency of Vertebral Fractures in Patients presenting with Hip Fractures

Pakistan Journal of Medical Sciences


Authors: Muhammad Amin Chinoy , Salman Javed
Region / country: South-eastern Asia – Pakistan
Speciality: Neurosurgery, Trauma and orthopaedic surgery, Trauma surgery

Objective:To determine the frequency of vertebral fractures in patients presenting with hip fractures. Methods:This prospective study was conducted at The Indus Hospital, Karachi, from May 2018 to November 2018. All patients above 40 years presenting with hip fractures were enrolled and a dorsal lumbar lateral view radiograph was obtained to investigate for vertebral fractures. Data was entered and analyzed using SPSS. Post-stratification, Chi-square/Fisher exact test was applied as appropriate to assess the significant association. P value of ≤0.05 was considered significant. Results:Three hundred thirty five patients were enrolled. Of these, 189 (56.4%) were females and 165 (49.3%) presented with neck of femur fractures. Out of 335 hip fractures patients, 77 (23%) were found to have concomitant vertebral fractures, with 73 (96.1%) having a compression fracture. T12 was the most common vertebra involved and 68.8% of patients were asymptomatic. Co-morbid conditions were statistically significantly associated with vertebral fractures. Conclusion:There is a high prevalence of asymptomatic vertebral fractures in our population, but low compared to studies from western countries. There is a need to evaluate these fractures separately for the prevention of morbidity and mortality.


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293. Does insurance protect individuals from catastrophic payments for surgical care? An analysis of Ghana’s National Health Insurance Scheme at Korle-Bu teaching Hospital

BMC Health Services Research


Authors: Juliet Okoroh, Doris Ottie-Boakye Sarpong, Samuel Essoun, Robert Riviello, Hobart Harris & Joel S. Weissman
Region / country: Western Africa – Ghana
Speciality: Health policy, Other

Background
According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe.

Methods
We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017 – October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual’s income.

Results
Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58–87% of insured patients would face financial catastrophe, versus 83–98% of uninsured patients (all comparisons by definition were significant, p < .05).

Conclusion
This study—the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana—found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana’s national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care.


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294. Epidemiology and outcomes of trauma patients at The Indus Hospital, Karachi, Pakistan, 2017 – 2018

Pakistan Journal of Medical Science


Authors: Saima Salman, Syed Ghazanfar Saleem, Quratulain Shaikh, Anna Q Yaffee
Region / country: South-eastern Asia – Pakistan
Speciality: Trauma surgery

Objective: Structured trauma care has proven to improve patient outcomes, and this is more relevant in the low- and middle-income countries (LMICs). The objective of this study was to determine the distribution, etiology, severity and outcomes of trauma patients at the Indus Hospital.
Methods: All adult poly-trauma patients presenting to The Indus Hospital from July 2017 to June 2018 were included in this retrospective review. Data was extracted on etiology of trauma, severity of injury, investigations and final disposition of patients.
Results: Of 972 trauma patients presenting to TIH Emergency Department, 663 (68.2%) were males with a mean age of 36 (17.4) years. Road traffic accidents (RTAs) led to trauma in 766 patients (78.8%), followed by 121 falls (12.7%). Injury Severity score (ISS) was calculated upon arrival and 528 (54.3%) were found to be critically injured. Median length of stay was 60 (24-720) minutes while none utilized pre-hospital Emergency Medical services.
Conclusion: Most trauma patients were males suffering from RTA. Nearly half of the patients were critically injured on arrival. EMS is not utilized by trauma patients. There were gaps identified in the diagnosis and treatment of trauma.


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295. Determinants of surgeons’ adherence to preventive intraoperative measures of surgical site infection in Gaza Strip hospitals: a multi-centre cross-sectional study

BMC Surgery


Authors: Mohamedraed Elshami, Bettina Bottcher, Issam Awadallah, Ahmed Alnaji, Basel Aljedaili, Haytham Abu Sulttan, Mohamed Hwaihi
Region / country: Western Asia – Palestinian Territories
Speciality: Surgical Education

Background
Surgical site infection (SSI) is one of the most common hospital-acquired infections and is associated with serious impact on the rates of morbidity, mortality as well as healthcare costs. This study examined factors influencing the application of several intraoperative preventive measures of SSI by surgeons and surgical residents in the Gaza Strip.

Methods
A cross-sectional study was conducted from December 2016 to February 2017 at the operation rooms of the three major hospitals located in the Gaza-Strip, Palestine. Inclusion criteria for patients were being adult (aged ≥18 years), no history of wound infection at time of operation and surgical procedure under general anaesthesia with endotracheal intubation. The association between different patient- and procedure-related SSI risk factors and adherence to several intraoperative SSI preventive measures was tested.

Results
In total, 281 operations were observed. The mean patient age ± standard deviation (SD) was 38.4 ± 14.6 years and the mean duration of surgery ± SD was 58.2 ± 32.1 minutes. A hundred-thirty-two patients (47.0%) were male. Location and time of the operation were found to have significant associations with adherence to all SSI preventive measures except for antibiotic prophylaxis. Type of operation had a significant association with performing all measures except changing surgical instruments. Patient age did not have a statistically significant association with adherence to any measure.

Conclusion
The results suggest that the surgeon could be a major factor that can lead to a better outcome of surgical procedures by reducing postoperative complications of SSI. Operating department professionals would benefit from clinical guidance and continuous training, highlighting the importance of persistent implementation of SSI preventive measures in everyday practice to improve the quality of care provided to surgical patients.


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296. Heineke-Mikulicz pyloroplasty for isolated pyloric stricture caused by corrosive ingestion in children

Pakistan Journal of Medical Science


Authors: Muhammad Aqil Soomro, Maryam Aftab, Maria Hasan, Hana Arbab
Region / country: South-eastern Asia – Pakistan
Speciality: Paediatric surgery

Corrosive ingestion in children is a common problem in low income countries. These agents cause injuries and later strictures of esophagus and stomach. Gastric outlet obstruction is known complication of acids and surgery is the mainstay of treatment. There are multitude of surgical options for these strictures depending on the involved segment of the stomach and experience of the surgeon. Here we present three cases of children who accidentally ingested acid stored in soda bottles and subsequently developed isolated pyloric strictures. These cases presented between August 2018 and April 2019 to our facility, a tertiary care hospital in Karachi, Pakistan. All three patients had an initial latent period of one to two weeks following corrosive ingestion, after which symptoms of gastric outlet obstruction appeared. Intraoperatively, all three had normal esophagus and antrum but scarred and strictured pylorus. Heineke-Mikulicz pyloroplasty was done in these cases without complications and the outcomes were satisfactory.


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297. Female Gender Remains a Significant Barrier to Access Cataract Surgery in South Asia: A Systematic Review and Meta-Analysis

Hindawi Journal of Ophthalmology


Authors: Qunru Ye , Yanxian Chen, William Yan, Wei Wang , Jingxian Zhong, Cong Tang, Andreas Müller, and Bo Qiu
Region / country: Southern Asia
Speciality: Ophthalmology

Purpose. To determine whether the female gender is a barrier for the access to cataract surgery services in South Asia in the last two decades. Methods. Eligible cross-sectional studies were identified via computer searches and reviewing the reference lists of the obtained articles. The cataract surgical coverage (CSC) by sex based on person and eyes at visual acuity <3/60 and 6/18 is extracted. Pooled odds ratios (ORs) for males receiving cataract surgery in comparison with females were calculated by a random effect model. Results. Sixteen studies with 135972 subjects were included in the final analysis. The pooled ORs of CSC by sex on a person basis at visual acuity <3/60 and at visual acuity <6/18 were 1.46 (95% CI: 1.23–1.75) and 1.14 (95% CI: 1.05–1.24), respectively. For CSC on a per-eye basis at visual acuity <3/60, the associations were statistically significant, with a pooled OR of 1.40 (95% CI: 1.16–1.70). The values of population attributable risk percentage at a per-person and per-eye basis at visual acuity <3/60 were 6.28% and 7.48%, respectively. Subgroup analyses by design and location types attained similar results as the primary analyses. There was no evidence of publication bias. Conclusions. The female gender remains a significant barrier for the access to cataract surgery in South Asia. Visual impairment, including blindness, from unoperated cataract, could be reduced by approximately 6.28% with the elimination of gender disparities to access. More efforts are needed to increase eye care service utilization by female population.


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298. Improving emergency obstetric referral systems in low and middle income countries: a qualitative study in a tertiary health facility in Ghana.

BMC Health Services Research


Authors: Daniels AA, Abuosi A
Region / country: Western Africa – Ghana
Speciality: Obstetrics and Gynaecology

Timely access to emergency obstetric care is crucial in preventing mortalities associated with pregnancy and childbirth. The referral of patients from lower levels of care to higher levels has been identified as an integral component of the health care delivery system in Ghana. To this effect, in 2012, the National Referral Policy and Guidelines was developed by the Ministry of Health (MOH) to help improve standard procedures and reduce delays which affect access to emergency care. Nonetheless, ensuring timely access to care during referral of obstetric emergencies has been problematic. The study aimed to identify barriers associated with the referral of emergency obstetric cases to the leading national referral centre. It specifically examines the lived experiences of patients, healthcare providers and relatives of patients on the referral system. Korle Bu Teaching Hospital, Accra was used as a case study in 2016.The qualitative method was used and in-depth interviews were conducted with 89 respondents: healthcare providers [n = 34];patients [n = 31] and relatives of patients [n = 24] using semi-structured interview guides. Purposive sampling techniques were used in selecting healthcare providers and patients and convenience sampling techniques were used in selecting relatives of patients. The study identified a range of barriers encountered in the referral process and broadly fall under the major themes: referral transportation system, referrer-receiver communication barriers, inadequate infrastructure and supplies and insufficient health personnel. Some highlights of the problem included inadequate use of ambulance services, poor management of patients during transit, lack of professional escort, unannounced emergency referrals, lack of adequate information and feedback and limited supply of beds, drugs and blood. These findings have implications on type II and III of the three delays model. Initiatives to improve the transportation system for the referral of obstetric emergencies are vital in ensuring patients’ safety during transfer. Communication between referring and receiving facilities should be enhanced. A strong collaboration is needed between teaching hospitals and other stakeholders in the referral chain to foster good referral practices and healthcare delivery. Concurrently, supply side barriers at referred facilities including ensuring sufficient provision for bed, blood, drugs, and personnel must be addressed.


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299. Imported hepatopulmonary echinococcosis: first report of Echinococcus granulosus sensu stricto (G1) in Bolivia

Revista da Sociedade Brasileira de Medicina Tropical


Authors: Daniel Jarovsky, Clarissa Rodrigues da Silva Brito, Danieli Urach Monteiro, Maria Isabel de Azevedo, Sônia de Avila Botton, Marcelo Jenné Mimica, Mariana Volpe Arnoni, Marco Aurélio Palazzi Sáfadi, Eitan Naaman Berezin, Humberto Salgado Filho, Flavia Jacqueline Almeida, Mário Luiz de la Rue
Region / country: South America – Bolivia
Speciality: Cardiothoracic surgery, General surgery

Hepatopulmonary hydatidosis in young children is a rare and atypical presentation of Echinococcus granulosus infection. We report the first case of cystic echinococcosis caused by a microvariant of E. granulosus sensu stricto. Chemotherapy and systemic corticoids were administered before curative surgery was performed. Recurrence was not observed for more than 24 months of follow-up.


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300. Diagnostic Accuracy of Core Needle Biopsy in Bone Tumors. Results of 100 Consecutive Cases from a Sarcoma Unit in Pakistan

E-Cronicon


Authors: Imran Khan, Muhammad Jawad Saleem, Zeeshan Khan, Israr Ahmad, Muhammad Saeed and Arif Khan
Region / country: South-eastern Asia – Pakistan
Speciality: Trauma and orthopaedic surgery

Background: Histological diagnosis is the main step towards management of bone tumors. Although open biopsy is considered as gold standard but core needle biopsy is advantageous because of its low cost, low morbidity rates and less time consumption. The aim of this study was to determine the diagnostic yield of core needle biopsy.

Methods: From January 2016 to December 2018, 100 consecutive patients with suspected bone tumors underwent core needle biopsy in a single unit. Patients between 5 to 90 years of age were included in the study. Informed consent was obtained from all patients. Core needle biopsy was performed under Local or General anesthesia depending of the location of tumor and age. Multiple cores were obtained and were sent to a single histopathological lab.

Results: Out of 100 patients, 61 were male and 39 were females. The age range was from 5 to 73 years with a mean of 39 years. Diagnosis was made in 91% of cases with approximately 4% of them being negative and 5% of the patients had inconclusive results. Only 3 patients required repeat biopsy. None of our patients had any complications.

Conclusion: Core needle biopsy for diagnosis of bone tumors has high diagnostic and accuracy rates with minimal associated complications.


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301. Stricture of Urethra: Patterns and Outcomes of Management From a Single Centre in Pakistan Over 7 Years

Journal of the College of Physicians and Surgeons Pakistan


Authors: Manzoor Hussain , Muhammad Shamim Khan , Murli Lal , Altaf Hashmi , Syed Ali Anwer Naqvi , Syed Adibul Hasan Rizvi
Region / country: South-eastern Asia – Pakistan
Speciality: Urology surgery

Objective: To determine the outcomes of urethroplasty and its complications from a large cohort of patients managed in a single centre.

Study design: Descriptive study.

Place and duration of study: Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, from January 2010 to December 2016.

Methodology: A total of 546 patients with stricture urethra at different locations underwent urethroplasty from January 2010 to December 2016 were included. All patients had an ascending urethrogram followed by retrograde ± antegrade urethroscopy to assess the location and length of the stricture. Technique of urethroplasty was chosen according to the site, length and etiology. Following appropriate procedure, patients were followed up in the dedicated urethral stricture clinic. Procedure was considered successful if either no further therapeutic intervention was required and the maximum flow rate (Qmax) was >20 ml/sec with a voided volume of at least 200 mls. The procedure was regarded as unsuccessful, if further treatment was required or Qmax was <10ml/sec.

Results: A total of 546 patients with mean age of 32.3 +13.1 years (range: 12-74) involving anterior (n=323, 59.2%) or posterior (n=223, 40.8%) urethra were treated. Mean follow-up was 43.6 months (range: 3-84). The success rates of bulbar urethral strictures after excision and primary anastomosis (EPA) was 93. 3%, non-transecting urethroplasty 84.6% and oral mucosal graft (OMG), 81.8%. In penile urethral strictures, OMG, Orandi procedure and Johanson's techniques yielded success rates of 88.4%, 66.6% and 57.1%, respectively. In posterior urethral strictures, after excision and bulboprostatic anastomosis, good results were seen in 88.3%. In pan-urethral strictures, abdominal skin graft repair, combined tissue transfer and OMG urethroplasty yielded success rates of 74%, 78.5% and 75%, respectively. The complications/ adverse events were encountered in 251 / 546 (45.9%) patients in this series.

Conclusion: Anastomotic urethroplasty yielded best outcomes followed by OMG urethroplasty. In the long-term follow-up, erectile dysfunction (ED), infertility and recurrence of stricture are the main complications which need individualised management.


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302. Total Hip Arthroplasty for Femur Neck Fractures in Elderly Patients. A Multi-Centre Study from Pakistan

E-Cronicon


Authors: Mujahid Jamil Khattak, Sajjad Ahmed, Marij Zahid, Israr Ahmed, Arif Khan and Zeeshan Khan
Region / country: South-eastern Asia – Pakistan
Speciality: Trauma and orthopaedic surgery, Trauma surgery

Introduction: The burden of hip fractures on health care systems and professionals is increasing with increase in life expectancy of patients. There is an increasing global trend for total hip replacement rather than Hemiarthroplasty for femur neck fractures in elderly patients. This is based on large series reported from various countries showing efficacy, safety and better functional outcome associated with this procedure. The concerns with Total hip replacement procedure include increased risk of dislocation, infection and anaesthetic complications. The adoption of this practice in developing countries pose additional challenges including access to medical facility, availability of equipped operating room, financial burden and the surgical expertise required for Total Hip Replacement for this unique group of patients.

Objectives: To evaluate the effectiveness and associated complications of total hip arthroplasty for femur neck fractures in elderly patients from various centres in Pakistan.

Materials and Methods: Retrospective cohort of patients from 3 different hospitals in the country was included. Data was obtained from prospectively held databases and patients with at least 12 months follow up were included in the study.

Results: A total of 63 patients were included in the study, including 27 males and 36 females with an average age of approximately 62 years. The commonest implant type used was cemented hip replacement with commonest head size being 32 mm. Only two patients had superficial wound infection, 1 patient had pulmonary embolism and 1 patient had dislocation at 2 months. No mortalities were reported during the study period.

Conclusion: THA is a safe option for carefully selected patients with neck of femur fractures. In a developing country, despite numerous constraints we are still able to reproduce the same results as published in the international literature


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303. Intranasal Splints In Reducing Post-operative Adhesions After Endoscopic Sinus Surgery

Pakistan Armed Forces Medical Journal


Authors: Kamran Zamurrad Malik ,Muhammad Majid Shaikh ,Tarique Ahmed Maka
Region / country: South-eastern Asia – Pakistan
Speciality: ENT surgery

Objective: To compare the frequency of post-operative adhesions after endoscopic sinus surgery with and without intranasal silastic splint.

Study Design: Quasi experimental study.

Place and Duration of Study: Research was conducted at department of ENT, Combined Military Hospital Muzaffarabad, from Sep 2016 to Mar 2017.

Methodology: This study involved 62 patients of both genders aged between 15-60 years undergoing endoscopic sinus surgery who were randomly allocated into two treatment groups. Patients in groups-A received silastic splint in addition to anterior nasal packing while those in group-B received anterior nasal packing alone. Outcome variable was frequency of post-operative adhesions which was noted and compared between the groups.

Results: The mean age and SD of the patients was 33.58 ± 11.11 years. The mean duration of symptoms was 11.81 ± 3.20 months. Both the study groups were comparable in terms of mean age (p=0.910), mean duration of symptoms (p=0.876) and age (p=0.866), gender (p=1.000) and duration of symptoms (p=1.000) groups. Post-operative adhesions were observed in 5 (8.1%) cases and all of them belonged to study group-B. The frequency of post-operative adhesion formation was significantly higher in patients receiving anterior nasal packing alone (16.1% vs. 0.0%; p=0.020) as compared to those receiving silastic splint in addition to anterior nasal packing. Similar difference was observed across various age, gender and duration of symptoms groups.

Conclusion: The use of silastic splint was associated with significant reduction of post-operative adhesions in patients undergoing endoscopic sinus surgery regardless of patient’s age, gender and duration of symptoms.


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304. Optical Trocar Causing Aortic Injury: A Potentially Fatal Complication of Minimal Access Surgery

Journal of the College of Physicians and Surgeons Pakistan


Authors: Rashid Usman , Hafsa Ahmed , Zeeshan Ahmed , Maqsood Ali
Region / country: South-eastern Asia – Pakistan
Speciality: General surgery, Vascular surgery

Trocar injury to abdominal aorta is uncommon and even rare with optical trocars. Such injury, resulting from umbilical trocar insertion, is potentially fatal. It often causes on-table death due to torrential life-threatening haemorrhage and unavailability of expert vascular help. We present a rare case of an injury to infra-renal abdominal aorta, caused by optical trocar insertion for bariatric surgery. Immediate recognition of the injury, deployment of life-saving manoeuvres, timely resuscitation, followed by definitive repair of aorta by vascular surgeon was life-saving for this patient. The recovery phase was uneventful and patient had no residual clinical problems during follow-up.


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305. Incidence of progressive hemorrhagic injury in patients presenting with traumatic brain injury at a large tertiary care hospital in Karachi, Pakistan. A Case Series.

The Professional Medical Journal


Authors: Qazi Muhammad Zeeshan ,Ramesh Kumar ,Asim Rehmani , Muhammad Imran , Atiq Ahmed Khan , Shiraz Ahmed Gauri ,Muhammad Sheraz Raza
Region / country: South-eastern Asia – Pakistan
Speciality: Emergency surgery, Neurosurgery, Trauma surgery

Objectives: Our study aims to determine the frequency of progressive hemorrhagic injury as observed on the CT scan from the initial scan performed at the time of presentation to a subsequent one in the 12 hours after the initial scan. Study Design: The type of study is a prospective observational case series. Setting: At Tertiary Care Hospital in Karachi, Pakistan. Period: 3 months from June 2018 to August 2018. Materials & Methods: All patients over 18 years of age who presented to the Accident and Emergency Department of the hospital with traumatic brain injury and had a CT scan performed within four hours of the injury were included in the study. A predesigned proforma was used to note down patient findings. CT scan findings were classified as subdural hematoma (SDH), intraparenchymal contusion (IPC) extradural hematoma (EDH) and subarachnoid hemorrhage (SAH). A repeat CT scan was performed twelve hours after the initial CT scan. Data were analyzed using IBM SPSS version 20.0, mean and frequencies were calculated for continuous variables while frequencies and percentages were calculated for categorical variables. Results: Of the n= 110 patients in our study 79 were males and 31 were female, the mean age of the patients was 34.25 years. The Glasgow Coma Scale scores at the time of arrival were between thirteen and fifteen for n= 33 (30%) of the patients, between nine and twelve for n= 54 (49.09%) of the patients, less than and equal to eight for n= 23 (20.90%) of the patients. Subarachnoid hemorrhage was present in n= 32 (29.09%) patients, intraparenchymal hematoma was present in n= 42 (38.18%) of the patients, while subdural hematoma and epidural hematoma was present in n= 14 (12.72%) and n= 22 (20%) of the patients respectively. Progressive hemorrhagic injury was found in n= 66 (60%) of the patients, while in n= 11 (10%) of the patients there was resolution of the lesion and n= 33 (33%) of the patients showed no observable changes in the repeat CT scan. Finally, our results indicate that of the 110 patients in our study PHI was seen in n= 17 (53.12%) patients with SAH, n= 18 (81.81%) patients of EDH, n= 5 (35.71%) patients of SDH and n= 26 (61.90%) patients of IPC respectively. Conclusion: According to the results of our study PHI is observed in 60% of the patients with a traumatic brain injury observed within the initial 12 hours after injury, and epidural hematoma and intraparenchymal contusions had the highest incidences of PHI among all the different types of traumatic brain injuries.


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306. Prevalence of Trachoma in Pakistan: Results of 42 Population-Based Prevalence Surveys from the Global Trachoma Mapping Project

Journal of Ophthalmic Epidemiology


Authors: Asad Aslam Khan, Victor V. Florea, Arif Hussain, Zahid Jadoon, Sophie Boisson, Rebecca Willis, Michael Dejene, Ana Bakhtiari, Caleb Mpyet, Alexandre L. Pavluck, Munazza Gillani, Babar Qureshi & Anthony W. Solomon
Region / country: South-eastern Asia – Pakistan
Speciality: Ophthalmology

Purpose: Previous phases of trachoma mapping in Pakistan completed baseline surveys in 38 districts. To help guide national trachoma elimination planning, we set out to estimate trachoma prevalence in 43 suspected-endemic evaluation units (EUs) of 15 further districts.

Methods: We planned a population-based trachoma prevalence survey in each EU. Two-stage cluster sampling was employed, using the systems and approaches of the Global Trachoma Mapping Project. In each EU, residents aged ≥1 year living in 30 households in each of 26 villages were invited to be examined by trained, certified trachoma graders. Questionnaires and direct observation were used to evaluate household-level access to water and sanitation.

Results: One EU was not completed due to insecurity. Of the remaining 42, three EUs had trichiasis prevalence estimates in ≥15-year-olds ≥0.2%, and six (different) EUs had prevalence estimates of trachomatous inflammation—follicular (TF) in 1–9-year-olds ≥5%; each EU requires trichiasis and TF prevalence estimates below these thresholds to achieve elimination of trachoma as a public health problem. All six EUs with TF prevalences ≥5% were in Khyber Pakhtunkhwa Province. Household-level access to improved sanitation ranged by EU from 6% to 100%. Household-level access to an improved source of water for face and hand washing ranged by EU from 37% to 100%.

Conclusion: Trachoma was a public health problem in 21% (9/42) of the EUs. Because the current outbreak of extremely drug-resistant typhoid in Pakistan limits domestic use of azithromycin mass drug administration, other interventions against active trachoma should be considered here.


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307. Regional Variations in Acceptance, and Utilization of Minimally Invasive Spinal Surgery Techniques Among Spine Surgeons: Results of a Global Survey

Journal of Spine Surgery


Authors: Kai-Uwe Lewandrowski, José-Antonio Soriano-Sánchez , Xifeng Zhang , Jorge Felipe Ramírez León, Sergio Soriano Solis , José Gabriel Rugeles Ortíz, Carolina Ramírez Martínez, Gabriel Oswaldo Alonso Cuéllar , Kaixuan Liu, Qiang Fu, Marlon Sudário de Lima e Silva, Paulo Sérgio Teixeira de Carvalho, Stefan Hellinger, Álvaro Dowling, Nicholas Prada, Gun Choi, Girish Datar, Anthony Yeung
Region / country: Global
Speciality: Neurosurgery

Background: Regional differences in acceptance and utilization of MISST by spine surgeons may have an impact on clinical decision-making and the surgical treatment of common degenerative conditions of the lumbar spine. The purpose of this study was to analyze the acceptance and utilization of various minimally invasive spinal surgery techniques (MISST) by spinal surgeons the world over.

Methods: The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups in social media networks including Facebook, WeChat, WhatsApp, and Linkedin. Surgeons were asked the following questions: (I) Do you think minimally invasive spinal surgery is considered mainstream in your area and practice setting? (II) Do you perform minimally invasive spinal surgery? (III) What type of MIS spinal surgery do you perform? (IV) If you are performing endoscopic spinal decompression surgeries, which approach do you prefer? The responses were cross-tabulated by surgeons’ demographic data, and their practice area using the following five global regions: Africa & Middle East, Asia, Europe, North America, and South America. Pearson Chi-Square measures, Kappa statistics, and linear regression analysis of agreement or disagreement were performed by analyzing the distribution of variances using statistical package SPSS Version 25.0.

Results: A total of 586 surgeons accessed the survey. Analyzing the responses of 292 submitted surveys regional differences in opinion amongst spine surgeons showed that the highest percentage of surgeons in Asia (72.8%) and South America (70.2%) thought that MISST was accepted into mainstream spinal surgery in their practice area (P=0.04) versus North America (62.8%), Europe (52.8%), and Africa & Middle East region (50%). The percentage of spine surgeons employing MISST was much higher per region than the rate of surgeons who thought it was mainstream: Asia (96.7%), Europe (88.9%), South America (88.9%), and Africa & Middle East (87.5%). Surgeons in North America reported the lowest rate of MISST implementation globally (P<0.000). Spinal endoscopy (59.9%) is currently the most commonly employed MISST globally followed by mini-open approaches (55.1%), and tubular retractor systems (41.8%). The most preferred endoscopic approach to the spine is the transforaminal technique (56.2%) followed by interlaminar (41.8%), full endoscopic (35.3%), and over the top MISST (13.7%).

Conclusions: The rate of implementation of MISST into day-to-day clinical practice reported by spine surgeons was universally higher than the perceived acceptance rates of MISST into the mainstream by their peers in their practice area. The survey suggests that endoscopic spinal surgery is now the most commonly performed MISST.


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308. Prediction of Early TBI Mortality Using a Machine Learning Approach in a LMIC Population

Frontiers in Neurology


Authors: Robson Luis Amorim, Louise Makarem Oliveira, Luis Marcelo Malbouisson, Marcia Mitie Nagumo, Marcela Simoes, Leandro Miranda, Edson Bor-Seng-Shu, Andre Beer-Furlan, Almir Ferreira De Andrade, Andres M. Rubiano,Manoel Jacobsen Teixeira,Angelos G. Kolias,Wellingson Silva Paiva
Region / country: South America – Brazil
Speciality: Emergency surgery, Neurosurgery, Trauma surgery

Background: In a time when the incidence of severe traumatic brain injury (TBI) is increasing in low- to middle-income countries (LMICs), it is important to understand the behavior of predictive variables in an LMIC’s population. There are few previous attempts to generate prediction models for TBI outcomes from local data in LMICs. Our study aim is to design and compare a series of predictive models for mortality on a new cohort in TBI patients in Brazil using Machine Learning.

Methods: A prospective registry was set in São Paulo, Brazil, enrolling all patients with a diagnosis of TBI that require admission to the intensive care unit. We evaluated the following predictors: gender, age, pupil reactivity at admission, Glasgow Coma Scale (GCS), presence of hypoxia and hypotension, computed tomography findings, trauma severity score, and laboratory results.

Results: Overall mortality at 14 days was 22.8%. Models had a high prediction performance, with the best prediction for overall mortality achieved through Naive Bayes (area under the curve = 0.906). The most significant predictors were the GCS at admission and prehospital GCS, age, and pupil reaction. When predicting the length of stay at the intensive care unit, the Conditional Inference Tree model had the best performance (root mean square error = 1.011), with the most important variable across all models being the GCS at scene.

Conclusions: Models for early mortality and hospital length of stay using Machine Learning can achieve high performance when based on registry data even in LMICs. These models have the potential to inform treatment decisions and counsel family members.


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309. Priorities for peri‐operative research in Africa

Anaesthesia


Authors: B.M. Biccard
Region / country: Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Anaesthesia

Deaths following surgery are the third largest contributor to deaths globally, and in Africa are twice the global average. There is a need for a peri‐operative research agenda to ensure co‐ordinated, collaborative research efforts across Africa in order to decrease peri‐operative mortality. The objective was to determine the top 10 research priorities for peri‐operative research in Africa. A Delphi technique was used to establish consensus on the top research priorities. The top 10 research priorities identified were (1) Develop training standards for peri‐operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (2) Develop minimum provision of care standards for peri‐operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (3) Early identification and management of mothers at risk from peripartum haemorrhage in the peri‐operative period; (4) The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri‐operative care; (5) A facility audit/African World Health Organization situational analysis tool audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and level of training and knowledge of peri‐operative healthcare providers (surgeons, anaesthetists and nurses); (6) Establishing evidence‐based practice guidelines for peri‐operative physicians in Africa; (7) Economic analysis of strategies to finance access to surgery in Africa; (8) Establishment of a minimum dataset surgical registry; (9) A quality improvement programme to improve implementation of the surgical safety checklist; and (10) Peri‐operative outcomes associated with emergency surgery. These peri‐operative research priorities provide the structure for an intermediate‐term research agenda to improve peri‐operative outcomes across Africa


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310. Reducing Gastroschisis Mortality: A Quality Improvement Initiative at a Ugandan Pediatric Surgery Unit

World Journal of Surgery


Authors: A. Wesonga, M. Situma & K. Lakhoo
Region / country: Eastern Africa – Uganda
Speciality: Paediatric surgery

Introduction: With modern treatment, survival of gastroschisis exceeds 90% in high-income countries. Survival in these countries has been largely attributed to prenatal diagnosis, delivery at tertiary facilities with timely resuscitation, timely intervention, parenteral nutrition and intensive care facilities. In sub-Saharan Africa, due to lack of these facilities, mortality rates are still alarmingly high ranging from 75 to 100%. In Uganda the mortality is 98%.

Aim: The aim of this study was to reduce gastroschisis mortality in a feasible, sustainable way using a locally derived gastroschisis care protocol at a referring hospital in Western Uganda.

Methods: Data collection was performed from January to October 2018. Nursing staff were interviewed regarding the survival and management of gastroschisis babies. A locally derived protocol was created with staff input and commitment from all the team members.

Results: Four mothers absconded and 17 babies were cared for using the newly designed protocol. Seven survived and were well at one month post discharge follow-up, reducing the mortality for this condition from 98 to 59%.

Conclusion: A dedicated team with minimal resources can significantly reduce the mortality in gastroschisis by almost 40% using a locally derived protocol.


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

Annals of Pediatric Surgery


Authors: Philemon E. Okoro & Charles Ngaikedi
Region / country: Western Africa – Nigeria
Speciality: General surgery, Paediatric surgery

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

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

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


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312. The mobile surgical outreach program for management of patients with genital fistula in the Democratic Republic of Congo

International Journal of Gynecology & Obstetrics


Authors: Raha Maroyi , Laura Keyser, Lauren Hosterman, Amisi Notia, Denis Mukwege
Region / country: Central Africa – Democratic Republic of the Congo
Speciality: Obstetrics and Gynaecology, Surgical Education

Objective
To describe components of the mobile surgical outreach (MSO) program as a model of care delivery for women with genital fistula; present program results; and discuss operational strengths and challenges.

Methods
A retrospective observational study of routinely collected health data from women treated via the MSO program (2013–2018). The program was developed at Panzi Hospital in the Democratic Republic of Congo to meet the needs of women with fistula living in remote provinces, where travel is prohibited. It includes healthcare delivery, medico‐surgical training, and community sensitization components.

Results
The MSO team cared for 1517 women at 41 clinic sites across 18 provinces over the study period. Average age at presentation was 31 years (range, 1–81 years). Most women (n=1359, 89.6%) presented with vesicovaginal fistula. Most surgeries were successful, and few women reported residual incontinence postoperatively. Local teams were receptive and engaged in clinical skills training and public health education efforts.

Conclusion
The MSO program addresses the backlog of patients awaiting fistula surgery and provides a template for a national strategic plan to treat and ultimately end fistula in DRC. It offers a patient‐centered approach that brings medico‐surgical care and psychosocial support to women with fistula in their own communities.


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313. The Burden of Urological Disease in Zomba, Malawi: A Needs Assessment in a sub-Saharan Tertiary Care Center

Canadian Urological Association Journal


Authors: Tristan Juvet, MD, James R. Hayes, MD, Sarah Ferrara, MD, Duncan Goche, MD, Robert D. Macmillan, MD, and Rajiv K. Singal,
Region / country: Eastern Africa – Malawi
Speciality: Urology surgery

Introduction: A large part of the developing world continues to lack access to surgical care. Urology remains one of the least represented surgical subspecialties in global health. To begin understanding the burden of urological illness in sub-Saharan Africa, we sought to characterize all patients presenting to a tertiary care hospital in Malawi with a urological diagnosis or related complaint in the past year.

Methods: Retrospective review of the surgical clinic and surgical theater record books at Zomba Central Hospital (ZCH) was performed over a one-year time span. Patients presenting with urological diagnoses or undergoing a urological procedure under local or general anesthetic in the operating theater were identified and entered into a database.

Results: We reviewed 440 clinical patients. The most common clinical presentations were for urinary retention (34.7%) and lower urinary tract symptoms (15.5%). A total of 182 surgical cases were reviewed. The most common diagnoses for surgical patients were urethral stricture disease (22%), bladder masses (17%), and benign prostatic hyperplasia (BPH) symptoms (14.8%). Urethral stricture-related procedures, including direct visual internal urethrotomy and urethral dilatation, were the most common (14.2% and 7.7%, respectively). BPH-related procedures, including simple prostatectomy and transurethral resection of the prostate were the second most common (6.7% and 8.2%, respectively).

Conclusions: Urethral stricture disease, BPH, and urinary retention represent the clinical diagnoses with the highest burden of visits. Despite these numbers, few definitive procedures are performed annually. Further focus on urological training in sub-Saharan Africa should focus on these conditions and their surgical management.


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

Acta Neurochir


Authors: Enoch O. Uche, Wilfred C. Mezue, Obinna Ajuzieogu, Christopher C. Amah, Ephraim Onyia, Izuchukwu Iloabachie, Mats Ryttlefors & Magnus Tisell
Region / country: Central Africa, Southern Africa, Western Africa
Speciality: Neurosurgery, Surgical Education

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

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

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

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


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315. Addressing the fistula treatment gap and rising to the 2030 challenge

International Journal of Gynecology & Obstetrics


Authors: Gillian Slinger, Lilli Trautvetter
Region / country: Global
Speciality: Obstetrics and Gynaecology

Obstetric fistula is a neglected public health and human rights issue. It occurs almost exclusively in low‐resource regions, resulting in permanent urinary and/or fecal incontinence. Although the exact prevalence remains unknown, it starkly outweighs the limited pool of skilled fistula surgeons needed to repair this childbirth injury. Several global movements have, however, enabled the international community to make major strides in recent decades. FIGO’s Fistula Surgery Training Initiative, launched in 2012, has made significant gains in building the capacity of local fistula surgeons to steadily close the fistula treatment gap. Training and education are delivered via FIGO and partners’ Global Competency‐based Fistula Surgery Training Manual and tailored toward the needs and skill level of each trainee surgeon (FIGO Fellow). There are currently 62 Fellows from 22 fistula‐affected countries on the training program, who have collectively performed over 10 000 surgical repairs. The initiative also contributes to the UN’s Sustainable Development Goals (1, 3, 5, 8, 10, and 17). The UN’s ambitious target to end fistula by 2030 will be unobtainable unless sufficient resources are mobilized and affected countries are empowered to develop their own sustainable eradication plans, including access to safe delivery and emergency obstetric services.


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316. Rising trends in iatrogenic urogenital fistula: A new challenge

International Journal of Gynecology & Obstetrics


Authors: Nasira Tasnim , Kauser Bangash, Oreekha Amin, Sobia Luqman , Hadia Hina
Region / country: South-eastern Asia – Pakistan
Speciality: Obstetrics and Gynaecology

Objective: To analyze trends in iatrogenic urogenital fistula among patients admitted for fistula repair at the Pakistan Institute of Medical Sciences, Islamabad.

Methods: In this longitudinal study, all patients who presented for fistula repair between 2006 and 2018 were included in the study. Patient data were collected on age, parity, and type and etiology of fistula, which was classified as ischemic or iatrogenic.

Results: Of 634 fistula patients, 371 (58.5%) had iatrogenic fistula, while 263 (41.5%) patients developed ischemic fistula due to obstructed labor. Mean age of patients was 31.6 years. Yearly trends showed an increase in iatrogenic fistula from 43.2% in 2006-2008 to 71.4% in 2017-2018. The major etiological contributor to iatrogenic fistula was hysterectomy (52.5%), followed by cesarean hysterectomy (26.4%), and cesarean delivery (19.9%).

Conclusion: A rising trend in iatrogenic fistula was observed. This emphasizes the need for optimization of surgical approaches and surgical skills. Moreover, gynecologic surgeries should be restricted to authorized gynecologic surgeons.


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317. Major obstetric haemorrhage in Metro East, Cape Town, South Africa: a population-based cohort study using the maternal near-miss approach

BMC Pregnancy and Childbirth


Authors: Anke Heitkamp, Simcha Lot Aronson, Thomas van den Akker, Linda Vollmer, Stefan Gebhardt, Jos van Roosmalen, Johanna I. de Vries & Gerhard Theron
Region / country: Southern Africa – South Africa
Speciality: Obstetrics and Gynaecology

Background
Major obstetric haemorrhage is a leading cause of maternal mortality and accounts for one-third of maternal deaths in of Africa. This study aimed to assess the population-based incidence, causes, management and outcomes of major obstetric haemorrhage and risk factors associated with poor maternal outcome.

Methods
Women with major obstetric haemorrhage who met the WHO maternal near-miss criteria or died in the Metro East region, Cape Town, South Africa, were evaluated from November 2014–November 2015. Major obstetric haemorrhage was defined as haemorrhage in pregnancies of at least 20 weeks’ gestation or occurring up to 42 days after birth, and leading to hysterectomy, hypovolaemic shock or blood transfusion of ≥5 units of Packed Red Blood Cells. A logistic regression model was used to analyse associations with poor outcome, defined as major obstetric haemorrhage leading to massive transfusion of ≥8 units of packed red blood cells, hysterectomy or death.

Results
The incidence of major obstetric haemorrhage was 3/1000 births, and the incidence of massive transfusion was 4/10.000 births in the Metro East region (32.862 births occurred during the studied time period). Leading causes of haemorrhage were placental abruption 45/119 (37.8%), complications of caesarean section 29/119 (24.4%) and uterine atony 13/119 (10.9%). Therapeutic oxytocin was administered in 98/119 (82.4%) women and hysterectomy performed in 33/119 (27.7%). The median numbers of packed red blood cells and units of Fresh Frozen Plasma transfused were 6 (interquartile range 4–7) and 3 (interquartile range 2–4), ratio 1.7:1. Caesarean section was independently associated with poor maternal outcome: adjusted OR 4.01 [95% CI 1.58, 10.14].

Conclusions
Assessment of major obstetric haemorrhage using the Maternal Near Miss approach revealed that placental abruption and complications of caesarean section were the major causes of major obstetric haemorrhage. Caesarean section was associated with poor outcome.


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318. Variation in global uptake of the Surgical Safety Checklist

British Journal of Surgery


Authors: M. Delisle , J. C. Pradarelli, N. Panda, L. Koritsanszky, Y. Sonnay, S. Lipsitz, R. Pearse, E. M. Harrison, B. Biccard , T. G. Weiser and A. B. Haynes, on behalf of the Surgical Outcomes Study Groups and GlobalSurg Collaborative
Region / country: Global
Speciality: Anaesthesia, Surgical Education

Background: The Surgical Safety Checklist (SSC) is a patient safety tool shown to reduce mortality and to improve teamwork and adherence with perioperative safety practices. The results of the original pilot work were published 10 years ago. This study aimed to determine the contemporary prevalence and predictors of SSC use globally.

Methods: Pooled data from the GlobalSurg and Surgical Outcomes studies were analysed to describe SSC use in 2014–2016. The primary exposure was the Human Development Index (HDI) of the reporting country, and the primary outcome was reported SSC use. A generalized estimating equation, clustering by facility, was used to determine differences in SSC use by patient, facility and national characteristics.

Results: A total of 85 957 patients from 1464 facilities in 94 countries were included. On average, facilities used the SSC in 75⋅4 per cent of operations. Compared with very high HDI, SSC use was less in low HDI countries (odds ratio (OR) 0⋅08, 95 per cent c.i. 0⋅05 to 0⋅12). The SSC was used less in urgent compared with elective operations in low HDI countries (OR 0⋅68, 0⋅53 to 0⋅86), but used equally for urgent and elective operations in very high HDI countries (OR 0⋅96, 0⋅87 to 1⋅06). SSC use was lower for obstetrics and gynaecology versus abdominal surgery (OR 0⋅91, 0⋅85 to 0⋅98) and where the common or official language was not one of the WHO official languages (OR 0⋅30, 0⋅23 to 0⋅39).

Conclusion: Worldwide, SSC use is generally high, but significant variability exists. Implementation and dissemination strategies must be developed to address this variability.


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319. Reliability and versatility of the Wise pattern, medial pedicle for breast reduction in South Africa

Surgery Open Science


Authors: Marietha Nel, Elias Ndobe, Aylwyn Mannell, Letlhogonolo Brian Andrew Monaisa
Region / country: Southern Africa – South Africa
Speciality: General surgery, Plastic surgery

Background
Breast hypertrophy is a condition of abnormal enlargement of the breast which may continue until each breast weighs more than 1.5 kg (macromastia) or even more than 2 kg (gigantomastia). Supporting such heavy weights leads to cervical and upper thoracic back pain, costochondritis, and fungal infections in the mammary folds, making reduction mammoplasty essential. However, there is a lack of consensus among plastic surgeons as to the best technique. This study reports the results of reduction mammoplasties in South African women using the Wise pattern, minimally undermined with a medial pedicle.

Methods
A retrospective record review of the reduction mammoplasties was conducted over a 1-year period. Patient records were assessed for early complications related to vascular reliability.

Results
One hundred and fourteen Wise pattern minimally undermined, medial pedicle techniques were performed on 57 consecutive patients in the 1-year period at the NetCare Rand Clinic in Berea, Johannesburg, South Africa (EN). The patients’ sternal notch to nipple distances ranged from 28 to 52 cm. The volume of breast reduction ranged from 345 g to 3300 g per breast. The overall complication rate was 9.7%, consisting of fat necrosis (3.5%), infection (1.7%), dehiscence (3.5%), and nipple epidermolysis (0.9%).

Conclusion
The minimally undermined Wise pattern medial pedicle breast reduction technique proved to be a reliable technique for breast reduction in the South African population. Safety in pedicle breast reduction with sternal notch to nipple distances of up to 50 cm, as well as reliability and versatility in a wide range of breast sizes, was demonstrated.


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320. Incidence and factors associated with postoperative nausea and vomiting among elective adult surgical patients at University of Gondar comprehensive specialized hospital, Northwest Ethiopia, 2019: A cross-sectional study

International Journal of Surgery Open


Authors: Seid Adem Ahmed, Girmay Fitiwi Lema
Region / country: Eastern Africa – Ethiopia
Speciality: Anaesthesia

Background
Postoperative nausea and vomiting is a common complication of anaesthesia and surgery. It is considered the most common cause of morbidity following anaesthesia and has significant effects on patient satisfaction and cost. Despite modern anaesthetic and surgical techniques, the incidence of PONV remains high.

Objective
The objective of this study was to determine the incidence of postoperative nausea and vomiting and associated factors.

Methods
A cross-sectional study was conducted from January 1 to May 30, 2019. A total of 355 adult elective patients who were operated on this period were included in the study.

Results
The incidence of postoperative nausea and vomiting was 17.2% within 24 h after operation. Factors that were associated with postoperative nausea and vomiting were history of motion sickness (AOR = 6.0, CI = 2.51–14.49), previous history of postoperative nausea and vomiting (AOR = 13.55, CI = 6.37–28.81) and long duration of surgery (AOR = 10.1, CI = 3.97–25.92).

Conclusion
and recommendations: The incidence of postoperative nausea and vomiting was still high compared with most studies conducted in the world. However, when it compared to the previous study done in the study area, it showed significant reduction in the incidence of PONV by 19%.We suggest that the use of anti-emetic prophylaxis and the introduction of postoperative nausea and vomiting treatment protocols


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321. Vulvar cancer: surgical management and survival trends in a low resource setting

Journal of the Egyptian National Cancer Institute


Authors: Navin Kumar, Mukur Dipi Ray, D. N. Sharma, Rambha Pandey, Kanak Lata, Ashutosh Mishra, Durgesh Wankhede & Jyoutishman Saikia
Region / country: Northern Africa – Egypt
Speciality: Obstetrics and Gynaecology, Surgical oncology

Background
This study aims to analyze risk factors, clinical profiles, treatment protocols, and disease outcomes in histologically proven resectable vulvar cancer (VC) patients according to tumor stage. This is a retrospective analysis of a prospectively collected database of 20 VC patients from May 2014 to June 2019.

Results
The mean age of VC diagnosis was 55 years, with a range of 38–84 years. The incidence was four cases per year. The disease incidence was significantly more in post-menopausal (65%) and multiparous (90%) women. According to FIGO staging of vulvar cancer, stages I, II, and III were assigned to 6, 1, and 11 patients respectively. Two patients suffered from stage IVa vulvar melanoma. All patients had undergone surgical interventions. Patients treated with only nonsurgical (chemotherapy/radiotherapy/chemo-radiotherapy) treatment modalities were excluded from the study. Fifteen patients were treated with wide local excision (WLE), bilateral inguinofemoral dissection (B/L IFLND), and primary repair. Four and one patients were treated with radical vulvectomy (RV) and modified radical vulvectomy (MRV) [with or without B/L IFLND and PLND] respectively. Reconstruction with V-Y gracilis myocutaneous and local rotation advancement V-Y fasciocutaneous flaps were done in two patients. Therapeutic groin nodal dissection was performed in 19 patients except in one patient who was treated by palliative radical vulvectomy. In the final histopathology reports, tumor size varies from 0.5 to 6.5 cm (mean 3.35 cm) with the predominance of squamous cell carcinoma (18 out of 20 patients). Only 10 out of 18 eligible patients received adjuvant treatment. Poor patient compliance has been one of the major reasons for adjuvant treatment attrition rate. Systemic and loco-regional metastasis occurred in 3 patients each arm respectively. Poor follow up of patients is the key limitation of our study.

Conclusion
Vulvar cancer incidence was significantly high in post-menopausal and multiparous women. The most important prognostic factors were tumor stage and lymph node status. Oncological resection should be equated with functional outcome. The multidisciplinary team approach should be sought for this rare gynecological malignancy.


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322. Compliance and Barriers Facing Nurses with Surgical Site Infection Prevention Guidelines

Open Journal of Nursing


Authors: Magda M. Mohsen, Neima Ali Riad, Amina Ibrahim Badawy
Region / country: Northern Africa – Egypt
Speciality: General surgery

Background: Surgical Site Infection (SSI) is defined as infection that occurring within 30 days after surgical procedure or within a year of implantation of prosthesis. Surgical Site Infection can happen in up to 30% of surgical procedures and records for up to 14% of Hospital Acquired Infection (HAIs). Aim of the Study: The aim of this study was to assess levels of nurse’s Compliance; knowledge and practice regarding prevention of surgical site infection Guidelines and identify the barriers facing nurses’ compliance with surgical site infection prevention Guidelines. Design: Cross sectional descriptive study design self-reported survey. Settings: Data was collected from surgical departments from selected Menoufia Governorate Hospitals, Egypt. Sample: A large convenience sample of 450 nurses was selected. Initially 600 questionnaires were distributed, of which only 400 returned completed, a response rate of 66.6%. Tools: was comprised of the: 1) Pre-designed structured questionnaire to assess nurses’ socio-demographic characteristics’ and Nurses’ knowledge, 2) Likert-scale: to assess nurses’ compliance, nurses’ practice and nurses’ barriers facing nurses with surgical site infection prevention guidelines. Study period: The study was conducted from July to November 2019 in the selected hospitals. Results: nurses’ compliance mean scores were in low level with a mean of 13.01, it is clear that most of the nurses have poor knowledge, most of the nurses have poor practice about surgical site infection, concerning the most barriers of compliance facing nurses with surgical site infection prevention guidelines, were lack of a professional model, having no enough time, and some measures for the prevention of surgical site infection are not nurses’ responsibilities. Conclusions: Nurses working in the surgical related wards reported a low level of knowledge, practice and compliance regarding the prevention of surgical site infection guidelines. The most barriers of compliance with surgical site infection prevention guidelines that reported by nurses were, lack of a professional model, nurses do not have enough time, and some measures for the prevention of surgical site infection are not nurses’ responsibilities. Recommendations: Evaluation of nurses’ and hospitals’ application of the guidelines is important to improve the quality of care. Education and training program should be conducted to improve nurses’ knowledge and practice in some areas using evidence-based practice.


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323. Epidemiology of surgical valvular heart diseases in a north african tertiary referral hospital

Archives of Cardiovascular Diseases Supplements


Authors: W.Ouechtati Ben Attia, E. Allouche, Z.Oumaya, A.Ben Salem, H.Ben Ahmed, L.Bezdah
Region / country: Northern Africa – Tunisia
Speciality: Cardiothoracic surgery

Introduction
The etiology of valvular heart disease (VHD) has changed dramatically in the last five decades. In the western world, the significant reduction of acute rheumatic fever and its sequelae, and the recognition of non-rheumatic causes of VHD induced the metamorphosis in the etiology of valvular disorders. The aim of this study was to assess the epidemiological profile of the patients undergoing valvular surgery in a north African center of cardiology.

Methods
A retrospective study involving the 246 last patients hospitalized in our department and proposed for valvular surgery from January 2012 to December 2017.

Results
The mean age was 57 years. One hundred twenty-one patients were male (49%). Before surgery mean LVEF is 60% ± 13. Ten percent of the patients were operated with (left ventricular dysfunction LVEF ≤ 40%). Arterial hypertension, diabetes mellitus and smoking are respectively present in 29, 7%, 21, 8% and 27, 7% of the patients. A history of rheumatic fever was present in 60, 8% of rheumatic valvular disease. The rheumatic etiology was the most important (50,5%). A preoperative coronary angiography was performed in 63,4% of the patients and coronary artery disease was associated to the valvular heart disease in 14,9%. Mitral valve replacement, aortic-valve replacement and double valve replacement were respectively performed in 38,7%, 35,4% and 18,7% of the cases. Bioprothesis were implanted in 5,29% of the cases. One eighth of the patients underwent coronary artery bypass graft in addition to the valvular surgery. In 16,8% of the cases it was a redo surgery.

Conclusion
Contemporary epidemiological data show a rise of the degenerative etiology and associated coronary artery disease. Surgery offers good results for patients with significant valvular heart disease. Valve replacement and repair are the main surgical options. Older patients and redo procedures are increasingly frequent.


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324. Challenges in Public Health Rapid Response Team Management

health security


Authors: Ashley L. Greiner, Tasha Stehling-Ariza, Dante Bugli, Adela Hoffman, Coralie Giese, Lisa Moorhouse, John C. Neatherlin, and Cyrus Shahpar
Region / country: Global
Speciality: Emergency surgery, Health policy, Trauma surgery

The International Health Regulations (2005) dictate the need for states parties to establish capacity to respond promptly
and effectively to public health risks. Public health rapid response teams (RRTs) can fulfill this need as a component of a
larger public health emergency response infrastructure. However, lack of a standardized approach to establishing and
managing RRTs can lead to substantial delays in effective response measures. As part of the Global Health Security
Agenda, national governments have sought to develop and more formally institute their RRTs. RRT challenges were
identified from 21 countries spanning 4 continents from 2016 to 2018 through direct observation of RRTs deployed
during public health emergencies, discussions with RRT managers involved in outbreak response, and during formal
RRT management training workshops. One major challenge identified is the development and maintenance of an RRT
roster to ensure deployable surge staff identification, selection, and availability. Another challenge is ensuring that
RRT members are trained and have the relevant competencies to be effective in the field. Finally, the lack of defined
RRT standard operating procedures covering both nonemergency maintenance measures and the multistage emergency
response processes required for RRT function can delay the RRT’s response time and effectiveness. These findings
highlight the importance of planning to preemptively address these challenges to ensure rapid and effective response
measures, ultimately strengthening global health security.


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325. A woman’s worth: an access framework for integrating emergency medicine with maternal health to reduce the burden of maternal mortality in sub-Saharan Africa

BMC Emergency Medicine


Authors: Martina Anto-Ocrah, Jeremy Cushman, Mechelle Sanders & Timothy De Ver Dye
Region / country: Central Africa, Eastern Africa, Middle Africa, Southern Africa, Western Africa
Speciality: Emergency surgery, Obstetrics and Gynaecology

Background
Within each of the Sustainable Development Goals (SDGs), the World Health Organization (WHO) has identified key emergency care (EC) interventions that, if implemented effectively, could ensure that the SDG targets are met. The proposed EC intervention for reaching the maternal mortality benchmark calls for “timely access to emergency obstetric care.” This intervention, the WHO estimates, can avert up to 98% of maternal deaths across the African region.

Access, however, is a complicated notion and is part of a larger framework of care delivery that constitutes the approachability of the proposed service, its acceptability by the target user, the perceived availability and accommodating nature of the service, its affordability, and its overall appropriateness.

Without contextualizing each of these aspects of access to healthcare services within communities, utilization and sustainability of any EC intervention-be it ambulances or simple toll-free numbers to dial and activate EMS-will be futile.

Main text
In this article, we propose an access framework that integrates the Three Delays Model in maternal health, with emergency care interventions. Within each of the three critical time points, we provide reasons why intended interventions should be contextualized to the needs of the community. We also propose measurable benchmarks in each of the phases, to evaluate the successes and failures of the proposed EC interventions within the framework. At the center of the framework is the pregnant woman, whose life hangs in a delicate balance in the hands of personal and health system factors that may or may not be within her control.

Conclusions
The targeted SDGs for reducing maternal mortality in sub-Saharan Africa are unlikely to be met without a tailored integration of maternal health service delivery with emergency medicine. Our proposed framework integrates the fields of maternal health with emergency medicine by juxtaposing the three critical phases of emergency obstetric care with various aspects of healthcare access. The framework should be adopted in its entirety, with measureable benchmarks set to track the successes and failures of the various EC intervention programs being developed across the African continent.


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326. Endometriosis and Pregnancy: A Single Institution Experience

International Journal of Environmental Research and Public Health


Authors: Maria Grazia Porpora, Federica Tomao , Adele Ticino , Ilaria Piacenti , Sara Scaramuzzino , Stefania Simonetti , Ludovica Imperiale , Chiara Sangiuliano , Luisa Masciullo , Lucia Manganaro and Pierluigi Benedetti Panici
Region / country: Western Europe – Italy
Speciality: Obstetrics and Gynaecology

Endometriosis may compromise the physiological course of pregnancy. The aim of this prospective observational study was to evaluate whether endometriosis causes a higher prevalence of obstetric and neonatal complications as well as a higher risk of caesarean section and to detect a possible correlation between the presence, type, and location of endometriosis and obstetric complications, previous surgery, and pregnancy outcome, as well as the influence of pregnancy on the course of the disease. We compared two cohorts of women with spontaneous pregnancy, with and without endometriosis. Obstetric and neonatal outcomes, mode of delivery, presence, type, and location of endometriotic lesions and the effect of pregnancy on the disease were analyzed. A total of 425 pregnancies were evaluated: 145 cases and 280 controls. Patients with endometriosis showed a higher incidence of miscarriage, threatened miscarriage, threatened preterm labor, preterm delivery, placental abruption, and a higher incidence of caesarean section. A significant correlation with pregnancy-induced hypertension and preeclampsia was found in the presence of adenomyosis. No difference in fetal outcome was found. One case of hemoperitoneum during pregnancy was observed. Pregnancy in women with endometriosis carries a higher risk of obstetric complications, such as miscarriage, threatened miscarriage, preterm labor, preterm birth, and a higher caesarean section rate. Endometriosis does not seem to influence fetal well-being.


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327. Delivery Mode for Prolonged, Obstructed Labour Resulting in Obstetric Fistula: A Retrospective Review of 4396 Women in East and Central Africa

BJOG: An International Journal of Obstetrics and Gynaecology


Authors: CJ Ngongo, TJIP Raassen, L Lombard, J van Roosmalen, S Weyers, M Temmerman
Region / country: Central Africa, Eastern Africa – Ethiopia, Kenya, Malawi, Rwanda, Somalia, South Sudan, Tanzania, Uganda, Zambia
Speciality: Obstetrics and Gynaecology

Objective: To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula.

Design: Retrospective record review.

Setting: Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia.

Population: A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014.

Methods: Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries.

Main outcome measures: Mode of delivery, stillbirth.

Results: Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514).

Conclusions: In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth.


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328. Morbidity and mortality from road injuries: results from the Global Burden of Disease Study 2017

Injury Prevention


Authors: Spencer L James , Lydia R Lucchesi , Catherine Bisignano , Chris D Castle , Zachary V Dingels , Jack T Fox , Erin B Hamilton , Zichen Liu , Darrah McCracken , Molly R Nixon , Dillon O Sylte , Nicholas L S Roberts , Oladimeji M Adebayo , Teamur Aghamolaei , Suliman A Alghnam , Syed Mohamed Aljunid , Amir Almasi-Hashiani , Alaa Badawi , Masoud Behzadifar , Meysam Behzadifar , Eyasu Tamru Bekru , Derrick A Bennett , Jens Robert Chapman , Kebede Deribe , Bereket Duko Adema , Yousef Fatahi , Belayneh K Gelaw , Eskezyiaw Agedew Getahun , Delia Hendrie , Andualem Henok , Hagos de Hidru , Mehdi Hosseinzadeh , Guoqing Hu , Mohammad Ali Jahani , Mihajlo Jakovljevic , Farzad Jalilian , Nitin Joseph , Manoochehr Karami , Abraham Getachew Kelbore , Md Nuruzzaman Khan , Yun Jin Kim , Parvaiz A Koul , Carlo La Vecchia , Shai Linn , Reza Majdzadeh , Man Mohan Mehndiratta , Peter T N Memiah , Melkamu Merid Mengesha , Hayimro Edemealem Merie , Ted R Miller , Mehdi Mirzaei-Alavijeh , Aso Mohammad Darwesh , Naser Mohammad Gholi Mezerji , Roghayeh Mohammadibakhsh , Yoshan Moodley , Maziar Moradi-Lakeh , Kamarul Imran Musa , Bruno Ramos Nascimento , Rajan Nikbakhsh , Peter S Nyasulu , Ahmed Omar Bali , Obinna E Onwujekwe , Sanghamitra Pati , Reza Pourmirza Kalhori , Farkhonde Salehi , Saeed Shahabi , Seifadin Ahmed Shallo , Morteza Shamsizadeh , Zeinab Sharafi , Sharvari Rahul Shukla , Mohammad Reza Sobhiyeh , Joan B Soriano , Bryan L Sykes , Rafael Tabarés-Seisdedos , Degena Bahray Bahrey Tadesse , Yonatal Mesfin Tefera , Arash Tehrani-Banihashemi , Boikhutso Tlou , Roman Topor-Madry , Taweewat Wiangkham , Mehdi Yaseri , Sanni Yaya , Muluken Azage Yenesew , Mustafa Z Younis , Arash Ziapour , Sanjay Zodpey , David M Pigott , Robert C Reiner Jr , Simon I Hay , Alan D Lopez , Ali H Mokdad
Region / country: Global
Speciality: Emergency surgery, Trauma surgery

Background: The global burden of road injuries is known to follow complex geographical, temporal and demographic patterns. While health loss from road injuries is a major topic of global importance, there has been no recent comprehensive assessment that includes estimates for every age group, sex and country over recent years.

Methods: We used results from the Global Burden of Disease (GBD) 2017 study to report incidence, prevalence, years lived with disability, deaths, years of life lost and disability-adjusted life years for all locations in the GBD 2017 hierarchy from 1990 to 2017 for road injuries. Second, we measured mortality-to-incidence ratios by location. Third, we assessed the distribution of the natures of injury (eg, traumatic brain injury) that result from each road injury.

Results: Globally, 1 243 068 (95% uncertainty interval 1 191 889 to 1 276 940) people died from road injuries in 2017 out of 54 192 330 (47 381 583 to 61 645 891) new cases of road injuries. Age-standardised incidence rates of road injuries increased between 1990 and 2017, while mortality rates decreased. Regionally, age-standardised mortality rates decreased in all but two regions, South Asia and Southern Latin America, where rates did not change significantly. Nine of 21 GBD regions experienced significant increases in age-standardised incidence rates, while 10 experienced significant decreases and two experienced no significant change.

Conclusions: While road injury mortality has improved in recent decades, there are worsening rates of incidence and significant geographical heterogeneity. These findings indicate that more research is needed to better understand how road injuries can be prevented.


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329. Addressing Supply Chain Management Issues in Cost-effective Maternal and Pediatric Global Surgery: A Call to Action

International Journal of Maternal and Child Health and AIDS


Authors: Sergio M. Navarro, MBA, Andile Sibiya, MBChB, FCORL, MBA, Maziar M. Nourian, MD, Kelsey A. Stewart, MD, Taylor D. Ottesen, BS, Raymond R. Price, MD
Region / country: Global
Speciality: Paediatric surgery

Persistent global disparities in maternal and neonatal outcomes exist, in part, due to a lack of access to safe surgery. This commentary examines the relative need for increased focus on access to safe maternal and pediatric surgery globally, starting with a focus on cost-effective surgeries. There is a need to understand context-specific surgeries for regions, including understanding regional versus tertiary development. Most important is a need to understand the crucial role of supply chain management (SCM) in developing better access to maternal and pediatric surgery in limited resource settings. We evaluate the role of SCM in global surgery and global health, and the current landscape of inefficiency. We outline specific findings and takeaways from recent solutions developed in pediatric and maternal surgery to address SCM inefficiencies. We then examine the applicability to other settings and look at the future. Our goal is to summarize the challenges that exist today in a global setting to provide better access to maternal and pediatric surgery and outline solutions relying on structural, SCM-related framework.


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330. Missed opportunities for epilepsy surgery referrals in Bhutan: A cohort study

Epilepsy Research


Authors: Andrew Siyoon Ham, Damber K. Nirola, Neishay Ayub, Lhab T shering, Ugyen Dem, Nathalie Jette, Chencho Dorji, Farrah J. Mateen
Region / country: Southern Asia – Bhutan
Speciality: Neurosurgery

Objective: To quantify the missed opportunities for epilepsy surgery referral and operationalize the Canadian Appropriateness of Epilepsy Surgery (CASES) tool for use in a lower income country without neurologists.

Methods: People with epilepsy were recruited from the Jigme Dorji Wangchuck National Referral Hospital from 2014-2016. Each participant was clinically evaluated, underwent at least one standard EEG, and was invited to undergo a free 1.5 T brain MRI. Clinical variables required for CASES were operationalized for use in lower-income populations and entered into the free, anonymous website tool.

Findings: There were 209 eligible participants (mean age 28.4 years, 56 % female, 179 with brain MRI data). Of the 179 participants with brain MRI, 43 (24.0 %) were appropriate for an epilepsy surgery referral, 21 (11.7 %) were uncertain, and 115 (64.3 %) were inappropriate for referral. Among the 43 appropriate referral cases, 36 (83.7 %) were “very high” and 7 (16.3 %) were “high” priorities for referral. For every unit increase in surgical appropriateness, quality of life (QoL) dropped by 2.3 points (p-value 1 antiepileptic drug prior to enrollment, 42 (61.8 %) were appropriate referrals, 14 (20.6 %) were uncertain, and 12 (17.6 %) were inappropriate.

Conclusion: Approximately a quarter of Bhutanese epilepsy patients who completed evaluation in this national referral-based hospital should have been evaluated for epilepsy surgery, sometimes urgently. Surgical services for epilepsy are an emerging priority for improving global epilepsy care and should be scaled up through international partnerships and clinician support algorithms like CASES to avoid missed opportunities.


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331. Barriers to Women Entering Surgical Careers: A Global Study into Medical Student Perceptions

World Journal of Surgery


Authors: I. H. Marks, A. Diaz, M. Keem, Seyedeh-Sanam Ladi-Seyedian, G. S. Philipo, H. Munir, T. I. Pomerani, H. M. Sughayer, N. Peter, C. Lavy & D. C. Chang
Region / country: Global
Speciality: Other, Surgical Education

Background: Barriers to female surgeons entering the field are well documented in Australia, the USA and the UK, but how generalizable these problems are to other regions remains unknown.

Methods: A cross-sectional survey was developed by the International Federation of Medical Students’ Associations (IFMSA)’s Global Surgery Working Group assessing medical students’ desire to pursue a surgical career at different stages of their medical degree. The questionnaire also included questions on students’ perceptions of their education, resources and professional life. The survey was distributed via IFMSA mailing lists, conferences and social media. Univariate analysis was performed, and statistically significant exposures were added to a multivariate model. This model was then tested in male and female medical students, before a further subset analysis by country World Bank income strata.

Results: 639 medical students from 75 countries completed the survey. Mentorship [OR 3.42 (CI 2.29-5.12) p = 0.00], the acute element of the surgical specialties [OR 2.22 (CI 1.49-3.29) p = 0.00], academic competitiveness [OR 1.61 (CI 1.07-2.42) p = 0.02] and being from a high or upper-middle-income country (HIC and UMIC) [OR 1.56 (CI 1.021-2.369) p = 0.04] all increased likelihood to be considering a surgical career, whereas perceived access to postgraduate training [OR 0.63 (CI 0.417-0.943) p = 0.03], increased year of study [OR 0.68 (CI 0.57-0.81) p = 0.00] and perceived heavy workload [OR 0.47 (CI 0.31-0.73) p = 0.00] all decreased likelihood to consider a surgical career. Perceived quality of surgical teaching and quality of surgical services in country overall did not affect students’ decision to pursue surgery. On subset analysis, perceived poor access to postgraduate training made women 60% less likely to consider a surgical career [OR 0.381 (CI 0.217-0.671) p = 0.00], whilst not showing an effect in the men [OR 1.13 (CI 0.61-2.12) p = 0.70. Concerns about high cost of training halve the likelihood of students from low and low-middle-income countries (LICs and LMICs) considering a surgical career [OR 0.45 (CI 0.25-0.82) p = 0.00] whilst not demonstrating a significant relationship in HIC or UMIC countries. Women from LICs and LMICs were 40% less likely to consider surgical careers than men, when controlling for other factors [OR 0.59 CI (0.342-1.01 p = 0.053].

Conclusion: Perceived poor access to postgraduate training and heavy workload dissuade students worldwide from considering surgical careers. Postgraduate training in particular appears to be most significant for women and cost of training an additional factor in both women and men from LMICs and LICs. Mentorship remains an important and modifiable factor in influencing student’s decision to pursue surgery. Quality of surgical education showed no effect on student decision-making.


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332. Burden of Neonatal Surgical Conditions in Northern Ghana

World Journal of Surgery


Authors: Alhassan Abdul-Mumin, Theophilus T. K. Anyomih, Sheila A. Owusu, Naomi Wright, Janae Decker, Kelli Niemeier, Gabriel Benavidez, Francis A. Abantanga, Emily R. Smith & Stephen Tabiri
Region / country: Western Africa – Ghana
Speciality: Paediatric surgery

Background: Congenital anomalies have risen to become the fifth leading cause of under-five mortality globally. The majority of deaths and disability occur in low- and middle-income countries including Ghana. This 3-year retrospective review aimed to define, for the first time, the characteristics and outcomes of neonatal surgical conditions in northern Ghana.

Methods: A retrospective study was conducted to include all admissions to the Tamale Teaching Hospital (TTH) neonatal intensive care unit (NICU) with surgical conditions between January 2014 and January 2017. Data were collected on demographics, diagnosis and outcomes. Descriptive analysis was performed on all data, and logistic regression was used to predict determinants of neonatal mortality. p < 0.05 was deemed significant.

Results: Three hundred and forty-seven neonates were included. Two hundred and sixty-one (75.2%) were aged 7 days or less at presentation, with males (n = 177, 52%) slightly higher than females (n = 165, 48%). The majority were delivered by spontaneous vaginal delivery (n = 247, 88%); 191 (58%) were born in hospital. Congenital anomalies accounted for 302 (87%) of the neonatal surgical cases and 45 (96%) deaths. The most common anomalies were omphalocele (n = 48, 13.8%), imperforate anus (n = 34, 9.8%), intestinal obstruction (n = 29, 8.4%), spina bifida (n = 26, 7.5%) and hydrocephalus (n = 19, 5.5%). The overall mortality rate was 13.5%. Two-thirds of the deaths (n = 30) from congenital anomalies were conditions involving the digestive system with gastroschisis having the highest mortality of 88%. Omphalocele (n = 11, 23.4%), gastroschisis (n = 7, 14.9%) and imperforate anus (n = 6, 12.8%) contributed to the most deaths. On multivariate analysis, low birthweight was significantly associated with mortality (OR 3.59, CI 1.4-9.5, p = 0.009).

Conclusion: Congenital anomalies are a major global health problem associated with high neonatal mortality in Ghana. The highest burden in terms of both caseload and mortality is attributed to congenital anomalies involving the digestive system, which should be targeted to improve outcomes.


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333. Global Unmet Needs in Cardiac Surgery.

Global heart


Authors: Zilla, P; Yacoub, M; Zühlke, L; Beyersdorf, F; Sliwa, K; Khubulava, G; Bouzid, A; Mocumbi, AO; Velayoudam, D; Shetty, D; Ofoegbu, C; Geldenhuys, A; Brink, J; Scherman, J; du Toit, H; Hosseini, S; Zhang, H; Luo, XJ; Wang, W; Mejia, J; Kofidis, T; Higgins, RSD; Pomar, J; Bolman, RM; Mayosi, BM; Madansein, R; Bavaria, J; Yanes-Quintana, AA; Kumar, AS; Adeoye, O; Chauke, RF; Williams, DF
Region / country: Global – Algeria, Brazil, China, Cuba, Germany, India, Iran, Morocco, Mozambique, Namibia, Nigeria, Russian Federation, Singapore, South Africa, Tunisia, United States of America
Speciality: Cardiothoracic surgery

More than 6 billion people live outside industrialized countries and have insufficient access to cardiac surgery. Given the recently confirmed high prevailing mortality for rheumatic heart disease in many of these countries together with increasing numbers of patients needing interventions for lifestyle diseases due to an accelerating epidemiological transition, a significant need for cardiac surgery could be assumed. Yet, need estimates were largely based on extrapolated screening studies while true service levels remained unknown. A multi-author effort representing 16 high-, middle-, and low-income countries was undertaken to narrow the need assessment for cardiac surgery including rheumatic and lifestyle cardiac diseases as well as congenital heart disease on the basis of existing data deduction. Actual levels of cardiac surgery were determined in each of these countries on the basis of questionnaires, national databases, or annual reports of national societies. Need estimates range from 200 operations per million in low-income countries that are nonendemic for rheumatic heart disease to >1,000 operations per million in high-income countries representing the end of the epidemiological transition. Actually provided levels of cardiac surgery range from 0.5 per million in the assessed low- and lower-middle income countries (average 107 ± 113 per million; representing a population of 1.6 billion) to 500 in the upper-middle-income countries (average 270 ± 163 per million representing a population of 1.9 billion). By combining need estimates with the assessment of de facto provided levels of cardiac surgery, it emerged that a significant degree of underdelivery of often lifesaving open heart surgery does not only prevail in low-income countries but is also disturbingly high in middle-income countries.


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334. A longitudinal study of the prevalence and characteristics of breast disorders detected by clinical breast examination during pregnancy and six months postpartum in Ibadan, Southwestern Nigeria.

BMC women’s health


Authors: Odedina, SO; Ajayi, IO; Adeniji-Sofoluwe, A; Morhason-Bello, IO; Huo, D; Olopade, OI; Ojengbede, OA
Region / country: Western Africa – Nigeria
Speciality: Obstetrics and Gynaecology

Breast disorders cause great anxiety for women especially when they occur in pregnancy because breast cancer is the most common cause of cancer related deaths in women. Majority of the disorders are Benign Breast Diseases (BBD) with various degrees of associated breast cancer risks. With increasing breast cancer awareness in Nigeria, we sought to determine the prevalence and characteristics of breast disorders among a cohort of pregnant women.A longitudinal study of 1248 pregnant women recruited in their first trimester- till 26 weeks gestational age consecutively from selected antenatal clinics (ANCs), in Ibadan, Southwest Nigeria. A pretested interviewer- administered questionnaire was used to collect information at recruitment. Clinical Breast Examination (CBE) using MammaCare® technique was performed at recruitment and follow up visits at third trimester, six weeks postpartum and six months postpartum. Women with breast disorders were referred for Breast Ultrasound Scan (BUS) and those with Breast Imaging Reporting and Data System (BIRADS) ≥4 had ultrasound guided biopsy. Statistical analysis was performed using Stata version 14.Mean age of participants was 29.7 ± 5.2 years and mean gestational age at recruitment was 20.4 ± 4.4 weeks. Seventy-two participants (5.8%) had a past history of BBD and 345 (27.6%) were primigravidae. Overall, breast disorder was detected among 223 (17.9%) participants and 149 (11.9%) had it detected at baseline. Findings from the CBE showed that 208 (69.6%) of 299 breast disorders signs found were palpable lumps or thickenings in the breast, 28 (9.4%) were persistent pain, and 63 (21.1%) were abscesses, infection and mastitis. Twenty out of 127 (15.7%) participants who had BUS performed were classified as BIRADS ≥3. Lesions found by BUS were reactive lymph nodes (42.5%), prominent ducts (27.1%), fibroadenoma (9.6%), breast cysts (3.8%) and fibrocystic changes (2.5%). No malignant pathology was found on ultrasound guided biopsy.Breast lump is a major breast disorder among pregnant women attending antenatal clinics in Ibadan. Routine clinical breast examination and follow up of pregnant women found with breast disorders could facilitate early detection of pregnancy associated breast cancer in low resource settings.


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335. Essential fracture and orthopaedic equipment lists in low resource settings in Africa.

BMJ open


Authors: Chan, Y; Banza, L; Martin, C; Harrison, WJ
Region / country: Central Africa, Eastern Africa, Middle Africa, Northern Africa, Southern Africa, Western Africa
Speciality: Trauma and orthopaedic surgery

Low/middle-income countries (LMICs) have a growing need for trauma and orthopaedic (T&O) surgical interventions but lack surgical resources. Part of this is due to the high amount of road traffic accidents in LMICs. We aimed to develop recommendations for an essential list of equipment for three different levels of care providers.The Delphi method was used to achieve consensus on essential and desirable T&O equipment for LMICs. Twenty experts with T&O experience from LMICs underwent two rounds of questionnaires. Feedback was given after each round of questionnaires. The first round of questionnaire consisted of 45 items graded on a Likert scale with the second round consisting of 50 items. We used an electronic questionnaire to collect our data for three different levels of care: non-operative-based provider, specialist provider with operative fracture care and tertiary provider with operative fracture care and orthopaedics.After two rounds of questionnaires, recommendations for each level of care in LMICs included 4 essential equipment items for non-operative-based providers; 27 essential equipment items for specialist providers with operative fracture care and 46 essential equipment items for tertiary providers with operative fracture care and orthopaedic care.These recommendations can facilitate in planning of appropriate equipment required in an institution which in turn has the potential to improve the capacity and quality of T&O care in LMICs. The essential equipment lists provided here can help direct where funding for equipment should be targeted. Our recommendations can help with planning and organising national T&O care in LMICs to achieve appropriate capacity at all relevant levels of care.


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336. Incidence of unintended pregnancy among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis.

BMJ open


Authors: Ampt, FH; Willenberg, L; Agius, PA; Chersich, M; Luchters, S; Lim, MSC
Region / country: Central Africa, Eastern Asia, Northern America – Cambodia, China, Kenya, Mexico, Thailand
Speciality: Obstetrics and Gynaecology

To determine the incidence of unintended pregnancy among female sex workers (FSWs) in low-income and middle-income countries (LMICs).We searched MEDLINE, PsychInfo, Embase and Popline for papers published in English between January 2000 and January 2016, and Web of Science and Proquest for conference abstracts. Meta-analysis was performed on the primary outcomes using random effects models, with subgroup analysis used to explore heterogeneity.Eligible studies targeted FSWs aged 15-49 years living or working in an LMIC.Studies were eligible if they provided data on one of two primary outcomes: incidence of unintended pregnancy and incidence of pregnancy where intention is undefined. Secondary outcomes were also extracted when they were reported in included studies: incidence of induced abortion; incidence of birth; and correlates/predictors of pregnancy or unintended pregnancy.Twenty-five eligible studies were identified from 3866 articles. Methodological quality was low overall. Unintended pregnancy incidence showed high heterogeneity (I²>95%), ranging from 7.2 to 59.6 per 100 person-years across 10 studies. Study design and duration were found to account for heterogeneity. On subgroup analysis, the three cohort studies in which no intervention was introduced had a pooled incidence of 27.1 per 100 person-years (95% CI 24.4 to 29.8; I2=0%). Incidence of pregnancy (intention undefined) was also highly heterogeneous, ranging from 2.0 to 23.4 per 100 person-years (15 studies).Of the many studies examining FSWs’ sexual and reproductive health in LMICs, very few measured pregnancy and fewer assessed pregnancy intention. Incidence varied widely, likely due to differences in study design, duration and baseline population risk, but was high in most studies, representing a considerable concern for this key population. Evidence-based approaches that place greater importance on unintended pregnancy prevention need to be incorporated into existing sexual and reproductive health programmes for FSWs.CRD42016029185.


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337. Effects of Socioeconomic Status on Clinical Outcomes with Ventricular Assist Devices.

Clinical cardiology


Authors: Ahmed, MM; Magar, SM; Jeng, EI; Arnaoutakis, GJ; Beaver, TM; Vilaro, J; Klodell, CT; Aranda, JM
Region / country: Northern America – United States of America
Speciality: Cardiothoracic surgery, Other, Vascular surgery

Lower socioeconomic status (SES) is a known risk factor for worse outcomes after major cardiovascular interventions. Furthermore, individuals with lower SES face barriers to evaluation for advanced heart failure therapies, including ventricular assist device (VAD) implantation.Examination of the effects of individual determinants of SES on VAD outcomes will show similar survival benefit in patients with lower compared with higher SES.All VAD implants at the University of Florida from January 2008 through December 2015 were reviewed. Patient-level determinants of SES included place of residence, education level, marital status, insurance status, and financial resources stratified by percent federal poverty level. Survival or transplantation at 1 year, 30-day readmission, implant length of stay (LOS), and an aggregate of VAD-related complications were assessed in univariate fashion and multivariable regression modelling.A total of 111 patients were included (mean age at time of implant 57.6 years, 82.8% men). More than half received destination therapy. At 1 year, 78.3% were alive on device support or had undergone successful transplantation. There were no differences in survival, 30-day readmission, or aggregate VAD complications by SES category. Although patients with lower levels of education had longer LOS in univariate analysis, on multivariable ordinal regression modelling, this relationship was no longer seen.Patients with lower SES receive the same survival benefit from VAD implantation and are not more likely to have 30-day readmissions, complications of device support, or prolonged implant LOS. Therefore, VAD implantation should not be withheld based on these parameters alone.


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338. Propensity score matching comparison of laparoscopic versus open surgery for rectal cancer in a middle-income country: short-term outcomes and cost analysis.

ClinicoEconomics and outcomes research : CEOR


Authors: Tayar, DO; Ribeiro, U; Cecconello, I; Magalhães, TM; Simões, CM; Auler, JOC
Region / country: South America – Brazil
Speciality: General surgery, Surgical oncology

Laparoscopic surgery for rectal cancer is associated with improved postoperative outcomes compared to open surgery; however, economic studies have yielded contradictory results. The aim of this study was to compare the clinical and economic outcomes of laparoscopic versus open surgery for patients with rectal cancer.Propensity score matching analysis was performed in a retrospective cohort of patients who underwent elective low anterior resection for rectal cancer treatment by laparoscopic and open surgery in a single Brazilian cancer center. Matched covariates included age, gender, body mass index, pTNM stage, American Society of Anesthesiologists score, type of anesthesia, neoadjuvant chemoradiotherapy, and interval between neoadjuvant chemoradiotherapy and index surgery. The clinical and economic outcomes were evaluated. The follow-up period was within 30 days of the index procedure. The clinical outcomes were reoperation, postoperative complications, operative time, length of stay in the intensive care unit, and postoperative hospital stay. For economic outcomes, a cost analysis was used to compare the costs.Initially, 220 patients were evaluated. After propensity score matching, 100 patients were included in the analysis (50 patients in the open surgery group and 50 patients in the laparoscopic surgery group). There were no differences in patients’ baseline characteristics. Operative time was longer for laparoscopic surgery (247 minutes vs 285 minutes, P=0.006). There were no significant differences in other clinical outcomes. The hospital costs were similar between the two groups (Brazilian reais 21,233.15 vs Brazilian reais 21,529.28, P=0.115), although the intraoperative costs were higher for laparoscopic surgery, mainly owing to the surgical devices and the theater-related costs. The postoperative costs were lower for laparoscopic surgery, owing to lower intensive care unit, ward, and reoperation costs.Laparoscopic surgery for rectal cancer is not costlier than open surgery from the health care provider’s perspective, since the intraoperative costs were offset by lower postoperative costs. Open surgery tends to have a longer length of stay.


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339. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries.

Lancet (London, England)


Authors: Kruk, ME; Gage, AD; Joseph, NT; Danaei, G; García-Saisó, S; Salomon, JA
Region / country: Global
Speciality: Other

Universal health coverage has been proposed as a strategy to improve health in low-income and middle-income countries (LMICs). However, this is contingent on the provision of good-quality health care. We estimate the excess mortality for conditions targeted in the Sustainable Development Goals (SDG) that are amenable to health care and the portion of this excess mortality due to poor-quality care in 137 LMICs, in which excess mortality refers to deaths that could have been averted in settings with strong health systems.Using data from the 2016 Global Burden of Disease study, we calculated mortality amenable to personal health care for 61 SDG conditions by comparing case fatality between each LMIC with corresponding numbers from 23 high-income reference countries with strong health systems. We used data on health-care utilisation from population surveys to separately estimate the portion of amenable mortality attributable to non-utilisation of health care versus that attributable to receipt of poor-quality care.15·6 million excess deaths from 61 conditions occurred in LMICs in 2016. After excluding deaths that could be prevented through public health measures, 8·6 million excess deaths were amenable to health care of which 5·0 million were estimated to be due to receipt of poor-quality care and 3·6 million were due to non-utilisation of health care. Poor quality of health care was a major driver of excess mortality across conditions, from cardiovascular disease and injuries to neonatal and communicable disorders.Universal health coverage for SDG conditions could avert 8·6 million deaths per year but only if expansion of service coverage is accompanied by investments into high-quality health systems.Bill & Melinda Gates Foundation.


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340. Decreasing birth asphyxia: utility of statistical process control in a low-resource setting.

BMJ open quality


Authors: Mukhtar-Yola, M; Audu, LI; Olaniyan, O; Akinbi, HT; Dawodu, A; Donovan, EF
Region / country: Western Africa – Nigeria
Speciality: Paediatric surgery

The neonatal period is a critical time for survival of the child. A disproportionate amount of neonatal deaths occur in low-resource countries and are attributable to perinatal events, especially birth asphyxia. This project aimed to reduce the incidence of birth asphyxia by 20% by June 2014 through training in neonatal resuscitation and improving the availability of resuscitation equipment in the delivery room in the National Hospital Abuja, Nigeria. A prospective, longitudinal study using statistical process control analytical methods was done enrolling babies delivered at the National Hospital Abuja. Low Apgar scores or birth asphyxia (defined a priori as any score <7 at 1, 5 and/or at 10 min) was assessed. To ensure reliability and validity of Apgar scoring, trainings on scoring were held for labour and delivery staff. Interventions included provision of additional equipment and trainings on neonatal resuscitation. Apgar scores were aggregated weekly over 25 months. Control charts with three SE confidence limits were used to monitor the proportion of scores ≤7. The baseline incidence of low Apgar scores, as defined a priori, was 33%, 17% and 10% while postintervention the incidence was 18%, 17% and 6% at 1, 5 and 10 min, respectively-a reduction of 45% and 40% in the 1-min and 10-min low Apgar scores. Increased communication, additional resuscitation equipment and training of delivery personnel on neonatal resuscitation are associated with reductions in measures of birth asphyxia. These improvements have been sustained and efforts are ongoing to spread our interventions to other special care delivery units/nursery in adjoining states. Our study demonstrates the feasibility and utility of using improvement science methods to assess and improve perinatal outcome in low-resource settings.


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341. Clubfoot treatment in 2015: a global perspective.

BMJ global health


Authors: Owen, RM; Capper, B; Lavy, C
Region / country: Global
Speciality: Trauma and orthopaedic surgery

Clubfoot affects around 174 000 children born annually, with approximately 90% of these in low-income and middle-income countries (LMIC). Untreated clubfoot causes life-long impairment, affecting individuals’ ability to walk and participate in society. The minimally invasive Ponseti treatment is highly effective and has grown in acceptance globally. The objective of this cross-sectional study is to quantify the numbers of countries providing services for clubfoot and children accessing these.In 2015-2016, expected cases of clubfoot were calculated for all countries, using an incidence rate of 1.24/1000 births. Informants were sought from all LMIC, and participants completed a standardised survey about services for clubfoot in their countries in 2015. Data collected were analysed using simple numerical analysis, country coverage levels, trends over time and by income group. Qualitative data were analysed thematically.Responses were received from 55 countries, in which 79% of all expected cases of clubfoot were born. More than 24 000 children with clubfoot were enrolled for Ponseti treatment in 2015. Coverage was less than 25% in the majority of countries. There were higher levels of response and coverage within the lowest income country group. 31 countries reported a national programme for clubfoot, with the majority provided through public-private partnerships.This is the first study to describe global provision of, and access to, treatment services for children with clubfoot. The numbers of children accessing Ponseti treatment for clubfoot in LMIC has risen steadily since 2005. However, coverage remains low, and we estimate that less than 15% of children born with clubfoot in LMIC start treatment. More action to promote the rollout of national clubfoot programmes, build capacity for treatment and enable access and adherence to treatment in order to radically increase coverage and effectiveness is essential and urgent in order to prevent permanent disability caused by clubfoot.


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

International urogynecology journal


Authors: Raassen, TJIP; Ngongo, CJ; Mahendeka, MM
Region / country: Central Asia, Eastern Africa, South-eastern Asia, Southern Africa, Southern Asia – Afghanistan, Bangladesh, Ethiopia, Kenya, Malawi, Rwanda, Somalia, South Sudan, Tanzania, Uganda, Zambia
Speciality: Obstetrics and Gynaecology, Urology surgery

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


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343. Haves and have nots must find a better way: The case for open scientific hardware.

PLoS biology


Authors: Maia Chagas, A
Region / country: Global
Speciality: Other

Many efforts are making science more open and accessible; they are mostly concentrated on issues that appear before and after experiments are performed: open access journals, open databases, and many other tools to increase reproducibility of science and access to information. However, these initiatives do not promote access to scientific equipment necessary for experiments. Mostly due to monetary constraints, equipment availability has always been uneven around the globe, affecting predominantly low-income countries and institutions. Here, a case is made for the use of free open source hardware in research and education, including countries and institutions where funds were never the biggest problem.


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344. The global burden of sepsis: barriers and potential solutions.

Critical care (London, England)


Authors: Rudd KE, Kissoon N, Limmathurotsakul D, Bory S, Mutahunga B, Seymour CW, Angus DC, West TE
Region / country: Global
Speciality: Other

Sepsis is a major contributor to the global burden of disease. The majority of sepsis cases and deaths are estimated to occur in low and middle-income countries. Barriers to reducing the global burden of sepsis include difficulty quantifying attributable morbidity and mortality, low awareness, poverty and health inequity, and under-resourced and low-resilience public health and acute health care delivery systems. Important differences in the populations at risk, infecting pathogens, and clinical capacity to manage sepsis in high and low-resource settings necessitate context-specific approaches to this significant problem. We review these challenges and propose strategies to overcome them. These strategies include strengthening health systems, accurately identifying and quantifying sepsis cases, conducting inclusive research, establishing data-driven and context-specific management guidelines, promoting creative clinical interventions, and advocacy.


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345. An estimation of global volume of surgically treatable epilepsy based on a systematic review and meta-analysis of epilepsy.

Journal of Neurosurgery


Authors: Kerry A. Vaughan , Christian Lopez Ramo, Vivek P. Buch, Rania A. Mekary, Julia R. Amundson , Meghal Shah, Abbas Rattani, Michael C. Dewan and Kee B. Park
Region / country: Global
Speciality: Neurosurgery

OBJECTIVE Epilepsy is one of the most common neurological disorders, yet its global surgical burden has yet to be characterized. The authors sought to compile the most current epidemiological data to quantify global prevalence and incidence, and estimate global surgically treatable epilepsy. Understanding regional and global epilepsy trends and potential surgical volume is crucial for future policy efforts and resource allocation. METHODS The authors performed a systematic literature review and meta-analysis to determine the global incidence, lifetime prevalence, and active prevalence of epilepsy; to estimate surgically treatable epilepsy volume; and to evaluate regional trends by WHO regions and World Bank income levels. Data were extracted from all population-based studies with prespecified methodological quality across all countries and demographics, performed between 1990 and 2016 and indexed on PubMed, EMBASE, and Cochrane. The current and annual new case volumes for surgically treatable epilepsy were derived from global epilepsy prevalence and incidence. RESULTS This systematic review yielded 167 articles, across all WHO regions and income levels. Meta-analysis showed a raw global prevalence of lifetime epilepsy of 1099 per 100,000 people, whereas active epilepsy prevalence is slightly lower at 690 per 100,000 people. Global incidence was found to be 62 cases per 100,000 person-years. The meta-analysis predicted 4.6 million new cases of epilepsy annually worldwide, a prevalence of 51.7 million active epilepsy cases, and 82.3 million people with any lifetime epilepsy diagnosis. Differences across WHO regions and country incomes were significant. The authors estimate that currently 10.1 million patients with epilepsy may be surgical treatment candidates, and 1.4 million new surgically treatable epilepsy cases arise annually. The highest prevalences are found in Africa and Latin America, although the highest incidences are reported in the Middle East and Latin America. These regions are primarily low- and middle-income countries; as expected, the highest disease burden falls disproportionately on regions with the fewest healthcare resources. CONCLUSIONS Understanding of the global epilepsy burden has evolved as more regions have been studied. This up-to-date worldwide analysis provides the first estimate of surgical epilepsy volume and an updated comprehensive overview of current epidemiological trends. The disproportionate burden of epilepsy on low- and middle-income countries will require targeted diagnostic and treatment efforts to reduce the global disparities in care and cost. Quantifying global epilepsy provides the first step toward restructuring the allocation of healthcare resources as part of global healthcare system strengthening.


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346. Pediatric neurosurgical workforce, access to care, equipment and training needs worldwide.

Journal of Neurosurgery


Authors: Dewan MC, Baticulon RE, Rattani A, Johnston JM Jr, Warf BC, Harkness W.
Region / country: Global
Speciality: Neurosurgery, Paediatric surgery, Surgical Education

OBJECTIVE:
The presence and capability of existing pediatric neurosurgical care worldwide is unknown. The objective of this study was to solicit the expertise of specialists to quantify the geographic representation of pediatric neurosurgeons, access to specialist care, and equipment and training needs globally.

METHODS:
A mixed-question survey was sent to surgeon members of several international neurosurgical and general pediatric surgical societies via a web-based platform. Respondents answered questions on 5 categories: surgeon demographics and training, hospital and practice details, surgical workforce and access to neurosurgical care, training and equipment needs, and desire for international collaboration. Responses were anonymized and analyzed using Stata software.

RESULTS:
A total of 459 surgeons from 76 countries responded. Pediatric neurosurgeons in high-income and upper-middle-income countries underwent formal pediatric training at a greater rate than surgeons in low- and lower-middle-income countries (89.5% vs 54.4%). There are an estimated 2297 pediatric neurosurgeons in practice globally, with 85.6% operating in high-income and upper-middle-income countries. In low- and lower-middle-income countries, roughly 330 pediatric neurosurgeons care for a total child population of 1.2 billion. In low-income countries in Africa, the density of pediatric neurosurgeons is roughly 1 per 30 million children. A higher proportion of patients in low- and lower-middle-income countries must travel > 2 hours to seek emergency neurosurgical care, relative to high-income countries (75.6% vs 33.6%, p < 0.001). Vast basic and essential training and equipment needs exist, particularly low- and lower-middle-income countries within Africa, South America, the Eastern Mediterranean, and South-East Asia. Eighty-nine percent of respondents demonstrated an interest in international collaboration for the purposes of pediatric neurosurgical capacity building.

CONCLUSIONS:
Wide disparity in the access to pediatric neurosurgical care exists globally. In low- and lower-middle-income countries, wherein there exists the greatest burden of pediatric neurosurgical disease, there is a grossly insufficient presence of capable providers and equipped facilities. Neurosurgeons across income groups and geographic regions share a desire for collaboration and partnership.


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

Annals of medicine and surgery


Authors: Hasan O, Samad A, Nawaz Z, Ahmad T, Abdul Muhammad Z, Noordin S
Region / country: Southern Asia – Pakistan
Speciality: Other, Trauma and orthopaedic surgery

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

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

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

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


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348. Ineffective insurance in lower and middle income countries is an obstacle to universal health coverage.

Journal of global health


Authors: El-Sayed, AM; Vail, D; Kruk, ME
Region / country: Global
Speciality: Other

Recent health policy efforts have sought to promote universal health coverage (UHC) as a means of providing affordable access to health services to populations. However, insurance schemes are heterogeneous, and some schemes may not provide necessary services to those covered. We explored the prevalence and determinants of ineffective insurance across 42 lower and middle income countries (LMICs) from the 2002-2004 World Health Survey.Respondents were defined as having ineffective health insurance if they reported being insured and: were forced to borrow or sell personal items to pay for health services; had an untreated chronic condition; or had recently delivered a child outside of a skilled health facility (women only).Among the insured, 13% had ineffective insurance, which was most commonly due to having to borrow or sell to pay for health care. The likelihood of ineffective insurance was lowest in upper-middle income countries and higher in other lower-middle and low-income countries. Ineffective insurance also decreased with family wealth and was higher among rural residents.Our findings suggest that a high proportion of insurance in LMICs is ineffective, particularly among those who need it most, and that attention should be paid to effectiveness when defining health insurance in policy conversations about UHC.


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349. Maternal and perinatal adverse outcomes in women with pre-eclampsia cared for at facility-level in South Africa: a prospective cohort study.

Journal of global health


Authors: Nathan, HL; Seed, PT; Hezelgrave, NL; De Greeff, A; Lawley, E; Conti-Ramsden, F; Anthony, J; Steyn, W; Hall, DR; Chappell, LC; Shennan, AH
Region / country: Southern Africa – South Africa
Speciality: Obstetrics and Gynaecology

Hypertensive disorders of pregnancy contribute to 14% of all maternal deaths, the majority of which occur in low- and middle-income countries. The aim of the study was to describe the maternal and perinatal clinical outcomes of women with pre-eclampsia living in middle- and low-income countries.The study was a prospective observational study of women with pre-eclampsia (n = 1547, 42 twin pregnancies) at three South African tertiary facilities. Using stepwise logistic regression model area under the receiver operating characteristic curve (AUROC) values, the association between maternal baseline and admission characteristics and risk of adverse outcomes was evaluated. Main outcome measures were eclampsia, kidney injury and perinatal death.In 1547 women with pre-eclampsia, 16 (1%) died, 147 (9.5%) had eclampsia, four (0.3%) had a stroke and 272 (17.6%) had kidney injury. Of the 1589 births, there were 332 (21.0%) perinatal deaths; of these, 281 (84.5%) were stillbirths. Of 1308 live births, 913 (70.0%) delivered <37 completed weeks and 544 (41.7%) delivered <34 weeks' gestation. Young maternal age (AUROC = 0.76, 95% confidence interval (CI) = 0.71-0.80) and low Body Mass Index BMI (AUROC 0.65, 95% CI = 0.59-0.69) were significant predictors of eclampsia. Highest systolic blood pressure had the strongest association with kidney injury, (AUROC = 0.64, 95% CI = 0.60-0.68). Early gestation at admission was most strongly associated with perinatal death (AUROC = 0.81, 95% CI = 0.77-0.84).The incidence of pre-eclampsia complications, perinatal death and preterm delivery in women referred to tertiary care in South Africa was much higher than reported in other low- and middle-income studies and despite access to tertiary care interventions. Teenage mothers and those with low BMI were at highest risk of eclampsia. This information could be used to inform guidelines, the research agenda and policy.


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350. Intravenous lidocaine as adjuvant to general anesthesia in renal surgery.

The Libyan journal of medicine


Authors: Nakhli, MS; Kahloul, M; Guizani, T; Zedini, C; Chaouch, A; Naija, W
Region / country: Northern Africa – Tunisia
Speciality: Anaesthesia, General surgery

The role of intraoperative intravenous lidocaine infusion has been previously evaluated for pain relief, inflammatory response, and post-operative recovery, particularly in abdominal surgery. The present study is a randomized double-blinded trial in which we evaluated whether IV lidocaine infusion reduces isoflurane requirement, intraoperative remifentanil consumption and time to post-operative recovery in non-laparoscopic renal surgery. Sixty patients scheduled to undergo elective non-laparoscopic renal surgery under general anesthesia were enrolled to receive either systemic lidocaine infusion (group L: bolus 1.5 mg/kg followed by a continuous infusion at the rate of 2 mg/kg/hr until skin closure) or normal saline (0.9% NaCl solution) (Group C). The depth of anesthesia was monitored using the Bispectral Index Scale (BIS), which is based on measurement of the patient’s cerebral electrical activity. Primary outcome of the study was End-tidal of isoflurane concentration (Et-Iso) at BIS values of 40-60. Secondary outcomes include remifentanil consumption during the operation and time to extubation. Et-Iso was significantly lower in group L than in group C (0.63% ± 0.10% vs 0.92% ± 0.11%, p < 10-3). Mean remifentanil consumption of was significantly lower in group L than in group C (0.13 ± 0.04 µg/kg/min vs 0.18 ± 0.04 µg/kg/min, p < 10-3). Thus, IV lidocaine infusion permits a reduction of 31% in isoflurane concentration requirement and 27% in the intraoperative remifentanil need. In addition, recovery from anesthesia and extubation time was shorter in group L (5.8 ± 1.8 min vs 7.9 ± 2.0 min, p < 10-3). By reducing significantly isoflurane and remifentanil requirements during renal surgery, intravenous lidocaine could provide effective strategy to limit volatile agent and intraoperative opioids consumption especially in low and middle income countries.


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351. The power of practice: simulation training improving the quality of neonatal resuscitation skills in Bihar, India.

BMC pediatrics


Authors: Vail, B; Morgan, MC; Spindler, H; Christmas, A; Cohen, SR; Walker, DM
Region / country: Southern Asia – India
Speciality: Anaesthesia, Other, Paediatric surgery

Globally, neonatal mortality accounts for nearly half of under-five mortality, and intrapartum related events are a leading cause. Despite the rise in neonatal resuscitation (NR) training programs in low- and middle-income countries, their impact on the quality of NR skills amongst providers with limited formal medical education, particularly those working in rural primary health centers (PHCs), remains incompletely understood.This study evaluates the impact of PRONTO International simulation training on the quality of NR skills in simulated resuscitations and live deliveries in rural PHCs throughout Bihar, India. Further, it explores barriers to performance of key NR skills. PRONTO training was conducted within CARE India’s AMANAT intervention, a maternal and child health quality improvement project. Performance in simulations was evaluated using video-recorded assessment simulations at weeks 4 and 8 of training. Performance in live deliveries was evaluated in real time using a mobile-phone application. Barriers were explored through semi-structured interviews with simulation facilitators.In total, 1342 nurses participated in PRONTO training and 226 NR assessment simulations were matched by PHC and evaluated. From week 4 to 8 of training, proper neck extension, positive pressure ventilation (PPV) with chest rise, and assessment of heart rate increased by 14%, 19%, and 12% respectively (all p ≤ 0.01). No difference was noted in stimulation, suction, proper PPV rate, or time to completion of key steps. In 252 live deliveries, identification of non-vigorous neonates, use of suction, and use of PPV increased by 21%, 25%, and 23% respectively (all p < 0.01) between weeks 1-3 and 4-8. Eighteen interviews revealed individual, logistical, and cultural barriers to key NR skills.PRONTO simulation training had a positive impact on the quality of key skills in simulated and live resuscitations throughout Bihar. Nevertheless, there is need for ongoing improvement that will likely require both further clinical training and addressing barriers that go beyond the scope of such training. In settings where clinical outcome data is unreliable, data triangulation, the process of synthesizing multiple data sources to generate a better-informed evaluation, offers a powerful tool for guiding this process.


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352. Development of Low-Cost Locally Sourced Two-Component Compression Bandages in Western Kenya.

Dermatology and therapy


Authors: Chang, AY; Tonui, EC; Momanyi, D; Mills, AR; Wasike, P; Karwa, R; Maurer, TA; Pastakia, SD
Region / country: Eastern Africa – Kenya
Speciality: Other, Trauma and orthopaedic surgery

Compression therapy is well-established standard of care for chronic leg ulcers from venous disease and lymphedema. Chronic leg ulcers and lymphedema have a significant impact on quality of life, driven by pain, foul odor, and restricted mobility. Provision of layered compression therapy in resource-limited settings, as in Western Kenya and other regions of sub-Saharan Africa, is a major challenge due to several barriers: availability, affordability, and access to healthcare facilities. When wound care providers from an Academic Model Providing Access to Healthcare (AMPATH) health center in Western Kenya noted that a donated, finite supply of two-component compression bandages was helping to heal chronic leg ulcers, they began to explore the potential of finding a local, sustainable solution. Dermatology and pharmacy teams from AMPATH collaborated with health center providers to address this need.Following a literature review and examination of ingredients in prepackaged brand-name kits, essential components were identified: elastic crepe, gauze, and zinc oxide paste. All of these materials are locally available and routinely used for wound care. Two-component compression bandages were made by applying zinc oxide to dry gauze for the inner layer and using elastic crepe as the outer layer. Feedback from wound clinic providers was utilized to optimize the compression bandages for ease of use.Adjustments to assembly of the paste bandage included use of zinc oxide paste instead of zinc oxide ointment for easier gauze impregnation and cutting the inner layer gauze in half lengthwise to facilitate easier bandaging of the leg, such that there were two rolls of zinc-impregnated gauze each measuring 5 inches × 2 m. Adjustments to use of the compression bandage have included increasing the frequency of bandage changes from 7 to 3 days during the rainy seasons, when it is difficult to keep the bandage dry. Continuous local acquisition of all components led to lower price quotes for bulk materials, driving down the production cost and enabling a cost to the patient of 200 KSh (2 USD) per two-component compression bandage kit. Wound care providers have provided anecdotal reports of healed chronic leg ulcers (from venous stasis, trauma), improved lymphedema, and patient tolerance of compression.Low-cost locally sourced two-component compression bandages have been developed for use in Western Kenya. Their use has been initiated at an AMPATH health center and is poised to meet the need for affordable compression therapy options in Western Kenya. Studies evaluating their efficacy in chronic leg ulcers and Kaposi sarcoma lymphedema are ongoing. Future work should address adaptation of compression bandages for optimal use in Western Kenya and evaluate reproducibility of these bandages in similar settings, as well as consider home- or community-based care delivery models to mitigate transportation costs associated with accessing healthcare facilities.


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

The Lancet. Global health


Authors: Global Research on Developmental Disabilities Collaborators
Region / country: Northern Africa, Southern Asia
Speciality: Other

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


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354. The Cape Town Declaration on Access to Cardiac Surgery in the Developing World.

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde


Authors: Zilla, P; Bolman, RM; Yacoub, MH; Beyersdorf, F; Sliwa, K; Zühlke, L; Higgins, RSD; Mayosi, B; Carpentier, A; Williams, D
Region / country: Southern Africa – South Africa
Speciality: Cardiothoracic surgery

Twelve years after cardiologists and cardiac surgeons from all over the world issued the ‘Drakensberg Declaration on the Control of Rheumatic Fever and Rheumatic Heart Disease in Africa’, calling on the world community to address the prevention and treatment of rheumatic heart disease (RHD) through improving living conditions, to develop pilot programmes at selected sites for control of rheumatic fever and RHD, and to periodically review progress made and challenges that remain, RHD still accounts for a major proportion of cardiovascular diseases in children and young adults in low- and middle-income countries, where more than 80% of the world population live. Globally equal in prevalence to human immunodeficiency virus infection, RHD affects 33 million people worldwide. Prevention efforts have been important but have failed to eradicate the disease. At the present time, the only effective treatment for symptomatic RHD is open heart surgery, yet that life-saving cardiac surgery is woefully absent in many endemic regions. In this declaration, we propose a framework structure to create a co-ordinated and transparent international alliance to address this inequality.


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355. Long-term repercussions of Roux-en-Y gastric bypass in a low-income population: assessment ten years after surgery.

Revista do Colegio Brasileiro de Cirurgioes


Authors: Rolim, FFA; Cruz, FS; Campos, JM; Ferraz, ÁAB
Region / country: South America – Brazil
Speciality: General surgery

to evaluate the weight, nutritional and quality of life of low-income patients after ten years of Roux-en-Y gastric bypass (RYGB).we conducted a longitudinal, retrospective and descriptive study evaluating the excess weight loss, weight regain, arterial hypertension, type 2 diabetes mellitus, anemia and hypoalbuminemia in 42 patients of social classes D and E submitted to RYGB. We assessed quality of life through the Bariatric Analysis and Reporting Outcome System (BAROS).of the 42 patients, 68.3% defined themselves as doing non-regular physical activity, and only 44.4% and 11.9% had regular medical and nutritional follow-up, respectively. We found a mean excess weight loss of 75.6%±12 (CI=71.9-79.4), and in only one patient there was insufficient weight loss. The mean weight loss was 22.3%±16.2 (CI=17.2-27.3) with 64.04% of the sample presenting regain greater than 15% of the minimum weight; 52.3% of the sample presented anemia after ten years of surgery and